Transcript General Examination for CVS

General Examination for CVS
Physical signs:
These are the manifestations that the doctor finds during
examination. Certain abnormalities in the general
examination may help in the diagnosis and assessment of a
cardiac patient.
General appearance:
1. Physical development
2. Mental changes
3. Evidence of pain
4. Evidence of heart failure
5. Color (complexion) of the patient
6. Fingers
7. Evidence of generalized disease
8. Vital signs
1. Physical development:
• somatic infantilism: retarded physical and
mental growth in severe cardiac diseases
starting in childhood
• cachexia in advanced heart failure
2. Mental changes:
• depression: following myocardial infarction
• Restlessness, lack of concentration, lethargy
or confusion due to hypoxia, electrolyte
imbalance or cerebral atherosclerosis
3. Evidence of pain:
• myocardial infarction: patient looks
distressed, may be pale, cold and sweaty
• pericarditis: patient is uncomfortable, prefers
to sit up and lean forward , respiration is
painful.
4. evidence of heart failure:
• breathlessness and
orthopnea in left sided
heart failure
• Lower limb oedema in
right sided heart failure
Orthopnea
5. Complexion:
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Pallor: anemia - Heart failure
Malar flush: mitral stenosis
cyanosis: pulmonary oedema - right to left shunt
Plethora: polycythaemia - Cushing's disease - alcohol
abusers
• Pigmentation (brownish): long standing cases with
right heart failure complicated by tricuspid regurge
• Jaundice: cardiac cirrhosis - pulmonary infarction
Mitral facies
Cyanosis
6. Fingers:
• Clubbing: infective
endocarditis congenital cyanotic
heart diseases
• splinter haemorrhages:
infective endocarditis
7. Evidence of generalized disease:
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Thyrotoxicosis
Myxoedema
Acromegaly
Stigmata of hyperlipidaemia: xanthelasma and
corneal arcus
8. Vital signs:
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temperature
Pulse
blood pressure
Respiratory rate
Cyanosis
Definition:
Bluish discoloration of the skin and
mucous membranes due to increased
amounts of reduced haemoglobin.
Cyanosis manifests when the absolute concentration
of reduced haemoglobin exceeds 5 g/dl, therefore it
may be absent in anaemia despite severe
hypoxaemia and it’s easily detected in
ploycythaemia.
If cyanosis is just seen in the nails, tips of nose it is
called peripheral cyanosis, whereas if seen in the
tongue, lips and nails it is central cyanosis.
Peripheral cyanosis:
It is usually due to increased oxygen extraction with a
slow moving circulation. It is seen in cold weather,
Raynaud's phenomenon or peripheral vascular
diseases.
Causes of central cyanosis:
Acute:
• severe pneumonia
• acute bronchial asthma
• pulmonary oedema
• pulmonary embolism
Chronic:
• severe chronic airflow obstruction
• pulmonary fibrosis
• right to left cardiac shunt
Clubbing
It is caused by connective tissue proliferation
leading to increase in the soft tissue at the base
of the nails
Pathogenesis is unclear, may be neurogenic or
hormonal. There is an increased blood flow
through the fingers. Vagotomy can abolish
clubbing
Signs of clubbing:
• 1. increased sponginess of the nail bed with increase
in the angle between it and the nail usually more
than 180°
• 2. Increased curvature of nails in both longitudinal
and lateral axes (beaking)
• 3. Increased bulk of soft tissues over the terminal
phalanges giving a drum-stick appearance
Signs of clubbing (contd):
4. Hypertrophic pulmonary osteoarthropathy:
pain and swelling over the beds of the long
bones above the wrists and ankles
symmetrically due to subperiosteal new bone
formation. It is usually associated with
squamous cell carcinoma of the lung
Detection of clubbing
Normal
Clubbing
Causes of clubbing:
Cardiac:
• infective endocarditis
• cyanotic congenital heart diseases
Pulmonary:
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Bronchial carcinoma
Fibrosing alveolitis
Lung abscess
Bronchiactesis
Empyema
Gastrointesinal:
• Ulcerative colitis
• Crohn's disease
• Liver cirrhosis
Peripheral oedema
Definition of oedema:
swelling of tissues due to an increase in the
interstitial fluid.
When the pressure in the capillaries exceeds the
osmotic pressure of the blood, fluid will leak out of the
circulation into the interstitial space.
Oedema is usually found in the lower limbs,
especially over ankles, or over the sacrum in patients
lying in bed.
Causes:
Unilateral:
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Deep vein thrombosis
soft tissue infection
trauma
immobility (e.g.
hemiplegia)
Deep vein thrombosis
Bilateral:
• Heart failure
• Chronic venous insufficiency
• Hypoproteinaemia e.g. nephrotic syndrome cirrhosis - malnutrition (soft pitting oedema)
• Lymphatic obstruction: e.g. pelvic tumour, Filariasis (
hard non-pitting oedema)
Soft pitting oedema
Filariasis
Lymphatic obstruction following
mastectomy
• Drugs: NSAIDs, corticosteroids, calcium channel
blockers (e.g. nifedipine)
• Inferior vena caval obstruction
• Immobility
• Thiamine deficiency (wet beri beri)