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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:

  • 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

  • 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
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

+ ± +
  • CXR (Cardiac enlargement, Increased pulmonary vascular markings)
Ebstein anomaly + ± +
  • CXR (Cardiac enlargement, decreased pulmonary vascular markings)
Tetralogy of Fallot + ± + (systolic)
  • CXR (Boot shaped heart, decreased pulmonary vascular markings)
Pulmonic stenosis + ± + (systolic)
  • CXR (Cardiac enlargement, decreased pulmonary vascular markings)
Total anomalous pulmonary venous connection + ± + (Systolic)
  • CXR (normal heart size and venous congestion but in patients without obstruction have cardiomegaly and increased pulmonary blood flow.)
Transposition of the great vessels + ± -
  • CXR (Cardiac enlargement, increased pulmonary vascular markings)
Truncus arteriosus + ± sys/±dias
  • CXR (Cardiac enlargement, increased pulmonary vascular markings)
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 ± + +
Myocardial infarction + + +
Central Nervous system Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Methemoglobinemia + + + Family history of methemoglobinemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency is important to determine.
Polycythemia + + 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
  • 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)
Smoke inhalation + + +

Electrolytes

BUN and CR,

Lactate levels

Toxicology screen

CO-oximetry 

  • CO toxicity should be suspected in any patient who presents following smoke inhalation unless co-oximetry shows normal carboxyhemoglobin.
Cold exposure
  • 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.








Causes of cyanosis 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[5] 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










Coma
Seizures
Head trauma
Breath holding spells
Miscellaneous Shock
Smoke inhalation + + +
Cold exposure
  • CBC
  • Fingerstick glucose (Hyperglycemia)
  • EKG-
    • J wave
    • Sinus bradycardia
    • Prolongation of all ECG intervals.
  • Serum electrolytes -K+ and calcium
  • ABG
Drugs†



  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.
  5. Cherry, James D. (2008). "Croup". New England Journal of Medicine. 358 (4): 384–391. doi:10.1056/NEJMcp072022. ISSN 0028-4793.


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:

  • 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

  • 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
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

+ ± +
  • CXR (Cardiac enlargement, Increased pulmonary vascular markings)
Ebstein anomaly + ± +
  • CXR (Cardiac enlargement, decreased pulmonary vascular markings)
Tetralogy of Fallot + ± + (systolic)
  • CXR (Boot shaped heart, decreased pulmonary vascular markings)
Pulmonic stenosis + ± + (systolic)
  • CXR (Cardiac enlargement, decreased pulmonary vascular markings)
Total anomalous pulmonary venous connection + ± + (Systolic)
  • CXR (normal heart size and venous congestion but in patients without obstruction have cardiomegaly and increased pulmonary blood flow.)
Transposition of the great vessels + ± -
  • CXR (Cardiac enlargement, increased pulmonary vascular markings)
Truncus arteriosus + ± sys/±dias
  • CXR (Cardiac enlargement, increased pulmonary vascular markings)
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 ± + +
Myocardial infarction + + +
Central Nervous system Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings
Methemoglobinemia + + + Family history of methemoglobinemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency is important to determine.
Polycythemia + + 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
  • 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)
Smoke inhalation + + +

Electrolytes

BUN and CR,

Lactate levels

Toxicology screen

CO-oximetry 

  • CO toxicity should be suspected in any patient who presents following smoke inhalation unless co-oximetry shows normal carboxyhemoglobin.
Cold exposure
  • 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.








Causes of cyanosis 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[5] 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










Coma
Seizures
Head trauma
Breath holding spells
Miscellaneous Shock
Smoke inhalation + + +
Cold exposure
  • CBC
  • Fingerstick glucose (Hyperglycemia)
  • EKG-
    • J wave
    • Sinus bradycardia
    • Prolongation of all ECG intervals.
  • Serum electrolytes -K+ and calcium
  • ABG
Drugs†



  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.
  5. Cherry, James D. (2008). "Croup". New England Journal of Medicine. 358 (4): 384–391. doi:10.1056/NEJMcp072022. ISSN 0028-4793.