Paediatric Cardiovascular Examination – OSCE Guide


The paediatric cardiovascular exam can be a logistical minefield, requiring a good understanding of cardiac anatomy and possible congenital anomalies. With babies especially, it’s important to be opportunistic with your examination – doing the three ‘quiet things’ first: auscultation of heart sounds, auscultation of breath sounds and palpation of femoral pulses.

With all children, don’t expect to follow a pre-defined order. Be creative and playful, making the examination into a game involving parents, siblings and the toys available to you.

Check out the paediatric cardiovascular examination mark scheme here.


Introduction

  • Wash your hands
  • Introduce yourself to both the parents and the child
  • Explain what the cardiovascular examination will involve
  • Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform an examination of your child’s heart, which will involve first watching your child, then feeling their pulse and listening to their chest with my stethoscope.

Are you happy for me to carry out the examination?


General Inspection

Appearance and Behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour:

  • How alert is the child?
  • How active is the child?
  • Do they appear to be a normal colour? (e.g. Is there any pallor, cyanosis or jaundice?)
  • Do they have an obvious rash?
  • Do they appear a healthy weight

Pay attention to features that may indicate the presence of an underlying genetic condition:

  • Stature (e.g. tall/short)
  • Syndromic facial features
  • See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with cardiovascular system pathology.

Equipment

Observe for any equipment in the patient’s immediate surroundings and consider why this might be relevant to the cardiovascular system:

  • O2 saturation probe and monitor
  • Oxygen mask, nasal prongs, oxygen tank and other breathing support
  • Intravenous medication
  • Wheelchair

Medications

Note any medications by the bedside or in the patient’s room and consider what underlying diagnoses they may indicate:

  • Anticoagulants (e.g. Warfarin/Heparin) – artificial heart valves
  • Antihypertensives (e.g. ACE inhibitors) – hypertension
  • Diuretics (e.g. Furosemide) – heart failure

Hands

Inspect the hands

  • Peripheral cyanosis – cyanotic congenital heart disease, hypothermia
  • Finger clubbing – infective endocarditis, cyanotic congenital heart disease
  • Osler’s nodes (tender red nodules on finger pulps/thenar eminence)infective endocarditis
  • Janeway lesions (non-tender maculopapular erythematous palm pulp lesions) infective endocarditis
  • Splinter haemorrhages (reddish/brown streaks on the nail bed) infective endocarditis
  • Absent thumbs – Holt-Oram syndrome

Pulses

Radial pulse (femoral pulse in babies) – assess the rate, rhythm and character

Radio-radial or radio-femoral delay:

  • Palpate both radial pulses simultaneously (or contralateral radial and femoral pulses)
  • The pulses should occur at the same time in a healthy child
  • A delay may suggest aortic coarctation 

Jugular Venous Pressure (JVP)

Assessment of the JVP is only performed in children older than 8 years old.

1. Ensure the patient is positioned at 45°

2. Ask the child to turn their head away from you

3. Observe the neck for the JVP – located inline with the sternocleidomastoid

4. Measure the JVP – number of centimetres from the sternal angle to the upper border of pulsation

A raised JVP may indicate, fluid overload, right ventricular failure or tricuspid regurgitation.


Face

Observe the child’s facial complexion and features, including their eyes, ears, nose, mouth and throat.

General

  • Malar flush – mitral stenosis
  • Nasal flaring/grunting – congenital cyanotic heart disease, heart failure

Eyes

  • Conjunctival pallor – anaemia
  • Scleral icterus – jaundice

Mouth

  • Central cyanosis – bluish discolouration of the lips and/or the tongue – cyanotic congenital heart disease
  • Angular stomatitis – inflammation of the corners of the mouth – iron deficiency 
  • High arched palate – suggestive of Marfan syndrome – increased risk of aortic aneurysm/dissection
  • Dental hygiene –important if considering sources for infective endocarditis
  • Tip: Ask the child to see how long their tongue is or how big their mouth is

Expose the Chest

  • Ask the parent or child (if appropriate) to expose the child’s chest.
  • Observe the chest, looking for any scars or visible pulsations.
  • Note the shape of the chest wall.
  • Tip: If you ask a child to show you their tummy they’ll almost always lift their top up to expose their chest as well.

Chest wall shape

Observe the shape of the child’s chest, looking for any abnormalities:

  • Pectus excavatum (hollow chest) and pectus carniatum (Pigeon chest) – Marfan syndrome, Noonan syndrome
  • Pre-cordial bulge – cardiomegaly
  • Visible ventricular impulse – normal in thin children, can be associated with left ventricular hypertrophy

Chest wall scars

Locations of different scar types on the thorax
Locations of different scar types on the thorax

1. Sternotomy

  • All complex cardiac surgeries
  • Pulmonary artery banding

2. Right thoracotomy

  • Blalock–Taussig shunt (used to increase pulmonary blood flow for palliation in duct-dependent cyanotic heart defects like pulmonary atresia)
  • Pulmonary artery banding
  • Non-cardiac – lobectomy, tracheoesophageal fistula repair

3. Left thoracotomy

  • Patent ductus arteriosus ligation
  • Blalock–Taussig shunt
  • Pulmonary artery banding
  • Coarctation of aorta repair
  • Non-cardiac – lobectomy

4. Pacemaker or implantable cardioverter-defibrillator scar

5. Chest drain scars


Palpation

Start with the abdomen and then work up to the chest. If appropriate, ask the child what they ate for their last meal and try to ‘find it’. If you can’t ‘find it’, you’ll have to listen – leading you to auscultation (sneaky right?).

Abdomen

Liver

In a healthy child, the liver edge may be palpated up to 2cm below the costal margin. If the liver edge is more prominent, it would suggest the presence of hepatomegaly. Heart failure is a potential cause of hepatomegaly.

1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger)

2. Press your hand into the abdomen as the child breathes in

3. Feel for a step, as the liver edge passes below your hand

4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher 

 

If you feel the liver edge, note the following:

  • The degree of extension below the costal margin
  • The consistency of the liver edge (smooth/irregular)
  • Tenderness – suggestive of hepatitis 
  • Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation

Spleen

If hepatomegaly is present, you should also assess for splenomegaly. See the paediatric abdominal examination guide for details on how to perform splenic palpation.

Chest

Palpate the apex beat

Palpate the cardiac apex, noting its position.

Normal position:

  • <7 years old: 4th intercostal space, to the left of the midclavicular line
  • >7 years old: 5th intercostal space, midclavicular line

 

Abnormal position:

  • Left displacement – cardiomegaly, pectus excavatum, scoliosis
  • Right displacement – dextrocardia, left diaphragmatic hernia, collapsed lung on right, left pleural effusion, left pneumothorax

Assess for heaves and thrills

Heaves:

  • A parasternal heave is a precordial impulse that can be palpated
  • Parasternal heaves are present in patients with right ventricular hypertrophy
  • Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
  • If heaves are present you should feel the heel of your hand being lifted with each systole
  • Tip: Instead of the heel of your hand, use your fingertips with babies and younger children

 

Thrills:

  • A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
  • You should assess for a thrill across each of the heart valves in turn
  • To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed

Auscultation

Auscultate the heart

Start by showing the child your stethoscope and demonstrate it on your own chest and/or on one of their toys to familiarise them with this piece of equipment.

Suggest listening to their chest, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.

Tip: Play a game to see who can stay quiet the longest – involve the parents!

Areas of the heart to auscultate

Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope:

  • Mitral valve – 5th intercostal space – midclavicular line (apex beat)
  • Tricuspid valve  4th or 5th intercostal space – lower left sternal edge
  • Pulmonary valve  2nd intercostal space – left sternal edge
  • Aortic valve – 2nd intercostal space – right sternal edge

Listen over each area with both the bell (for low pitched sounds – gallops and split S2) and the diaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).

Tip: Complex cardiac anomalies may cause you to hear multiple dynamic murmurs (e.g. Tetralogy of Fallot)

Auscultate the lungs

  • Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths
  • Auscultate each side of the chest in a symmetrical pattern, comparing side to side
  • Pay attention to the inspiratory and expiratory sounds at each placement
  • Note the quality and volume of breath sounds
  • Note any additional sounds
  • Repeat auscultation on the posterior aspect of the chest
  • Coarse bibasal crackles may be a late sign of pulmonary congestion secondary to congestive heart failure.
Areas of the anterior chest to auscultate
Areas of the anterior chest to auscultate
 

To Complete the Examination…

Assess for oedema

  • Ask the parents if the child looks puffy or swollen.
  • Inspect the limbs, sacral area and face – affected areas will depend on the age of the child and mobility status.
  • Peripheral oedema often occurs in right-sided heart failure.

Final steps

  • Ensure the child is re-dressed after the examination
  • Thank the child and/or parents
  • Explain your findings to the parents and/or child
  • Ask if the parents and/or child have any questions
  • Wash your hands

Further clinical assessments to consider

Further investigations


Extra information

Murmurs

More than 50% of children will have a murmur at some point while congenital heart disease is present in less than 1% of children. The table below includes a non-exhaustive list of murmur characteristics and underlying causes. 

LOCATIONAortic area – aortic stenosis

Pulmonary area:
  • Ejection systolic with fixed P2 – atrial septal defect;
  • Ejection systolic without fixed P2 – pulmonary stenosis (radiates to axilla/back, louder on inspiration)

Subclavian, holosystolic – patent ductus arteriosus

Lower right sternal edge – tricuspid regurgitation

Tricuspid area:
  • Pansystolic murmur – ventricular septal defect
  • Diastolic – tricuspid stenosis, aortic regurgitation

Apex – mitral regurgitation – increases on lying on left, radiates to the axilla
TIMING
  • Systolic
  • Diastolic
  • Continuous
DURATION
  • Mid-systolic (ejection)
  • Pan-systolic
LOUDNESS (systolic murmur grade)
  • 1-2: Soft, difficult to hear
  • 3: Easily audible, no thrill
  • 4-6: Loud, with a thrill
SITE OF MAXIMAL INTENSITY
  • Mitral
  • Pulmonary
  • Aortic
  • Tricuspid area
RADIATION
  • To the neck: aortic stenosis
  • To the back: coarctation of the aorta or pulmonary stenosis
  • To the axilla: mitral regurgitation (increases lying on the left)

Syndromes that may impact the cardiovascular system

Below is a table containing a non-exhaustive list of syndromes that can impact the cardiovascular system.

The features of each syndrome relevant to the cardiovascular system are shown in bold.

Alagille syndrome
In 90 percent of cases, caused by mutations in the JAG1 gene.

Broad forehead

Small chin

Flat face

Pulmonary stenosis

Tetralogy of Fallot

CHARGE syndrome

CHARGE syndrome is a genetic syndrome with a characteristic set of features.

Coloboma (of the eye)

Choanal atresia

Heart anomalies (see below)

Tetralogy of Fallot

Patent ductus arteriosus

Ventricular septal defect

Atrial septal defect

Atrioventricular septal defect
DiGeorge syndrome
A constellation of signs and symptoms associated with defective development of the pharyngeal pouch system. Most cases are caused by a heterozygous chromosomal deletion at 22q11.2.  

Hearing loss

Cleft palate

Micrognathia

Hypoplastic malar

Ventricular septal defect

Tetralogy of Fallot

Interrupted aortic arch

Down syndrome
A genetic disorder caused by the presence of all or part of a third copy of chromosome 21.

Epicanthic folds

Brushfield spots

Protruding tongue

Low set ears

Ventricular septal defect

Atrial septal defect

Atrioventricular septal defect

Fetal alcohol spectrum disorder
A range of effects that can occur in an individual who was prenatally exposed to alcohol.

Macrocephaly

IUGR

Smooth philtrum

Joint abnormality

Ventricular septal defect

Atrial septal defect

Fragile X syndrome
An X-linked disorder and the most common inherited cause of intellectual disability: Both males and females can be affected.

Macrocephaly

Prominent ears and jaw

Hypermobility

Macroorchidism

Mitral valve
prolapse

Marfan syndrome
An autosomal dominant connective tissue disorder.

Marfanoid habitus (tall, long limbs)

Hypermobility

Arachnodactyly

Chest wall deformities

Aortic dilatation/regurgitation

Mitral prolapse

Noonan syndrome
An autosomal dominant condition. 50% of children have a pathogenic variant in protein tyrosine phosphatase, nonreceptor type 11 (PTPN11).
Turner phenotype

Pulmonary stenosis

Hypertrophic cardiomyopathy
Turner syndrome
Caused by loss of part or all of an X chromosome – affecting only females.

Short stature

Delayed puberty

Webbed neck

Shield chest

Coarctation of the aorta

Aortic stenosis

Williams syndrome
Caused by the deletion of genetic material from a specific region of chromosome 7.

Short palpebral fissures

Upturned nose

Cupid bow lip

Supravalvular aortic stenosis

Pulmonary stenosis


Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar


 

References

  • Bishop (2011). Cardiac Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK] (Accessed 18 Mar 2019)
  • Lissauer, T., Clayden, G., & Craft, A. (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
  • Miin Lee (2013). Cardiovascular Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics. [LINK] (Accessed 18 Mar 2019)
  • Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.
  • Towers, A (2015). Examination: cardiovascular, Don’t Forget the Bubbles. [LINK](Accessed 18 Mar 2019)

Photo credits

  1. Ragesoss, Physical exam of a child with stethoscope on the chest, Colour, CC BY-SA 3.0. Available at: [LINK]

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