I. Physical Examination

A. Heart Rate
Refer to the first page of this book for normal heart rate (HR) by age.

B. Blood Pressure

1. 1. Blood pressure (BP):

See Chapter 19 for normal BP values by age.

1. 2. Mean arterial pressure (MAP)
   1. a. MAP = diastolic pressure + 1/3 pulse pressure OR MAP = 1/3 systolic pressure + 2/3 diastolic pressure
   2. b. Preterm infants and newborns: Normal MAP = gestational age in weeks
2. 3. Abnormalities in BP
   1. a. Four-limb BP measurements can be used to assess for coarctation of the aorta.
   2. b. Pulsus paradoxus: Exaggeration of the normal drop in systolic blood pressure (SBP) with inspiration. Determine SBP at the end of exhalation and during inhalation; difference >10 mmHg, consider pericardial effusion, tamponade, pericarditis, severe asthma, or restrictive cardiomyopathies.
3. 4. Hypertension (HTN)
   1. a. See Chapter 1 for management of acute HTN.
   2. b. See Chapter 19 for screening, workup, and management of chronic HTN.

C. Heart Sounds

1. 1. S ₁ : Associated with closure of mitral and tricuspid valves; heard best at the apex or left lower sternal border (LLSB)
2. 2. S ₂ : Associated with closure of pulmonary and aortic valves; heard best at the left upper sternal border (LUSB) and has normal physiologic splitting that increases with inspiration
3. 3. S ₃ : Heard best at the apex or LLSB
4. 4. S ₄ : Heard at the apex

D. Systolic and Diastolic Sounds
See Box 7.1 for abnormal heart sounds.¹

E. Murmurs
Clinical characteristics are summarized in Table 7.1.¹

1. 1. Grading of heart murmurs: Intensified by states of higher cardiac output (e.g., anemia, anxiety, fever, exercise)¹
   1. a. Grade I: Barely audible
   2. b. Grade II: Murmur softer than heart sounds, but audible
   3. c. Grade III: Murmur moderately loud, equally loud as heart sounds, not accompanied by a thrill
   4. d. Grade IV: Murmur louder than heart sounds, associated with a thrill
   5. e. Grade V: Audible with a stethoscope barely on the chest
   6. f. Grade VI: Audible with a stethoscope off the chest
2. 2. Benign heart murmurs²:
   1. a. Caused by a disturbance of the laminar flow of blood; frequently produced as the diameter of the blood’s pathway decreases and velocity increases
   2. b. Present in >80% of children sometime during childhood, most commonly beginning at age 3 to 4 years
   3. c. Accentuated in high-output states, especially with fever and anemia
   4. d. Normal electrocardiogram (ECG) and radiographic findings
   5. NOTE: ECG and chest radiograph are not routinely used, nor are they cost-effective screening tools for distinguishing benign from pathologic murmurs.
3. 3. A murmur is more likely to be pathologic when one or more of the following are present: Symptoms (e.g., chest pain, dyspnea with exertion, syncope with exertion); cyanosis; a systolic murmur that is loud (grade ≥3/6), harsh, pansystolic, or long in duration; diastolic murmur; abnormal heart sounds; presence of a click; abnormally strong or weak pulses^1,2
4. 4. Systolic and diastolic heart murmurs (Box 7.2)