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

Differential diagnosis

Abbreviations: AP= Anteroposterior, CXR= Chest X-ray, CT= Computed tomography, ABG= Arterial blood gas, V/Q= Ventilation/perfusion scan , EKG= Electrocardiogram, COPD= Chronic obstructive pulmonary disease, BNP= Brain natriuretic peptide, DVT= Deep vein thrombosis, HRCT= High Resolution CT, IgE= Immunoglobulin E

Causes of cyanosis Disease Cyanosis Clinical manifestations/association Diagnosis Additional

findings

Symptoms Signs
Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard
Respiratory Airway

disorder

Severe croup[1] Audible stridor at rest AP Neck X ray for soft tissues:

Lateral neck X ray:

Clinical diagnosis
  • Croupy cough and stridor
  • Intercostal, subcostal retractions
Epiglottitis Stridor Lateral neck X ray
Foreign body aspiration CXR

CT scan

Complications:
Bacterial tracheitis Lateral neck X ray
  • Brassy cough
  • Retractions
  • No drooling
  • Hoarseness
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Parenchymal

disorder

Pneumonia
  • CXR
  • CT chest
  • Bronchoscopy
  • Sputum culture and gram stain
  • Blood cultures
  • Urine antigen
Asthma

(Late)

✔ in interstitial lung disease
  • End expiratory wheeze
  • Absent wheeze and breath sounds in severe form
CXR
  • to rule out other diagnosis
  • complications like pneumonia, atelactasis

HRCT

Cystic fibrosis when infected Wheeze or crackles CXR

HRCT for detecting lung changes

  • Clinical history
  • Sweat test
COPD

(Severe emphysema)

  • Reduced breath sounds
  • Prolonged expiration
  • Wheeze
  • Inspiratory crackles
CXR
  • Elongated heart
  • Flattening of diaphragms
  • Prominent hilar vasculature

HRCT

  • Bullae
  • HRCT
  • Spirometry (FEV1) to assess severity
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Pulmonary vascular disorders Massive pulmonary embolism
  • Reduced breath sounds
  • Rales, crackles
  • Loud P2
Pulmonary arterio-venous malformation[2][3][4]
  • Pulmonary bruit
CXR
  • Round/oval mass
    • lobulated
    • well defined
  • Connecting vessel in hilum
  • Hemothorax
Chest

wall

disorders

Flail chest
Cardiovascular Pneumothorax
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings

Atrioventricular canal defect

+ ± +

(splitting of the S2)

  • CXR (Cardiac enlargement, Increased pulmonary vascular markings)
Ebstein anomaly + ± +
Hypoplastic left heart syndrome + ± +
Pulmonary atresia + ± +
Tetralogy of Fallot + ± +
Pulmonic stenosis + ± +
Total anomalous pulmonary venous drainage + ± +
Transposition of the great vessels + ± +
Truncus arteriosus + ± +
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Heart failure + + + +

(S3)

  • CXR
    • Increase in heart size compared to the old film.
    • Pleural fluid
    • Interstitial edema
  • Echocardiography
  • Angiography
  • Cardiac MRI
  • Nuclear imaging
  • Endomyocardial biopsy can be used when a specific diagnosis is suspected that would influence therapy in heart failure patients.
Valvular heart disease ± + +
  • CBC
  • Complete metabolic profile
  • Cardiac enzymes
  • BNP
  • Thyroid profile
  • Renal function tests
  • EKG
  • CXR
    • To assess pulomary congestion or other lung pathology.
  • Echocardiography
  • Doppler echocardiography
  • Angiography
    • To assess the need for concomitant coronary artery bypass surgery in elderly people.
Myocardial infarction + + +
  • CBC
  • Complete metabolic profile
  • Cardiac enzymes
  • BNP
  • Thyroid profile
  • Renal function tests
  • EKG
  • Lipid profile
  • CXR
    • Normal or may show signs of CHF
  • Echocardiography
  • Angiography
Central Nervous system Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Methemoglobinemia + + +
  • CBC
  • Peripheral smear
  • Complete metabolic profile
  • Hemoglobin electrophoresis
  • Serum nitrite levels
  • Pulse oximetry
  • ABG's
  • Drug screen
  • LDH
  • CXR
  • EKG
Family history of methemoglobinemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency is important to determine.
Polycythemia + +
  • CBC
    • Raised all cell lines in primary and only raised erythrocytes in secondary polycythemia
  • Pulse oximetry
  • Erythropoietin levels (EPO)
  • Ferritin levels
  • ABG's
  • Increased leukocyte alkaline phosphatase
  • B12 levels
  • JAK 2 mutation
  • CXR
  • EKG
Tenderness in the sternum may indicate transformation to acute myeloid leukemia and should be properly investigated.
Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Breath holding spells
  • No confirmatory study
  • CBC
  • Serum ferritin
  • Blood lead level
  • video-EEG monitoring can be use in non diagnostic cases.
  • Cyanotic breath-holding spells most commonly occur around 1 year of age with a range of six months to four years.
  • Iron deficiency anemia is more prevalent in children with breath-holding spells. 
Miscellaneous Shock + + (septic shock) + + (Cardiogenic shock)
  • Complete metabolic profile
  • CBC
  • Cardiac enzymes
  • ABG's
  • Lactate
  • BNP
  • Renal function tests
  • Coagulation studies and D-dimer level
  • Echocardiography
  • Chest radiography
  • Angiography
Smoke inhalation + + +
  •  CBC

Electrolytes

BUN and CR,

Lactate levels

Toxicology screen

CO-oximetry 

    • CXR
    • ECG
    • Serial cardiac enzymes (in patients with chest pain)\
    • Pulmonary function testing
    • Direct laryngoscopy and fiberoptic bronchoscopy
  • CO toxicity should be suspected in any patient who presents following smoke inhalation unless co-oximetry shows normal carboxyhemoglobin.
Cold exposure
  • Fingerstick glucose (Hyperglycemia)
  • Electrocardiogram (ECG) may show J wave, sinus bradycardia and prolongation of all ECG intervals.
  • Serum electrolytes (including potassium and calcium)
  • BUN and creatinine
  • Serum hemoglobin, white blood cell, and platelet counts ( Raised HCT due to volume contraction)
  • Coagulation profile (clotting factors impairment)
  • Serum lactate ( lactic acidosis)
  • Creatine kinase (Rhabdomylosis)
  • Arterial blood gas
  • CXR
  • Mild hypothermia: core temperature 32 to 35°C ; patient presents with confusion, tachycardia, and increased shivering.
  • Moderate hypothermia: 28 to 32°C patient presents with lethargy, bradycardia and arrhythmia and decreased shivering.
  • Severe hypothermia: below 28°C patient presents with coma, hypotension, arrhythmia, pulmonary edema, and rigidity.
  1. Cherry, James D. (2008). "Croup". New England Journal of Medicine. 358 (4): 384–391. doi:10.1056/NEJMcp072022. ISSN 0028-4793.
  2. Khurshid I, Downie GH (2002). "Pulmonary arteriovenous malformation". Postgrad Med J. 78 (918): 191–7. PMC 1742331. PMID 11930021.
  3. Doshi HM, Robinson S, Chalhoub T, Jack S, Denison A, Gibson G (2009). "Massive spontaneous hemothorax during the immediate postpartum period". Tex Heart Inst J. 36 (3): 247–9. PMC 2696501. PMID 19568398.
  4. Chanatry BJ (1992). "Acute hemothorax owing to pulmonary arteriovenous malformation in pregnancy". Anesth. Analg. 74 (4): 613–5. PMID 1554132.