CARDIOVASCULAR EXAMINATION

I.U. Cerrahpaşa Medical Faculty

Department of Pediatrics

Division of Pediatric Cardiology

Prof. Dr. Ayşe Güler EROĞLU

HISTORY

Sweating Exercise intolerance Common respiratory tract infections Growth retardation Feeding difficulties Palpitation Dyspne Cyanosis Chest pain Syncope

HISTORY

Medical history Ilnesses Medications

Prenatal history Mother’s ilnesses (diabetes mellitus, lupus) Mother’s medications

Natal history Prematurity Birth weight

Family history Congenital heart diseases Sudden death

PHYSICAL EXAMINATION

INSPECTION

General appearance Chromosomal, hereditary, nonhereditary

syndroms Pallor Cyanosis Clubbing Neck vein distension Left precordial bulge

PALPATION

Pulses Volume Rate Rhythm Character

Chest Apical impulse

In newborn and infants 4. intercostal space/midclavicular line In older children and adults 5. intercostal space/midclavicular line

Precordial activity Thrills

VOLUME OF PULSES

Increase in pulse volume Fever, anemia, exercise and thyrotoxicosis

Weak pulses Low cardiac output (left heart obstructive lesions:

aortic valve atresia or stenosis) Bounding pulses

Patent ductus arteriosus, aortic regurgitation, large systemic arteriovenous fistula

Differences in pulse volume between extremities Coarctation of the aorta

OSCULTATION

Heart rate and rhythm Heart sounds Other sounds Murmurs

HEART SOUNDS First heart sound (S1): The S1 is associated with

closure of the atrioventricular valves (mitral and tricuspid) It corresponds to the beginning of systole. Abnormally wide splitting: right bundle branch

block, Ebstein’s anomaly Increased S1: Fever, anemia, excitement,

thyrotoxicosis, short PR interval, mitral stenosis

Decreased S1: long PR interval and mitral regurgitation

Second heart sound (S2): The S2 is associated with closure of semilunar valves (aortic and pulmonary). It corresponds to the beginning of diastole. In every normal child, the s2 is split during inspiration and single during expiration (normal splitting of the S2).

HEART SOUNDS Widely split S2

Right ventricle volume overload: ASD, partial anomalous pulmonary venous return)

Right ventricle pressure overload: pulmonary stenosis

Delay in electrical activation of right ventricle: right bundle branch block

Early aortic valve closure: mitral regurgitation Narrowly split S2

Pulmonary hypertension Aortic stenosis

Paradoxically split S2

Severe aortic stenosis Left bundle branch block

HEART SOUNDS

Single S2

Only one semilunar valve is present: aortic or pulmonary atresia, persistent truncus arteriosus

P2 is not audible: transposition of the great arteries, tetralogy of Fallot, severe pulmonary stenosis

Aortic closure is delayed: severe aortic stenosis

P2 occurs early: pulmonary hypertension P2 increases in pulmonary hypertension and

decreases in severe pulmonary stenosis, tetralogy of Fallot and tricuspid stenosis

HEART SOUNDS Third heart sound (S3): The S3 is a low-frequency

sound in early diastole and is related to rapid filling of the ventricle. It is commonly heard in normal children and

young adults. A loud S3 is abnormal and is audible in large

shunt VSD, congestive heart failure. Fourth heart sound (S4): The S4 is a low-frequency

of late diastole and is rare in infants and children. It is always pathologic. It is seen in conditions with decreased

ventricular compliance.

OTHER SOUNDS Ejection clic: It follows the S1 very closely,

therefore it sounds like a splitting of the S1 Valvular aortic and pulmonary stenosis, dilated

great arteries Midsystolic click with or without late systolic

murmur Mitral or tricuspid valve prolapse

Opening snup: It occurs earlier than the S3 during diastole Mitral or tricuspid stenosis

Pericardial friction rub (frotman) Pericarditis

Pericardial knock Constrictive pericarditis

CHARACTERISTICS OF HEART MURMURS

Location

Intensity Quality

Radiation

Timing

Murmur

TIMING OF HEART MURMURS

Murmurs

Systolic Continuous Diastolic

Ejection(Diamond Crescendo-

decrescendo)

EarlyRegurgitant(HolosistolicPansistolic)

Late Early Middiastolic Late

Sistolic ejektion murmurs(Diamond shaped,

crescendo-decrescendo)

Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery

Sistolic regurgitant murmurs(Holosistolic, pansistolic)

Ventricular septal defect Mitral regurgitation Tricuspid regurgitation

Late sistolic murmurs

Mitral valve prolapse Tricuspid valve prolapse

Early diastolic murmurs(Decrescendo)

Aortic regurgitation Pulmonary regurgitation

Middiastolic murmurs(Flow murmurs)

Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA

Late diastolic murmurs(Presistolik)

Mitral valve stenosis Tricuspid valve stenosis

Continuous murmurs

Arterial PDA Coronary artery

fistula Pulmonary AV fistula Sistemic AV fistula

Venous Venous hum

LOCATION OF HEART MURMURS

Aortic area: right parasternal 2. intercostal space

Pulmonary area: left parasternal 2. intercostal space

Tricuspid area: left parasternal 4.-5. intercostal space

Mitral area (cardiac apex): 5.-6.intercostal space/ midclavicular line

Mezocardiyak area (second aortic area, Erb): left parasternal 3.-4. intercostal space

Aorta Pulmonary

TricuspidMitral

INTENSITY OF HEART MURMURS

Graded from 1 to 6. Grade 1: Barely audible. Grade 2: Soft, but easily audible. Grade 3: Moderately loud, but no accompanied

with a thrill. Grade 4: Louder and associated with a thrill. Grade 5: Audible with the stethescope barely on

the chest. Grade 6: Audible with the stethoscope off the

chest.