Inspection

The first question on general inspection should be: is there evidence of dysmorphology? A number of dysmorphic syndromes are closely associated with specific heart lesions, and their presence lends a strong clue.

From here the hands are inspected:

• is there clubbing - first seen in the thumbs
• cyanosis may be apparent from the nail beds, as may anaemia

Inspection of face:

• central cyanosis may be seen in the lips, or more convincingly the tongue
• the teeth should be inspected for caries, which are a risk factor for infective endocarditis

Inspection of the neck is only useful in the older child - for example in teenagers. Features are similar to the adult cardiovascular examination.

Inspection of the chest:

• a careful examination should be made for scars:
  • lateral thoracotomy scars might imply Blalock Taussig shunting in tetralogy of Fallot, or on the left might imply pulmonary artery banding.
  • midline scars are usually associated with intracardiac surgery
• Harrison's sulcus is rarely a cardiological sign, but may be seen in chronic pulmonary hypertension with reduced lung compliance.