1. CARDIOVASCULAR EXAMINATION
I.U. Cerrahpaşa Medical Faculty
Department of Pediatrics
Division of Pediatric Cardiology
Prof. Dr. Ayşe Güler EROĞLU

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

3. HISTORY Medical history Prenatal history Natal history Family 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

4. PHYSICAL EXAMINATION

5. INSPECTION General appearance
Chromosomal, hereditary, nonhereditary syndroms
Pallor
Cyanosis
Clubbing
Neck vein distension
Left precordial bulge

6. PALPATION Pulses Chest Volume Rate Rhythm Character Apical impulse
In newborn and infants 4. intercostal space/midclavicular line
In older children and adults 5. intercostal space/midclavicular line
Precordial activity
Thrills

7. VOLUME OF PULSES Increase in pulse volume Weak pulses Bounding pulses
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

8. OSCULTATION
Heart rate and rhythm
Heart sounds
Other sounds
Murmurs

9. 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).

10. HEART SOUNDS Paradoxically split S2 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

11. 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

12. 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.

13. 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

14. CHARACTERISTICS OF HEART MURMURS

15. TIMING OF HEART MURMURS

16. Sistolic ejektion murmurs (Diamond shaped, crescendo-decrescendo)
Aortic stenosis
Pulmonary stenosis
Increased flow in aorta
Increased flow in pulmonary artery 16

17. Sistolic regurgitant murmurs (Holosistolic, pansistolic)
Ventricular septal defect
Mitral regurgitation
Tricuspid regurgitation 17

18. Late sistolic murmurs Mitral valve prolapse Tricuspid valve prolapse18

19. Early diastolic murmurs (Decrescendo)
Aortic regurgitation
Pulmonary regurgitation 19

20. Middiastolic murmurs (Flow murmurs)
Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA 20

21. Late diastolic murmurs (Presistolik)
Mitral valve stenosis
Tricuspid valve stenosis 21

22. Continuous murmurs Arterial Venous PDA Coronary artery fistula
Pulmonary AV fistula
Sistemic AV fistula
Venous
Venous hum 22

23. LOCATION OF HEART MURMURS
Aortic area: right parasternal 2. intercostal space
Pulmonary area: left parasternal 2. intercostal space
Tricuspid area: left parasternal intercostal space
Mitral area (cardiac apex): 5.-6.intercostal space/ midclavicular line
Mezocardiyak area (second aortic area, Erb): left parasternal intercostal space
Aorta
Pulmonary
Mitral
Tricuspid

24. 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.