presence of lymphadenopathy, especially supra- clavicular lymphadenopathy (Virchow’s node), suggests metastatic abdominal malignancy. Care should be taken during the cardiac examination to evaluate for elevation of jugular venous pressure (JVP); Kussmaul’s sign (elevation of the JVP during inspiration); a pericardial knock, which may be seen in heart failure or constrictive pericarditis; or a murmur of tricuspid regurgitation. Spider angio- mas, palmar erythema, dilated superficial veins around the umbili- cus (caput medusae), and gynecomastia suggest chronic liver disease.