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Examination: cardiovascular


Jake is a 3 year old boy sent to your clinic after his GP heard a murmur. How do you approach the examination?

Firstly, as with all clinical examination (and even moreso with children!) start with an end of bed assessment of the ABCs.

Look - end of bed inspection

  • Are they comfortable or distressed?
  • Is their behaviour appropriate?
  • Observations if available (HR, RR, BP) – otherwise do them yourself throughout your examination
  • Growth; weight and height ideally to be measured and plotted
  • Colour; pale, cyanosed, pink, plethoric
  • Dysmorphic features
    • Trisomy 21
    • Williams
    • Di George
    • Turners
    • Noonans

Secondly, keep an open mind. There tends to be a presumption that if you’ve got to preschool years without any major health concerns then you can’t have a significant cardiac anomaly. Not true!

Once you’ve established the patient is stable and you’ve got the mindset that the murmur could well be significant, then continue with the rest of the cardiac examination.

Although it’s easy to remember a set order of things to examine, you are unlikely to succeed in doing things “your way” with the average toddler. A much more realistic option is to be opportunistic and creative in your examination; you will probably end up doing little bits of inspection, palpation and auscultation in a fairly haphazard way, but whatever order the child lets you do it in is the best way to get the job done.

It’s best to spend some time gaining the child’s trust before thrusting your stethoscope onto their chest and squashing their belly with your cold hands. It’s amazing how much information you can glean from inspection whilst ensuring that a child is comfortable and ready to proceed.

Most aspects of examination can be made into a game. I’ve put some top tips that I use commonly in the following descriptions. Use parents and toys as much as possible. I’ve probably auscultated hundreds of mummies/daddies/teddy bear chests during my career but that’s allowed me to successfully auscultated hundreds of children’s chests too.

With babies, I generally go straight in for the three essential ‘quiet’ things before fully undressing them:

  1. Auscultation of heart sounds
  2. Auscultation of the lungs
  3. Femoral pulses

Virtually all the rest can be done once they’ve started crying (which will inevitably happen). If you miss the window of quietness at the start, don’t worry, the baby will go quiet again at some point – leaving the room for a few minutes to allow a child to calm down is sometimes the best option.

Look - inspection

  • Hands
    • Clubbing
    • Splinter haemorrhages
    • Peripheral cyanosis
    • Bony abnormalities (absent radii, VACTERL, absent thumbs, Holt-Oram syndrome)
  • Face and neck
    • Respiratory distress – nasal flare, grunt
    • Central cyanosis *top tip* ask to see how long their tongue is or how big their mouth is
    • Scleral icterus (hepatic congestion due to heart failure)
    • Conjunctival pallor
    • High arch palate (Marfan)
    • JVP (older child)
  • Chest
    • *Top 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
    • Visible apex beat
    • Shape
    • Scars
      • Sternotomy
        • All complex cardiac surgeries
        • If multiple scars, may be a staged surgical repair
        • PA banding
      • Thoracotomy
        • Left
          • PDA ligation
          • BT Shunt
          • PA banding
          • Coarctation of aorta repair
          • Non cardiac – lobectomy
        • Right
          • BT shunt
          • PA banding
          • Non cardiac – lobectomy, oesophageal surgeries
        • Chest drain scars
        • Pacemaker/ICD scars

Feel – peripheral palpation

  • Pulses
    • Femoral, brachial, radial
    • Rate, rhythm, volume
    • Brachio/radio- and femoro-femoral delay
    • (Femorals – look for inguinal scars – cardiac catheterisation)
  • Perfusion

Feel – precordium

  • *Top tip* – I usually feel the abdomen first and then work up to the chest afterwards
  • Apex beat
    • Baby or toddler – 4th intercostal space mid clavicular line
    • Child – 5th intercostal space mid clavicular
    • Displaced – scoliosis, pleural effusion, pneumothorax, collapsed lung, diaphragmatic hernia, dextrocardia
  • Heaves = palpable forceful contraction
  • Thrills = palpable murmur
    • Four auscultatory areas + suprasternal notch (aortic flow)
    • Side of hand with older children
    • Finger tips with babies and younger children

Feel – abdomen

  • *Top tip* – ask what they ate for breakfast/lunch/dinner and try to ‘find it’. Then say that you can’t find it and you have to listen to see if you can hear it…leads you nicely into auscultation.
  • Situs solitus
  • Liver
    • Up to 2cm in babies and younger children is normal
    • If enlarged, think right heart failure
  • Dependent oedema
    • Depends on age of child where this will be
    • Sacrum, genitalia, limbs of face
    • *Top tip* – ask parents if the child looks puffy, particularly their genitalia or face
  • Ascites
  • Abdominal pacemaker

Listen – auscultation

  • *Top tip* – ask mum/dad/siblings to play a game with the patient to see who can stay quiet for the longest
  • Heart sounds
    • Aortic
      • 2nd right intercostal space
    • Pulmonary
      • 2nd left intercostal space
      • Listen for split S2
        • If variable with breathing = normal
          • Inspiration causes increased venous return to the right heart therefore increased blood volume therefore widens the gap between the sounds of aortic closure and pulmonary closure
        • If wide and fixed = ASD (this is a subtle sign so don’t worry if you can’t hear it)
      • Tricuspid
        • Lower left sternal edge
      • Mitral
        • Apex
      • Extra heart sounds
        • S3 = often normal
        • S4 = just before the next S1, suggests reduced ventricular compliance
        • Gallop rhythm = S3 or S4 and tachycardia, heart failure
        • Ejection clicks
          • Aortic stenosis or bicuspid aortic valve
          • Pulmonary stenosis
        • Systolic click
          • Mid systole, mitral valve prolapse
        • Murmurs
          • Systolic vs diastolic
          • Intensity /6
            • 1 – Barely audible murmur
            • 2 – Faint but immediately audible with stethoscope on chest
            • 3 – Loud murmur easily audible
            • 4 – Loud murmur easily audible with thrill
            • 5 – Loud murmur with thrill that is audible with only the rim of the stethoscope touching the skin
            • 6 – Loud murmur with thrill that is audible with stethoscope not touching the skin
          • Radiation
            • Carotids
            • Suprasternal notch
            • Axilla
            • Back
          • Pitch
            • Low pitch best heard with bell (typically diastolic)
          • Lungs
            • Basal crepitations if heart failure

Identifying the type of murmur


Area where murmur is heard Cause of murmur
Aortic Ejection systolic

  • Aortic stenosis (loudest in expiration)
  • Bicuspid aortic valve
  • Sub/supra valvular aortic stenosis


  • Right BT shunt
  • Venous hum
Pulmonary Ejection systolic

  • Pulmonary stenosis (loudest in inspiration)
  • ASD
Mitral Pansystolic

  • VSD
  • Mitral regurgitation

Late systolic

  • Mitral valve prolapse (Marfan’s)

Ejection systolic

  • Aortic stenosis
  • Mid diastolic
  • Mitral stenosis
Back Systolic

  • Coarctation of aorta (between scapulae)
  • Peripheral pulmonary stenosis


  • PDA

** with complex cardiac anomalies you may hear multiple dynamic murmurs** e.g. Tetralogy of Fallot

Pulmonary stenosis – ejection systolic murmur in pulmonic area which reduces/disappears when in cyanotic spell

VSD – may have a pansystolic murmur, lower sternum (depends how big the defect is)

Innocent murmurs

  • heard in 25-50% of all children at some point
  • often worse if febrile/unwell
Still’s murmur

  • Lower left sternal
  • Systolic
  • Musical

Pulmonary flow murmur

  • Lower left sternal
  • Ejection

Venous hum

  • Infraclavicular
  • Continuous
  • Changes with turning neck

Supraclavicular/carotid bruit

  • Above clavicles
  • Systemic flow murmur




Bottom line

  • Don’t underestimate the value of careful end-of-bed inspection
  • Be opportunistic – don’t expect to follow a pre-defined order
  • Be creative and playful – make examination into a game involving parents/siblings/toys
  • Try to do the three ‘quiet things’ first with babies – heart sounds, breath sounds, femoral pulses






  • Ashley Towers is a paediatric trainee, usually based in Wessex in the UK but currently working in Melbourne, Australia. She has an interest in emergency medicine with a splash of cardiology and critical care for good measure.


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