Published online: 2019-07-16

THIEME 42 Clinical Rounds

General Physical Examination for a Cardiovascular Patient

Jyotsna Maddury1 Shagun Aggarwal2

1Department of , Nizam’s Institute of Medical Sciences Address for correspondence Jyotsna Maddury, MD, DM, FACC, (NIMS), Punjagutta, Hyderabad, Telangana, India FESC, FICC, Department of Cardiology, Nizam’s Institute of Medical 2Department of , Nizam’s Institute of Medical Sciences (NIMS), Punjagutta, Hyderabad 500 082, Telangana, India Sciences (NIMS), Punjagutta, Hyderabad, Telangana, India (e-mail: [email protected]).

Ind J Car Dis Wom 2019;4:42–49

The “innocent eye, which should see the world afresh, does Skin not see it at all.”1 1. and clubbing: Cyanosis and clubbing were The general physical examination is important in patients described in detail in earlier issues of this journal. with cardiovascular for specific diagnosis, to assess 2. Telangiectasia and hemangiomas: Cyanosis due to the severity and progression of the disease and, in some the right-to-left shunt through the pulmonary arterio- cases, even to know the therapeutic response. venous fistulas along with telangiectasia on the lips, tongue, and mucous is seen in Osler-Rendu-Weber General Appearance syndrome. Tight, shiny skin with telangiectasias is due to scleroderma. Endothelial cell malignancy is called Examination of the patient starts by observing the patient hemangiomas, which are different from the vascular when he/she enters the room. We have to pay attention to malformations (►Fig. 1). Cardiac lesions in scleroderma the patient’s functional age, posture, and general condi- are pulmonary arterial hypertension, myocardial, peri- tion. If the patient is suffering from acute pain, the severity cardial, and endocardial .2 Even long exposure of the pain is perceived by seeing the face, the presence of to radiation such as in chronic total occlusion (CTO) diaphoresis, and posture he/she adapts. To get relief from interventions can produce telangiectasia on the back. the pericardial pain, the patient sits and leans forward and 3. Skin color change: Hemochromatosis causes tanned takes shallow respirations (“the praying Muslim position”). or bronze discoloration of the skin in unexposed areas. Noisy respiration with a pursed lip in sitting position Associated cardiac lesions are restrictive or dilated supports him/her with his/her hands (fixation of the cardiomyopathy.3 girdle facilitating the use of accessory respiratory 4. Petechiae and ecchymosis: The drugs that can produce muscles), which suggests pulmonary as the cause petechiae are anticoagulation or antiplatelet drugs. Leu- for dyspnea. In acute beriberi and thyrotoxicosis-related kocytoclastic vasculitis or infective endocarditis can dyspnea, skin is warm. Palpitation along with chest pain also produce petechiae due to thrombocytopenia. and sweating of palm and feet, suggestive of anxiety, may 5. Xanthomas: Subcutaneous accumulation of the fat is be seen in neurocirculatory asthenia (DaCosta’s syndrome). called xanthomas. Presence of xanthomas represents If cold feet with intermittent claudication are present, we the lipid disorder. Usually, they are present along the have to suspect peripheral arterial disease. Generalized cold tendon sheaths or on the extremities over the extensor extremities of recent onset are the manifestation of low surfaces. If they are present on eyelids, they are called cardiac output. Warm extremities in the presence of low xanthelasma. There are varieties of xanthomas: cardiac output are due to palmar erythema suggests cardiac cirrhosis. Dyspnea in pale conjunctiva is due to anemia. a. Striated xanthomas are yellowish streaks seen in Icterus in a patient with cardiovascular disease (CVD) the palm, which are specific for type III hyperlipop- suggests liver abnormality secondary to congestive heart roteinemia. failure or primary liver associated with CVDs, b. Tuberous xanthomas are yellowish, coalescing nodules such as viral hepatitis with myocarditis, or prosthetic valve seen on the or . dysfunction (hemolysis), or from hemolysis following a large c. Eruptive xanthomas are seen on the , legs, and pulmonary infarct or alcoholic liver disease with dilated buttocks. These are erythematous halos with central cardiomyopathy or chronic liver disorders associated with yellow-orange papules. pulmonary arteriovenous fistulas and pulmonary arterial 6. Pseudoxanthoma elasticum: Axillary skin shows hypertension. Emaciation suggests chronic heart failure or the leathery, tannish yellowish papules giv- another systemic disorder (e.g., malignancy, infection). ing cobblestone (plucked chicken) appearance in

DOI https://doi.org/ ©2019 Women in Cardiology and 10.1055/s-0039-1692306 Related Sciences Clinical Rounds 43

Fig. 1 Hemangioma—this patient had pulmonary arteriovenous malformation also.

pseudoxanthoma elasticum. The associated cardio- 10. reticularis: The marbling reticulation or fish- vascular disorders are accelerated atherosclerosis and net type of mottling is called the . It is endocardial lesions.4 seen in the lower trunk, buttocks, and extremities. Pre- 7. Lentigines: Lentigines are freckle-like brown macules cipitating factors are emotion and exposure to clod. Its and café-au-lait spots over the trunk and neck (►Fig. 2). presence represents the underlying connective tissue These are seen in Leopard, Lamb, and Carney’s syn- disorders such as lupus erythematosus, periarteritis dromes, and also with the multiple atrial myxomas, nodosa, or cryoglobulinemia. Livedo reticularis in a man atrialseptal defect (ASD), hypertrophic cardiomyopathy of 50 years suggests cholesterol embolization from an (HCM), and valvular stenoses. abdominal aortic aneurysm. 8. Cutaneous sarcoid: Lupus pernio, erythema nodo- 11. Carcinoid faces: Intermittent episodes of red and purple

sum, granuloma annulare, or yellowish-brown papules, color changes of the skin on the face suggest underlying nodules, or plaques indicate cutaneous sarcoid. Usual- carcinoid disease. In a long-standing case, even telangi- ly, these lesions are associated with pruritus. Cardiac ectasias are seen. sarcoidosis manifests as pericardial effusion, pulmo- 12. Pheochromocytoma: Crowe’s sign means axillary nary hypertension, complete heart block, ventricular freckling that is a feature in pheochromocytoma along arrhythmias, congestive heart failure, and ventricular with neurofibromatosis and cafe-au-lait spots. aneurysms. 13. Acromegaly: Large stature, coarse facial features, 9. Erythromelalgia: Periodically skin becomes hot and red, “spade” hands. Associated with cardiac hypertrophy. due to arteriolar dilation. This condition is associated 14. Pickwickian syndrome: This syndrome is seen in with hypertension and venous insufficiency. markedly obese person. They present with somnolence

Fig. 2 Lentiginosis—this patient has hypertrophic cardiomyopathy (HCM) in addition.

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and dyspnea. Associated with pulmonary hypertension. the palm, and hypotonia of the limbs during infancy are To classify the obesity, usually body mass index (BMI) present. Hypotonia improves as the child grows.6 Cardiac is taken, but cardiac risk due to abnormal body fat lesions associated with this syndrome vary from simple distribution is detected by waist circumference (WC) ASD, VSD to complex endocardial cushion defects. and waist-to- ratio (WHR).5 17. Facies of myxedema: A patient with hypothyroid has 15. Facies of supravalvular aortic stenosis: A flattened puffy lids, loss of hair in the outer third of the eyebrows, occiput, broad high forehead, puffy cheeks, ocular scanty and dry hair, coarse and dry skin, expressionless with strabismus, low ears, a large mouth, face, and an enlarged tongue. Associated with cardiomy- patulous lips, small chin, underdeveloped nasal bones, opathy and pericardial effusion (►Table 1). upturned nose with a long filtrum (the vertical groove 18. Friedreich’s ataxia and other neuromuscular disor- between the nose and mouth), dental abnormalities, ders: Lurching gait, hammertoe, with ham- and hypoplastic mandible are seen in William’s syn- mer toe, and nystagmus suggest Friedrich’s ataxia, drome. Cardiac lesions expected in this syndrome are which is associated with HCM. In Duchenne’s dystrophy supravalvular aortic stenosis (AS), ASD, and ventricular (slow, clumsy waddling gait caricatured by exaggerated septal defect (VSD) (►Table 1). lumbar and protuberant abdomen), the pos- 16. Facies of down syndrome: In this condition, the facial fea- terobasal left ventricular wall involvement is specific. tures include a flattened occiput, disproportionately small Myotonic muscular dystrophy patient looks aged with head, inner epicanthal folds that give the impression of graying of hair and boldness with expressionless face slanted eyes, Brushfield’s spots (a circle of punctate, de-pig- and cataracts. Usually, the convexity of is to mented dots circumferentially arranged at the periphery of the right; if it occurs to left, we have to suspect systemic the iris), congenital coloboma or fissures of the iris (looks neuromuscular disease or poliomyelitis. Abnormal like cats eye), and a mouth held open by a large protrud- cardiac impulse formation and conduction are seen in ing tongue. In extremities, the fourth and fifth fingers are these varieties of neuromuscular disorders. abnormally separated, and the fifth finger is short. A dis- 19. Facies of Werner’s syndrome: Premature aging is the tal triaxial radius, curved inward Simian crease traversing characteristic feature of this syndrome. Face reflects all

Table 1 Facial features and other systemic findings in patients with important genetic cardiac diseases Syndrome Facial dysmorphism Other characteristic features Type of cardiac defect

Williams’ Periorbital fullness, epicanthal folds, bitemporal Overfriendliness, attention deficit, Supravalvular aortic syndrome narrowing, broad forehead, short nose, broad intellectual disability, soft and lax stenosis (75%), peripheral tip, malar flattening, long philtrum, thick lips, skin, hernia pulmonary stenosis large mouth, large ear lobes 22q11.2 Hooded eyelids, hypertelorism, orofacial cleft, Hypocalcemia, immunodeficiency, Conotruncal defects deletion asymmetric crying facies, ear abnormalities, a velopharyngeal insufficiency, learn- syndrome square tip of the nose, small mouth ing disability, psychiatric symptoms Turner’s Hypertelorism, epicanthal folds, neck Short stature, ovarian failure, shield- Coarctation of aorta, syndrome webbing, low hairline, small mandible, like chest, , short bicuspid aortic valve increased pigmented nevi fourth metacarpals, renal anomalies Noonan’s Hypertelorism, ptosis, downslanting Short stature, neck webbing, Pulmonary valve stenosis, syndrome palpebral fissures, low set posteriorly pectus deformity, cryptorchidism, hypertrophic cardiomyop- rotated ears with fleshy helices learning disability athy, ECG abnormalities Down’s , flat facies, upslanting Intellectual disability, low hairline, Septal defects—AVSD, syndrome palpebral fissures, epicanthal folds, open hypotonia, , simian VSD, ASD mouth with tongue protrusion, low-set ears crease, sandal gap, duodenal atresia, tracheoesophageal fistula, hearing deficits, atlantoaxial dislo- cation, increased risk of leukemia Trisomy 18 Prominent occiput, retrognathia, low-set Multiple internal malformations, Septal defects, complex dysplastic ears, small eyes, mouth, and nose overlapping fingers, rocker bottom cardiac defects feet or heel prominence, arthrogry- posis, limb defects, early lethality Trisomy 13 Midline cleft lip, hypotelorism, Holoprosencephaly, renal anomalies, Septal defects, complex micro-ophthalmia, dysplastic ears postaxial , multiple cardiac defects internal malformations, early lethality Marfan’s Long, narrow face, malar hypoplasia, Ectopia lentis, tall stature, arach- Aortic root dilatation, syndrome retrognathia, deep-set eyes with a nodactyly, dolichostenomelia joint predisposition to downward slant, high-arched palate laxity, pectus deformity, Scoliosis aneurysm formation and rupture, valvular prolapse Abbreviations: ASD, atrial septal defect; AVSD, atrioventricular septal defect; ECG, electrocardiogram; VSD, ventricular septal defect.

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features of aging such as graying of hair, cataract, bold- 27. The subtle, small, translucent, waxy, flat-topped nodules ness, etc. Atrophic, tightly drawn skin, ischemic ulcers, are seen on the skin and in the eye, which can be better and hypoplastic nails due to peripheral vascular disease appreciated with a hand lens to see these small lesions, in associated with this syndrome, in addition to premature systemic amyloidosis. Taking a punch biopsy from these coronary and systemic atherosclerosis.7 nodules yields more positive diagnosis of amyloidosis. 20. Hound-dog face: Hound-dog facies typically described 28. Subcutaneous nodules of acute rheumatic fever vary in cutis laxa (dermatochalasis). The face looks prema- from very small like pinhead to as large as 1 to 2 cm, turely aged with an antimongoloid slant, slightly everted unattached to the skin, seen commonly on the bony nostrils, prominent ears, and epicanthic folds and asso- prominences of the elbows, dorsa of the hands or feet, ciated with premature atherosclerosis. In contrast to and malleoli or vertebrae. Ehlers-Danlos syndrome, there is no joint laxity.8 29. Yellow to orange-red nevi of different sizes called 21. Potter’s face: In Potter’s syndrome, there is hyper- ­adenoma sebaceum are seen on the malar and nasolabial telorism, prominent epicanthal folds, low-set ears, skin, in tuberous sclerosis and sometimes accompanied receding chin, and flattened nose. There may be by cardiac rhabdomyoma. ventricular septal defect, endocardial cushion defect, 30. Loeys-Dietz syndrome (LDS): Features include doli- tetralogy of Fallot, and patent ductus arteriosus.8 chocephaly, hypertelorism, enophthalmos, downslant- 22. Aortic face: Also called Corvisart’s face, due to aortic ing palpebral fissures, bifid uvula, retrognathia, pectus regurgitation (AR) with congestive heart failure—puffy, carinatum, , and increased span. cyanotic, with swollen eyelids, and shiny eyes.9 Cardiac lesions are aortopathy, vasculopathy, and mitral 23. Ankylosing spondylitis: This condition causes straight valve prolapse.10 back syndrome and a stiff spine. It can be associated with AR and heart block. Specific for Infants and Children 24. Sickle cell anemia: During a painful crisis time in sickle cell anemia, the patient may develop cutaneous ulcers. 1. Neonatal gigantism is a feature of the infant of a diabetic These patients can have pulmonary hypertension and mother.11 secondary cardiomyopathy. 2. Noonan’s syndrome (►Fig. 3). has a normal chromo- 25. Rheumatoid arthritis: Typical hand deformity and the somal pattern with phenotypic features of Turner’s presence of subcutaneous nodules give a clue for rheu- syndrome. Dwarfism may not be there. Cardiac lesions

matoid arthritis (RA) diagnosis. RA patients may have are dysplastic pulmonary valve stenosis or hypertrophic the myocardial, pericardial, and endocardial disease.2 obstructive cardiomyopathy.12 26. In Graves’ disease, occasionally on the distal extremities, 3. The Ellis-van Creveld (EVC) syndrome is characterized symmetrical vitiligo may be there. by dwarfism and polydactyly.13

Fig. 3 Phenotypic features of few important syndromes. (a) Patient with Turner’s syndrome with features such as neck webbing, cubitus valgus, and facial dysmorphism. (b) Patient with Noonan’s syndrome depicting ptosis, facial dysmorphism, and pectus deformity. (c) Patient with William’s syndrome depicting characteristic facies with bitemporal narrowing, periorbital fullness, long philtrum, and thick lips. (d) Pa- tient with trisomy 18 showing facial dysmorphism, prominent occiput, and overlapping fingers. (e) Patient with Marfan’s syndrome with long face, malar hypoplasia, retrognathia, arachnodactyly, and finger joint laxity. (f) Patient with Down’s syndrome showing flat face, upslanting palpebral fissures, epicanthal folds, and small ears.

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4. In Hutchinson-Gilford syndrome, premature aging and either resemble cotton wool or be hard and shiny; atherosclerosis are features. grade 4: papilledema), atherosclerosis (grade 1: 5. Gargoylism is a feature in Hurler’s syndrome. In this the light reflex is increased in width; grade 2: malformed skull, the features include prominent supra- crossing abnormalities—arteriovenous nicking orbital ridges, depression of nasal bridge, and thick lips and right-angled crossing of the arteries over the with peg teeth. Cardiac associations are mitral and aor- veins; grade 3: copper-wire arteries—red color of tic valves involvement and narrowing of the lumina of the artery is slightly brownish due to thick walls; the coronary arteries.13 grade 4: silver-wire arteries—no red color is seen, 6. In fetal alcohol syndrome, the baby has short palpebral only a whitish light reflex), diabetes, toxemia of fissures, a hypoplastic upper lip with thin vermilion, pregnancy or in young persons with rapid onset of diminished to absent philtrum, micrognathia, and mid- hypertension (pure attenuation of the arterioles), facial growth deficiency.14 This condition occurs when endocarditis (oval- or canoe-shaped hemorrhages maternal ingestion of alcohol is massive during gesta- near optic disk with white spot in center—Roth’s tion. Associated cardiac anomalies are ASD or VSD alone spots), neurologic signs or symptoms, Hollenhorst’s or with pulmonary valve stenosis. plaques (flakes of cholesterol emboli seen as glinting 7. In the cardiofacial syndrome, the child has a unilateral spots, often seeming larger than the vessels in which partial lower facial weakness that becomes more prom- they reside, highly refractile),18 fibrin-platelet embo- inent during crying. Cardiac lesions are VSD and coarc- li (whitish plugs sometimes seen moving through tation of aorta.15 the retinal arteries), coarctation of aorta (cork- screw tortuosity with frequent “U turns” without hypertensive changes),12 or known carotid or aortic Head and Neck arch disease. Fundus changes observed in cyanotic 1. A high-arched palate is a feature of Marfan’s and other congenital heart disease and at high altitude include connective tissue disease syndromes. an increase in retinal vascularity and an increase in 2. A large protruding tongue with parotid suggests amyloi- vascular caliber probably due to vascular endotheli- dosis. It is associated with restrictive cardiomyopathy. al growth factor, and, exceptionally, papilledema and 3. In LDS, the vascular lesions can be seen in the cerebral, retinal may occur. thoracic, and abdominal arteries in the form of aneu- 10. Retinal detachment may occasionally be in Ehlers-

rysms and/or dissections. Multiple skeletal manifesta- Danlos syndrome. Also, skin exhibits remarkable tions such as or , hyperextensibility, with a rubber-like response to stretch scoliosis along with craniofacial features of widely and with cigarette paper scars that result from fragility spaced eyes, and strabismus are present. Mainly, skin and poor healing. is velvety and translucent with easy bruising and with 11. Lacrimal gland hyperplasia is sometimes a feature of dystrophic scars. sarcoidosis. Eversion of the lid permits direct inspection 4. Long-term ingestion of amiodarone causes deep blue of the enlarged lacrimal glands.19 discoloration around the malar area and nose.16 12. Malar flush—The “mitral facies” of rheumatic mitral 5. Orange tonsils are characteristic of Tangier’s disease. stenosis (pink-purplish patches with telangiectasias 6. Ptosis and ophthalmoplegia occur in muscular dystro- over the malar eminences) also can accompany other phies. For example, in Kearns-Sayre syndrome, ptosis disorders associated with pulmonary hypertension and is asymmetrical, and the external ophthalmoplegia reduced cardiac output. with pigmentary retinopathy is seen. In this condition, 13. In EVC syndrome, there may be prematurely erupted infranodal conduction abnormalities are culminating in teeth present at birth along with gingival hypertrophy complete heart block.17 and multiple frenuls.12 EVC syndrome reveals a char- 7. Proptosis is seen in Graves’ disease, severe tricuspid acteristic pattern of atrioventricular (AV) canal defects regurgitation (TR). Lid lag and stare are addition points with systemic and pulmonary venous abnormalities for the Graves’ hyperthyroidism. Proptosis in patients and heterotaxy syndromes. with severe TR may be accompanied by systolic anterior 14. Retraction of the tongue—glossoptosis—in the Pierre movement of the ocular bulb that is best detected when Robin syndrome. The retraction may cause upper air- the examiner observes the eyes with an oblique light way obstruction and pulmonary hypertension.20 while the patient sits and looks directly forward. 15. Relapsing polychondritis is suggested by inflamma- 8. The findings in osteogenesis imperfecta are blue tion of the pinnae and nasal association with a sad- sclerae, mitral regurgitation (MR) and AR, and fre- dle-nose deformity. Cardiac lesions are aortic incom- quent spontaneous fractures. petence, mitral regurgitation, complete AV block, and 9. Fundus examination is essential in the evalua- pericarditis. tion of patients with hypertension (four grades— 16. De Musset’s sign (Lincoln’s sign)—Bobbing of the head grade 1: generalized attenuation-arteriovenous in significant AR is due to increased carotid arterial pul- ratio of < 2–3; grade 2: focal constriction or spasm; sations striking the angles of the mandibles. The patient grade 3: hemorrhages and exudates, exudates may appears to be nodding “yes.”

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17. Patients with significant TR will exhibit lateral head 2. In Holt-Oram syndrome, the unopposable “fingerized” movement. This occurs when regurgitant blood in the thumb is present. The thumb may be hypoplastic with superior vena cava (SVC) strikes the right mandibular an accessory phalanx (triphalangeal). The most common angle. The patient appears to be nodding “no.”21 coexisting cardiac anomaly is an ostium secundum ASD.12 18. The thyroid gland has to be palpated for its size, symme- 3. Arachnodactyly is a feature of the Marfan’s syndrome. try, and consistency. 4. Signs of infective endocarditis include Janeway lesions, 19. Earlobe crease: Earlobe crease is an oblique crease Osler’s nodes, and splinter hemorrhages. in the earlobe. Ninety percent of patients older than a. Janeway lesions are seen in palms and soles. These 50 years with significant triple-vessel coronary disease are nontender, circular or oval, pink to tan macules have a deep earlobe crease. with slightly raised areas of hemorrhage. Usually 20. Eyes small size of 5 mm macules, which does not a. Corneal arcus: This condition is associated with with pressure. hypercholesterolemia. It has to be differentiated b. Osler’s nodes are seen on the pads of the fingers­ from the arcus senilis that is not associated with or toes. They are tender and raised nodules, hypercholesterolemia. Corneal arcus is a thick band occasionally with a whitish center, of variable starts inferiorly and inside the limbus. Thin rim of ­diameters (3–15 mm). iris can be seen between the corneal arcus and sclera. c. Splinter hemorrhages do not occur due to embolic On the contrary, in arcus senilis, the arcus that starts phenomenon, are linear in the mid-nailbed. Embolic superiorly extends to the rim or limbus of the iris. splinters are subungual. Fresh red hemorrhages are b. Cataract in children: Consider rubella syndrome, myo- more important than brown linear streaks. tonic muscular dystrophy, and Werner’s syndrome.12 d. Localized linear scars along the course of antecubital c. Argyll Robertson pupil (reacts to accommodation but veins imply “mainline” intravenous drug abuse with not to light)—suspect luetic aortic aneurysm or luetic the risk of staphylococcic bacteremia and right-sided AR with ostial coronary stenosis. infective endocarditis. d. Exophthalmos: Thyrotoxicosis with heart failure, 5. Examine the hands for tobacco staining.23 severe TR. 6. “Half and half nails” (proximal portion white to pink e. Tremulous iris (iridodonesis)—Marfan’s syndrome: and distal portion red or brown: Terry’s nails)—chronic In Marfan’s syndrome, lens subluxation is typically­ renal failure, cirrhosis.

upward, whereas in homocystinuria, downward 7. Paired, transverse, white bands in the second, third, ­dislocation is the rule. Homocystinuria is accompa- and fourth fingers (Muehrcke’s lines) suggest chronic nied by systemic arterial and venous thromboses, hypoalbuminemia. These types of nails are present in myocardial infarction, and pulmonary embolism. three-fourths of the patients with nephrotic syndrome, f. Blue sclera is seen in osteogenesis imperfecta (asso- liver disease, and malnutrition.24 ciated with AR), Marfan’s syndrome (associated with 8. In Quincke’s pulse, after slight compression of the great-vessel aneurysms and mitral or aortic valve nailbed, there is alternate red blanching of the finger- regurgitation), and Ehlers-Danlos syndrome (associ- nails, coinciding with each cardiac cycle. Quincke’s ated with the atrial septal defect, tetralogy of Fallot, pulse is a sign of AR. or regurgitant valves). 9. Capillary refill time (CRT): By nail blanching, we can g. Angioid streaks are brown linear streaks perpen- assess the volume status at the bedside. Keep the hand dicular to blood vessels seen in pseudoxanthoma­ at the heart level, and then compress and release the ­elasticum, Paget’s bone disease, and sickle cell distal phalanx of the middle finger and observe the time ­anemia. Cardiac lesions are endocardial fibrosis and taken to get the normal color of the finger. Two seconds regurgitation of the valves. in children and adult men, 3 seconds in adult women, h. Conjunctivitis with urethritis points to the diagnosis and 4.5 seconds in elderly persons are normal.25 of Reiter’s disease. Acute cardiac involvement takes 10. Pedal edema may occur due to heart failure, venous the form of pericarditis and abnormalities in AV con- insufficiency, or drug-induced–like dihydropyridine duction, whereas chronic involvement is represented calcium channel blockers or other fluid-retaining drugs. by AV block and AR.22 11. Chronic venous insufficiency may be represented by i. Staphyloma: Congenital staphyloma is a component extensive varicosities, medial ulcers, or brownish pig- of Kabuki’s syndrome. The cardiac defects in this mentation from hemosiderin deposition. syndrome are coarctation of the aorta and atrial and 12. Asymmetric swelling can occur due to unilateral venous ventricular septal defects. thrombosis, the sequelae of previous vein graft harvest- ing, or lymphatic obstruction. Extremities 13. Homan’s sign is the calf pain elicited by forceful dorsi- flexion of the foot. Even though its presence is a clue to 1. Clubbing implies the presence of central shunting deep vein thrombosis (DVT), it is neither specific nor (described in the previous issue of this journal). sensitive for DVT.

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14. Chronic arterial insufficiency is represented by mus- fingertips. The skin over the dorsa of the hands sub- cular atrophy and the absence of hair in an extremity. sequently becomes swollen, tense, discolored, and 15. Lipodystrophy is the redistribution of fat from the ­wrinkled. The changes may culminate in Dupuytren’s extremities to central/abdominal stores and may relate . Pain, stiffness, and limitation of motion in to antiretroviral treatment or be associated with insulin the shoulder girdle, usually the left, may coexist.31 resistance. 6. A thrill may be present over well-developed intercostal 16. Features of Marfan’s syndrome: Fingers are slender and artery collaterals in patients with aortic coarctation. long (“spider” fingers or arachnodactyly), thumb sign 7. Significant shunt lesions in infancy or childhood may (when a fist is made over a clenched thumb, the thumb cause chest wall deformities. The usual variety of chest should not extend beyond the ulnar side of the hand), deformity in such patients is anterior asymmetry, espe- wrist sign (when the thumb encircles the wrist, the lit- cially a left precordial bulge. When cardiac dyspnea in tle finger will overlap at least 1 cm), and the span of the infants and young children causes chronic repetitive outstretched arms exceeds the height by at least 5 cm. traction on the diaphragmatic insertions of the cage Usually sitting height is one-half of the total height or during growth and development, nonrachitic Harrison’s arm span. In Marfan’s syndrome and hypogonadism, grooves commonly result. arm span is more than the sitting height.26 8. Scars on the chest may occur due to previous 17. Jaccoud’s arthritis is the sequelae of the postrheumat- or healed chronic inflammations. ic fever. The deformity occurs due to the subluxation of 9. Abdominal paradox precedes the fall of oxygen satura- the joints but not due to the erosion and can be correct- tion and a good indicator of respiratory failure.32 ed voluntarily.27 10. If clavicular movement upward is > 5 mm, it suggests 18. Broad thumbs and toes are characteristic of the Rubin- severe respiratory obstructive disease and correlating stein-Taybi syndrome28 in which the coexisting cardiac with forced expiratory volume (FEV), of 0.6 L.33 malformation is usually patent ductus arteriosus. 11. The laryngeal height that is the distance from the top 19. The extra digit is almost always an accessory finger as of the thyroid cartilage to the suprasternal notch; if it is in EVC syndrome, which is accompanied by a common < 4 cm, postoperative pulmonary risk is high.34 atrium. Polydactyly of the hands is invariable in EVC 12. The forced expiratory time (FET) is the best bedside pre- syndrome, but polydactyly of the feet occurs in only 10% dictor of the severity of airflow obstruction. FET > 6 sec- of patients. onds corresponds to a forced expiratory volume in 1 sec-

20. Rocker-bottom appearance of the foot caused by the ond/forced vital capacity (FEV1/FVC) < 40%. Conversely, 35 protruding heel in trisomy 18, which is usually associ- FET <5 seconds indicates an FEV1/FVC > 60%. ated with patent ductus arteriosus or ventricular septal 13. The liver often is enlarged and tender in heart failure; defect.12 systolic hepatic pulsations signify severe TR. 14. Patients with infective endocarditis of long duration Chest and Abdomen may have splenomegaly. 15. Ascites can develop with advanced and chronic right 1. Cutaneous venous collaterals over the anterior chest sug- heart failure or constrictive pericarditis. gest chronic obstruction of the SVC or subclavian vein. 16. The abdominal aorta usually may be palpated between 2. Asymmetric unilateral breast enlargement may occur the epigastrium and umbilicus in thin patients and chil- 29 due to aldosterone antagonists or digitalis glycosides dren. Lateral expansion of an abdominal mass > 3 cm treatment for heart failure. with pulsation suggests an abdominal aortic aneurysm. 3. Thoracic cage abnormalities: Pectus carinatum or If expansile pulsations are present in a small aneurysm, pectus excavatum is seen in Marfan’s syndrome and it is more specific and less false negative but less fre- ­connective tissue disorders. Cor pulmonale is suspected quently seen. This sign is so important that in a thin in the barrel chest of emphysema or advanced kypho- individual if expansile pulsations are absent, then better scoliosis. The severe may occur in ankylosing not to consider the aortic aneurysm diagnosis.36 spondylitis. The “straight back syndrome” is associated 17. Arterial bruits in the abdomen should be sought. with mitral valve prolapse. 4. Features of Turner’s syndrome—shield chest is a broad The eye is the chief means whereby the understanding chest with a greater angle than usual between the may most fully and abundantly appreciate the infinite works manubrium and body of the , as well as widely of nature. separated nipples. In a female with neck webbing, wide Leonardo da Vinci carrying angle and short stature. (under 5 ft in height). Short fourth metacarpal that becomes evident on making References a fist is seen.30 In Turner’s syndrome, coarctation of aorta is 1 Gombrich EH. Meditations on a Hobby Horse. London, UK: seen. In a male, it is called Noonan’s or Ullrich’s syndrome Phaidon;1978 and is commonly associated with pulmonary stenosis. 2 Murphy Joseph G, Lloyd Margaret A. Cardiovascular exam- 5. Postmyocardial infarction shoulder-hand syndrome is ination. In: Mayo Clinic Cardiology: Concise Textbook. characterized by painless erythema of the palms and 4th ed. Section I Fundamentals of Cardiovascular Disease,

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Clarence Shub. Mayo Clinic Scientific Press Oxford Universi- 21 Allen HD, Philips JR, Chan DP. History and physical examina- ty Press:1–26, chap 1 tion. Vol. 1 Part II—Diagnostic methods. In: Allen HD, Driscoll 3 Dabestani A, Child JS, Henze E, et al. Primary hemochroma- DJ, Shaddy RE, Feltes TE, eds. Moss and Adams’ Heart Disease tosis: anatomic and physiologic characteristics of the cardiac in Infants, Children, and Adolescents: Including the Fetus and ventricles and their response to phlebotomy. Am J Cardiol Young Adults. 7th ed. Philadelphia, PA: Lippincott Williams 1984;54(1):153–159 and Wilkins; 2007 4 Fang JC, O’Gara PT. The history and physical examination: an 22 Ruppert GB, Lindsay J, Barth WF. Cardiac conduction abnor- evidence based-approach. In: Libby PP, Bonow RO, Mann DL, malities in Reiter’s syndrome. Am J Med 1982;73(3):335–340 and Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of 23 Mills NL, Japp AG, Robson J. The cardiovascular system. In: Cardiovascular . 8th ed. Philadelphia, PA: Elsevier Alastair Innes J, Dover AR, Fairhurst K, eds. Macleod’s Clinical Science; 2007 Examination. 14th ed. Amsterdam, The Netherlands: Elsevier;­ 5 Salvatore M. In: Chest inspection, palpation, and percussion. 2018:46, chap 4 Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby 24 Salvatore M. Physical Diagnosis Secrets. 2nd ed. Philadelphia, Elsevier;2007:371, chap 13 PA: Mosby Elsevier; 7 September 2007:1 6 Freedom RM, Gerald PS. Congenital cardiac disease and the 25 Salvatore M. In: Appearance, facies, and body habitus. Physical “cat eye” syndrome. Am J Dis Child 1973;126(1):16–18 Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby Elsevier; 7 Perloff JK, Phelps ET. A review of Werner’s syndrome, with 7 September 2007:13, chap 1 a report of the second autopsied case. Ann Intern Med 26 Muhammad I, Ahmed NS, eds. In: History taking and phys- 1958;48(6):1205–1220 ical examination. Bedside Techniques Methods of Clinical 8 Salvatore M. In: General appearance, facies, and body habitus. Examination. 4th ed. Karachi, Pakistan: Paramount Publishing Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby Enterprise;2013:15 Elsevier; 7 September 2007:18, chap 1 27 Bittl JA, Perloff JK. Chronic post-rheumatic fever arthropathy 9 Salvatore M. In: General appearance, facies, and body habitus. of Jaccoud. Am Heart J 1983;105(3):515–517 Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby 28 Gellis SS, Feingold M. Rubinstein-Taybi syndrome. Am J Dis Elsevier; 7 September 2007:20, chap 1 Child 1971;121(4):327–328 10 Miranda WR, Nishimura RA. The history, physical examina- 29 Lewinn EB. Gynecomastia during digitalis ; report of tion, and cardiac auscultation. In: Fuster V, Harrington RA, Jagat eight additional cases with liver-function studies. N Engl J N, Eapen ZJ, eds. Hurst’s The Heart. 14th ed. New York, NY: Med 1953;248(8):316–320 McGraw-Hill Education; 2017:228 30 Muhammad I, Ahmed NS, eds. In: History taking and phys- 11 Farquhar JW. The child of the diabetic woman. Arch Dis Child ical examination. Bedside Techniques Methods of Clinical 1959;34(173):76–96 Examination. 4th ed. Karachi, Pakistan: Paramount Publishing 12 Perloff JK. The Clinical Recognition of Congenital Heart ­Disease. Enterprise;2013:18 5th ed. Philadelphia, PA: WB Saunders;2003 31 Edeiken J. Shoulder-hand syndrome following myocardi-

13 Rentería VG, Ferrans VJ, Roberts WC. The heart in the Hurler al infarction with special reference to prognosis. Circulation syndrome: gross, histologic and ultrastructural observations 1957;16(1):14–19 in five necropsy cases. Am J Cardiol 1976;38(4):487–501 32 Salvatore M. In: Chest inspection, palpation, and percussion. 14 Clarren SK, Smith DW. The fetal alcohol syndrome. N Engl J Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby Med 1978;298(19):1063–1067 Elsevier; 7 September 2007:378, chap 13 15 Cayler GG, Blumenfeld CM, Anderson RL. Further studies 33 Salvatore M. In: Chest inspection, palpation, and percussion. of patients with the cardiofacial syndrome. Chest Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby 1971;60(2):161–165 Elsevier; 7 September 2007:392, chap 13 16 Talley NJ, Simon O. Section 1: The general principles of 34 Salvatore M. In: Chest inspection, palpation, and percussion. history taking and physical examination. Examination Physical Diagnosis Secrets. 2nd ed. Philadelphia, PA: Mosby ­Medicine—E-Book. 8th ed. A Guide to Training. Elsevier; 7 September 2007:395, chap 13 15 October 2016:30 35 Straus SE, McAlister FA, Sackett DL, Deeks JJ; CARE-COAD2 17 Roberts NK, Perloff JK, Kark RAP. Cardiac conduction in the Group. Clinical Assessment of the Reliability of the Examina- Kearns-Sayre syndrome (a neuromuscular disorder associated tion-Chronic Obstructive Airways Disease. Accuracy of his- with progressive external ophthalmoplegia and pigmentary tory, wheezing, and forced expiratory time in the diagnosis retinopathy). Am J Cardiol 1979;44:1396 of chronic obstructive pulmonary disease. J Gen Intern Med 18 Hollenhorst RW. Significance of bright plaques in the retinal 2002;17(9):684–688 arterioles. JAMA 1961;178:23–29 36 Salvatore M. Physical Diagnosis Secrets. 2nd ed. Philadelphia, 19 Silverman KJ, Hutchins GM, Bulkley BH. Cardiac sarcoid: a clin- PA: Mosby Elsevier; 7 September 2007:7 icopathologic study of 84 unselected patients with systemic sarcoidosis. Circulation 1978;58(6):1204–1211 20 Jeresaty RM, Huszar RJ, Basu S. Pierre Robin syndrome. Cause of respiratory obstruction, cor pulmonale, and pulmonary edema. Am J Dis Child 1969;117(6):710–716

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