Published online: 2019-07-16 THIEME 42 Clinical Rounds General Physical Examination for a Cardiovascular Patient Jyotsna Maddury1 Shagun Aggarwal2 1Department of Cardiology, 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 Medical Genetics, 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. Cyanosis 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 disease 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 diseases.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 shoulder girdle facilitating the use of accessory respiratory 4. Petechiae and ecchymosis: The drugs that can produce muscles), which suggests pulmonary pathology 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 pathologies associated with CVDs, b. Tuberous xanthomas are yellowish, coalescing nodules such as viral hepatitis with myocarditis, or prosthetic valve seen on the elbows or knees. dysfunction (hemolysis), or from hemolysis following a large c. Eruptive xanthomas are seen on the arms, 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. Livedo reticularis: The marbling reticulation or fish- vascular disorders are accelerated atherosclerosis and net type of mottling is called the livedo reticularis. 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. Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4 No. 1/2019 44 Clinical Rounds 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-hip 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 hypertelorism 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, Pes cavus 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 lordosis 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 scoliosis 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