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: 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 faciesCyanosis

6. Fingers: Clubbing: infective endocarditis - congenital cyanotic heart diseases splinter haemorrhages: infective endocarditis

7. Evidence of generalized disease: Thyrotoxicosis Myxoedema Acromegaly Stigmata of hyperlipidaemia: xanthelasma and corneal arcus

8. Vital signs: 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 NormalClubbing

Causes of clubbing: Cardiac: infective endocarditis cyanotic congenital heart diseases

Pulmonary: 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: 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)