Cardiovascular history &Examination

(osce module) at pediatric skill department

DR FATMA BENAMER
2018
Objective:
1. Understanding clinical history relevant to heart
disease
2. Recognized the signs of heart disease
3. Understand the auscultations character of heart
murmur
4. Recognized the feature of pathological versus
benign murmurs
If you Suspected child had a heart disease

3 station
good focused …….
HISTORY AND EXAMINATION
of this child make you sure that your child
really has heart problem or not..
Clinical history in pediatric
1. Personal history:
2. Main complain:
3. Analysis of main complain:
4. Systemic review:
5. Past history:
6. Drug history
7. Perinatal history:
8. Growth &development history:
9. Nutritional history:
10. Family history:
11. Social history:
Focused history of cardiovascular disease
1. Personal hx: name ,Age …
 first few hours of life : pulmonary or aortic atresia/critical stenosis,hypoplastic left
heart syndrome.
 first few days of life: transposition of the great arteries, tetralogy of Fallot,
hypoplastic left heart syndrome, PDA in small premature infants.
 first few weeks of life: critical aortic stenosis, coarctation of the aorta.
 first few months of life: any of the left to right shunts (caused by falling pulmonary
vascular resistance).
History cont
2.Main C/O:
.Infant : cyanosis ,breathlessness ,feeding difficulty , frontal sweeting ,
Irritable and lethargy, failure to gain weight
.Child :shortness of breath during exercise ,palpitation .chest pain, fatigue,
dizziness, palpitation
.Or may the child with CHD asymptomatic…
Or present with complication… IE, HF, Stroke,
3.Analysis of main c/o:….be sure that symptom belong to heart
4.Systemic review: resp… CNS…..
HISTORY CONT..
5. .Perinatal &gestational history ( search for etiology)
◦ Maternal health:- healthy , receive prenatal care& routine ultrasound
◦ Maternal infection (TORCH)
◦ Maternal medication thalidomide (Thalomid), (ACE) inhibitors, statins, the acne medication
and lithium

7. Family history:- sudden unexplained death in family( hypertrophy cardiomyopathy)

6. Growth &development: FTT

Other history is important ….

CVS Examination

Befor Examining the child…….

 Wash your hand ,greeting&
 Introduce yourself and explain what are you going to do
 Position your patient (parent laps)
 Exposure the area of examination
(WIPE)
Cvs examination
General Inspection
 General look :well or un well
 Age
 Growth: centile chart
 Colour: pink, pale or blue (or jaundice as in Alagille’s)
 Dysmorphic features
 Monitoring (may have oxygen saturation probe)
 Supplemental oxygen
 Increased work of breathing (recession, tachypnoea)
CVS examination
palpation
1- Hand
examination
 Clubbing is present
after long-standing
arterial desaturation
(over 6 months).
 Evidence of
endocarditis
 Capillary refilling
time(normally < 2
sec)
 Peripheral cyanosis
 2- peripheral pulses
1- Pulse rate:-

Age Beats/min

<1 year 110-160

2-5 years 95-140

5-12 years 80-120

>12 years 60-100

2- rhythm :regular or irregular

3-volume: good volume weak or pounding

4-special character; collapsing in patent

ductus arteriosus, aortic regurgitation.

5- synchronized :radifemoral delayed

3-Blood pressure

• the width of the inflatable bladder

within the cuff should be at least
40% of the circumference of the
limb, and the bladder length
should encompass 80–100% of the
circumference of the limb at the
point of measurement.
• an undersized cuff causes false
elevation of the blood pressure
reading.
• example of The normal blood
pressure values for different age
groups are given in table 1.2
• BP >90th percentile now termed
‘elevated BP (AAP 2017)
4-Face examintion

• Dysmorphic feature.
• Colour
• Dental careies
5-Abdomen, base of
lung& lower limb
Features of heart failure
in infants:
• Poor feeding/failure to thrive

• Sweating

• Tachypnoea

• Tachycardia

• Gallop rhythm

• Cardiomegaly

• Hepatomegaly.
6-Pericardium
examination
 inspection
1. . Scars: Back &Front
scars
2. . Visible pulsations
(hyperdynamic apex
beat ,suprasternal )
3. . Chest wall deformity
Anterior bulge chest
(cardiomegaly)
,Harrison sulcus
(Increased pulmonary
blood flow / asthma)
4. 4. Respiratory rate and
recession
 don’t forget to Stand at end of bed in
inspection
Pericardium palpation
1. Apex Beat
a) Site :normally in 4th or 5th ICS MCL
 -Displaced to left: Cardiomegaly, pectus
excavatum, scoliosis
 -Displaced to right: dextrocardia, Left
pleural effusion, Left pneumothorax

b) Character
 - Sustained Forceful (LVH)
 -Thrusting : Volume overload (Large stroke
volume ventricle in mitral/aortic
incompetence, or left to right shunt)

2. Left parasternal heave :

Right IVH / RV outflow tract obstruction

3. Thrills , palpaple heart sound

Auscultation
1-area of auscultation
2-Heart sounds.(s1 &s2):
• S1 =normal or loud(eg in high co)

• S2=normal or loud (pulm hypertention)

s2 normal or fixed splitting(ASD)

3-Added sounds ( S3, S4, Opening snap,

Ejection click).&pericardial rub

• S3 heart sound ,Often heard in normal

children, Can indicate reduced ventricular
compliance Best heard with bell over
apex/lower left sternal border

• S4 heart sound .This occurs shortly before

the first heart sound Almost always
pathological but rare in children Indicates
reduced ventricular compliance

• Gallop rhythm Implies loud S3 or S4 and

tachycardia Always pathological

• Ejection clicks Classically occur in aortic

valve and pulmonary valve stenosis.
 4- murmur
1) – site of max intensity
2) - Timing.(systolic or diastolic)
3) – Type.
4) – Grade (I–VI)
• I Barely audible
• II Medium intensity
• III Loud but no thrill
• IV Loud with a thrill
• V Very loud but still requires stethoscope
to be on the chest
• VI So loud, can be heard with stethoscope
off the chest

5) – Radiation(neck, axilla or back)

 Note : Innocent murmurs are non
pathological murmur
Auscultation of heart sound..
 At the end….
You will learn a lot of skills in your medical life …..
..But The First &most important skill you have to gain
is how to take proper history and
examination…
Lectures will be in……