GENERAL EXAMINATION OF CARDIAC PATIENTS: Conscious level and mentality. Appearance Built Complexion Decubitus Vital signs: (pulse, BP, Temperature, R.R.) U.L & L.L. Head & Neck Other system review; Chest, Abdomen , Neurological, … Summary flowchart for CVS EXAMINATION.

1. (for undergraduate 3rd Integrated Medicine)
Compiled by Ahmed Redwan, 2021 © COPYRIGHTED
Assist. Lecturer Int. Med. Depart.
El-Minia University, EGYPT.

2. Topics Discussed:
 Conscious level and mentality.
 Appearance
 Built
 Complexion
 Decubitus
 Vital signs: (pulse, BP, Temperature, R.R.)
 U.L & L.L.
 Head & Neck
 Other system review; Chest, Abdomen ,
Neurological, …
 Summary flowchart for CVS EXAMINATION.

3. Conscious level and mentality.
 Intellectual functions with cloudy mentality may be affected
with generalized atherosclerosis that also may lead to
Transient ischemic attack (T.I.A).
 Embolic manifestations : M.S ,A.F. leads to Cerebral Stroke.
 Hypertensive Encephalopathy (e.g. Posterior reversible
encephalopathy Syndrome (PRES) and cerebral Hge->Fits).
 Pulmonary edema also affects the patient consciousness
especially after development of Respiratory Failure (hypoxia
+/- hypercapnia)
 Disease Association CVS + NS:
 Fridriech’s ataxia with Cardiomyopathy
 Parkinson’s disease with primary orthostatic hypotension + syncope.

4. Appearance
Toxemia with:
 I.E.
 Rh.Fever
 Chest infection
 Pericarditis
 Myocard. Infarction & pulm. Embolism.
Cardiac Cachexia

6. Cachexia
 Cachexia refers to severe muscle and
fat loss, anorexia and marked weight
loss due to an underlying chronic
disease condition leading to lower life
expectancy.
 The title cachexia, from the Greek
kakos (i.e., bad) and hexis (i.e.,
condition or appearance), or 'bad
condition‘.

7. Cachexia D.D.
Cachexia is a serious and underestimated
consequence in many conditions:
 Cancer
 Organ failure
 Chronic conditions like chronic heart failure,
chronic kidney disease, chronic obstructive
pulmonary disease
 Infectious diseases like tuberculosis, acquired
immunodeficiency syndrome(AIDS)
 Inflammatory disorders like rheumatoid
arthritis

8. Built
1.Height:
Marfan's syndrome: (Tall+arachnodactyly+pes-
cavas-high arched palate+ ectopia lentis) dissecting
aortic aneurysm, aortic incompetence and MVP.
2.Dwarf undergrowth: Congenital heart disease or
in long standing heart disease since childhood.
2.Weight (BMI):
Underweight: Prolonged heart disease whatever
congenial or rheumatic.
Overweight: Atherosclerosis, HTN, MI.
3. Well developed upper part and under
developed lower part in coarctation of the aorta.

10. Marfan’s wide span as compared to
height:

11. Thumb test in Marfan syndrome

12. Aortic Coarctation

14. Decubitus
 Orthopnea: Left sided heart failure.
 Squatting: Congenital cyanotic heart
disease.
 Prayer (knee-chest): Pericardial
effusion, mediastinal syndrome.

16. CARDIOVASCULAR

18. Squatting position

19. Complexion:
Pallor:
 Anaemia (congest. Gastropathy) , Low
cardiac output, Shock.
 Facial pallor with acute MI, pallor with
anemic HF.
 Pallor also commonly associated with:
Endocarditis, Rheumatic fever.

22. Jaundice:
Causes of jaundice in a cardiac patient:
1. Hemolytic J.: in pulmonary infarction, artificial
valves.
2. Hepato-cellular J.: in marked hepatic
congestion (cardiac cirrhosis)due to severe Rt.
sided HF - pericardial effusion -TS & TR.
3. Obstructive J.: bile & inspissation of bile in
canalicular lumen.
4. Associated viral hepatitis: the Commonest !!.

24. Cyanosis
1. Central: Congenital cyanotic heart
disease (F4)- Advanced heart failure.
2. Peripheral: L.C.O.P., C.H.F., Peripheral
vascular disorders.
3. False (chemical) cyanosis:
Methemoglobinemia in nitrate ttt.
4. N.B.: "differential cyanosis": Means
cyanosis more apparent in lower part of
the body in reversed P.D.A.

25. Cyanosis

28. VITAL SIGNS

29. Temperature
Fever in CVS:
 IE
 Rh.Fever
 Chest infection
 Pericarditis
 Myocard. Infarction & pulm. Embolism
 DVT and thrombophlepitis
 Associated fever

30. Pulse:
Feel the right radial artery to
determine, pulse rate , rhythm, volume,
character equality (volume) in both upper
limbs, radiofemoral delay (Aortic
coarctation) and state of arterial wall.
One should also examine all
peripheral pulses in the carotides
brachial,femorals, post. tibial and dorsalis
pedis as routine specially in cardiac cases
with history of embolization.

32. PULSE RHYTM
Normally sinus regular.
Path. Irregularities:
A- Regular irregular: Extrasystole
B- Irregular ( total) irregularity: A.F. ,V.F

36. Tachycardia

37. During sleep
Drugs:
B blockers
Ca #
Digitalis.

40. R.R.
Tachypnea:
Pulm edema
H.F, MI, pulm. embolism
Associated chest infection.
Complication: Resp. Failure.
Distressed sweaty or clammy
('diaphoretic') Acute MI

41. Upper Limb
• 1-Dorsal aspect of the hands:
Tobacco "tar" staining
Peripheral cyanosis.
Temperature.
Clubbing(cyanotic HD or toxic I.E.)
I.E. THROMBOEMBOLC MANIFESTATIONS:
 Splinter haemorrhages (linear, reddish brown marks along the
axis of the finger and to nails, thought to be due to circulating
immune complexes).
 Jenway’s lesions
 Oslar’s nodules
• Sc nodules
• Arthritis due to Rheumatic fever.
• Abnormal movement (chorea)
• Xanthomatas around tendons

42. Upper Limb
• 1-Dorsal aspect of the hands:
Tobacco "tar" staining
Peripheral cyanosis.
Temperature.
Clubbing(cyanotic HD or toxic I.E.)
I.E. THROMBOEMBOLC MANIFESTATIONS:
 Splinter haemorrhages (linear, reddish brown marks,
multiple >2, along the axis of the finger and to nails,
thought to be due to circulating immune complexes).
 Jenway’s lesions
 Osler’s nodules
• Sc nodules (Rh. Fever).
• Arthritis due to Rheumatic fever.
• Abnormal movement (chorea) H.F.
• Xanthomatas around tendons

43. Upper Limb
2-Palmar aspect of the hands:
• Janeway lesions - painless red spots/macules, which blanch on
pressure, on the thenar/hypothenar eminences of the Palms, and
soles of the feet.
• Osler's nodes – small painful raised erythematous lesions
(nodules) which are rare but found most often on the pads of the
fingers (finger pulps) And toes representing digital microinfarction.
3-Palmar and extensor surfaces of the hands:
xanthomata (yellow skin or tendon nodules from lipid deposits).
4-Entire skin surface: petechiae.

47. Lower Limb
• Bilat. Bitting LL edema wih H.F
• Unilat edema: redness, hotness, pain,
tense, tender swollen calf muscles in
DVT --- risk for PE.
• Clubbing
• Peripheral pulsations.
• Differential cyanosis

49. D.V.T.

50. Head & neck
Toxic look: endocarditis, rheumatic fever, severe
pulmonary infection.
• Malar flush: M.S (tight).
• Yellow-bluish complexion: Cyanoicterus features: In
tricuspid valve disease (cardiac cirrhosis).
• Mongolic features: Fallot's tetralogy and V.S.D.
• Turner: Coarctation of aorta.
• Ehlers-Danlos syndrome: joint hypermobility, elastic
skin, easy bruising: mitral valve prolapse, aortic (and
other arterial) aneurysms.
• Low set ear, big lips, depressive nose: may appear in
congenital aorticstenosis.
• Butter fly: S.L.E.

51. Cont.
 Thyrotoxicosis: (heat intolerance, weight loss,
tremor) : tachycardia.
 Hypothyroidism• (cold intolerance, fatigue,
weight gain, depression): Bradycardia.
 Acromegaly: (enlargement of hands and feet,
prominent eye brow): cardiomyopathy.

52. Ehler-Danlos Syn.

53. Turner

54. Down’s Synd.
 Down's syndrome: (microgenia,
macroglossia, epicanthic folds.single
transverse palmar crease): complete
atrioventricular septal defects (e.g.
VSD), F4, repeated chest infection (the
commonest cause of death rather than
H.F. !!!!).

55. What a beautiful creature !!!:

56. Marfan Syndrome

57. Eye
 Peticheal haemorrhage inhypertension.
 Roth spots: Flame shaped retinal Hge
with cotton wool center (clear center)
 Palate: High arched palate: congenital
heart diseases,Tonsills: Tonsillitis
rheumatic fever.

58. Roth’s spots

59. Roth’s spots

60. Neck
Neck veins: venous waves and venous
pressure (Congestion) by examination of the
internal jugular vein (the window of the right
atrium).
Normally there is no congestion , but only normal
pulsation.
Thrill: Palpate the neck for thrill.
Causes:
A.S.Thyrotoxicosis, Aneurysm of carotid artery.

63. Corneal arcus in young patient.
(Familial Hypercholestrol.)

64. Also young !!

65. Abdomen
C-ABDOMINAL EXAMINATION:
1-Liver:-Enlarged & tender in: RVF,
pericardial disease-Enlarged, tender with
expansile pulsation: TR. TS-Enlarged firm,
with sharp border: cardiac cirrhosis
2-Spleen: enlarged in RVF, pericardial
disease3-Ascites: after edema in RVF, or
ascites precox in TR. TS. Pericardial
diseas.

66. BACK EXAMINATION:
1) Murmurs: - Bruit:of MR left scapolar regionOf coarctation
of aorta: interscapular region -Bnist of renal artery
stenosis in renal angle.
2) Crepitations:-Bilateral basal crepitation: LVF-Bubbling
coarse crepitations pulmonary edema
3) Ewart's sign: collapse of left lower lobe in pericardial
effusion
4) Vertebrae - Scapula:-Spina bifida: associated congenital
anomaly in congenital HD-Low back pain, stiffness &
limited spine mobility m ankylosing spondylitis
associated with AR -Anastomosis around scapula in
coarctation of aorta
5) Skin: Cafe au lait patches in neurofibromatosas
associated with pheochromocytoma & IHSS.
6) Sacral edema: pitting edema at sacral area in prolonged
bed ridden patients with Heart failure.

68. Thank You
‫هللا‬ ‫بحمد‬ ‫تم‬