Dysmorphism After assessment of physical growth, the child should be inspected for facial dysmorphism, as a number of congenital malformation syndromes are associated with dysmorphic facial features and congenital heart disease. 

Cyanosis Central cyanosis, a bluish discoloration of the skin and mucous membranes, is a clinical manifestation of hypoxaemia. It occurs in cyanotic congenital heart disease or respiratory disease.  Central cyanosis is usually obvious from examination of the colour of the tongue. The conjunctiva may appear congested as a result of secondary polycythaemia.  If the bluish discoloration is only limited to the extremities, this is referred to as peripheral cyanosis.  Peripheral cyanosis is usually due to vasoconstriction secondary to hypothermia or a low cardiac output rather than hypoxaemia.

Hands and Feet Examination of the hands and feet can provide clues to associated cardiac conditions. Clubbing of fingers and toes occurs in cyanotic congenital heart disease. A single transverse palmer crease with clinodactyly are seen in Down syndrome, polydactyly of the hands is seen in Ellis-van Creveld syndrome, and long and slender fingers with hyperextensible joints are found in Marfan syndrome; these syndrome being associated with cardiovascular abnormalities. The classic peripheral signs of infective endocarditis include splinter haemorrhages in the nail beds and Osler nodes.

Edema Fluid retention is a feature of congestive heart failure related to impaired cardiac function.  The edema is pitting and dependent.  In older children and adults, fluid retention manifests as edema of the ankle and feet in the upright position and sacral edema in the supine position.  However, this feature is uncommon in infants as the cause of heart failure is usually related to conditions causing cardiac overload rather than poor cardiac function.

Upper Limb Pulses The rate, rhythm, character and volume of the pulses should be noted. In older children and adolescents, the radial arterial pulse is usually palpated to define pulse characteristics. In small infants, palpation of the brachial arterial pulse is preferred as the brachial artery has a larger calibre and is closer to the central arteries, hence allowing better appreciation of the pulse volume and character.

Lower limb pulses After examining the upper limb pulses, the femoral arterial pulse at the groin region should be palpated.  It is important to compare the volume of the brachial pulse in young infants, or the radial pulse in older children, to that of the femoral pulse.

Respiratory distress Signs of respiratory distress include tachypnoea, subcostal and suprasternal insucking, and the use of accessory respiratory muscles. 

Chest deformities Chest deformity and asymmetry should be noted.  Bulging of the praecordium is seen in infants and children with cardiomegaly, and is most prominent when the right ventricle is dilated.  Pectus excavatum and carinatum are features of Marfan syndrome.

Surgical scars The mid-sternotomy scar, which suggests previous open heart surgery, is easy to recognize.  On the other hand, a thoracotomy scar due to previous systemic-pulmonary arterial shunt insertion or repair of aortic coarctation may be missed if the patient is not exposed adequately.

Cardiac pulsation While a visible cardiac pulsation may be seen in children with a thin chest wall, its presence may signify volume or pressure overloading of either the left or the right ventricle, depending on the site of the pulsation.  In the normal heart, the left ventricle is at the cardiac apex, while the right ventricle is anterior and underlies the left lower sternal border at the fourth and fifth intercostal spaces.

Define cardiac apex The position of the apex beat, which is the lowest and outermost point of distinct cardiac pulsation, is defined in terms of the intercostal space and distance from the mid-clavicular line.  In children, it is best identified using the tips of the index and middle fingers.  It is normally located in the fourth intercostal space in infants and the fifth intercostal space in older children at or medial to the mid-clavicular line.

Characterize cardiac impulses A strong apical cardiac impulse suggests either pressure or volume loading of the left ventricle.  Whereas the cardiac apex is usually not displaced in pressure loading conditions, it displaces laterally with dilation of the volume-loaded left ventricle.  A left parasternal impulse suggests right ventricular hypertrophy or dilation.  It may be felt by placing the heel of the hand (distal metacarpals) over the praecordium to the left of the sternum.  In infants, use the finger tips to assess a mildly increased left parasternal impulse.

Feel for suprasternal pulsation Prominent pulsation with or without associated thrills occurs in the presence of aortic stenosis, pulmonary stenosis and less commonly, coarctation of the aorta and persistent arterial duct.

Palpate for thrills A thrill is a palpable cardiac murmur.  The intensity of the murmur, if accompanied by a thrill, is at least of grade 4/6.  The location and timing, in relation to the cardiac cycle, of a thrill help in the diagnosis of the underlying heart disease.  Thrills should be sought over the praecordium, at the suprasternal region and over the carotid arteries.  The presence of carotid thrills suggests aortic stenosis.

Use of stethoscope The stethoscope consists of a diaphragm and a bell-type chest piece. Most of heart sounds and murmurs found in children and adolescents with heart conditions are medium- to high-pitched sounds and better heard with the diaphragm.  Low-pitched sounds and heart murmurs (for example the rumbling diastolic murmur in mitral stenosis) are heard better with the bell.  

Cardinal auscultatory areas Start by listening to the four cardinal auscultatory areas with the diaphragm.  These cardinal areas are customarily called by the name of the valve from which murmurs and sounds arise:  i) mitral area (cardiac apex), ii) tricuspid area (left lower sternal border), iii) pulmonary area (left of the sternum in the second intercostal  space), and iv) aortic area (right of the sternum in the second intercostal space).  These terms may not be applicable to children with complex congenital heart lesions.  Furthermore, sounds and murmurs heard in a particular area may not necessarily arise from that particular valve. Hence, the areas for auscultation are best described by the exact location.

Other auscultatory areas Apart from listening to the praecordium, one should also place the stethoscope over the carotid arteries as systolic murmurs of aortic in origin may radiate to the carotid arteries.  Murmurs should also be sought from the posterior chest wall.  Murmurs arising stenotic branch pulmonary arteries radiate to the back.  Soft, continuous murmurs of collaterals (in association with severe aortic coarctation or pulmonary atresia and ventricular septal defect) are also better heard on the back.

Positioning for auscultation When the pulse is collapsing and aortic regurgitation is suspected, one should ask the patient to sit forward and breathe out to listen for a high-pitched diastolic murmur at the left sternal edge using the diaphragm.  Turning of the patient to the left lateral decubitus position brings the left ventricle closer to the bell of the stethoscope and facilitates auscultation of diastolic flow murmur across a stenotic mitral valve.

Abdominal and respiratory examination When cardiovascular signs suggestive of heart failure are evident, perform an abdominal examination to assess for hepatomegaly.  Cardiac wheeze due to increased lung fluid may be audible in infants with large left-to-right shunts and increased pulmonary blood flow.  Auscultation for basal crepitations are usually not required as the cause of heart failure in children is usually related to conditions causing cardiac overload rather than poor left ventricular function.  However, in children with acute left ventricular systolic failure due to myocarditis or cardiomyopathy, bilateral basal crepitations due to pulmonary edema may be obvious.