This document discusses clubbing, cyanosis, edema, and jaundice. It defines clubbing and describes the grading and causes. It also defines cyanosis, distinguishing central and peripheral types. Edema is defined and causes discussed including low oncotic pressure and increased capillary permeability. Jaundice is defined as excess bilirubin in blood and potential physical exam findings are outlined depending on the underlying etiology.

1.  CHAIRPERSON – Dr.KALINGA.B.E
 STUDENT – Dr. VINAYKUMAR

2.  Defn- Is the bulbous swelling of the terminal
part of the fingers and the toes with an
increase in the soft tissue mass and increased
anteroposterior ,transverse diameter of the
nail due to proliferation of subungual
connective tissue ,interstitial edema, and
dilatation of arterioles and capillaries

8. Digital index- Objective measurement of clubbing
Circumference at nail bed is divided by the
circumference of the distal interphalangeal joint
The individual ratio of 10 fingers are added and
now divided by 10
If > 1 clubbing to be present

9.  Grade I –Increased fluction of nail bed with
loss of onychodermal angle
 Grade II –Increase in AP and Transverse
diameter of the nails as well as nail become
smooth and glossy with loss of longitudinal
ridge
 Grade III – Increased pulp tissue,Parrot
beak/Drumstick
 Grade IV – Wrist and ankle swelling due to
HOA

10. HYPERTROPHIC PULMONARY OSTEOARTHROPATHY
• Subperiosteal new bone formation at the lower end of
radius,ulna,tibia
• Swelling ,Pain in wrist , ankle, elbow and knee
•Also other bones like ribs ,clavical,scapula may be affected
• Seen in Bronchogenic carcinoma(Squamous)
• Familial(Pachydermoperiostitis) or Idiopathic

11.  Neurogenic-Vagal stimulation
 Humoral- GH,PTH,Estrogen,Bradykinin,PG
 Ferritin - Decreased
 Hypoxia-Persistent hypoxia causes opening
of deep AV fistula of the terminal phalanx
 Toxic-SBE
 Metabolic-Thyrotoxicosis
 PDGF-Released secondary to infection(latest
and most acceptable)

12. PULP TISSUE INCREASE DUE TO-
o Proliferation of subungual connective tissue
o Interstitial Oedema
o Dilatation of arterioles and capillaries or Opening of
anastomoting channels at nail bed

13. Cardiac causes
 Cyanotic congenital heart diseases like
 Fallot’s tetralogy
 SBE
 Atrial myxoma
 Primary pulmonary hypertension
 Eisenmenger’s syndrome

14. Lung and Pleural causes
Bronchogenic carcinoma (rare in adenocarcinoma)
b. Metastatic lung cancer
c. Suppurative lung disease
1. Bronchiectasis
2. Cystic fibrosis
3. Lung abscess
4. Empyema
d. Interstitial lung disease
e. Longstanding pulmonary tuberculosis
f. Chronic bronchitis
g. Mesothelioma
h. Neurogenic diaphragmatic tumour
i. Pulmonary AV malformation
j. Sarcoidosis
k. Fibrosing Alveolitis

15. Gastro Intestinal Causes-
oUlcerative colitis
oBiliary cirrhosis , Hepato cellular carcinoma
o Malabsorption syndrome,
oCrohns disease,
oPolyposis coli,
oCoeliac Disease
oGI malignancy

16. Miscellaneous
oSyphilis
oSyringomyelia
oAcromegaly
oThyrotoxicosis
oNormally in some people
oGenetic

17. PAINFUL CLUBBING-
Brochogenic Carcinoma
SBE
Lung abscess
REVERSIBLE CLUBBING
Lung abscess
Empyema Thoracis
UNILATERAL CLUBBING
Presubclavian coarctation of aorta
Bronchogenic carcinoma
Pancoast tumour
Cervical rib
Aneurysm of subclavian or Axillary artery
Hemiplegia
Erythromelalgia
Arteriovenous fistula of brachial vessels

18. UNIDIGITAL CLUBBING
Hereditary
Repeated local trauma
Median nerve injury or Deposition of tophi
Sarcoidosis
CLUBBING LIMITED TO UPPER EXTREMITY
Chronic obstructive phlebitis of upper extremity in chronic IV drug user
CLUBBING LIMITED TO LOWER EXTREMITY
Infective abdominal aortic aneurysm
PDA with reversal of shunt
ACUTE CLUBBING – Very rapidly as early as 10-14 days after the
onset of illness like Lung abscess ,Empyema thorasis

19.  Subperiosteal bone resorption of terminal
phalanges
Seen in
Scleroderma
Acromegaly
Hyperparathyrodism
Leprosy
People working with vinyl chloride

20.  Kyanos –dark blue color , osis- condition
 Def – Bluish discoloration of the skin and
mucous membrane due to presence of
increased amount of reduced haemoglobin
>5g/dl or Haemoglobin derivatives in the
capillary blood

21.  A) CENTRAL CYANOSIS
 B) PERIPHERAL CYANOSIS
 C) Others- Enterogenous,
Mixed
Diffrential cyanosis

24. PATHOPHYSIOLOGY
 Decreased arterial oxygen saturation(80-85%)
due to imperfect oxygenation of blood in
lungs or admixture of venous and arterial
blood
 Sites- Tongue
Inner aspect of lips
Mucous membrane of gum,palate,cheeks
Lower palpebral conjunctiva
Others-Nasal and Rectal Mucous
membrane Retina

25. Mech- Hypoxic hypoxia
Causes- Cynotic heart disease
Acute pulmonary edema
Eisenmengers syndrome
Acute severe asthma
COPD, Cor pulmonale
Resp failure ,Resp depression
Lobar pneumonia
Fibrosing alveolitis
Tension pneumothorax
Acute laryngeal edema
Acute pulmonary thromboembolism
Pulmonary artetiovenous fistula

26. Sites- Tip of nose
Ear lobules
Outer aspect of lips,chin,cheek
Tip of fingers and toes
Nail bed of fingers and toes
Palms and soles

27. Pathophysiology-
Arterial blood normally saturated but there is oxygen
unsaturation due to excessive extraction of oxygen at venous
end of capillary
Mech- Stagnant as well as over utelisation
hypoxia
oReduced cardiac output
oPeripheral Vasoconstriction
oSlow speed of circulation in the extremities

28. Causes of Perpheral cyanosis
a) Exposure to cold air or cold water
b) Congestive cardiac failure
c) Frost bite
d) Raynaud’s phenomenon
e) Shock or peripheral circulatory failure
f) Venous obstruction-SVC Syndrome
g) Hyperviscosity syndrome-
MM,Polycythemia,Macroglobulinaemia
h) Arterial obstruction
i) Cryoglobulinaemia-Abnormal globin-gel low temp
j) Mitral stenosis
k) Septicaemia

29. FEATURES CENTRAL PERIPHERAL
Sites Tongue and Oral cavity Tongue uneffected
Handshake Warm Cold
Application of warmth No change Warmth-Cyanosis
Decrease
Cold- Cyanosis
Increase
Application of pure
oxygen
For 10 min
Cyanosis may improve No response
Clubbing and
Polycythemia
Usually Present Absent
Pulse Volume Normal or High Low
Dyspnoea Often Breathless Absent

30.  CCF due to left sided heart failure
 Acute MI with acute LVF
 Rarely polycythemia

31.  Due to presence of excessive
Sulphaemoglobin>0.5g/dl or
Methaemoglobin >1.5g/dl
 Causes- Hereditary Haemoglobin M disease
Poisoning by aniline dyes
Drugs like nitrates and nitrites
Carboxyhaemoglobinaemia
Confirmed- Spectroscopic examination

32. Orthocyanosis
Cyanosis only in upright position due to hypoxia
occuring in erect posture as a result of associated
pulmonary arteriovenous malformations
Intermitant cynosis – Ebstein’s anomaly
Differential Cyanosis
Hands red and feet blue- PDA with reversal of shunt
Hands blue and feet red- Coarctation of aorta with TGA

33.  a) Carbon monoxide poisoning-Cherry red
flush
 b) Argyria-Deposition of silver salt ,not
blanch, slatey grey hue
 c) Osteogenesis imperfecta – Fragile
bone,blue sclera,loose jointedness and
deafness
 d) Drugs like Amiodarone

34. Cyanosis with Clubbing- Cyanotic cong heart disease
Pulmonary arteriovenous fistula
Fibrosing alveolitis
Extensive Bronchiectasis
Cystic Fibrosis
Cyanosis without Clubbing- Peripheral cyanosis
Acutely devp central cyanosis
Clubbing without Cyanosis – SBE,
Ulcerative colitis
Normal healthy persons

35. Hypoxaemia without cyanosis- Severe Anaemia
Cyanosis with hypoxaemia –Reduced Hb is >5gm/dl
Cyanosis without Hypoxaemia- Polycythemia Vera

36.  Accumulation of excessive amount of tissue
fluid in the subcutaneous tissue(or serous
sac)due to increase in extravascular
component of the ECF resulting in swelling of
tissue

37.  Total body water- 60% of body wt
 Total body water-
2/3 ICF + 1/3 ECF(3/4 IF +1/4 Plasma)

39.  Low plasma oncotic pressure-
Hypoprotienaemia
 High capillary hydrostatic pressure-CCF ,DVT
 Increased capillary permiability-Acute
inflammation ,Amlodipine
 Obstructed lymphatic drainage-
Filariasis,Radiation

40.  Inspect leg for swelling
 Apply firm pressure
 Look for -Sacral edema
Parietal edema
Puffy face
Puffy lower eyelids
Scrotal edema

41.  Whether it pits on pressure or not
 Pitting oedema
CCF
Cirrhosis
Nephrotic syndrome
Hypoproteinaemia with severe anaemia
Pericardial effusion
Constrictive pericarditis
Drugs
Venous obstruction
Beriberi
Epidemic dropsy

44. Non pitting oedema
Myxoedema
Lymphatic oedema(Late stage)
Angioneurotic oedema
Scleredema

46.  a) Generalised-Anasarca
 b) Localised-
i)Venous obstruction-
Pregnancy
SVC Syndrome,
IVC Syndrome,
Varicose veins in legs
DVT
Immobilised or paralysed limb

47. ii)Lymphatic obstruction(lymphoedema)-
Filariasis,
TB
Carcinoma of breast
Radical mastectomy
Radiation
Milroy’s disease

48.  iii)Allergic cause
 iv)Inflamatory-insect bite,snake
bite,trauma,ischemia,infection
 iv)Miscellanous-
Bruise,sprain,cellulitis,fracture ,gout

49.  10-15% increase in body wt –see pitting
 Most reliable index of progress to treatment
in a case of edema-Alteration in body wt day
to day

50.  Congestive cardiac failure-LEG-FACE-
ASCITES
 Nephrotic Syndrome-FACE-LEGS –ASCITES
 Cirrhosis – ASCITES-LEGS-FACE
 Nutritional edema- Edema of feet-FACE-
ASCITES

51.  Familial
 Facial cellulitis
 Hypoprotienaemia
 Congestive cardiac failure
 Myxedema
 SVC Syndrome
 Cushing syndrome
 Angineurotic edema
 Trichinosis

52.  DVT
 Cellulitis
 Filariasis(early stage)
 Hemiplagic side
 Trauma

53.  Yellowish discolouration of skin and mucous
membrane due to excess amount of bilirubin
present in the blood.
 Clinical jaundice-S.bilurubn-3mg/dl
 Latent jaundice-S.bilurubin-1-3mg/dl

54.  Upper bulbar conjunctiva
 Under surface of tongue
 Mucous membrane of palate
 Palms and Soles
 General skin surface

56.  Carotenaemia
 Atabrine toxicity
 Diffuse Xanthomatosis
 Muddy sclera
 Old subconjunctival haemorrhage

57.  Found in body fluids like-CSF,Joint fluid,Cysts
 Absent from ture secretion-
Tear,Saliva,Pancreatic juice

58. If the physical examination shows
1. Excoriation, consider cholestasis or high grade
biliary obstruction
2. Greenish hue (due to biliverdin) suggests
longstanding liver disease like biliary
cirrhosis,sclerosing cholangitis, severe chronic
hepatitis or long standing malignant obstruction
3.Fever, epigastric or right hypochondrial
tenderness suggests choledocholithiasis,
cholangitis or Cholestasis

59. 4. Painless jaundice suggests malignant biliary
obstruction
5. Enlarged tender liver suggests acute
hepatitis,rapidly enlarging hepatic tumour
6. Palpable gallbladder suggests distal biliary
obstruction due to malignant tumour
7. Splenomegaly suggests portal hypertension
or haemolytic jaundice

60. 8. Palmar erythema, facial telangiectasia, Dupuytren’s
contracture are seen in chronic ethanol ingestion
9. Evidence of hyperestrogenic state in cirrhosis
(gynaecomastia, testicular atrophy, spider angiomata)
10. Wasting or lymphadenopathy suggests malignancy
11. Wasting and splenomegaly suggests pancreatic
tumour obstructing the splenic vein or a widely
metastatic lymphoma
.

61. 12. Look for increased JVP, KF ring,
xanthomata
13. Look for primaries from thyroid, GIT,
breast, etc.
14. Hyperbilirubinaemia
i. Predominantly unconjucated—> 85% of
totalBilirubin
ii. Predominantly conjucated—> 15% of total
bilirubin

63.  Acholuric urine
 Stool-High color
 Jaundice-Lemon yellow tinge (as
s.bil<6mg/dl)
 Anaemia
 Spleenomegaly
 May have typical facies(chipmunk facies in
thalassaemia)
 Reticulocytosis

64.  Urine-Deep yellow
 Stool-Pale or clay colored with Steatorrhoea
 Jaundice-Greenish-yellow
 Generalised pruritis
 Sinus bradycardia
 Xanthelasma
 Petechiae,purpura or echymosis-Vit k def
 Gall bladder my be palpable
 Prolonged case- Osteomalasia,bone
pain,fracture-Hepatic osteodystrophy
 Rarely hepatospleenomegaly,h/o fever ,pain abd

65.  Urine-Yellowish
 Stool-High colored and become pale
 Orange yellow tinge bulbar conjunctiva
 Anorexia,nausea,vomiting,fever may be
present before jaundice
 Tender hepatomegaly is frequent
 Variable pruritus
 Bleeding manifestations
 h/o affection of other member of the family
or locality

74.  Mitral Stenosis
 Acute myocardial infraction
 Acute PTE
 Corrhosis of liver
 Pernicious Anaemia
 Acute Pancreatitis
 Congestive cardiac failure

75.  Gilbert syndrome
 Stone impaction in CBD
 Periampullary carcinoma
 Haemolytic anaemia
 Chronic parenchymal liver disease
 Dubin johnson syndrome

76.  Sclerosing cholangitis in ulcerative colitis
 Obstruction by round worm in CBD
 Enlarged lymph nodes at porta hepatis in
Lymphoma

78.  HARRISON’S INTERNAL MEDICINE – 19th Edtn
 GOLWALLA – 15 th Edition
 ARUP KUMAR KUNDU – 6th Edition
 ALAGAPPAN – 5th Edition