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Although the cardiovascular examination centers on the heart, peripheral signs often provide important information.


Although cardiac patients may appear healthy and comfortable at rest, many with acute MI appear anxious and restless. Diaphoresis may result from hypotension due to pericardial tamponade, tachyarrhythmias, MI, or the presence of a high vagal state. Cold and clammy skin or pallor suggests low cardiac output and may be a sign of cardiogenic shock or anemia. Patients with severe chronic HF or other long-standing low cardiac output states may appear cachectic.

Certain physical features may provide clues to underlying heart disease. Some examples include a person with Down syndrome who is likely to have an AV canal defect. Someone with the Marfan phenotype is likely to have aortic root disease or mitral valve prolapse. A bifid uvula may be a marker of Loeys-Dietz syndrome and diffuse aortic aneurysms. Tendon xanthomas or lipid deposits around the eyes may signal underlying atherosclerotic disease. Systemic inflammatory diseases, such as SLE or rheumatoid arthritis may be associated with underlying myocardial, pericardial, conduction system, or valvular heart disease. Underlying pulmonary hypertension may be present in a patient who has both obesity and sleep apnea.

Cyanosis may be central, due to arterial desaturation, or peripheral, reflecting impaired tissue delivery of adequately saturated blood in low-output states, polycythemia, or peripheral vasoconstriction. Clubbing may be present in chronic cyanotic states. Central cyanosis may be caused by pulmonary disease, left HF, or right-to-left intracardiac or intrapulmonary shunting; the latter will not be improved by increasing the inspired oxygen concentration. Differential clubbing of the toes but not the fingers suggest pulmonary hypertension related to a ductus arteriosus and a right-to-left shunt through the ductus. Edema may be present and its pitting nature and extent quantified. Note also if presacral edema is present. Severe right HF may also present with ascites and scrotal edema.


Although the normal resting heart rate usually ranges from 50 to 90 beats/min, both slower and more rapid rates may occur in healthy individuals or may reflect noncardiac conditions such as anxiety or pain, medication effect, fever, thyroid disease, pulmonary disease, anemia, or hypovolemia. If symptoms or clinical suspicion warrants, an ECG should be performed to diagnose arrhythmia, conduction disturbance, or other abnormalities. The range of normal BP is wide, but even in asymptomatic individuals. Guidelines were issued in 2017 that updated the JNC 7. BP should be categorized as normal, elevated, or stage 1 or 2. Normal BP is defined as less than 120/80 mm Hg, elevated BP as 120–129/less than 80 mm Hg, hypertension stage 1 is 130–139/80–89 mm Hg and hypertension stage 2 as greater than or equal to 140/90 mm Hg. Out-of-office readings should be taken as accurate. Nonpharmacologic treatment for BP reduction with weight loss, sodium restriction, potassium supplementation and a structured physical activity program are recommended ...

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