Approach to Clubbing

Differential diagnosis

• Cardiovascular
  • Atrial myxoma
  • Infective endocarditis
  • Cyanotic congenital heart disease
• Respiratory
  • Bronchiectasis
  • Pulmonary fibrosis
  • Lung cancer
  • Mesothelioma
  • Tuberculosis
  • Lung abscess
  • Empyema
• Gastrointestinal
  • Inflammatory bowel disease
  • Liver disease / cirrhosis
  • Coeliac disease
  • Chronic parasitic infection
• Endocrine
  • Thyroid acropachy (Graves’ disease)
• Human immunodeficiency virus
• Polyneuropathy, organomegaly, endocrinopathy, M protein and skin changes (POEMS) syndrome
• Hemiplegic stroke
• Congenital (hypertrophic osteoarthropathy)

History

• Clubbing
  • Duration
  • Unilateral (neurological or trauma causing ipsilateral aneurysm / AVM) / bilateral
  • Does it affect the hands and feet, or just the feet?
  • Family history of clubbing
• Cardiovascular symptoms
  • Have you had a fever?
  • Do you have chest pain?
  • Have you experienced situations where you feel like you are about to faint or have fainted?
  • Have your lips or hands every turned blue?
  • Do you feel short of breath when you walk?
  • Do you ever wake up in the middle of the night feeling breathless?
  • How many pillows do you sleep on at night?
• Respiratory
  • Have you been coughing recently?
  • Do you bring up phlegm when you cough?
  • What colour is the phlegm?
  • Is there any blood in the phlegm?
  • Did you have chest infections as a child?
  • What do you do for a living?
  • Have you ever been exposed to any dusts like asbestos or construction dusts?
  • Do you have any pets?
  • Do you have any joint pain or stiffness?
  • Do you have any rashes?
  • Have you had problems with mouth ulcers?
  • Do you, or have you ever, smoked?
  • Have you lost any weight recently?
  • Do you experience episodes of sweating at night?
• Gastrointestinal
  • Has there been any recent change in the number of times per day that you pass motion?
  • Have you noticed a change in the colour of your stools?
  • Is there any blood in your stool?
  • Have you noticed that your stool floats on the surface of the toilet water instead of sinking?
  • Have you noticed that your stool has become unusually smelly?
  • Have you noticed any tummy pain?
  • Have you noticed a change in the colour of your skin or your eyes?
  • Have you noticed that your urine has become dark?
  • Do you find that you have an uncontrollable itch?
  • Have you noticed any bloating in your tummy or leg swelling?
• Thyroid
  • Have tyou noticed that the weather is unusually hot or cold?
  • Have you ever experienced a sensation of your heart beating very fast?
  • Do your hands tremble?
  • Have you noticed that your periods have become heavier or more irregular?
• HIV
  • Are you currently sexually active?
  • How many partners do you have?
  • Are they male or female?
  • Do you use any recreational drugs?

Examination

• General inspection
  • Distribution of clubbing – unilateral / bilateral / hands and feet / feet only
  • Stigmata of infective endocarditis
  • Stigmata of chronic liver disease
  • Proptosis
  • Active arthritis / deforming polyarthropathy
  • Rashes
• Pulse: rate, regular / irregular
• Head and neck
  • Eye movements / lid lag
  • Scleral icterus (liver cirrhosis)
  • Palpable goitre
  • Cervical lymphadenopathy
• Cardiovascular
  • Fixed, widely-split S2 (atrial septal defect)
  • Pan-systolic murmur (ventricular septal defect)
  • Continuous machinery murmur under left clavicle (patent ductus arteriosus)
  • Ejection systolic murmur (coarctation of the aorta, pulmonary stenosis)
• Respiratory
  • Coarse pan-inspiratory crepitations (bronchiectasis)
  • Fine end-inspiratory crepitations (pulmonary fibrosis)
  • Decreased air entry, stony dull percussion note (empyema)
• Gastrointestinal
  • Hepatosplenomegaly (POEMS syndrome)
  • Splenomegaly (hypersplenism secondary to cirrhosis)

Investigations

• Blood tests
  • Thyroid function tests
  • Screening for human immunodeficiency virus
  • If organomegaly detected: look for M band
  • Full blood count (haematological malignancy)
  • Tests of synthetic function of the liver (albumin, prothrombin time)
  • Blood culture (infective endocarditis)
• Chest radiograph
  • Bronchiectatic changes (tram lining, dilated bronchioles)
  • Reticular shadowing seen in pulmonary fibrosis
  • Rule out pleural effusion (empyema)
  • Look for cardiomegaly (cyanotic congenital heart disease)
• Electrocardiogram
• Echocardiogram
  • To look for congenital heart defects causing cyanosis
  • Valvular vegetations of infective endocarditis
• Consider:
  • High resolution computed tomography scan of the lungs
  • Lung function testing
  • Colonoscopy / enteroscopy for inflammatory bowel disease

Management

• Patient education
• Treat the underlying cause
• If the underlying cause is reversible or controllable (e.g. resection of large bowel in ulcerative colitis), clubbing may regress completely