Approach to Clubbing 2018-01-30T16:37:04+00:00

Differential diagnosis

  • Cardiovascular
    • Atrial myxoma
    • Infective endocarditis
    • Cyanotic congenital heart disease
  • Respiratory
    • Bronchiectasis
    • Pulmonary fibrosis
    • Lung cancer
    • Mesothelioma
    • Tuberculosis
    • Lung abscess
    • Empyema
  • Gastrointestinal
    • Inflammatory bowel disease
    • Liver disease / cirrhosis
    • Coeliac disease
    • Chronic parasitic infection
  • Endocrine
    • Thyroid acropachy (Graves’ disease)
  • Human immunodeficiency virus
  • Polyneuropathy, organomegaly, endocrinopathy, M protein and skin changes (POEMS) syndrome
  • Hemiplegic stroke
  • Congenital (hypertrophic osteoarthropathy)

History

  • Clubbing
    • Duration
    • Unilateral (neurological or trauma causing ipsilateral aneurysm / AVM) / bilateral
    • Does it affect the hands and feet, or just the feet?
    • Family history of clubbing
  • Cardiovascular symptoms
    • Have you had a fever?
    • Do you have chest pain?
    • Have you experienced situations where you feel like you are about to faint or have fainted?
    • Have your lips or hands every turned blue?
    • Do you feel short of breath when you walk?
    • Do you ever wake up in the middle of the night feeling breathless?
    • How many pillows do you sleep on at night?
  • Respiratory
    • Have you been coughing recently?
    • Do you bring up phlegm when you cough?
    • What colour is the phlegm?
    • Is there any blood in the phlegm?
    • Did you have chest infections as a child?
    • What do you do for a living?
    • Have you ever been exposed to any dusts like asbestos or construction dusts?
    • Do you have any pets?
    • Do you have any joint pain or stiffness?
    • Do you have any rashes?
    • Have you had problems with mouth ulcers?
    • Do you, or have you ever, smoked?
    • Have you lost any weight recently?
    • Do you experience episodes of sweating at night?
  • Gastrointestinal
    • Has there been any recent change in the number of times per day that you pass motion?
    • Have you noticed a change in the colour of your stools?
    • Is there any blood in your stool?
    • Have you noticed that your stool floats on the surface of the toilet water instead of sinking?
    • Have you noticed that your stool has become unusually smelly?
    • Have you noticed any tummy pain?
    • Have you noticed a change in the colour of your skin or your eyes?
    • Have you noticed that your urine has become dark?
    • Do you find that you have an uncontrollable itch?
    • Have you noticed any bloating in your tummy or leg swelling?
  • Thyroid
    • Have tyou noticed that the weather is unusually hot or cold?
    • Have you ever experienced a sensation of your heart beating very fast?
    • Do your hands tremble?
    • Have you noticed that your periods have become heavier or more irregular?
  • HIV
    • Are you currently sexually active?
    • How many partners do you have?
    • Are they male or female?
    • Do you use any recreational drugs?

Examination

  • General inspection
    • Distribution of clubbing – unilateral / bilateral / hands and feet / feet only
    • Stigmata of infective endocarditis
    • Stigmata of chronic liver disease
    • Proptosis
    • Active arthritis / deforming polyarthropathy
    • Rashes
  • Pulse: rate, regular / irregular
  • Head and neck
    • Eye movements / lid lag
    • Scleral icterus (liver cirrhosis)
    • Palpable goitre
    • Cervical lymphadenopathy
  • Cardiovascular
    • Fixed, widely-split S2 (atrial septal defect)
    • Pan-systolic murmur (ventricular septal defect)
    • Continuous machinery murmur under left clavicle (patent ductus arteriosus)
    • Ejection systolic murmur (coarctation of the aorta, pulmonary stenosis)
  • Respiratory
    • Coarse pan-inspiratory crepitations (bronchiectasis)
    • Fine end-inspiratory crepitations (pulmonary fibrosis)
    • Decreased air entry, stony dull percussion note (empyema)
  • Gastrointestinal
    • Hepatosplenomegaly (POEMS syndrome)
    • Splenomegaly (hypersplenism secondary to cirrhosis)

Investigations

  • Blood tests
    • Thyroid function tests
    • Screening for human immunodeficiency virus
    • If organomegaly detected: look for M band
    • Full blood count (haematological malignancy)
    • Tests of synthetic function of the liver (albumin, prothrombin time)
    • Blood culture (infective endocarditis)
  • Chest radiograph
    • Bronchiectatic changes (tram lining, dilated bronchioles)
    • Reticular shadowing seen in pulmonary fibrosis
    • Rule out pleural effusion (empyema)
    • Look for cardiomegaly (cyanotic congenital heart disease)
  • Electrocardiogram
  • Echocardiogram
    • To look for congenital heart defects causing cyanosis
    • Valvular vegetations of infective endocarditis
  • Consider:
    • High resolution computed tomography scan of the lungs
    • Lung function testing
    • Colonoscopy / enteroscopy for inflammatory bowel disease

Management

  • Patient education
  • Treat the underlying cause
  • If the underlying cause is reversible or controllable (e.g. resection of large bowel in ulcerative colitis), clubbing may regress completely

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.