CLUBBING

IS THE BULBOUS SWELLING OF THE TERMINAL PART OF THE FINGERS AND TOES WITH AN INCREASE IN THE SOFTISSUE MASS , AND INCREASED AP AND TRANSVERSE DIAMETER OF NAILS DUE TO THE PROLIFERATION OF SUBUNGAL CONNECTIVE TISSUE

ONYCHO-DERMAL ANGLE
ANGLE BETWEEN THE NAIL AND NAILFOLD . LOVIBONDS ANGLE NORMAL - 120 DEGREES . LOVIBONDS SIGN

HOW DO U EXAMINE
STEPS KEEP FINGERS AT THE EYE LEVEL -- GRADES SCHAMROTHS S SIGN DIAMOND SHAPED .

GRADING 1 TO 4
1. SOFTENING OF THE NAILBED / INCREASED FLUCTUATION OF THE NAILBED WITH LOSS OF ONYCHODERMAL ANGLE . 2. 1 + INCREASE IN AP AND TRANSVERSE DIAMETERS OF NAIL . 3. 2 + INCREASED PULP TISSUE PARROT BEAK .

4. 3+ swelling in the wrist and ankle due to HOA HYPERTROPHIC OSTEOARTHROPATHY.(HOPA)

CLUBBING----HOPA
DUE TO SUBPERIOSTEAL NEW BONE FORMATION in lower end of radius , ulna , fibula . Seen in Bca .

..

CAUSES OF CLUBBING
CARDIAC 1. SABE 2. CONGENITAL CYANOTIC FALLOTS 3. CARDIAC TUMOURS .

PULMONARY CAUSES
LUNG AND PLEURAL 1.Bronchiectasis 2.Lung abscess 3.B ca 4.Cystic fibrosis 5.Fibrocaseous TB 6.Empyema thoracis 7.Pleural mesothelioma 8.Fibrosing alveolitis

Gi causes
Ulcerative colitis Biliary cirrhosis Malabsorption syndrome. Crohns disease Polyposis coli Coeliac disease

Other causes
Normal --- idiopathic Seen in some families Genetic Thyrotoxicosis Asbestosis Sarcoidosis Amoebic liver abscess Portal cirrhosis Occupational in jack hammer workers.

Opposite of clubbing
?

koilonychia
Iron deficiency anaemia Idiopathic or familial Onycholysis Overuse of solvents Very rarely in thyrotoxicosis.

Painful clubbing
In bronchogenic ca SBE

UNILATERAL CLUBBING ? WHERE ?????

Unilateral
Presubclavian co arctation of aorta lt sided clubbing. CERVICAL RIB ANEURYSM OF SUBCLAVIAN ARTERY ERYTHROMELALGIA B ca Av fistula of brachial vessels ?????UNIDIGITAL CLUBBING???????

unidigital
Hereditary Local trauma Gout-rare Sarcoidosis

Pseudo clubbing
Acromegaly Scleroderma Hyperparathyroidism

Mech of CLUBBING
1.anoxia- so opens up the the deep a v fistulas 2.toxic eg SABE 3.Reflex vagotomy often improves the clubbing in br ca . 4.Metabolic eg thyrotoxicosis 5.Humoral increased GH acromegaly. 6.Pressure changes between radial and digital arteries. 7.Reduced ferritin .

THANK S

CYANOSIS
BLUISH DISCOLORATION OF SKIN AND MUCOUS MEMBRANE DUE TO PRESENCE OF INCREASED AMOUNT OF REDUCED HAEMOGLOBIN IN THE BLOOD (> 5gm/dl)

types
Central Decreased arterial oxygen due to reduction in O2 tension in arterial blood . Sites Tongue , inner aspect of lips . Mucous membrane of gum ,soft palate and cheeks. Lower palpebral conjunctiva .

Causes- central cyanosis

Fallots Ac pulmo oedema Eisenmengers syndrome Acute severe asthma Copd . Cor pulmonale Lobar pneumonia Fibrosing alveolitis Tension pneumothorax , high altitude . Acute laryngeal edema. Pulmo t emboli

Peripheral cyanosis
Sites Tip of nose . Ear lobules . tip of fingers and toes Nail bed , palms and soles .

In this type the arterial blood is saturated but there is 02 unsaturation at the venous end of capillary .

Peripheral cyanosis
Exposure to cold air/water Ccf Frost bite Raynauds phenomenon Shock Hyperviscosity syndrome Pvd s

Pigment/enterogenous cyanosis
Due to presence of excessive sulphaemoglobin (>.5gm/dl)or methhaemoglobin(>1.5gm/dl) in the blood . Eg Hereditary haemoglobin M disease Aniline dye poisoning .sweets Drugs nitrates ,sulphonamides

D/d s
C0 poisoning Argyria- in silver poisoning silver grey skin Osteogenesis imperfecta only sclera blue Drugs amiodarone .

Dd s
Hands red and feet blue ? PDA with reversal of shunt.

Hands blue and feet red ?? Co arctation of aorta with transposition of great vessels .

cyanosis
central Sites Handshake warm O 2 response improves Clubbing and polycythemia usually present Pulse volume -may be high Dyspnoea often breathless peripheral - Cold No response Absent

Low volume No respi distress .

cyanosis
Other sites for central cyanosis Nasal mucous membrane Rectal mucous membrane Retina by by opthalmoscopy.

---both cyanosis and polycythemia in ---conge cyanotic h diseaseand COPD .

THANK YOU ALL

DR JAMES PALLIVATHUKKAL- MD CO OP HOSPITAL , KOOTHATTUKULAM COCHIN