· Colour and cyanosis examine the colour of the sclerae and conjunctivae.
· Teeth: assess the number and condition of the teeth.
· Clubbing: assess fingers and toes. Is there any peripheral oedema?
· Pulses and rhythm: compare the strength of the femoral and right brachial pulse. Pulse rate varies with the phase of respiration. It increases with inspiration and decreases with expiration.
· Chest: identify the position of the apex beat and consider whether it is displaced. In young children (<7yrs) it will be in the 4th intercostal space, to the left of the mid-clavicular line, on the left. In the child older than 7yrs, it will be in the 5th to 6th intercostal spaces. If it is not palpable, check the right side to exclude dextrocardia. Can you feel any other pulsations, heaves, or vibrations in the chest wall?
· Murmurs: auscultate the heart with the child in the sitting and supine positions. Listen over the whole precordium—the apex, the 2nd intercostal space to the left of the sternum (pulmonary valve area), the 2nd intercostal space to the right of the sternum (aortic valve area), and the 4th intercostal space over the sternum (tricuspid valve area). Listen to the heart sounds in each of these areas. Are the sounds muffled and suggestive of pericardial fluid? In the pulmonary valve area, is the second heart sound split during inspiration? (Fixed splitting is found with atrial septal defect.) At the apex, is a third heart sound present, indicating mitral valve prola pse or atrial septal defect? Is there a gallop rhythm of congestive heart failure?