STUDY - Technical - New Dacian's Medicine
Clubbing
(Classical / Allopathic Medicine)
A nonspecific sign
of pulmonary and cyanotic cardiovascular disorders, cirrhosis,
colitis, and thyroid disease, clubbing is the painless,
usually bilateral increase in the soft tissue around the
terminal phalanges of the fingers or toes. (See Rare causes of
clubbing.)
It doesn't involve
changes in the underlying bone. In early clubbing, the normal
160-degree angle between the nail and the nail base
approximates 180 degrees. As clubbing progresses, this angle
widens and the base of the nail becomes visibly swollen. In
late clubbing, the angle where the nail meets the now-convex
nail base extends more than halfway up the nail.
HISTORY:
Ask the patient if he has experienced hemoptysis, a productive cough, chest pain, dyspnea, anorexia, fatigue, or fever.
Review the patient's medical history for pulmonary or cardiovascular disease.
Ask the patient about a history of alcohol use or thyroid disease.
Review the patient's current treatment plan because clubbing may resolve with the correction of the underlying disorder.
Ask the patient if he has experienced hemoptysis, a productive cough, chest pain, dyspnea, anorexia, fatigue, or fever.
Review the patient's medical history for pulmonary or cardiovascular disease.
Ask the patient about a history of alcohol use or thyroid disease.
Review the patient's current treatment plan because clubbing may resolve with the correction of the underlying disorder.
PHYSICAL
ASSESSMENT:
Take the patient's vital signs.
Evaluate the extent of clubbing in the fingers and toes. (See Evaluating clubbed fingers.)
Auscultate the patient's lungs for abnormal sounds.
Take the patient's vital signs.
Evaluate the extent of clubbing in the fingers and toes. (See Evaluating clubbed fingers.)
Auscultate the patient's lungs for abnormal sounds.
SPECIAL
CONSIDERATIONS:
Don't mistake curved nails - a normal variation - for clubbing. Always remember that the angle between the nail and its base remains normal in curved nails but not in clubbed nails.
Don't mistake curved nails - a normal variation - for clubbing. Always remember that the angle between the nail and its base remains normal in curved nails but not in clubbed nails.
PEDIATRIC
POINTERS:
In children, clubbing occurs most commonly in cyanotic congenital heart disease and cystic fibrosis. Surgical correction of heart defects may reverse clubbing.
In children, clubbing occurs most commonly in cyanotic congenital heart disease and cystic fibrosis. Surgical correction of heart defects may reverse clubbing.
Rare causes of
clubbing
Clubbing is typically a sign of pulmonary or cardiovascular disease, but it can also result from certain hepatic and GI disorders, such as cirrhosis, Crohn's disease, and ulcerative colitis. However, clubbing occurs only rarely with these disorders, so first check for more common signs and symptoms. For example, a patient with cirrhosis usually experiences right-upper-quadrant pain and hepatomegaly. A patient with Crohn's disease typically has abdominal cramping and tenderness. A patient with ulcerative colitis may develop diffuse abdominal pain and blood-streaked diarrhea.
Clubbing is typically a sign of pulmonary or cardiovascular disease, but it can also result from certain hepatic and GI disorders, such as cirrhosis, Crohn's disease, and ulcerative colitis. However, clubbing occurs only rarely with these disorders, so first check for more common signs and symptoms. For example, a patient with cirrhosis usually experiences right-upper-quadrant pain and hepatomegaly. A patient with Crohn's disease typically has abdominal cramping and tenderness. A patient with ulcerative colitis may develop diffuse abdominal pain and blood-streaked diarrhea.
Evaluating clubbed
fingers
To quickly examine a patient's fingers for early clubbing, gently palpate the bases of his nails. Normally, they feel firm; however, in early clubbing, nail bases feel springy when palpated. To evaluate late clubbing, have the patient place the first phalanges of the forefingers together, as shown. Normal nail bases are concave and create a small space when the first phalanges are opposed (as shown above right).
In late clubbing, however, the now-convex nail bases can touch without leaving a space (as shown below right).
AGING ISSUES:
Arthritic deformities of the fingers or toes may disguise the presence of clubbing.
To quickly examine a patient's fingers for early clubbing, gently palpate the bases of his nails. Normally, they feel firm; however, in early clubbing, nail bases feel springy when palpated. To evaluate late clubbing, have the patient place the first phalanges of the forefingers together, as shown. Normal nail bases are concave and create a small space when the first phalanges are opposed (as shown above right).
In late clubbing, however, the now-convex nail bases can touch without leaving a space (as shown below right).
AGING ISSUES:
Arthritic deformities of the fingers or toes may disguise the presence of clubbing.
PATIENT
COUNSELING:
Inform the patient that clubbing doesn't always disappear, even if the cause has been resolved.
Inform the patient that clubbing doesn't always disappear, even if the cause has been resolved.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)