The General Examination

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The general inspection of patients has been discussed in Chapter 2. In particular, the hands (p. 46), the optic fundi (Ch. 7) and the face (Figf3.7) may provide important signs of cardiac disease. Features which are relevant to a cardiac diagnosis include whether or not the patient appears breathless, distressed or anxious or if there is evidence of alcohol abuse (Fig. 1.9) or tobacco consumption (Fig. 1.8),

TAB LE 3.15 Scheme of cardiovascular exami nation

1 Get a general impression of Ihe patient: look for signs ol anxiety, breathlessness or pain

2. Shake hands: assess peripheral circulation (warmth), sweating, look for dubbing, splinter haemorrhages

3. Palpate radial pulses: measure rate, assess rhythm

4. Palpate brachial pulses: measure blood pressure

5. Palpate carotid pulses: assess quality and listen for bruits

6. Examine jugular venous pulse

7. Examine face; look for features of hypercholesterolaemia or anaemia examine tongue for cyanosis

8. Examine chest: assess cardiac impulse, locate apex beat

9. Auscultate the heart

10. Examine back of chest; listen for crepitations. Look for sacral oedema

11. Examine Ihe abdomen especially for hepatomegaly and ascites.

12. Assess femoral pulses: look lor radiofemoral delay

13. Examine legs: palpate pulses, assess oedema

14. Examine the optic fundi

Corneal arcus Xanthelasma


Fig. 3,7 Facial clues to heart disease.

or evidence of anaemia or cyanosis (p. 126). Cyanosis of cardiac origin is usually caused by pulmonary oedeina. although cyanosis may be absent even in severe pulmonary oedema. When associated with congenital heart disease, the presence of cyanosis implies the development of a right-to-left shunt. The resultant cyanosis is not corrected when breathing 100% oxygen and is usually associated with linger clubbing.

Sometimes signs may be present in the absence of symptoms. For example, hyperlipidaemia is an important risk factor in vascular disease. Evidence to suggest its presence include:

• Corneal arcus, due to precipitation of cholesterol crystals at the periphery of the cornea. In young people it is associated with hypercholesterolaemia but the association gets weaker with increasing age,

Corneal arcus Xanthelasma


Malar Flush

Malar flush

Venous pulsation

Carotid bruit

Splinter haemorrhage

Absent pulses, signs of

Petechial haemorrhages

Finger/toe clubbing

Malar Flush

Fig. 3.9 Xanthelasma.

Fig. 3.10 Signs in infective endocarditis.

Fig. 3.8 Eruptive xanthomata.

Fig. 3.9 Xanthelasma.

• Xanthelasma, a yellowish eruption at the inner side of the eyelids and periorbital skin, associated with hypercholesterolemia in people under the age of 50 (Fig. 3.9).

Additional detailed examination to elicit specific signs will be influenced by the history and the presenting features. 1 xamples include the examination of a patient with hypertension (see Fig. 3.18). Less commonly, in patients in whom infective endocarditis is a possibility, various signs may acquire diagnostic significance. These are shown in Figure 3.10. In the hands, possible changes include Janeway lesions, which are non-tender nodules and Osier's nodes on the palms or finger pads (Fig. 3.11). Splinter haemorrhages (Fig. 2.29AI and haematuria both suggest the development of immune complex disease, and finger clubbing only occurs in chronic infection.

Fig. 3.11 Osier's nodes.


Infective Endocarditis And Oral Health

Fig. 3.10 Signs in infective endocarditis.



Changing murmurs

Basal creps


Subconjunctival haemorrhage

Roth spots

Dental caries/surgery

'Cafe au lait' lesions

IV injections



Osiers' nodes, Janeway's lesions

Splinter haemorrhage

Absent pulses, signs of

Petechial haemorrhages

Finger/toe clubbing

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  • terzo
    What is the usual sequence of the general examination?
    7 years ago
    How to examine sacral oedema?
    4 years ago
  • Marigold
    What are the 5 steps in general examination of a patient?
    2 years ago

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