Be a Palm Reader
The residents and cardiology fellows who round with me know that I am a nut about physically examining the patient. It is amazing what you find, if you look, and if you look with a purpose. Sometimes, I don’t think a physical examination is really necessary, but I will do parts of it anyway, such as listening to the carotids, examining the neck and thyroid, listening to the heart. I tell my trainees in such instances that this is my “ceremonial examination”, designed to exert some human to human physical interaction.
One thing I stress is looking at the back for melanomas. I do not do a full skin examination because I’m a cardiologist, but I do look at patients’ backs because they can’t see what’s back there. I have found 11 in the 23 years because I look. I suspect my rate of finding these has decreased over the years because more patients get yearly skin checks, but patients with fewer financial assets do not have that luxury so I am especially careful to look in these folks. I look for the standard features of melanoma: variation in color, irregular border, raised lesion and very dark coloration. A melanoma does not need all of these, but when in doubt I ask the patient to see a dermatologist. I am always thrilled when a dermatologist calls to thank me.
I am also big on looking at palms. I usually look for evidence of Type III hyperlipidemia, that classic extreme yellowing of the palmar creases. I will blog more about this condition later because I have some great pictures of this, but the palm shows lots of other stuff. Rough palms indicate hard work without gloves, and I will comment, “You do a lot of hard physical work”. I admire people who work hard and want the patient to know I admire that. It lets them know I respect them . With the athletes I see, I will say, “So, you lift without gloves” to show them I am paying attention to stuff. You can also see yellowing of the palms from carotene in someone who eats a lot of carrots and yellow squash, like vegetarians, an important issue with my lipid patients. Hypothyroid patients also have yellow palms, and a yellowing of their skin in general, because the thyroid hormone accelerates carotene breakdown.
When I look at the palm, I pause a minute and say, “Your palm says ‘You’re going to meet a short, balding cardiologist.’ “ At least I, and a very occasional patient, thinks that’s funny.
Anyway, here is the palm of a 50ish year old patient who came to me with the diagnosis of hypertrophic cardiomyopathy (HCM). He had actually seen a world famous HCM expert, who agreed with the diagnosis. That is not a criticism of the expert; diseases evolve and the last MD who sees a patient has an enormous advantage. But look at the tendons to the 4th and 5th digits. The patient had also been told he was developing a Dupuytren’s contracture, but these are not a pre-Dupuytren’s phenomenon. These are amyloid deposits from transthyretin amyloidosis (TTR). Remember that TTR produces orthopedic injuries including carpal tunnel and tendon ruptures as an early presentation of the disease. This person does not have HCM, but TTR amyloid heart disease.
So, be a palm reader, and tell patients, “You’re going to meet a short, balding cardiologist” or some such self-disparaging comment. (Sorry to use the same line twice, but after 30+ years of saying it {I only started to go bald in my 40’s} I still think it’s a riot.)
