Regular rate for age

Regular rhythm

S1 and S2 audible

No extra heart sounds

2+ pulses

Capillary refill < 2 seconds

Normal blood pressure for age


Abnormal rate for age

Abnormal rhythm

Obscured S1 or S2

Murmur present

Weak or brisk pulses

Prolonged capillary refill

Abnormal blood pressure


Clubbing of digits




heart rate percentiles - pat brady article

Bonafide, Christopher P., et al. “Development of heart and respiratory rate percentile curves for hospitalized children.” Pediatrics 131.4 (2013): e1150-e1157.


normal sinus rhythm

  • Monitor shows normal sinus rhythm


  • PMI
  • Pulses
  • Circulation/perfusion
  • Capillary refill


Normal Heart Sound

  • Listen at 4 points – A, P, T, M
  • Listen for radiation to axillae or back, as well as to neck

Physiologic split S2

  • Variation with respiration, can hear split during inspiration

Blood Pressure

  • Cuff size is important – if cuff is too small, can falsely give reading of systolic hypertension
  • If concern for coarctation of aorta or valvular disease, should be checking 4-limb BPs


Heart Rates


sinus tachycardia


sinus bradycardia

Sinus arrhythmia

sinus arrhythmia

  • Rate increases during inspiration and decreases during expiration

Pathologic Rhythms

Supraventricular tachycardia


  •  Rate over 200 bpm, most frequent at 0-3 months of age, then 8-10 years of age and adolescence

Ventricular tachycardia


  • Rate in upper 100 bpm, associated with hemodynamic instability


1st degree heart block

1st degree heart block

  • Prolonged PR interval; seen in hypokalemia, increased vagal tone, or myocarditis


2nd degree heart block, type II

2nd degree heart block

  • Dropped beats; seen in autoimmune or inflammatory conditions and hyperkalemia



  • Premature beat initiated outside of the SA node; benign, feels like palpitations



  • Heartbeat is initiated in Purkinje fibers of ventricle rather than SA node; also feel like palpitations; intermittent can be benign; more frequent may transition to v-tach

Torsades de pointes

torsades de pointes

  • Polymorphic v-tach; can progress to v-fib; associated with long QT; can be seen with hypokalemia and hypomagnesemia



  • Heart has stopped beating or leads are disconnected


Things to Look Out For:

  1. Location or valve area where murmur is best heard
  2. Frequency and pitch
  3. Intensity – I to VI grading system
    1. Barely audible in a quiet room with good stethoscope
    2. Quiet but audible with stethoscope
    3. Easily audible with stethoscope
    4. Loud obvious murmur with a thrill
    5. Loud murmur with thrill that is heard with stethoscope barely on chest
    6. Loud murmur with thrill heard with stethoscope off of chest
  4. Quality – blowing, harsh, rough, rumbling
  5. Timing – systolic, diastole, or both; early, mid, or late
  6. Radiation of sound
  7. Changes due to position or respiration

Innocent Murmurs

Still’s murmur

  • Vibratory musical murmur, loudest at mid left sternal border

Peripheral Pulmonic Stenosis

  • Early systolic ejection murmur, radiates to axillae and back; due to narrow size of pulmonary branch arteries compared to main pulmonary artery

Venous Hum

  • Continuous, at neck and under clavicle, loudest when sitting, absent when supine

Pathologic Murmurs


  • Systolic ejection murmur at left upper sternal border under clavicle, machine-like quality


  • Holosystolic at left sternal border, cannot appreciate S1 or S2; usually louder if defect is smaller; large defect may not produce sound in newborn due to minimal shunting with high pulmonary vascular resistance

Aortic stenosis

  • Systolic murmur at right upper sternal border, ejection click with crescendo-decrescendo, radiates to neck; harsh quality

Mitral insufficiency

  • Holosystolic murmur at apex, radiates to axilla; blowing and musical in quality

Mitral valve prolapse

  • Mid to late systolic click with late systolic murmur, heard at apex

AV malformation

  • Continuous murmur heard over peripheral vessel due to abnormal flow from artery to vein

* Diastolic murmurs are always pathologic!*

Aortic regurgitation

  • High frequency blowing quality, early diastolic, heard best at right upper sternal border

Pulmonic regurgitation

  • Rough quality, heard slightly after P2, best during inspiration at left sternal border

Mitral stenosis and tricupsid stenosis

  • Low and rumbling, mid to late diastole

Abnormal Heart Sounds


  • Fixed split S2


  • S3 – KEN-tuck-y or SLOSH-ing in
  • S4 – te-NNE-ssee or a STIFF…wall

Friction Rub

  • Scratching or grating quality, high in frequency; may be heard in pericarditis, MI, after trauma, or with autoimmune disease; best heard at left lateral sternal border

Other Exam Findings

Delayed capillary refill

Right sided heart failure

  • JVD
  • Liver edge

Left sided heart failure

  • Cyanosis

Bacterial endocarditis

  • New murmur. May also have petechiae, Osler nodes, splinter hemorrhages, Janeway lesions

Signs of Congenital Heart Disease

  • Clubbing – can be seen as early as 3 months of age, loss of angle of nail, may indicate chronic hypoxemia or presence of right-to-left shunt
  • Cyanosis – seen at lips or mucous membranes
  • Pathologic heart murmurs – see above

Findings Associated with Congenital Syndromes

  • Down syndrome – AV septal defects, VSD, PDA
  • DiGeorge syndrome – abnormalities with aortic arch, right-sided aortic arch
  • Marfan syndrome – aortic root dilation
  • Noonan syndrome – ASD, abnormal pulmonic valve
  • Turner syndrome – coarctation of aorta, bicuspid aortic valve
  • Williams syndrome – aortic or pulmonic stenosis

Systemic Diseases with Cardiac Findings

  • Acute rheumatic fever – occurs after Strep infections, associated with serpiginous rash, fever, painful joints, subcutaneous nodules, and chorea; can cause pericarditis or myocarditis; if chronic, can lead to valvular damage and can progress to heart failure
  • Kawasaki disease – unknown etiology; associated with 5+ days of fever, swollen lymph nodes, hands and feet, rash, conjunctivitis, and erythema of mucous membranes; if untreated, can progress to coronary artery aneurysms

Causes of Chest Pain

  • Anxiety
  • Costochondritis

Causes of Syncope

  • Vasovagal
  • Breath holding spells
  • Orthostatic hypotension
  • Hypoglycemia
  • Hyperventilation
  • Migraines
  • Emotional trigger
  • Conversion disorder
  • Seizures
  • Toxic Exposures
  • Arrhythmias
  • Less likely, structural heart defect