Paediatric Cardiovascular Examination - OSCE Guide | Geeky Medics (2023)

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.

Download the paediatric cardiovascular examination PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our adult cardiovascular examination guide.


Wash your hands and don PPE if appropriate.

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?”

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

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.


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.


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 caused by hypoplastic left ventricle 1


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

Inspect the hands

General observations

Inspect the handsfor 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 theterminalphalanxof adigitwith subsequentloss of the normal anglebetween thenailand thenail 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 diseaseand infective endocarditis.

To assess for finger clubbing:

  • Ask the child to copy you in placing the nailsof their index fingers back to back.
  • In a healthy individual, you should be able to observe asmall diamond-shaped window(known asSchamroth’s window).
  • When finger clubbing develops, thiswindow 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 withendocarditisincluding:

  • 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’snodes: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 4

    (Video) Cardiovascular Examination - OSCE Guide



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

  • In healthy individuals, the hands should besymmetrically warm, suggesting adequate perfusion.
  • Cool handsmay suggestpoor peripheral perfusion (e.g. congestive cardiac failure, cardiac shunting).

Capillary refill time (CRT)

Measuringcapillary refill time(CRT) in the hands is a useful way of assessingperipheral perfusion:

  • Applyfive seconds of pressureto thedistal phalanx of one of a child’s fingers and then release.
  • In healthy individuals, the initial pallor of the area you compressed shouldreturn to its normal colourinless than two seconds.
  • A CRT that isgreater than two secondssuggestspoor peripheral perfusion(e.g. hypovolaemia, congestive heart failure) and the need to assesscentral capillary refill time.


Radial pulse

Palpate the child’s radial pulse, located at the radial side of the wrist, with thetipsof yourindexandmiddle fingersaligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess therateandrhythm.

In babies, assess the femoral pulse instead.

Heart rate

Assessingheart 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.
  • Forirregular rhythms, you should measure the pulse for afull 60 secondsto improve accuracy.

Radio-radial delay

Radio-radial delaydescribes aloss of synchronicitybetween 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

Causes of radio-radial delay include:

  • Subclavian artery stenosis (e.g. compression by a cervical rib)
  • Aortic dissection
  • Aortic coarctation
  • 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 JVPby 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

    (Video) Cardiovascular Examination - OSCE Guide (Old Version)
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.


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.


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).


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: afeature 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

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.
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 4thor 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 4thor 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 forpacemaker insertion.
  • Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
  • Subclavicular incision


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?)



  • 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).

(Video) Paediatric Cardiovascular Examination - OSCE Guide - MUMPS

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 theliver 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.

  • Palpate the liver


Palpate the apex beat

Palpatethe apex beat with yourfingersplacedhorizontally 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 tension pneumothorax.

Assess for heaves and thrills


  • Aparasternal heaveis a precordial impulse that can be palpated.
  • Place theheel of your handparallel to theleft 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 beingliftedwith each systole.
  • Parasternal heaves are typically associated withright ventricular hypertrophy.


  • Athrillis apalpable vibrationcaused byturbulent blood flowthrough a heart valve (a thrill is a palpable murmur).
  • You should assess for a thrill acrosseach of the heart valvesin turn (see valve locations below).
  • To do this place your handhorizontallyacross the chest wall, with theflats of your fingersandpalmover thevalveto 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


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

(Video) Cardiovascular Examination - OSCE Guide (Old Version)

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

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 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.

Dispose of PPE appropriately and wash your hands.

Summarise your findings to the examiner.

Further assessments and investigations

Suggest further assessments and investigations to the examiner:

  • Abdominal examination: if hepatomegaly was noted.
  • Respiratory examination: if abnormalities noted during inspection and auscultation of the chest.
  • Peripheral vascular examination: if poor peripheral perfusion or oedema were identified.
  • Vital signs
  • ECG: if concerned about cardiac pathology.
  • Measure and plot height and weight on a growth chart.
  • Urinalysis: if oedema present.


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.

SyndromeClinical features
LOCATIONAortic 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
  • Systolic
  • Diastolic
  • Continuous
  • 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
  • Mitral
  • Pulmonary
  • Aortic
  • Tricuspid area
  • 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.

SyndromeClinical 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


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.


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.


Prominent ears and jaw



Mitral valve

Marfan syndrome
An autosomal dominant connective tissue disorder.

Marfanoid habitus (tall, long limbs)



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


Dr SunilBhopal

Senior Paediatric Registrar


Text references

  1. Bishop (2011). Cardiac Examination. 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. MiinLee (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.
  2. Nephrotic syndrome. Adapted by Geeky Medics. Licence:CC BY-SA.
  3. Hektor. Adapted by Geeky Medics. Purpura. Licence:CC BY-SA.
  4. Adapted by Geeky Medics. Min.neel. Xanthoma in a child. Licence:CC BY-SA.
  5. Adapted by Geeky Medics. Desherinka. Finger clubbing. Licence:CC BY-SA.
  6. Adapted by Geeky Medics. Warfieldian. Janeway lesions. Licence:CC BY-SA.
  7. Adapted by Geeky Medics. Roberto J. Galindo. Osler’s nodes. LicenceCC BY-SA.
  8. Adapted by Geeky Medics. Klaus D. Peter, Gummersbach, Germany. Xanthelasma. Licence:CC BY 3.0 DE.
  9. Adapted by Geeky Medics. Herbert L. Fred, MD, Hendrik A. van Dijk. Kayser-Fleischer ring. Licence:CC BY 3.0.
  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.
  11. Adapted by Geeky Medics. Matthew Ferguson. Angular stomatitis. Licence:CC BY-SA.
  12. Adapted by Geeky Medics. Jprealini. Pectus carinatum. Licence:CC BY-SA.
  13. Adapted by Geeky Medics. Aurora Bakalli, Tefik Bekteshi, Merita Basha, Afrim Gashi, Afërdita Bakalli and Petrit Ademaj. Pectus excavatum. Licence:CC BY-SA.
  14. Ragesoss, Physical exam of a child with stethoscope on the chest, Colour, CC BY-SA 3.0.
  15. Adapted by Geeky Medics. James Heilman, MD. Pedal oedema. Licence:CC BY-SA.
(Video) Cardiovascular examination demonstration


What is the correct sequence of cardiovascular examination? ›

Pulse palpation and auscultation. Vein observation. Chest inspection, and palpation. Cardiac percussion, palpation, and auscultation.

How do you palpate apex beat for kids? ›

Identification. The normal apex beat can be palpated in the precordium left 5th intercostal space, half-inch medial to the left midclavicular line and 3–4 inches left of left border of sternum. In children the apex beat occurs in the fourth rib interspace medial to the nipple.

How do you palpate P2? ›

The heel of the hand is lifted off the chest wall with each systole. Palpation with the fingers over the pulmonary area may reveal the palpable tap of pulmonary valve closure (palpable P2) in cases of pulmonary hypertension.

What is the fastest way to assess a child's cardiovascular status? ›

The easiest way to measure the heart rate of a child in any age group is to place a finger on the child's wrist, applying slight pressure until their pulse can be felt. Count the number of pulses for a period of 15 seconds, and then multiply that number by four to obtain the overall heart rate.

What is Erb's point? ›

Erb's point is the auscultation location for heart sounds and heart murmurs located at the third intercostal space and the left lower sternal border.

Is pulse S1 or S2? ›

Heart Sounds

Clinically, S1 corresponds to the pulse. The second heart sound (S2) represents closure of the semilunar (aortic and pulmonary) valves (point d). S2 is normally split because the aortic valve (A2) closes before the pulmonary valve (P2).

Why do you perform cardio exams at a 45 degree angle? ›

The jugular veins. The patient is lying at a 45° angle, thus revealing the surface markings of the neck.

Is the radial pulse S1 or S2? ›

The sound that precedes the carotid pulse is S1, whereas the sound that follows it is S2. For this to work, only the carotid pulse should be used, not the radial, as there is a significant delay between the sound of S2 and the pulsation.

How do I find my childs apex beat? ›

From birth to age 3 years the apex beat is located in the 4th intercostal space and with increasing age gradually moves into the 5th space in most children.

What are heaves and thrills? ›

A thrill is a palpable murmur whereas a heave can be a sign of right ventricular hypertrophy. A thrill feels like a vibration and a heave feels like an abnormally large beating of the heart. Feel for these all over the precordium. Palpate for any heaves or thrill.

Is apex beat same as heart beat? ›

Your apical pulse is a pulse point on your chest that gives the most accurate reading of your heart rate. It's also called the point of maximal impulse (PMI) and the apex beat. Your other pulse points are located along your arteries. There are eight common arterial pulse points.

What is heard at Erb's point? ›

At Erb's Point, you can usually hear both the S1 and S2 sounds. The S1 sound comes from the closure of the mitral valve and tricuspid valves. The S2 sound comes from the closure of the aortic and pulmonic valves. When the heart sounds are referred to as Lub-Dub, S1 is the Lub and S2 is the Dub.

What is a loud P2 heart sound mean? ›

a loud P2 is heard in pulmonary hypertension. a loud P2 occurs in an atrial septal defect without pulmonary hypertension. This is caused by a sharp rise and fall of pulmonary arterial pressure. in thin-chested people with a forward projecting aorta.

Where is S1 best heard? ›

For example, the S1 heart sound — consisting of mitral and tricuspid valve closure — is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. Timing: The timing can be described as during early, mid or late systole or early, mid or late diastole.

When inserting an OPA in a child you should? ›

EMS Skills - Oropharyngeal Airway Insertion (Pediatric) - YouTube

How do you check perfusion in a child? ›

The child has to be supine. Raise the leg up slightly, blanch the bottom of the foot, and look for that capillary refill time. Again, it should be less than 2 seconds. If it's greater than that, we may have some perfusion issues.

What are pediatric vital signs? ›

Vital signs include heart rate, respiration (breathing rate), blood pressure, and temperature. Knowing the ranges for vital signs for your child can help you notice problems early or relieve concerns you may have about how your child is doing.

What are the 5 cardiac landmarks? ›

The Five Critical Auscultation Points or “Cardiac Landmarks”
  • Aortic. Typically, the heart creates a “lub-dub” sound, which occurs when blood is being pumped and flowed to and from the heart. ...
  • Pulmonic. ...
  • Erb's Point. ...
  • Tricuspid. ...
  • Mitral. ...
  • Stethoscope Differences.
26 May 2022

What are the 5 heart sounds? ›

The 5 points of auscultation of the heart include the aortic, pulmonic, tricuspid, and mitral valve as well as an area called Erb's point, where S2 is best heard. The five points of auscultation of the heart center around the heart valves and allow the listener to hear detailed mechanics of each heart valve.

What are S3 and S4 heart sounds? ›

The third and fourth heart sound (S3 and S4) are two abnormal heart sound components which are proved to be indicators of heart failure during diastolic period.

What are the 4 heart sounds? ›

Heart Sounds
Heart SoundOccurs during:
S1Isovolumetric contraction
S2Isovolumetric relaxation
S3Early ventricular filling
S4Atrial contraction

What are the two heart sounds? ›

Normally, two distinct sounds are heard through the stethoscope: a low, slightly prolonged “lub” (first sound) occurring at the beginning of ventricular contraction, or systole, and produced by closure of the mitral and tricuspid valves, and a sharper, higher-pitched “dup” (second sound), caused…

Is S1 a lub or dub? ›

Identify: S1 – The first heart sound (lub) can be heard the loudest at the mitral area. This sound represents the closure of the mitral and tricuspid valves and is a low pitched, dull sound at the beginning of ventricular systole. S2 – The second heart sound (dub).

Where do you palpate in a cardiac exam? ›

Palpation the Precordial Cardiac Exam

Along with palpating for near the apex, you should also palpate both lower parasternal, pulmonary, aortic, suprasternal and epigastric regions for a complete exam.

What is the appropriate angle to position the patient to begin the cardiovascular exam? ›

Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination. Always stand on the right side of the bed during the cardiovascular examination.

What is a2 and p2 heart sounds? ›

The second heart sound (S2) is a short burst of auditory vibrations of varying intensity, frequency, quality, and duration. It has two audible components, the aortic closure sound (A2) and the pulmonic closure sound (P2), which are normally split on inspiration and virtually single on expiration.

Why is S3 heard in heart failure? ›

The S3 heart sound occurs as the mitral valve — which sits between the left atrium and left ventricle — opens and allows blood to fill the left ventricle passively. The sound happens due to blood striking the left ventricle during early diastole.

Where are murmurs best heard? ›

The murmur is heard best between the apex and the left sternal border. It becomes louder with any maneuver that decreases preload or afterload, such as Valsalva or abrupt standing.

Where do you hear a murmur? ›

Mitral murmurs are best heard at the apex and radiate to the axilla. Mitral sounds can be accentuated with the patient in the left lateral position. Hence, to listen to a mitral murmur, first listen to the apex, then listen round to the mid-axillary line at the same level.

What is normal apex beat? ›

The apex beat is the lowest and outermost point at which the cardiac pulse may be felt; it may be visible in thin subjects. The normal apex is located in the fifth intercostal space, in the midclavicular line.

What is tapping apex beat? ›

When an impulse was palpable, the apex beat was categorized into three patterns: 'tapping', when it was palpable as a single, brief outward impulse; 'sustained', when it was associated with an outward impulse lasting up to or longer than the second heart sound; or 'double apical impulse', when one impulse was felt in ...

Why apex beat is palpable? ›

The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum and farthest down on the chest wall, usually caused by the LV and located near the midclavicular line (MCL) in the fifth intercostal space.

Where is s1 and S2 best heard? ›

Normally, S1 is louder than S2 at the apex, and softer than S2 at the base of the heart.

Is thrill a murmur? ›

A thrill is nothing more than a palpable, and therefore loud, murmur, and has the same diagnostic significance as the murmur itself. Most thrills are more easily palpable when the patient is sitting up and holding his breath in full expiration.

How do you palpate s1 and S2? ›

How to Hear S1 and S2 Heart Sounds - YouTube

What is the normal pulse rate? ›

A normal resting heart rate for adults ranges from 60 to 100 beats per minute. Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats per minute.

Which artery is used to measure pulse? ›

A pulse is the heart rate, or the number of times your heart beats in one minute. The pulse can be measured using the radial artery in the wrist or the carotid artery in the neck.

Where do you place the stethoscope for apical pulse? ›

Measuring the apical pulse

The doctor will place a stethoscope on the left side of the breastbone, over the apex of the heart. They can also feel the apical pulse at the point of maximal impulse (PMI). The PMI is in the space between the fifth and sixth ribs on the left side of the body.

How do you perform a pediatric assessment? ›

Pediatric Assessment, Vital Signs, and Pain - Principles - @Level Up RN

What is the best method for performing a physical examination on a toddler? ›

The classic systematic approach to the physical examination is to begin at the head and proceed to the toes. For children, painful or frightening procedures should be left until last. Involving parents by asking them to hold or stand by the child can decrease children's anxiety and assist them in relaxing.

Where can you check a pulse on an infant and a child? ›

Taking an Infant's Pulse

Lay your baby down on the back with one arm bent so the hand is up by the ear. Feel for the pulse on the inner arm between the shoulder and the elbow: Gently press two fingers (don't use your thumb) on the spot until you feel a beat. When you feel the pulse, count the beats for 15 seconds.

What are the 3 components of the Pediatric Assessment Triangle? ›

Using the PAT, the provider makes observations of 3 components: appearance, work of breathing, and circulation to the skin (Figure 1). The Pediatric Assessment Triangle and its components.

What are the six basic guidelines to follow when assessing a child? ›

Parents' capacities are detailed across the six areas identified in the parenting capacity domain of the Framework for the Assessment of Children in Need and their Families: basic care; ensuring safety; emotional warmth; stimulation; guidance and boundaries; and stability.

How do you remember your pediatric heart rate? ›

Start with an average heart rate of 140 for the first group (birth to 1 year of age). For each subsequent age group (1 to 4 years, 4 to 12 years, and over 12 years), simply decrease this average heart rate by 20 (140 goes down to 120, then to 100, and finally to 80).

What is a full paediatric assessment? ›

The paediatric assessment triangle (PAT) is an internationally accepted tool in paediatric life support for the initial emergency assessment of infants and children. It is a rapid, global assessment using only visual and auditory clues, and takes only seconds to perform.

What is the best position for examining a child? ›

It is often best to examine kneeling down alongside the patient. Children may prefer palpation to be done with their hand underneath the examiner's.

What are the principles and techniques of physical examination in a small child? ›

The basic principles of physical assessment include: review the perinatal history for clues to potential pathology, assess the infant's color for clues to potential pathology, auscultate only in a quiet environment, keep the infant warm during examination, have the necessary tools at hand, calm the infant before ...

What are the six 6 steps in the assessment process? ›

  1. Step 1: Develop SLOs/POs. • A statement.
  2. Step 2: Identify methods and measures learning. • We are already and always assessing how we are doing and/or. ...
  3. Step 3: Determine criteria for success.
  4. Step 4: Collect and analyze data.
  5. Step 5: Plan and execute improvement actions. ...
  6. Step 6: Document assessment activities.
20 Sept 2017

What are the 4 types of assessment? ›

A Guide to Types of Assessment: Diagnostic, Formative, Interim, and Summative.

What are the four steps of the pediatric triage process? ›

Components of the Triangle
  1. Appearance. The "Appearance" portion of the Triangle measures a variety of things, designed to determine whether the child is experiencing mental status changes (as these can be difficult to identify in an infant or young child). ...
  2. Work of Breathing. ...
  3. Circulation to Skin.

What is the CPR ratio for an infant? ›

Two-person CPR ratio for the child and infant will be 15 compressions to 2 breaths. Finger placement for the Infant changes to Two-Thumb Technique.

Where do you place your hands for CPR on a child? ›

Performing Child & Baby CPR
  1. For a child, place the heel of one hand in the center of the child's chest, with your other hand on top and your fingers interlaced and off the child's chest. ...
  2. For a small child, use a one-handed CPR technique.

How many rescue breaths should a child with a pulse? ›

Provide rescue breathing, 1 breath every 2-3 seconds, or about 20-30 breaths/min. Assess pulse rate for no more than 10 seconds. Continue rescue breathing; check pulse about every 2 minutes.


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