Peripheral cyanosis, dyspnea, and chest pain

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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 Foreign body aspiration[1] + - + - +/- - - Decreased breath sounds, Wheezing Normal Normal Normal - Hyperinflation, Atelectasis, Objects Foreign body entrapment with edema or granulation tissue - Bronchoscopy Mediastinitis
Bacterial tracheitis[2] + - + + + - - Inspiratory stridor Leukocytosis Normal Normal Blood culture, Gram stain Irregular tracheal margin Normal Steeple sign (confusing) Laryngotracheobronchoscopy Brassy cough, Hoarseness
Parenchymal disorder Alveolitis[3] +/- + + + + +/- - 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[4] + - + +/- +/- + - 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)[5]

+ - + +/- + +/- +/- 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[6] + - + +/- + - +/- 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[7] + - + - + - - Normal Normal ↓O2, ↑CO2 Normal - ≥3 adjacent ribs with segmental fractures, >5 adjacent rib fractures Normal - CXR Bruises over chest
Pneumothorax[8] + - + - + - - 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
Cardiac diseases Congenital disorders Atrioventricular canal defect[9] +/- + + - +/- +/- - 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[10] + - + +/- + - + Coarse crackles, S3 Anemia ↓O2, ↑CO2 Hyponatremia, Hypokalemia, Hypomagnesemia Elevated BNP Pleural effusion, Cardiomegaly Kerley B lines Normal Radioisotope scan Echocardiography Generalized edema, Hepatomegaly
Vascular disease Arterial disorders Arterial embolism[11] + - + - + +/- - Normal Normal Normal Hyperkalemia ↓PaO2 in pulse oximetry Normal Normal Transesophageal echocardiography (TEE) Clinical findings Headache, Decreased sensation
Venous disorders Superior vena cava obstruction[12] + - +/- - +/- +/- + 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

Hematologic diseases Polycythemia[13] + + + +/- +/- + - 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[14] +/- + + - +/- + - 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[15] + - + + +/- - - 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[16] +/- + + - + - - Wheezing Anemia, Carboxyhemoglobin ↓O2, ↑CO2, Respiratory acidosis Normal CO-oximetry Diffuse opacities Pulmonary infiltration Pulmonary function testing Bronchoscopy Cough, Hoarseness, Hemoptysis, Headache, Fainting

References

  1. ↑ Qureshi A, Behzadi A (2008). "Foreign-body aspiration in an adult". Can J Surg. 51 (3): E69–70. PMC 2496600. PMID 18682760.
  2. ↑ Liston SL, Gehrz RC, Siegel LG, Tilelli J (August 1983). "Bacterial tracheitis". Am. J. Dis. Child. 137 (8): 764–7. PMID 6869336.
  3. ↑ Lee JS, Im JG, Ahn JM, Kim YM, Han MC (August 1992). "Fibrosing alveolitis: prognostic implication of ground-glass attenuation at high-resolution CT". Radiology. 184 (2): 451–4. doi:10.1148/radiology.184.2.1620846. PMID 1620846.
  4. ↑ "Cystic fibrosis - Genetics Home Reference".
  5. ↑ Qureshi H, Sharafkhaneh A, Hanania NA (2014). "Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications". Ther Adv Chronic Dis. 5 (5): 212–27. doi:10.1177/2040622314532862. PMC 4131503. PMID 25177479.
  6. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
  7. ↑ Pettiford BL, Luketich JD, Landreneau RJ (February 2007). "The management of flail chest". Thorac Surg Clin. 17 (1): 25–33. doi:10.1016/j.thorsurg.2007.02.005. PMID 17650694.
  8. ↑ Luh SP (2010). "Review: Diagnosis and treatment of primary spontaneous pneumothorax". J Zhejiang Univ Sci B. 11 (10): 735–44. doi:10.1631/jzus.B1000131. PMC 2950234. PMID 20872980.
  9. ↑ Macris MP, Ott DA, Cooley DA (1992). "Complete atrioventricular canal defect: surgical considerations". Tex Heart Inst J. 19 (3): 239–43. PMC 326195. PMID 15227445.
  10. ↑ Inamdar AA, Inamdar AC (2016). "Heart Failure: Diagnosis, Management and Utilization". J Clin Med. 5 (7). doi:10.3390/jcm5070062. PMC 4961993. PMID 27367736.
  11. ↑ Lyaker MR, Tulman DB, Dimitrova GT, Pin RH, Papadimos TJ (2013). "Arterial embolism". Int J Crit Illn Inj Sci. 3 (1): 77–87. doi:10.4103/2229-5151.109429. PMC 3665125. PMID 23724391.
  12. ↑ Cohen R, Mena D, Carbajal-Mendoza R, Matos N, Karki N (2008). "Superior vena cava syndrome: A medical emergency?". Int J Angiol. 17 (1): 43–6. PMC 2728369. PMID 22477372.
  13. ↑ Spivak JL (February 2002). "The optimal management of polycythaemia vera". Br. J. Haematol. 116 (2): 243–54. PMID 11841424.
  14. ↑ Parati G, Agostoni P, Basnyat B, Bilo G, Brugger H, Coca A, Festi L, Giardini G, Lironcurti A, Luks AM, Maggiorini M, Modesti PA, Swenson ER, Williams B, Bärtsch P, Torlasco C (January 2018). "Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions". Eur. Heart J. doi:10.1093/eurheartj/ehx720. PMID 29340578.
  15. ↑ Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL (2016). "Sepsis and septic shock". Nat Rev Dis Primers. 2: 16045. doi:10.1038/nrdp.2016.45. PMC 5538252. PMID 28117397.
  16. ↑ Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL (2009). "Pathophysiology, management and treatment of smoke inhalation injury". Expert Rev Respir Med. 3 (3): 283–297. doi:10.1586/ERS.09.21. PMC 2722076. PMID 20161170.
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