Paediatric Cardiovascular Examination – OSCE Guide

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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.


Introduction

Introduce yourself to the parents and the child, including your name and role.

Confirm the child’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language: “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.”

Gain consent from the parents/carers and/or child before proceeding: “Are you happy for me to carry out the examination?”

Wash your hands.


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:

  • Activity/alertness: note if the child appears alert and engaged, or quiet and listless.
  • Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
  • Shortness of breath: may indicate underlying cardiovascular (e.g. congenital heart disease) or respiratory disease (e.g. asthma).
  • Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. blood dyscrasia, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
  • Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites). There are many causes of oedema including cardiac failure and nephrotic syndrome.
  • Rashes: note the characteristics and distribution of any skin rashes (e.g. petechiae suggesting clotting disorder).
  • Weight: note if the child appears a healthy weight for their age and height.

Syndromic features

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 child’s immediate surroundings and consider why this might be relevant to the cardiovascular system:

  • Oxygen: saturation probe, mask, nasal prongs, oxygen tank and other breathing support.
  • Mobility equipment: wheelchair, crutches and walking frame.

Medications

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

  • Anticoagulants (e.g. warfarin/heparin): commonly prescribed for children with artificial heart valves.
  • Antihypertensives (e.g. ACE inhibitors)
  • Diuretics (e.g. furosemide): often used in the management of heart failure.
  • Cyanosis
    Cyanosis caused by hypoplastic left ventricle 1

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspect the hands

General observations

Inspect the hands for clinical signs relevant to the cardiovascular system:

  • Colour: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
  • Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
  • Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
  • Absent thumbs: associated with Holt-Oram syndrome, an autosomal dominant genetic condition which causes abnormalities in the bones of the arms and hands as well as the heart (atrial septal defect, heart block).

Finger clubbing

Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease and infective endocarditis.

To assess for finger clubbing:

  • Ask the child to copy you in placing the nails of their index fingers back to back
  • In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
  • When finger clubbing develops, this window is lost.
  • If the child is too young for this to be possible, you can simply inspect the fingers, looking for soft tissue swelling of the terminal phalanx of the digits.

Signs in the hands associated with endocarditis

There are several other signs in the hands that are associated with endocarditis including:

  • Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
  • Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
  • Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
  • Xanthomata
    Xanthomata 4

Palpation

Temperature

Place the dorsal aspect of your hand onto the child’s to assess temperature:

  • In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
  • Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, cardiac shunting).

Capillary refill time (CRT)

Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral perfusion:

  • Apply five seconds of pressure to the distal phalanx of one of a child’s fingers and then release.
  • In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
  • A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Pulses

Radial pulse

Palpate the child’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm.

In babies, assess the femoral pulse instead.

Heart rate

Assessing heart rate:

  • You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
  • For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.

Radio-radial delay

Radio-radial delay describes a loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.

To assess for radio-radial delay:

  • Palpate both radial pulses simultaneously.
  • In healthy individuals, the pulses should occur at the same time.
  • If the radial pulses are out of sync, this would be described as radio-radial delay.

Causes of radio-radial delay include:

  • Subclavian artery stenosis (e.g. compression by a cervical rib)
  • Aortic dissection
  • Aortic coarctation
  • Palpate the radial pulse
    Palpate the radial pulse

Jugular venous pressure (JVP)

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV).

The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle).

Because of the inability to easily visualise the IJV, it’s tempting to use the external jugular vein (EJV) as a proxy for assessment of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous pressure.

See our guide to jugular venous pressure (JVP) for more details.

Measure the JVP

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

1. Position the child in a semi-recumbent position (at 45°).

2. Ask the child to turn their head slightly to the left.

3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.

4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves. The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle). Because of the inability to easily visualise the IJV, the external jugular vein (EJV) is used as a proxy for assessment of central venous pressure during clinical assessment. It should be noted that because the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous pressure. The instructions below are for measuring the level of the EJV.

  • Assess the JVP
    Assess the JVP
Causes of a raised JVP

A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised JVP include:

  • Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure.
  • Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
  • Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Face

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

General appearance

Inspect the general appearance of the child’s face for signs relevant to the cardiovascular system:

  • Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis.
  • Nasal flaring/grunting: may be associated with congenital cyanotic heart disease or heart failure.

Eyes

Inspect the eyes for signs relevant to the cardiovascular system:

  • Conjunctival pallor: suggestive of underlying anaemia. Gently pull down their lower eyelid to inspect the conjunctiva.
  • Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
  • Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).

Mouth

Inspect the mouth for signs relevant to the cardiovascular system (tip – ask the child to see how long their tongue is or how big their mouth is):

  • Central cyanosis: bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt).
  • Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
  • High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
  • Dental hygiene: poor dental hygiene is a risk factor for infective endocarditis.
  • Conjunctival pallor
    Conjunctival pallor

Close inspection of the chest

Ask the parent or child (if appropriate) to expose the child’s chest.

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.

Closely inspect the anterior chest

Look for clinical signs that may provide clues as to the child’s past medical/surgical history:

  • Scars suggestive of previous thoracic surgery: see the thoracic scars section below.
  • Pectus excavatum: a caved-in or sunken appearance of the chest (e.g. Marfan syndrome).
  • Pectus carniatum: protrusion of the sternum and ribs (e.g. Noonan syndrome).
  • Visible ventricular impulse: normal in thin children, can be associated with left ventricular hypertrophy.
  • Pectus carinatum
    Pectus carinatum 12
Thoracic scars
  • Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and pulmonary artery banding.
  • Right thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space on the right. This surgical approach is used to perform pulmonary artery banding and a Blalock–Taussig shunt.
  • Left thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space on the left. This surgical approach is used to perform pulmonary artery banding, patent ductus arteriosus ligation, a Blalock–Taussig shunt and coarctation of the aorta repair.
  • Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
  • Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
  • Subclavicular incision
    Subclavicular incision

 


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

Before beginning abdominal palpation:

  • The child should already be positioned lying flat on the bed if possible.
  • Kneel beside the child to carry out palpation and observe their face throughout the examination for signs of discomfort.

Liver palpation

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, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).

2. Ask the child to take a deep breath and as they begin to do this palpate the abdomen. Feel for a step as the liver edge passes below your hand during inspiration (a palpable liver edge this low in the abdomen suggests gross hepatomegaly).

3. Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the right costal margin.

4. As you get close to the costal margin (typically 1-2 cm below it) the liver edge may become palpable in healthy individuals.

If you are able to identify the liver edge, assess the following characteristics:

  • Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.
  • Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.
  • Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder).
  • Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.

Splenic palpation

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

  • Liver palpation (hepatomegaly)
    Palpate the liver

Chest

Palpate the apex beat

Palpate the apex beat with your fingers placed horizontally across the chest, noting its position.

Normal position:

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

Abnormal position:

  • Left displacement: causes include cardiomegaly, pectus excavatum and scoliosis.
  • Right displacement: causes include dextrocardia, left diaphragmatic hernia, collapsed right lung, left pleural effusion and left pneumothorax.

Assess for heaves and thrills

Heaves:

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

Thrills:

  • thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
  • You should assess for a thrill across each of the heart valves in turn (see valve locations below).
  • 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.
Valve locations
  • Mitral valve: 5th intercostal space in the midclavicular line.
  • Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
  • Pulmonary valve: 2nd intercostal space at the left sternal edge.
  • Aortic valve: 2nd intercostal space at the right sternal edge.
  • Palpate the apex beat
    Palpate the apex beat

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 in the midclavicular line.
  • Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
  • Pulmonary valve: 2nd intercostal space at the left sternal edge.
  • Aortic valve: 2nd intercostal space at the right sternal edge.

Repeat auscultation across the four valves with the bell of the stethoscope.

Bell vs diaphragm
The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis. The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.

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

Auscultate the lungs

Auscultate the lung fields on the anterior and posterior aspect of the chest:

  • Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if the child is 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 and note any additional sounds.
  • Coarse bibasal crackles may be a late sign of pulmonary congestion secondary to congestive heart failure.
  • Areas to auscultate the lungs on the anterior chest wall
    Areas to auscultate the lungs on the anterior chest wall

Final steps

Assess for evidence of 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.
  • Periorbital oedema in nephrotic syndrome
    Periorbital oedema in nephrotic syndrome 2

To complete the examination…

Explain to the child and parents that the examination is now finished.

Ensure the child is re-dressed after the examination.

Thank the child and parents for their time.

Explain your findings to the parents.

Ask if the parents and child (if appropriate) have any questions.

Wash your hands.

Summarise your findings to the examiner.

Further assessments and investigations

Suggest further assessments and investigations to the examiner:


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. 

Syndrome Clinical features
LOCATION Aortic 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.

Syndrome Clinical features
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’s 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.

Microcephaly

Intrauterine growth restriction

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

William’s 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

Text references

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

Image references

    1. Cornelia Csuk. Adapted by Geeky Medics. Cyanosis. Licence: CC BY-SA. Available from: [LINK].
    2. Nephrotic syndrome. Adapted by Geeky Medics. Licence: CC BY-SAAvailable from: [LINK].
    3. Hektor. Adapted by Geeky Medics. Purpura. Licence: CC BY-SA. Available from: [LINK].
    4. Adapted by Geeky Medics. Min.neel. Xanthoma in a child. Licence: CC BY-SA. Available from [LINK].
    5. Adapted by Geeky Medics. Desherinka. Finger clubbing. Licence: CC BY-SA. Available from [LINK].
    6. Adapted by Geeky Medics. Warfieldian. Janeway lesions. Licence: CC BY-SA. Available from [LINK].
    7. Adapted by Geeky Medics. Roberto J. Galindo. Osler’s nodes. Licence CC BY-SA. Available from [LINK].
    8. Adapted by Geeky Medics. Klaus D. Peter, Gummersbach, Germany. Xanthelasma. Licence: CC BY 3.0 DE. Available from [LINK].
    9. Adapted by Geeky Medics. Herbert L. Fred, MD, Hendrik A. van Dijk. Kayser-Fleischer ring. Licence: CC BY 3.0 Available from [LINK].
    10. Adapted by Geeky Medics. Ankit Jain, MBBS, corresponding author Anuradha Patel, MD, FRCA and Ian C. Hoppe, MD. Central cyanosis. Licence: CC BY-SA. Available from [LINK].
    11. Adapted by Geeky Medics. Matthew Ferguson. Angular stomatitis. Licence: CC BY-SA. Available from [LINK].
    12. Adapted by Geeky Medics. Jprealini. Pectus carinatum. Licence: CC BY-SA. Available from: [LINK].
    13. Adapted by Geeky Medics. Aurora Bakalli, Tefik Bekteshi, Merita Basha, Afrim Gashi, Afërdita Bakalli and Petrit Ademaj. Pectus excavatum. Licence: CC BY-SA. Available from: [LINK].
    14. Ragesoss, Physical exam of a child with stethoscope on the chest, Colour, CC BY-SA 3.0. Available at: [LINK]
    15. Adapted by Geeky Medics. James Heilman, MD. Pedal oedema. Licence: CC BY-SA. Available from [LINK].

 

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