Endocarditis physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Common signs on physical examination of endocarditis include fever, presence of a new or changing heart murmur, rigors, Osler’s nodes, Janeway lesions and evidence of embolization. Aortic insufficiency with a wide pulse pressure, mitral regurgitation or tricuspid regurgitation may be present depending upon the valve that is infected.

• Patients with endocarditis usually appear ill.^[1][2]

• A fever will likely be present.
• Rigors may be present.
• Some patients may have a wide pulse pressure due to aortic insufficiency. If the pulse pressure narrows, this may be a sign of left ventricular failure due to earlier closure of the mitral valve and a more rapid rise in the left ventricular end diastolic pressure which will in turn raise the diastolic pressure.

• Petechiae are present in 10% to 40% of patients
• Splinter hemorrhages are present in 5% to 15% of patients
• Osler’s nodes which are tender subcutaneous nodules in pulp of digits are present in 7% to 10% of patients
• Janeway lesions which are erythematous, nontender lesions on palm or sole are present in 6% to 10% of patients

Petechiae
Splinter hemorrhages
Osler’s nodes
Janeway lesions

Examine the oral cavity:

• Poor oral hygiene
  
• Teeth looking for periodontitis, plaque and calculus
  
• Gingiva looking for gingivitis
  
• Recent dental procedure

• Conjunctival hemorrhage
• Roth’s spots in the retina
• Bobbing of the uvula may be present among patients with new onset aortic regurgitation.

• Neck examination of patients with endocarditis is usually normal.

• Signs of heart failure such as rales may present

• Heart murmurs are present in 80% to 85% of patients including that of aortic insufficiency, tricuspid regurgitation and mitral regurgitation.^[3]

• Abdominal pain may be present due to mesenteric embolization or ileus both of which may manifest as reduced bowel sounds.
• Splenomegaly may be present in 15% to 30% patients.
• Left upper quadrant pain (LUQ pain) may be present as a result of a splenic infarct from embolization.
• Flank pain may be present as a result of an embolus to the kidney.

• Back examination of patients with endocarditis is usually normal

• Genitourinary examination of patients with endocarditis is usually normal.

• Septic emboli may result in stroke and focal neurologic findings^[4]
• Seizures may be present
• Intracranial hemorrhage may occur
• Signs of a brain abscess may be present

• Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles)
• Gangrene of fingers may occur
• The fingers may show splinter haemorrhages
• Osler’s nodes (painful subcutaneous lesions in the distal fingers)

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