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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 lowfrequency 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
Timing
Radiation
Location
Murmur
Intensity
Quality
TIMING OF HEART MURMURS
Murmurs
Systolic
Ejection
(Diamond
Crescendodecrescendo)
Regurgitant
(Holosistolic
Pansistolic)
Continuous
Early
Late
Diastolic
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
Pulmonary
Aorta
Tricuspid
Mitral
 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
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.