Peripheral cyanosis, fever, and clubbing

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Abbreviations: ABG= Arterial blood gas, ANP= Atrial natriuretic peptide, BNP= Brain natriuretic peptide, CBC= Complete blood count, COPD= Chronic obstructive pulmonary disease, CRP= C-reactive protein, CT= Computed tomography, CXR= Chest X-ray, DVT= Deep vein thrombosis, ESR= Erythrocyte sedimentation rate, HRCT= High Resolution CT, IgE= Immunoglobulin E, LDH= Lactate dehydrogenase, PCWP= Pulmonary capillary wedge pressure.

Diseases Cyanosis Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging
Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation CBC ABG Electrolytes Other X-ray CT scan Other
Pulmonary diseases Airway disorder Severe croup[1] + - + +/- - - - Stridor Lymphocytosis Normal Normal - Steeple sign Normal Distended hypopharynx during inspiration Clinical findings Intercostal and subcostal retraction, Barking cough
Epiglottitis[2] + - + + - - - Stridor Leukocytosis with neutrophilia Normal Normal - Thumb sign Normal - Laryngoscopy Muffled voice, Drooling
Foreign body aspiration[3] + - + - +/- - - Decreased breath sounds, Wheezing Normal Normal Normal - Hyperinflation, Atelectasis, Objects Foreign body entrapment with edema or granulation tissue - Bronchoscopy Mediastinitis
Bacterial tracheitis[4] + - + + + - - Inspiratory stridor Leukocytosis Normal Normal Blood culture, Gram stain Irregular tracheal margin Normal Steeple sign (confusing) Laryngotracheobronchoscopy Brassy cough, Hoarseness
Parenchymal disorder Alveolitis[5] +/- + + + + +/- - Wheeze, Crackles Leukocytosis, Eosinophilia O2, ↑CO2 Normal ESR, ↑CRP Scattered opacities, Fine reticulation Homogeneous ground-glass opacity - HRCT PLUS Clinical findings Malaise, Chills, Headache
Cystic fibrosis[6] + - + +/- +/- + - Wheeze, Crackles Normal O2, ↑CO2 Increased sweat chloride Sweat chloride test Hyperinflation, Nodules Peribronchial thickening, Bronchiectasis - Sweat chloride test Absent vas deferens
COPD

(Severe emphysema)[7]

+ - + +/- + +/- +/- Reduced breath sounds, Wheeze, Inspiratory crackles Polycythemia O2, ↑CO2 Normal Alpha 1-antitrypsin test Elongated heart, Flattened diaphragms, Prominent hilar vasculature Bullae - HRCT Pulmonary hypertension, Right heart failure
Pulmonary vascular disorders Massive pulmonary embolism[8] + - + +/- + - +/- Reduced breath sounds, Crackles, Loud P2 Leukocytosis O2, ↑CO2, Respiratory acidosis Normal D-dimer, BNP Fleischner sign, Hampton hump, Westermark sign, Pleural effusion  Filling defects in the pulmonary vasculature Spiral CT pulmonary angiogram Spiral CT pulmonary angiogram Tachycardia, Shock, Pulmonary hypertension
Chest wall disorders Flail chest[9] + - + - + - - Normal Normal O2, ↑CO2 Normal - ≥3 adjacent ribs with segmental fractures, >5 adjacent rib fractures Normal - CXR Bruises over chest
Pneumothorax[10] + - + - + - - Diminished breath sounds Normal O2, ↑CO2 Normal - No lung marking on one side, Collapsed lung Loculated air in thoracic cavity M-mode ultrasonography Chest CT scan Tachypnea
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation CBC ABG Electrolytes Other X-ray CT scan Other Gold standard Additional findings
Cardiac diseases Congenital disorders Atrioventricular canal defect[11] +/- + + - +/- +/- - Wheezing,Holosystolic or systolic ejection murmur Normal Normal Normal Pulse oximetry Cardiomegaly, Increased pulmonary vascular markings Normal Echocardiography, MRI Echocardiography Tachypnea, Lack of appetite, Pale skin color, Excessive sweating
Acquired disorders Heart failure[12] + - + +/- + - + Coarse crackles, S3 Anemia O2, ↑CO2 Hyponatremia, Hypokalemia, Hypomagnesemia Elevated BNP Pleural effusion, Cardiomegaly Kerley B lines Normal Radioisotope scan Echocardiography Generalized edema, Hepatomegaly
Valvular heart disease[13] + - + - - - + Murmurs Schistocyte Normal Normal Hyperthyroidism Valve calcification Normal Valvular dysfunction in echocardiography Echocardiography Syncope, Palpitation
Cardiogenic shock[14] +/- + + - - - + Muffled heart sound Anemia O2, ↑CO2 Hyperkalemia PaO2 in pulse oximetry Normal Normal Echocardiography  Clinical findings Tachypnea, Palpitation, Hypotension, Weak pulse
Vascular disease Arterial disorders Acrocyanosis[15] + - +/- - - + - Normal Anemia, Leukocytosis O2, ↑CO2 Hypercalcemia PaO2 in pulse oximetry Normal Normal - Clinical findings Brittle nails, Telangiectasia
Arterial embolism[16] + - + - + +/- - Normal Normal Normal Hyperkalemia PaO2 in pulse oximetry Normal Normal Transesophageal echocardiography (TEE) Clinical findings Headache, Decreased sensation
Raynaud's Phenomenon[17] + - - - - + - Normal Polycythemia O2 Normal Mild ↓PaO2 in pulse oximetry Normal Normal - Clinical findings Sensitivity to cold, Decreased sensation
Venous disorders Superior vena cava obstruction[18] + - +/- - +/- +/- + Normal Polycythemia O2 Normal PaO2 in pulse oximetry Superior mediastinal widening, Right hilar prominence  Thrombosis, Mediastinal mass or lymphadenopathy, Associated lung mass - Chest CT scan Headache,

Facial swelling

Venous stasis[19] + - - - - +/- + Normal Polycythemia O2 Hypercalcemia Normal Normal Normal Color-flow duplex ultrasound Color-flow duplex ultrasound Leg swelling, Pain during walking,

Leg ulcers

Hematologic diseases Polycythemia[20] + + + +/- +/- + - Normal RBC, ↑WBC, ↑HGB, ↑Plt O2 Hyperkalemia Leukocyte alkaline phosphatase, ↑Ferritin, ↑Erythropoietin AVM, COPD, pulmonary hypertension Normal Abdominal ultrasound or renal vascular studies for ruling out renal artery stenosis RBC mass (RCM) and plasma volume measurement Itchiness, Headache. Dizziness. Blurred vision
Miscellaneous High altitude exposure[21] +/- + + - +/- + - Wheezing Polycythemia O2, ↓CO2, Respiratory alkalosis Hyperphosphatemia, Hypercalcemia, Hyponatremia, Hypokalemia, Hypomagnesemia Decreased bicarbonate Central interstitial edema Pulmonary consolidation - Hypoxic challenge test Dizziness, Coma, Death
Septic shock[22] + - + + +/- - - Rales, crackles, Wheeze, Pleural friction rub Leukocytosis with neutrophilia O2, ↑CO2, Metabolic acidosis Hyperkalemia ESR, ↑CRP Consolidation Pulmonary infiltration Echocardiography Blood culture Chills, Hypothermia, Loss of consciousness
Smoke inhalation[23] +/- + + - + - - Wheezing Anemia, Carboxyhemoglobin O2, ↑CO2, Respiratory acidosis Normal CO-oximetry Diffuse opacities Pulmonary infiltration Pulmonary function testing Bronchoscopy Cough, Hoarseness, Hemoptysis, Headache, Fainting
Cold exposure[24] + - +/- - - - - Normal Leukopenia, ↑RBC O2, ↑CO2, Metabolic acidosis Hypokalemia, Hypocalcemia Hyperglycemia, ↑CK Normal Normal - Clinical findings Confusion, Tachycardia/Bradycardia, Coma

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