A logical sequence is to:
- Remove all clothing from chest - lateral thoracotomy scars are well hidden by a bra strap!
- Look at the hands for clubbing & at the tongue (central cyanosis) to exclude cyanotic disorders
- Feel the upper limb pulses and then the lower limb pulses (the dorsalis pedis & posterior tibial are more pleasant for the patient than the femorals) to exclude coarctation
- Palpate the precordium for thrills (to grade a murmur), heaves (ventricular hypertrophy) and an active precordium (volume overload eg shunt, regurgitation)
- Listen carefully for a murmur, if present assess all its
characteristics – place most weight on the site of maximum intensity
- Lie the patient down to assess the postural variations – commonly found in innocent murmurs
- Check the BP
- Physical Growth: failure to thrive is a feature of cardiac failure
- Dysmorphic Features: many syndromes are associated with cardiac disease
- Scars: thoracotomy & sternotomy scars give an indication as to the type of surgery undertaken (closed & open cardiac surgery respectively)
- Cyanosis & Clubbing: caused by cyanotic and common mixing conditions
- Respiratory Rate & Recession: occur with heart failure
- Chest asymmetry: the left parasternal area is more prominent in cardiomegaly
- Neck veins: to assess jugular venous pulsations and pressure
- Thrill implies that a murmur is grade 4/6 or louder
- Active Precordium: the cardiac beat is easily felt over the left side of the chest -usually due to a volume overload situation from a large left to right shunt but it may also be due to mitral or tricuspid regurgitation
- Heave: This may be localised to either the left sternal border (RV heave) or apex (LV heave) and is due to right or left ventricular hypertrophy
- diminished pedal or femoral pulses are a sign of coarctation
- if the left brachial is also impalpable then an interrupted aortic arch should be suspected
- If there is a lateral thoracotomy scar & the L brachial pulse is absent suspect coarctation repair by the sublcavian flap technique.
- If the pulse is merely diminished then there may be a modified BT shunt present.
- Blood Pressure – remember to take in the right arm (may be falsely low in left arm eg in coarctation)
Murmurs - see presentation section
- 1st sound due to tricuspid & mitral valve closure. Usually single.
- 2nd sound is due to aortic closure followed by pulmonary closure. The split is increased in inspiration because the aortic valve closes sooner as blood is held in the thorax (lungs) reducing LV filling and thus ejection time. Additionally more blood is sucked into the thorax from the caval veins increasing RV filling & hence ejection time thus delaying pulmonary valve closure.
- 3rd sound common in children due to ventricular filling of compliant ventricle
- 4th sound always abnormal due to filling of a non-compliant ventricle
Stenotic arterial valves create a systolic sound just at the moment the valve leaflets separate. This is referred to as an "ejection click" and occurs at the onset of the murmur. The same phenomenon in the mitral valve is known as an "opening snap" and occurs in diastole.
Cyanosis - see presentation section for more details