1. Cardiac Physical Exam—It’s more than the Heart!
Philip Thrush, MD
Assistant Professor – Clinical

2. Objectives
Identify the age appropriate differential diagnosis for heart murmur.
Identify and demonstrate elements of the physical exam that are particularly important for detection of asymptomatic illness.
Describe interventions or workup needed for abnormal results when obtained during well exams.

3. The Cardiac Exam
The cardiac exam encompasses so much more than auscultation of the heart.
This presentation is designed to supplement the murmur lecture designed by Dr. Jessica Bowman.

4. Components Vital signs General HEENT Neck Chest wall Pulmonary/Lungs
Cardiovascular
Abdomen
Extremities
Skin
Neuro
There are multiple components to the cardiac physical exam, and it encompasses almost every other organ system, including the general, HEENT, neck, pulmonary, abdominal, musculoskeletal, integumentary, and neurologic systems. It also requires careful review of the vital signs.

5. Helpful Tips Be systematic regarding your exam
Every time, all the time
There are clues to cardiac problems with every other system in addition to the cardiac exam itself
Environment should be quiet
Children should either be in a gown or have their shirt off
It’s important to be systematic in your exam every time. If you do it the same way every time, you’re less likely to forget or miss a system or important finding. It is important to ensure a quiet environment in order to appreciate soft heart murmurs, and children should be examined either without a shirt or utilizing a gown to keep them appropriately covered while still allowing access to the chest and other parts of the body for an unobstructed exam.

6. Do the cardiac exam first!
Most importantly…
Do the cardiac exam first!

7. Because this…

8. When you do things like…
Becomes this…
When you do things like…
Put a cold stethoscope on them
Try to look in their mouth
Palpate their abdomen
Percuss a liver edge
Attempt to feel femoral pulses
While these exam techniques, may not seem invasive or scary to us, to a toddler or child they can be incredibly invasive. In addition, stranger anxiety can play a significant role in what a child will or will not let you do.
Examine fingers/toes for clubbing
Lay them down
Look at them funny
No good reason at all

9. Things to do 1st
Any component that requires a cooperative child or auscultation
Cardiac
Lungs
Abodmen
Save “scary” or invasive exams until the end
Pupils, ears, oropharynx, organomegaly
It is important to try to do any part of the physical exam that requires auscultation before the child becomes distressed. This may mean that you won’t complete an entire organ system exam prior to moving to the next, but you may need to listen to the heart, lungs, and abdomen before you attempt to palpate the chest or percuss a lung field. When possible, you should try to save the most invasive or scary portions of the exam, such as examining ears or oropharynx, for the end.

10. Vital Signs Temperature Heart rate—AGE DEPENDENT
Fever leads to increased cardiac output results in increased intensity of innocent murmurs
Heart rate—AGE DEPENDENT
Tachycardic: arrhythmia, impaired CO
Regular rate
Bradycardic: arrhythmia, conditioning
Respiratory rate—AGE DEPENDENT
Tachypnea: Pulmonary congestion
Bradypnea: sedation
Vital signs can provide important clues regarding the diagnosis.
Fever can either be a sign of underlying disease, such as Kawasaki disease or heart failure, or it can result in increased cardiac output which leads to increased intensity of innocent heart murmurs such as Still’s murmurs.
All other vital signs normal values are age dependent.
Increased heart rates can be due to tachyarrhythmias, but they can also be normal responses to pain. In the patient with heart failure and depressed cardiac function, tachycardia may be a manifestation to increase cardiac output. Remember, Cardiac Output = Stroke Volume x Heart Rate, and if your stroke volume is fixed due to poor function, then heart rate augmentation is your only ability to increased cardiac output for increased demands. Bradycardia may be a normal finding in conditioned individuals, but it may also be due to arrhythmias such as 2nd or 3rd degree heart block, sick sinus syndrome, or blocked premature atrial contractions.
Tachypnea may be a manifestation of lung disease, pulmonary edema, or pulmonary overcirculation from left-to-right shunts (VSD or ASD). Bradypnea may be a manifestation of sedation.

11. Vitals—are these normal?
It depends!!!
Temp: F
HR: 160 bpm
RR: 40
BP: 72/40
O2 sat: 96%
Are these vitals normal? It depends! As previously mentioned, all vital signs are age dependent with the exception of temperature.

12. Vitals—are these normal?
If the patient is an 18 year old then NO! You should be treating them for SHOCK!
Temp: F
HR: 160 bpm
RR: 40
BP: 72/40
O2 sat: 96%
If the patient is a 1 day old in the well-baby nursery, then you have a perfectly healthy baby!
If these vital signs were for an 18 year old in the ER, then absolutely not. He is tachycardic, tachypneic, and hypotensive. This patient is in shock and you should be pushing fluids and determining why he is in shock.
However, if this is a neonate in the well-baby nursery, then these are all completely normal vital signs.
It is not important at this stage to memorize all of the normal age-dependent values, but have a resource that you can easily access to determine if the vitals are normal or not. You should, however, have a vague idea of what is normal in a baby, toddler, adolescent and adult.
It’s not as important to memorize all of the normal age-dependent values,
but rather have a resource where you can access the normal values

13. Vital Signs Blood pressure—AGE DEPENDENT Manual vs. Dynamap
Appropriate cuff size
Children able to compensate for inadequate cardiac output (hypotension is the last finding)
4 extremity blood pressures
Coarctation, arch augmentations
Hypertension
Blood pressure is also age-dependent. This can be obtained manually, but is increasingly obtained utilizing automated devices, such as a Dynamap. It’s important to realize that these automated machines are less accurate with lower diastolic blood pressures. If there is ever a question, the BP should be repeated manually.
It is important to utilize the appropriate cuff size. If there is concern about the size, it is better err on the side of a bigger cuff as a cuff that is too small will result in inaccurately high readings.
It is also important to remember that children are able to compensate for inadequate cardiac output remarkably well and hypotension is often the last sign of shock.
Blood pressures should be obtained in all 4 extremities at least once in childhood and for anybody who has undergone augmentations or enlargement of their aortic arch or if there is suspicion for coarctation. This is particularly important when a hypertensive BP is obtained in an upper extremity as we will see in the following example.

14. Coarctation Obstruction of blood flow Upstream pressure increases
145/90
Obstruction of blood flow
Upstream pressure increases
Coarctation results from obstruction of the aortic arch usually just after the takeoff of the left subclavian artery due to constriction of ductal tissue in the descending aorta. This is similar to kinking a garden hose. Upstream from the obstruction, the pressure increases, and the pressure distal to the obstruction decreases. This demonstrates the importance of the 4 extremity blood pressures. In this example, the obstruction has produced a 60 mmHg gradient which is a severe obstruction.
85/60

15. Vital Signs Oxygen saturation
Need to know what is normal for patient’s physiology
Normal >95%
Desaturation related to impaired oxygenation or RL shunting (LR shunt increased pulmonary blood flow)
Palliated single ventricle physiology >70-75%
Normal oxygen saturations are > 95%. However, the “normal” oxygen saturation level can vary depending on the congenital heart disease and the state of repair or palliation. Assuming a defect is completely repair with no residual shunts, the saturation should be >95%.
In the setting of a VSD (and normal pulmonary pressures), there will be extra blood shunting from the left ventricle to the right ventricle resulting in a higher ratio of pulmonary to systemic blood flow. In this setting, a patient can have saturations > 95% due to the “extra” blood flow to the lungs, even if there is some degree of pulmonary edema.
Decreased saturation may be related to right-to-left shunting, such as tricuspid atresia, or due to impaired
Patients with single ventricle physiology (in which we are dependent upon complete mixing of the venous and arterial blood) typically have oxygen saturations > 70-75% but is dependent upon the stage of palliation.

16. Vital Signs Height and weight BSA BMI—obesity epidemic
Change in weight helps assess fluid status, especially compared to pre-op weight
Weight gain important sign of optimized cardiac work
Height and weight are important aspects of the vital signs. They help to determine if a child is growing appropriately as poor growth can be a sign of heart failure.
BMI is important to review as obesity has become an epidemic and affects children in all subspecialties.
Weight is important to monitor in patients with heart failure to due to monitor fluid status.

17. General Examination Observation!!!
Playing in the room vs. lethargic/distress
Well-nourished vs. failure to thrive
Patient position
Leaning forward (pericarditis)
Unable to lie flat (severe CHF, tamponade)
Color
The general exam starts as soon as you walk into the room. You should be able to assess their activity level, their nutrition status, and color.
Some patients may also be maintaining positions that are clues towards the diagnosis such as the patient with pericarditis who leans forward to relieve chest pain or the patient with heart failure or tamponade physiology who is unable to lie flat.

18. Color Pink, pale, cyanotic
True cyanosis requires desaturation of 5g% of hemoglobin
Difficult to detect above 85% saturation
Acrocyanosis is common in young infants and after bathing
Assess the oral mucosa/tongue
Nail beds also good
When assessing color, it important to assess the skin AND oral mucosa (not the lips or perioral area). Mucous membranes can be pink, pale, or cyanotic, but true cyanosis requires at least 5gm% desaturation to be visible. It is very difficult to detect cyanosis when oxygen saturations are >85%.
Acrocyanosis, or cyanotic appearance of the distal extremities, is common in young infants and can be seen after swimming or bathing. This usually does not require further evaluation and is related to venous dilation.
Nail beds are also a good location to evaluate for cyanosis.

19. Cyanosis Cyanosis Normal
Note the purple appearance of the tongue on the left compared to pink mucosa/tongue on the right.
Cyanosis
Normal

20. HEENT Dysmorphic features Frontal bossing Mucous membranes
22q11 deletion
Down syndrome
Dysmorphic features
Down syndrome
Noonan syndrome
Alagille syndrome
Williams syndrome
22q11 deletion
Frontal bossing
Mucous membranes
Noonan syndrome
Williams syndrome
The HEENT exam, in addition to evaluating for cyanosis, can provide clues towards an underlying diagnosis or syndrome, many of which have characteristic cardiac lesions.
Patients with Down syndrome or trisomy 21, have a flat facial profile, small ears, upslanting palpebral fissures, epicanthal folds, and often have protruding tongues as infants.
Patients with Noonan syndrome have triangular facies, micrognathia, low-set posteriorly rotated ears, ptosis, downslanting palpebral fissures, hypertelorism, and webbed necks.
Patients Alagille syndrome have triangular facies, broad forehead, hypertelorism, a multitude of eye anomalies, and long nose with bulbous tip.
Patients with Williams syndrome have flat facies, puffy eyes, stellate pattern of the iris, long filtrums, depressed nasal bridges, and thick lips. These children are often described as having a cocktail personality.
Patients with 22q11 or DiGeorge syndrome have low-set abnormally folded ears, micrognathia, hypertelorism, short palpebral fissures, blunted nose, and can have cleft palates.
Frontal bossing can be seen in children who are polycythemic due to cyanotic heart disease.

21. HEENT Auscultation (Yes…auscultate the head!) Temples, fontanelle
Bruits associated with arterio-venous malformations
While this is not often done, auscultation of a cranial bruit is associated with a cerebral AVM. The fontanelle is the best place to auscultate in infants.

22. Neck Jugular pulsation is biphasic (a and v wave)
a wave is atrial contraction
v wave is venous filling (coincides with ventricular contraction)
Venous distentionimpaired RV filling
30-45 degrees upright
Jugular venous pressure
Estimate of RA pressure
Height above manubrium + 5cm (adults)
Paradoxical jugular venous pressure
JVP rises with inspiration/falls with expiration
Tamponade, constrictive pericarditis
Inspection of the jugular wave forms takes practice. Also, it is important to realize that infants and young children often have very short necks which makes this nearly impossible. This is best utilized in teenagers and adults and can provide valuable information. On the graph above, the a wave is due to atrial contraction and reflux of some blood back into the SVC. The c wave (usually not visible) is due to closure of the tricuspid valve, and the v wave is due to venous filling of the atria which occurs in systole.
To evaluate for jugular venous distention (JVD), which is found when there is impaired right ventricular filling or increased right atrial pressure, the patient must be placed in a position that is degrees upright. The height of the jugular pulsation above the manubrium + 5 cm (in adults) estimates the RA pressure in mmHg.
In tamponade or constrictive pericarditis, paradoxical jugular venous pressure may be seen where the venous pulsation rises with inspiration and falls with expiration due to impaired filling of the atria in these conditions. Normally inspiration results in a negative intrathoracic pressure and thus decreases the RA pressure.

23. CVP
This link demonstrates an excellent video example of how to evaluate for JVD.
Video tutorial

24. Neck
Cannon a waves (atrial contraction against closed tricuspid valve)
Flutter, 3rd degree heart block, VT
Loss of a wave common in atrial fibrillation
Head bobbing
Significant aortic regurgitation
Carotid pulsations striking mandibular angles
Lateral head movement
Significant TR due to regurgitant blood in SVC strikes right mandibular angle
Cannon a waves appear as periodically elevated a waves when evaluating the jugular venous pulsations. These occur when the right atrium contracts against a closed tricuspid valve, as in the examples listed.
In the setting of atrial fibrillation, the a wave is often lost as there is no organized atrial contraction.
Head bobbing (up and down) can be seen with significant aortic regurgitation due to Watson’s water hammer pulse – bounding, forceful carotid pulse due to rapidly increasing pulse (due to increased ejection volume) with sudden decrease (due to aortic regurgitation). This pulse strikes the mandibular angle causing a head bob.
Lateral head movement can be seen with significant TR due to regurgitant blood in the SVC striking the right mandibular angle, but this is rare in children.

25. Chest Wall Barrell-chested with hyperinflation
Pectus deformities (excavatum/carinatum)
Connective tissue disorder
Normal variants
Prior surgical scars can be clues to what has been done previously based on location
Barrell-chest deformities can be seen in asthma due to hyperinflation.
Pectus excavatum is when the sternum appears sunken or depressed and pectus carinatum is when the sternum protrudes from the chest. These can be seen in connective tissue disorders but are usually normal variants. Pectus carinatum can also be seen following a median sternotomy as it heals.
The location of surgical scars can be clues to a patient’s prior surgical interventions and potential congenital heart disease.

26. Chest Wall Scar Locations
Left thoracotomy
L Blalock-Thomas-Taussig shunt
PDA ligation
Coarctation repair
Right thoracotomy
R Blalock-Thomas-Taussig shunt
Mitral valve repair
Some ASD repairs
Left upper chest
Pacemaker/ICD
Median sternotomy
Most other cardiac surgeries or require bypass 4 3 2 1
A left thoracotomy is usually utilized for surgical PDA ligation (although this is often now done in the cath lab with occlusion devices) and isolated coarctation repair. It can also be utilized for a left-sided Blalock-Thomas-Taussig (BTT) shunt.
A right thoractomy is used for right-sided BTT shunt placement but can also be utilized for minimally invasive mitral valve repair and some ASD repairs.
Pacemakers and ICDs are usually placed in the left upper chest. However, in babies and small children, these devices are usually placed in the abdomen because the veins are insufficient size for a transvenous system, and thus epicardial leads are used.
A median sternotomy is utilized for most other cardiac surgeries and when cardiopulmonary bypass is required.

27. Cardiac—Inspection Needs to be well lit room
Poland’s anomaly—unilateral absence of pectoralis muscles
Left parasternal precordial bulge
Seen in RV volume overload conditions
Need to get down to chest level
Pulsations
Suprasternal notch in AI
Inspection of the chest should also be performed routinely, but requires a well-lit room.
Poland’s anomaly is the unilateral absence of pectoralis muscles and can be associated with congenital heart disease.
More importantly, it is necessary to evaluate for precordial bulges which can be seen in the left parasternal area in the setting of right ventricular volume load. These are hard to notice when looking down on the chest so it is best to view at chest level.
Occasionally pulsations can be noted in the suprasternal notch with aortic insufficiency.

28. Pulses
Pulses
Multiple locations: brachial, radial, carotid, femoral, dorsalis pedis (10% absent), posterior tibial
Right upper/lower extremity pulses simultaneous
Assess for rate and regularity
Normal variation with respiration (sinus arrhythmia)
Quality
Absent: obviously bad…maybe!
Weak: possible coarctation, shock, poor CO
Bounding: aortic runoff (AI, PDA, AVM)
Pulses should be examined in all four extremities and in multiple locations. At the minimum, the radial, femoral, and distal lower extremity pulse, such as the posterior tibial pulse, should be examined. However, the carotid, brachial, popliteal, etc may also need to be examined.
When evaluating for coarctation, it is necessary to examine an upper and lower pulse simultaneously. Usually the radial and femoral pulses are used because they can both be assess easily at the same time in the supine position, and more importantly, they are approximately equal distances from the heart so they pulses should arrive simultaneously. In the setting of a coarctation, the femoral pulse will be delayed. It is a good idea to examine both upper extremities as anomalous subclavian arteries can arise distally to the coarctation in a very small percent of patients.
Pulses should be assessed for both rate and regularity and may very with respirations (increased HR with inspiration and decreased HR with expiration, also known as sinus arrhythmia).
Pulses may be absent, which can be normal in the setting of a ventricular assist device or ECMO, weak, or bounding as previously discussed with aortic insufficiency. Bounding pulses are seen in all situations where the aortic pulse pressure is widened such as a PDA or AVM. Weak pulses may be secondary to shock but can also be seen in coarctation in addition to being delayed.

29. Perfusion Capillary refill
Time required for blanching to disappear after manual pressure applied
Normal is less than 3 sec
Prolonged in shock/poor cardiac output
Instantaneous in warm shock
Capillary refill is assessed by applying pressure over a capillary bed (such as the nail bed or the heal of a neonate) and assessing how long the color takes to return when the pressure is removed. Normal is less than 3 seconds and is prolonged in the setting of poor cardiac output or shock. In the setting of septic (warm) shock, the capillary refill can be instanteous.

30. Cardiac—Chest Wall Palpation
Use the most sensitive part of the hand
Point of maximal impulse (PMI)
Normal is 4th-5th intercostal space in the left midclavicular line
Often helpful to place in left lateral decubitus
Displaced inferiorly and laterally with LV enlargement
Should be soft, brief tap
Hyperdynamic/increased with increased CO or LVH
Chest wall palpation should be performed with the palmar aspect of the distal metacarpals which is the most sensitive part of the hand.
The PMI should normally be felt in the 4th or 5th intercostal space in the left midclavicular line, and positioning a patient (especially teenager or patient with muscular chest) in the left lateral decubitus position will bring the heart closer to the anterior chest wall for easier assessment. It should feel like a soft, brief tap. It is displaced inferolaterally with LV enlargement as in dilated cardiomyopathy. The PMI can be hyperdynamic or increased in intensity/duration with left ventricular hypertrophy as can be seen in hypertrophic cardiomyopathy or aortic stenosis.

31. Cardiac—Chest Wall Palpation
RV impulse
Felt at the left lower sternal border
Quick, localized “tap” consistent with RVH
Gradual, diffuse parasternal lift associated with RV enlargement
Normal finding in newborn
Absence suggests hypoplastic RV
A right ventricular impulse or heave can sometimes be felt at the lower left sternal border. This is a normal finding in newborns. However, in older children, a quick, localized “tap” is consistent with right ventricular hypertrophy. A more gradual, diffuse parasternal heave tends to be associated with right ventricular enlargement.

32. Cardiac—Chest Wall Palpation
Thrills
Always associated with a loud murmur
Location helps identify etiology
RUSB: Aortic stenosis
Suprasternal notch: Aortic stenosis
LUSB: Pulmonary stenosis, rarely PDA
Left sternal border: stenotic RV-PA conduit
LLSB: restrictive VSD
Cardiac thrills are always pathologic and associated with a loud murmur and significant pressure gradient. By definition, a thrill (with the exception of one palpated in the suprasternal notch) defines a grade IV/VI systolic murmur.
The location can help identify the etiology of the murmur as outlined on the slide.

33. Pulmonary Inspection Percussion Rate Symmetric chest rise
Tachypnea with increased pulm blood flow
Tachypnea with pulmonary edema
Symmetric chest rise
Work of breathing/retractions
Percussion
Sitting up
Helpful for pleural effusions
During the pulmonary exam, inspection includes assessment of the rate (although this can also be done via auscultation) and signs of increased work of breathing or respiratory distress. This can include accessory neck muscle use, suprasternal/supraclavicular retractions, or intercostal retractions. Nasal flaring can also be a sign of respiratory distress. Symmetry can be assessed visually or by placing both hands on the chest and the back and looking for symmetrical excursion.
If there is concern for pleural effusions, posterior lung fields should be percussed with the patient sitting upright. The demarcation between dullness and normal percussion is indicative of the height of pleural effusion.

34. Pulmonary Auscultation Wheezing is a common finding in heart failure
(Not all that wheezes is asthma)
Fine crackles may be noted with interstitial edema secondary to overcirculation
It is important to note whether a patient has wheezing or rales (crackles). Not all that wheezes is asthma, and it can be a common finding of congestive heart failure in children. This is usually due to pulmonary edema resulting in narrowing of airways. In the setting of left heart failure and congestion or excessive left-to-right shunting and pulmonary overcirculation, interstitial edema may develop resulting in fine rales.
A chest x-ray can be helpful in delineating the causes of wheezing and crackles.

35. Abdomen Save palpation for last
Often helpful to bend knees to loosen abdominal muscles
Start low (pelvic rim and work superiorly)
Organomegaly is secondary to increased systemic venous pressure
Palpation of the abdomen can be difficult, especially in ticklish children. Having them bend their knees and placing their feet on the table will help loosen the abdominal muscles. It can be helpful to palpate over top of a shirt in particularly ticklish children.
When palpating for hepatomegaly, one should start as low as possible at the pelvic rim and work superiorly. This helps ensure that a liver edge is not missed.
Hepatomegaly (or splenomegaly) due to heart failure is due to increased systemic venous pressure and usually results in a smooth, firm discrete liver edge.

36. Abdomen Assess for organomegaly
Hepatomegaly from congestive heart failure tends to have a more smooth palpable edge
Measured in midclavicular line (side dependent upon visceral situs)
Can palpate or percuss
Splenomegaly due to failure is less common
Can see in infective endocarditis or TORCH infections
Hepatomegaly should always be assessed in the midclavicular line, and can be assessed via palpation or by percussion.
Splenomegaly is less common, but when present should raise suspicion for infective endocarditis or TORCH infections in neonates.

37. Lymphedema in Turner syndrome
Extremities
Lymphedema in Turner syndrome
Edema
Due to systemic venous congestion
Rare in infants
? Lymphedema in newborn  Turner’s/Noonan
May be secondary to hypoproteinemia
Liver disease, renal disease, PLE
Clubbing
Thickening of tissues at the base of the nails
Capillary engorgement associated with chronic hypoxemia/polycythemia
Clubbing
Extremities are examined for edema and for signs of clubbing which can be seen when capillaries become engorged secondary to chronic hypoxemia and polycythemia.
Edema is typically due to venous congestion related to heart failure and fluid retention due to the counterproductive changes in the renin-angiotensin-aldosterone related to poor cardiac output. It can also be secondary to hypoproteinemia (and subsequent decreased oncotic pressure) associated with liver disease, renal disease, or protein-losing enteropathy (PLE) which can manifest in patients with chronic palliated single-ventricle physiology or chronic heart failure. Edema is rare in infants, but lymphedema can be seen in newborns with Turner syndrome or Noonan syndrome
Clubbing is due to the thickening of tissues at the base of the nails. The example provided is clearly obvious, but subtle cases are more difficult. The best way to assess for clubbing is to view the digits from the side and look for convexity or loss of the normal angle between the nailbed and the nail.

38. Extremities Finding associated with various syndromes
Polydactyly – extra digits
Arachnodactyly – long, slender digits
Calf pseudohypertrophy – Duchenne muscular dystrophy
Phocomelia – underdevelopment of limbs
Limb anomalies can also provide clues towards an underlying syndrome, again many of which have associated heart disease.
Polydactyly, or extra digits, can be associated with numerous syndromes, but can also be an isolated finding.
Arachnodactyly, or long, slender digits, is often seen in patients with Marfan syndrome. These patients can have mitral valve prolapse, aortic and mitral regurgitations, and aortic dilation or aneurysms.
Calf pseudohypertrophy, due to fibro-fatty replacement of muscle tissue, is a manifestation of Duchenne muscular dystrophy. These patients can manifest cardiomyopathy (often dilated), and arrhythmias.
Phocomelia, or underdevelopment of limbs, can be associated with numerous syndromes as well as thalidomide exposure (historically).

39. Musculoskeletal/Skin
Scoliosis evaluation
Evidence of connective tissue disorders
Joint laxity
Pectus deformities
Neurofibromas
Café-au-lait spots
The musculoskeletal system can also give clues regarding underlying diagnoses. Scoliosis can manifest in patients with neuromuscular disorders, who are also at risk for developing cardiomyopathy, or patients with connective tissue disorders, who are at risk for valve disease and aortopathy.
Joint laxity, body habitus, and pectus deformities can also be signs of a possible connective tissue disorder.
Neurofibromas should raise suspicion of neurofibromatosis and increased risk of hypertension.
Café-au-lait spots (as well as Shagreen patch, subungal fibromata, white ash leaf spots, and adenoma sebaceum) should raise concerns for tuberous sclerosis. These patients can have Wolf-Parkinson-White syndrome as well as cardiac rhabdomyomas.

40. Summary
Cardiac Exam
Vital Signs
Color and Perfusion
HEENT
Chest Inspection and Palpation
Pulmonary
Abdomen
Extremities
Musculoskeletal and Skin
Clearly, this module cannot include all possible extracardiac manifestations of heart disease.
It is important to realize the cardiac exam encompasses so much more than just auscultation of the heart. It includes nearly all other organ systems if you take the time and look closely.

41. Thank you for completing this module?
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