General Physical Examination in Cardiovascular Diseases
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General Physical Examination in Cardiovascular Diseases - GPE CVS Findings Importance
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General Physical Examination in Cardiovascular Diseases
- 1. GENERAL PHYSICAL EXAMINATION IN CARDIOVASCULAR SYSTEM • CHAIR PERSON : DR ANAND. KOPPAD • STUDENT : DR SHRIDEVI. R. H
- 2. Contents • Body Configuration:Posture,Gesture,Stature,Nourishment and Gait • Hair • Head and neck • Skin • Extremities • Thorax and Abdomen
- 3. • Posture or attitude and cardiovascular manifestations Posture/attitude Cause Sitting quietly Angina pectoris Moving restlessly Acute myocardial infarction Comfortable in sitting Left ventricular failure Bending forward Pericarditis Squatting Cyanotic congenital heart disease
- 5. • Gestures /signs and diseases Gestures/signs Cause Levine sign Ischaemic chest pain Localized chest discomfort Psychogenic chest discomfort Dyspneic Heart failure, pericardial effusion
- 7. STATURE Upper Segment And Lower Segment Ratio Equal ≤0.8 1. Pituitary Giant 2. Constituitional 1. Marfans Syndrome 2. Homocysteinuria 3. Klinefelter’s Syndrome LONG STATURE
- 9. SHORT STATURE:  Turners Syndrome  Noonan Syndrome  Hurlers Syndrome genetic disorder  Morquio Syndrome  Multiple Lentigines Syndrome  Ellis Van Creveld Syndrome  Cretin endocrine disorder  Cushings Syndrome  Osteogenesis Imperfecta - skeletal disorder
- 11. OBESITY • BMI • Waist Circumference • Waist To Hip Ratio
- 13. CAUSES OF OBESITY • Metabolic Syndrome • Cushings Syndrome • Pickwickian Syndrome • PCOS • Myxedema
- 15. Hair • Alopecia : SLE,autoimmune thyroiditis,Smoking,Myotonic dystrophy, hypothyroidism, syphilis, drugs like carbimazole,heparin. • Graying of hair: smoking • Excess hair: PCOS ( virilization), Cushings syndrome • Decreased body hair: Klinefelters syndrome
- 17. HEAD AND NECK 1.Face – Facial dysmorphism, facies 2. Eyes 3. Nose 4. Ears 5.Oral cavity 6. Neck
- 18. • Abnormal facies Facial Expression Syndromes/Cause Mongoloid Face Down Syndrome Mitral facies Mitral stenosis Moon Face Cushings Syndrome Ape Like Face Acromegaly Elfin Face Williams Syndrome Dull Expression Face Myxedema Frightened And Staring Thyrotoxicosis Grosteque Facies Hurler’s Syndrome
- 23. FOREHAED • Light house sign: AR • Loss of forehead wrinkles : thyrotoxicosis, myotonic dystrophy
- 24. • Hypertelorism Conditions Cardiac abnormaility Noonan syndrome PS Turner syndrome COA LEOPARD syndrome PS HCM Hurler syndrome Arrhythmias Valvular regurgtation William syndrome Supravalvular AS PS Klippel-Feil syndrome VSD
- 25. • Epicanthic fold CONDITIONS CARDIAC ABNORMALITY Downs syndrome Endocardial cushion defects Turners syndrome COA Noonan syndrome PS Klippel Feil syndrome VSD Cri-du chat syndrome TAPVC VSD TOF Cornelia de Lange syndrome VSD PDA
- 27. • EYES: 1. Hypertelorism 2. Exopthalmos 3. Enopthalmos - cachexia 4. Eye lids- lid lag , ptosis , xanthelasma 5. Conjunctiva- pallor, chemosis, sub conjunctival haemorrhage 6. Sclera-scleritis,episcleritis 7. Cornea- arcus, clouding 8. Iris- brushfield spots, coloboma,uveitis 9. Pupils- Argyl Robertson pupil 10. Lens- premature catarct , subluxation 11. Retina-papilloedema,hypertensive and diabetic retinopathy
- 28. • EXOPHTHOLMOS Exopthalmos CV abnormaility Exophthalmic ophthalmoplegia Thyrotoxicosis Pulsatile exophthalmos pulsating earlobes Severe TR
- 29. xanthelsma
- 30. • PTOSIS Ptosis CV abnormality Keans- sayre syndrome Myotonic dystrophy AV blocks ,DCM , HCM Klippel- Feil syndrome VSD Multiple lentigenes syndrome HCM
- 31. • CONJUCTIVA Findings CV abnormality Pallor Anemia, shock, Myxedema Petechiae/ subconjunctival hemorrhage Infective endocarditis,svc obstruction Conjunctivitis with Arthritis and urethritis Reiters disease Pericarditis, AV blocks, AR Phlykentenular conjuctivitis TB
- 33. • SCLERA Scleral abnormality CV condition Icterus CHF Large pulmonary infarct Hemolysis due to prosthetic valves Infective Endocarditias Drugs- ATT Blue sclera OI Ehler-Danlos syndrome Marfans syndrome Familial Scleritis and episcleritis SLE,Behcets,ankylosing Spondylitis, sarcoidosis, relapsing polychondritis, RA
- 35. • CORNEA Corneal abnormality CV condition Corneal arcus Dyslipidemia Arcus senilis Old age Corneal clouding MPS 1 4 6
- 37. PUPILS: • Argyll Robertson Pupil: Neurosyphilis • Landolfi’s Sign: Aortic Regurgitation
- 39. IRIS Iris findings Conditions CV abnormality Brushfield spots Downs syndrome Endocardial cushion defects Lisch nodules Neurofibromatosis ( Phaeocromocytoma) HTN Congenital coloboma Cat eye syndrome CHARGE SYNDROME TAPVC, TOF VSD AR, MR, Aortic root dilatation Uveitis sarcoidosis,relapsing polychondritis, RA, behcets symdrome, vasculitis,tuberculosis,Syphylis
- 41. LENS Lens findings Condition CV abnormality Premature cataract Diabetes mellitus Cushings syndrome Myotonic muscular dystrophy Refsums disease Rubella Conduction blocks, cardiomyopathy DCM HCM PDA Sunflower cataract Wilsons disease Cardiomyopthy arrhythmias Lens dislocation Marfans syndrome Homocystinuria Aortic root dilatation AR MVP Aortic and Pulmonary root dilatation Intravacular thrombosis
- 43. RETINA Retinal findings Conditions Hypertensive retinopathy HTN Wreathlike AV anastomosis Takayasu arteritis Diabetic retinopathy DM Corckscrew tortous retinal arteries COA Roth spots IE Papilledema Malignant HTN,SVC obstruction Angioid streaks Pseudoxanthoma elasticum Pagets disease Sickle cell anemia OI Beckers sign Retinal artery pulsations seen in AR
- 53. NOSE Nose findings Conditions Broad flat nose Cornelia de Lange syndrome Down syndrome William syndrome Hurlers syndrome Broad nose Acromegaly Thin beaked nose Robinstein- Taybi syndrome PDA VSD Saddle nose Syphylis,relapsisng polychondritis Drummond sign AR Bozzolo’s sign AR
- 55. EAR ABNORMALITIES Ear findings Conditions Low set ears Noonan syndrome Turners syndrome Klippel fleil syndrome Down syndrome Cornelia de Lange syndrome Rubinstein – Taybi syndrome Deformed ears Relapsing Polychondritis Ear lobe crease CAD Deafness Turners syndrome Klippel fleil syndrome Rubella Multiple lentigines syndrome
- 57. TEETH ABNORMALITIES: 1. Nicotine stain 2.Peg shaped teeth 3.Widely spaced teeth 4. Malformed teeth - non hereditary forms of 5. Delayed dentition- cretins, mongolism, rickets 6.Malformed and premature dentition at birth- Ellis Van Crevald syndrome
- 58. • Peg shaped teeth CONDITION CARDIAC ABNORMALITY HURLERS SYNDROME VI, COA WILLIAM SYNDROME SUPRAVALVILAR AS , PS CONGENITAL SYPHILIS
- 60. • Widely spaced teeth CONDITIONS CARDIAC ABNORMALITY ACROMEGALY Cardiomyopathy MORQUIOS SYNDROME Cardiomyopathy WILLIAM SYNDROME Supravalvular AS PS
- 61. • Lips Findings Conditions Pallor Anemia Cyanosis CHD Thick lips Hurler syndrome Acromegaly Myxedema Cretin Absent philtrum FAS Capillary pulsations AR Rhagades Congenital syphilis
- 63. Tongue Tongue findings Condition Colour- Blue Pale tongue Red beefy tongue Cyanosis IDA, Shock,hypothyroidism Vit b12, folic acid Macroglossia Acromegaly Myxedema Downs syndrome Hurler syndrome Cretin amyloidosis Glossoptosis Pierre Robin syndrome Minnervini sign AR
- 64. • Palate Palate findings Conditions High arched palate Marfans syndrome Pierre Robin syndrome Cri du chat syndrome Cleft/perforated palate Tertiary syphilis Velocardiofacial syndrome Tuberculosis Pierre Robin syndrome
- 66. Other Oral Cavity Findings: • Ulcerations –behcets,tobacco use with cigars,SLE, systemic sclerosis, syphilis, tuberculosis. • Nicotine stomatis(smoker’s palate)-hard palate discoloration • Leukokeratosis nicotina glossi(smokers tongue)-a homogenous leukoplakia evenly distributed pinpoint hemispherical depressions. • Smokers melanosis- gingival hyperpigmentation due to increase in basal layer of epidermis.
- 67. • Submucosal fibrosis: tobacco • Gum hypertrophy- amlopdipine • Muller’s sign- pulsatile uvula in AR • Membranous tonsillitis-diphtheria
- 69. • Neck Short neck Webbed neck Low hair line Klippel-Feil syndrome Noonan syndrome Noonan syndrome Morquios syndrome Edwards syndrome Edwards syndrome Turners syndrome Turners syndrome Cornelia de Lange syndrome
- 71. • Lymphaedenopthy: 1. Tuberculosis 2. Syphilis 3. Sarcoidosis • Thyroid Enlargement: • Parotid Enlargement: 1. Myocarditis 2. Sjogrens syndrome
- 72. • JVP: It is the reflection of phasic pressure changes in the right atrium and consists of three positive ways(a,c,v) and two negative troughs (x,y).
- 73. • Alfred de musset’s sign: visible oscillation or bobbing of head with each systole • Dancing carotid: seen in AR
- 74. Abnormalities of JVP • Absent a wave: atrial fibrillation • Prominent a waves : pulmonary stenosis pulmonary hypertension tricuspid atresia or stenosis • Cannon a waves : regular –junctional rhythm irregular-multiple ectopics - complete heart block.
- 76. • Prominent v wave: tricuspid regurgitation • Prominent x desent : constrictive pericarditis • Slow y desent :tricuspid stenosis • Fast y desent : tricuspid regurgitation • Absent y desent : cardiac tamponade
- 78. • Kussumaul’s sign: it is an inpiratory increase in JVP. Seen in : constrictive pericarditis restrictive cardiomyopathy right ventricular infarct Right ventricular failure • Friedreich’s sign: it is the rapid fall(steep y desent ) and rise of JVP seen in constrictive pericarditis and tricuspid regurgitation.
- 80. • Spine CONDITIONS CV ABNORMALITY 1. Marfan syndrome Dilatation of Aorta, AR, MVP+/- MR, MPA 2. Ankylosing spondylitis AR, MR,CHB 3. Straight back syndrome Mimics ASD
- 81. SKIN SKIN MANIFESTATION CONDITION CV ABNORMALITY Bronze pigmentation Hemochromatosis Cardiomyopathy Café au luit spots Von Recklinghausen’s disease Pheochromocytoma -> hypertension and myocarditis Multiple lentigines LEOPARD syndrome Hypertrophic cardiomyopathy Angiofibromas Tuberous sclerosis Rhabdomyoma and arrhythmias Erythema marginatum Rheumatic fever Carditis Janeway lesions and Oslers nodes Infective endocarditis Valvular lesions and embolism
- 85. SKIN MANIFESTATION CONDITION CV ABNORMALITY Coarse skin Myxedema Pericardial effusion, atherosclerosis Hyperextensible and rubber like skin Ehler- Danlos syndrome Arterial dilatation and rupture, AR, MVP Plucked chicken appearance Pseudoxanthoma elasticum Premature calcification of systemic and coronary arteries, systemic HTN Moist silky skin Hyperthyroidism Arrhtymias, wide pulse pressue, high output failure
- 88. Xanthomas Hyperlipoproteinemia type Palmar xanthomas Tuberoeruptive xanthomas Type III Tendinous xanthomas Type II Eruptive xanthomas Types I and V
- 90. Nodules Disease Waxy flat nodules Amyloidosis , restrictive cardiomyopathy Subcutaneous nodules Rheumatic fever, systemic lupus erythematosis, rheumatoid arthritis Osler’s node Infective endocarditis
- 92. EXTREMITIES/ LIMBS 1.Cyanosis 2.Edema 3. Peripheral signs of AR 4. Signs of peripheral vascular disease 5. Digits 6. Nails 7. Feet 8. Joints
- 93. CYANOSIS • Cyanotic Congenital Heart Disease • Acute Pulmonary Edema central cyanosis • Eisenmengers Syndrome • Congestive cardiac failure • Mitral stenosis peripheral cyanois • Differential cyanosis: PDA with reversal of shunt • Reverse differential cyanosis: TGA with PDA with reversal of shunt
- 94. Peripheral edema • Pitting type  CCF: Myacardial infarction Severe anemia Beri beri Thyrotoxicosis AV fistula  Constrictive pericarditis  Drugs : CCB • Non pitting edema  myxedema
- 95. Peripheral signs of AR in Extremities • Locomotor brachialis-pulsatile bhrachial artery pulsation • Waterhammer pulse/corrigan pulse-exagerated bounding radial pulse-specifically when limbs are in line with aortic axis. • Palfrey’s sign-pistol shot at radial artery. • Palmer click-palpable, abrupt flushing of palms with systole.
- 96. • Duroziez’s sign- to and fro murmur heard over femoral artery with stethoscope with light pressure applied over it.proximal compression causes systolic murmur while distal compression causes diastolic murmur. • Traube’s sign-loud systolic sound heard over femorals with stethoscope. • Hills’ s sign- acentuation of leg systolic pressure with poplitial pressure more than 20mmhg above brachial artery pressure
- 97. • Pulsus bisferiens • Lincoln sign-pulsatile poplitael fossa and artery. • Mayne’s sign-a decrease in diastolic blood pressure of 15 mmhg when arm is held above the head.
- 98. Signs Of Peripheral Vascular Disease: • Thinning of the skin • Diminished growth of hair • Loss of subcutaneous fat • Shininess • Trophic changes in nails which become brittle • Minor ulcerartions in pressure areas • gangrene
- 99. • Abnormalities of digit Digits description Disease a. Arachnodactyly Marfan syndrome b. Polydactyly Ellis-van Creveld and Laurence- Moon-Biedl syndromes c. Syndactyly Ellis-van Creveld and Laurence- Moon-Biedl syndromes d. Clindactyly Down, Ellis-van Creveld and Hurler’s syndromes e. Brachydactyly Down and Turner syndromes, hyperparathyroidism f. Sclerodactyly Scleroderma
- 101. • Abnormalities Of Thumb Abnormal thumbs Conditions CV abnormality Fingerized thumbs Holt-Oram syndrome ASD, VSD, Conduction defects Single thumb like digit Cornelia de Lange syndrome PS VSD COA Broad thumbs Rubinstein-Taybi syndrome ASD VSD PDA
- 103. • Others Abnormalities Conditions CV abnormality Clenched hands with index fingers overlapping third and fifth finger Edwards syndrome ASD VSD PDA Phocomelia Holt-Oram syndrome and Cornelia de Lange syndrome ASD Raynauds phenomenon Scleroderma Primary pulmonary hypertension
- 106. NAIL ABNORMALITIES • Clubbing: Cyanotic congenital heart disease Infective Endocarditis Atrial Myxoma Eisenmenger Syndrome • Differential Clubbing: PDA with reversal of shunt • Splinter Haemorrages : Infective Endocarditis • Koilonychia: Iron Deficiency Anemia • Quincke’s Sign: Aortic Regurgitation • Nicotine Stain
- 110. OTHER NAIL ABNORMALITIES Abnormal nails Conditions Nail fold teangiectais SSc,SLE Harlequin /quitter’s nail Smoking cessation Square/broad nails Acromegaly, cretin Dysplastic nails Ellis-van Creveld syndrome Plummer nails Hyperthyroidism Lindsay nail uremia
- 111. • Foot abnormalities Foot abnormality Conditions Pes cavus Friedrichs ataxia, peroneal muscular atrophy Cardiomyopathy Pes planus Marfans syndrome AR MR Rocker bottom foot Edwards syndrome ASD VASD PDA Bow legs Achondroplasia OI Rickets osteomalacia Sabre tibia- congenital syphilis Knock knees Ellis-van Creveld and Laurence-Moon-Biedl syndromes
- 114. • Joint abnormalities Joint abnormalities Conditions/ CV abnormality Migrating polyarthritis Rheumatic fever Jaccouds arthritis Post-streptococcal reactive arthritis Rheumatoid arthritis Pericarditis, Constrictive pericarditis, AR, MR, Conduction defects Gouty arthritis CAD, conduction abnormalities Hyperextensibility of joints Ehler – Danlos syndrome
- 117. Others a. Thumb sign b. Wrist sign
- 118. Peripheral signs of AR • Alfred de musset’s sign-visible oscillation or bobbing of head with each systole. • Light house sign-blanching and flushing of the forehead. • Ashraffian sign-pulsatile pseudo proptosis. • Landolffi’s sign-alternate constriction and dilatation of pupils. • Becker’s sign-pulsatile retinal vessels on fundoscopy.
- 119. Contd..... • Drummonds sign-systolic expulsion of air from nose when mouth is closed. • Bozzolo’s sign-pulsatile nasal mucosa. • Minnervini’s sign-strong lingual pulsation tongue moves up and down. • Muller’s sign-pulsatile uvula. • Corrigan’s sign-pulsations of supraclavicular and carotid arteries.
- 120. Contd.... • Locomotor brachialis-pulsatile bhrachial artery pulsation • Waterhammer pulse/corrigan pulse-exagerated bounding radial pulse-specifically when limbs are in line with aortic axis. • Palfrey’s sign-pistol shot at radial artery. • Palmer click-palpable, abrupt flushing of palms with systole.
- 121. Contd.... • Quincke’s sign-exaggerated capillary pulsation in nail bed or mucosa. • Rosenback’s sign-pulsatile liver • Gerhardt’s sign-pulsatile spleen • Dannison sign-pulsation of cervix.
- 122. Contd.... • Duroziez’s sign- to and fro murmur heard over femoral artery with stethoscope with light pressure applied over it.proximal compression causes systolic murmur while distal compression causes diastolic murmur. • Traube’s sign-loud systolic sound heard over femorals with stethoscope. • Hills’ s sign- acentuation of leg systolic pressure with poplitial pressure more than 20mmhg above brachial artery pressure.
- 123. Contd... • Pulsus bisferiens • Lincoln sign-pulsatile poplitael fossa and artery. • Mayne’s sign-a decrease in diastolic blood pressure of 15 mmhg when arm is held above the head.
- 124. TESTS FOR PERIPHERAL ARTERIES: • Elevated arm test • Allen's test • Branham's test/Nicoladoni's test • Costoclavicular compressive test • Hyperabduction manoeuvre
- 125. Thorax • Scars : midline sternotomy,left posterolateral thoracotomy, infraclavicular scar • Tortuous vessels pulsating around scapulas (suzzman sign) • Structural deformities of thorax: pectus exavatum pectus carinatum • Shield chest ( widely spaced nipples) • Gynaecomastia • Buffalo hump: cushings syndrome • Pulsation of the sternoclavicular joint • Precordial bulge
- 126. Abdomen • Hepatic pulsations : tricuspid regurgitation tricuspid stenosis aortic regurgitation • Aortic pulasations: aortic aneurysm • Abdominal ascitis • Purple striae: cushings syndrome
- 127. REFERENCES: 1. Harrisons principle of Internal Medicine 20th edition. 2. Diagnosis of Cardiovascular diseases Jonathan Abrahams. 3. Clinical examination in cardiology Vijay Raghav Rao. 4. Google for images.
- 128. THANK YOU