PHYSICAL EXAMINATION OF

THE HEART
INSPECTION:
> cyanosis
- central or peripheral
- cardiac or pulmonary?
> bulge or deformity over chest
 PHYSICAL EXAMINATION OF THE
HEART
PALPATION:
- peripheral pulses
brachial a.- neonates & infants
temporal a.
femoral a.
dorsalis pedis a.
posterior tibial a.
- pulses: sharp rise, firm, well localized
 PHYSICAL EXAMINATION OF THE
HEART
PALPATION:
PMI (point of maximal impulse)
neonate – 4th left ICS MCL
> 2y.o. - 5th left ICS MCL

precordial bulge – cardiac enlargement

substernal thrust – R ventricular enlargement
apical heave – L ventricular hypertrophy
hyperdynamic precordium – large shunts
- maybe normal in thin patients
 PHYSICAL EXAMINATION OF THE
HEART
PALPATION:
- palms or base of fingers and not
fingertips
THRILL – palpable turbulence within the
heart or great vessel
APICAL THRILL – patient on left lateral decubitus
BASAL THRILL – patient sitting up
 PHYSICAL EXAMINATION OF THE
HEART

AUSCULTATION:
Rate
newborn: 120-160/min
Rhythm
normal sinus dysrhythmia
skipped beats (PACs, PVCs)
 PHYSICAL EXAMINATION OF THE
HEART
AUSCULTATION:
Heart Sounds
S1 – AV valve closure
S2 – aortic v., pulmonic v.
S3 – early filling and distension of ventricles
S4 – atrial contractions
- beginning phase of active
ventricular filling
 PHYSICAL EXAMINATION OF THE
HEART
AUSCULTATION:
MURMURS
timing – systolic, diastolic, transient, continuous
nature – soft, blowing, crescendo-decrescendo
grade*
duration
point of maximal intensity
degree and localization of transmission
(ex. Grade 3 blowing holosystolic murmur heard best at the mitral
area with radiation to the axilla)
 PHYSICAL EXAMINATION OF THE
HEART
AUSCULTATION:

Grading of murmurs
1/6 – soft, transient
2/6 – soft, persistent
3/6 – moderate intensity
4/6 – loud, (+) thrill
5/6 – extremely loud, still require stet
6/6 – very loud, even with stet off the
chest
Heart sounds are louder due to thinner chest wall
and with higher pitch

1. innocent murmur
= systolic, short duration
grade 3 or less in intensity
low-pitched
vibratory, musical groaning quality

= loudest along the left sternal

= heard best in supine position
= heard in the absence of any other
demonstrable evidence of
cardiovascular disease
2. non-innocent or organic murmur
= caused by congenital or acquired heart ds.

= before 3 years of age – congenital

= after 3 years old – rheumatic valvulitis

= caused by abnormal communications between

the arterial and venous circuits of the heart
and great vessels or by valvular deformities

= usually coarse in character, systolic in timing

and heard best at the base of the heart
3. hemic murmur
= caused by increase blood flow through the heart

= occurs when the body’s tissues require more

oxygen than usual (exercise)
or when hemoglobin-depleted red blood cells
are not delivering oxygen to tissues (anemia)
 PHYSICAL EXAMINATION OF THE
HEART

PERCUSSION:
- cardiac area of dullness
- not useful in pediatric patients except in
cases of dextrocardia
Physical indications of severe
heart disease:
• tachypnea
• tachycardia
• hyperdynamic precordium
• cyanosis
• clubbing
• delayed development
Heart failure:
• venous engorgement
• pulsus alterans
= pulse alternates in amplitude
from beat to beat though the
rhythm is basically regular
= indicates left ventricular failure
• gallop rhythm
• hepatic enlargement
PHYSICAL EXAMINATION OF THE ABDOMEN

INSPECTION:

• protuberant – due to poorly developed abdominal

musculature

• concave – diaphragmatic hernia

- displacement of some of the abdominal
organs into the thoracic cavity
 PHYSICAL EXAMINATION OF THE ABDOMEN

Umbilical cord

-number of vessels present

- two thick-walled umbilical arteries and
one thin-walled umbilical vein
- amniotic portion dries up within 1 week and falls
off within 2 weeks
• Diatasis recti = congenital weakness of the
abdominal musculature or result from a
chronically distended abdomen.
= most are normal variants and disappear in
early childhood
Omphalocele = herniation of abdominal contents
into the base of the umbilical cord
Gastrochisis = centrally located, full thickness
abdominal wall defect
Auscultation:
• Metallic tinkling every 10-30 seconds

Percussion:
• Test for fluid wave

Palpation:
• Hold legs, flex knees and hips
• Start palpating low in the abdomen
• liver edge and spleen tip palpable
• both kidneys can be felt
Early and Late Childhood:
• ticklish = place child’s hand under
examiner’s hand to reduce
apprehension
and increase relaxation of the
abdominal
musculature
• Palpate lightly and then deeply in all
quadrants
• Examine last the area that the history
suggests as the site of pathology
 PHYSICAL EXAMINATION OF THE
ABDOMEN

• liver and spleen easily palpated

• liver edge 1-2 cm below the right
costal margin
• Size of liver is better determined by
percussion than by palpation
• Rovsing’s sign = press deeply and
evenly the left lower quadrant
– pain in the right lower quadrant

• Referred rebound tenderness = right

lower quadrant pain on quick
withdrawal of left pressure
• Psoas sign
= place hand just above the patients right knee
and ask the patient to raise the thigh against
the examiner’s hand
= ask the patient to turn to the left side and
extend patient’s right leg at the hip
= positive sign is pain on the abdomen
Obturator sign = flex the patient’s right thigh at the hip with
the knee bent and rotate the leg internally at
the hip
 Expected liver span of infants, children and adolescents by
percussion:
• Age Males Females
• 6 months 2.4 2.8
• 1 2.8 3.1
• 2 3.5 3.6
• 3 4 4
• 4 4.4 4.3
• 5 4.8 4.5
• 6 5.1 4.8
• 8 5.6 5.1
• 10 6.1 5.4
• 12 6.5 5.6
• 14 6.8 5.8
• 16 7.1 6.0
• 18 7.4 6.1
• 20 7.7 6.3
 GENITALIA AND RECTUM
Infancy:
Boys:
• Phimosis = tight prepuce that cannot be retracted
over the glans
Hypospadia = urethral orifice appears at some
point along the ventral surface of
the glans or shaft of the penis
Epispadia = urethral orifice appears at the dorsal
surface
Circumcision
difference between hydrocele and hernia : hydrocele does
not transilluminate and not reducible

HYDROCELE
Inguinal hernia
Umbilical Hernia
Girls:
• Inspect the perineal structures, the urethral
orifice, the hymen, and the vaginal mucosa
by separating the labia with the thumb and
forefinger of one hand while pressing
forward and downward from within the
rectum with the index finger of the other
hand.

Early and late childhood:

• size of the penis in early childhood and
prepubescence is of little significance unless
it is very large ( obese boys, fat pad over
the symphisis pubis may envelope the
penis)
Cryptorchidism = undescended testicle,
unilaterally or bilaterally, with the testicle remaining
in the abdomen or within the inguinal canal
• Fusion of the labia minora
= may be partial, with only the
posterior
portion of the labia is fused
= complete – both anterior and
posterior portion is fused