Assessment of Clubbing

Assessment
of clubbing
Straight to the point of care
Last updated: Aug 11, 2020

Table of Contents
Overview 3
Summary 3
Theory 8
Aetiology 8
Emergencies 16
Urgent considerations 16
Diagnosis 19
Approach 19
Differentials overview 29
Differentials 32
Guidelines 64
References 65
Images 72
Disclaimer 79
Assessment of clubbing Overview
Summary
• An important nail sign of systemic disease linked with underlying pulmonary, cardiovascular,
OVERVIEW
neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal disorders.
• Digital clubbing may also occur in isolation (e.g., familial clubbing, as an autosomal-dominant trait).
Definition
Clubbing is described as a bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit, with
subsequent loss of the normal angle between the nail and nail bed. The first stage of clubbing is a periungual
erythema and a softening of the nail bed; this is followed by an increase in the Lovibond's angle (the angle
between the proximal nail fold and the nail plate). Eventually the depth of the distal phalange increases, and
the distal interphalangeal joint may become hyper-extensible.[1]
The Schamroth window test can be used to identify or confirm clubbing. If 2 opposing fingers are held back
to back against each other, a diamond-shaped space should normally appear between the nail beds and the
nails of the 2 fingers. In clubbing, this space (or window) is missing.
Schamroth window test demonstrating a diamond-shaped window when fingers are not clubbed
Created by BMJ Knowledge Centre
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Aug 11, 2020.
BMJ Best Practice topics are regularly updated and the most recent version
3
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subject to our disclaimer. © BMJ Publishing Group Ltd 2020. All rights reserved.
OVERVIEW Assessment of clubbing Overview
Schamroth window test demonstrating lack of window with clubbed fingers

Clubbing is usually bilateral, although unilateral clubbing does exist (e.g., axillary artery aneurysm and
brachial arteriovenous malformations). It is painless unless associated with underlying conditions such
as pulmonary hypertrophic osteoarthropathy. The vast majority of patients are unaware of its presence.
However, an understanding of the causation and diseases associated with clubbing alerts the physician to
the seriousness of this sign and the need to investigate the patient appropriately.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Aug 11, 2020.
OVERVIEW
Finger clubbing
From the collection of Dr Murlidhar Rajagopalan
5
OVERVIEW Assessment of clubbing Overview
Pachydermoperiostosis: toe clubbing

OVERVIEW
Clubbing of nails showing loss of the classic Lovibond's angle (normally
≤160° in a normal distal digit, but >180° with definitive clubbing)
Pathophysiology
Advances in the study of the pathogenesis of clubbing have established that vascular endothelial growth
factor (VEGF) is key. This platelet-derived factor is stimulated by hypoxia and produced in diverse
malignancies and conditions that affect circulation. VEGF induces vascular hyperplasia, oedema, and
fibroblast or osteoblast proliferation at a peripheral level in the nails. In primary pulmonary conditions such as
lung cancer, this is the operative mechanism. When there is extra-pulmonary shunting of blood - for example,
in cyanotic heart disease - large megakaryocytic fragments gain access to the systemic circulation and affect
distal sites such as the nails. Here, these fragments release growth factors, including VEGF.[1] [2]
Unilateral clubbing secondary to local disorders (e.g., axillary artery aneurysm) is not due to a pulmonary
circulation defect.[3] In cases of bronchogenic carcinoma, growth hormone has been implicated as a cause
of clubbing. In hypertrophic osteoarthropathy, an additional unknown factor is considered necessary to
produce this syndrome; cyanosis may also be required.[4] [5]
Platelet derived growth factor (PDGF) may have a role. Platelets release PDGF in the vasculature of the
fingertips. PDGF stimulates growth, vascular permeability, and monocyte and neutrophil chemotaxis, and
leads to proliferation of vascular smooth muscle cells and fibroblasts, as is seen in clubbing.[4] In addition,
clubbing may be stimulated by local arteriovenous anastomoses provoked by neurocirculatory stimuli.
Conditions that involve chronic platelet excess (e.g., inflammatory bowel disease) result in peripheral platelet
trapping and release of PDGF.[4]
7
Assessment of clubbing Theory
Aetiology
Clubbing may be acquired or present as a hereditary anomaly.
THEORY
Pulmonary
Lung cancer
• Clubbing may be seen with any cell type of lung cancer.

• Most frequently associated with squamous and adenocarcinomas and least frequently with small cell
carcinoma.
Bronchiectasis
• Disease process characterised by abnormally dilated bronchi with thickened bronchial walls.
• More common in middle-aged and older people; usually due to an infectious cause.
• Underlying conditions associated with bronchiectasis include primary ciliary dyskinesia, Kartagener's
syndrome, cystic fibrosis, and diffuse panbronchiolitis.[6]
Lung abscess
• Risk factors include immunosuppression, poor oral hygiene, drug abuse, alcohol misuse, seizure
disorders, cerebrovascular accident, and lung cancer.
Empyema
• Most commonly results from untreated bacterial infection in the pleural space.
Pulmonary metastases
• Caused by a number of primary tumours (e.g., colorectal cancer, bone and soft-tissue sarcoma,
melanoma, renal cell carcinoma, breast cancer, germ cell tumour).
Pulmonary tuberculosis
• Clubbing is not usually a feature of pulmonary tuberculosis (TB) that occurs in isolation.
• Can occur in cavitating TB and in patients who have pulmonary TB with underlying HIV infection.
Cystic fibrosis
• The most common life-threatening autosomal-recessive disease in the US, occurring in approximately
1 in 3500 newborns.
• Characterised by multiple organ system involvement, mainly resulting in chronic respiratory tract
infections and the effects of pancreatic enzyme insufficiency.
Interstitial pulmonary fibrosis
• A group of conditions involving chronic fibrosing interstitial lung disease of varying causes. May be
idiopathic.
• Characterised by dyspnoea, reduced lung volumes, and poor gas exchange on lung function testing.[7]
• Digital clubbing has been associated with parameters of disease severity in patients with interstitial
lung disease.[8]
Sarcoidosis
• Chronic granulomatous disorder, characterised by accumulation of lymphocytes and macrophages in

the lungs and other organs.
• Lungs and lymph nodes involved in >90% of patients, but virtually any organ can be affected.
Asbestosis
THEORY
• Diffuse interstitial fibrosis of the lung as a consequence of chronic inhalation of asbestos fibres.[9] [10]
• Occupational history important, as type of work performed usually indicates asbestos exposure
(shipyard, construction, maintenance, vehicle brakes, asbestos cement, and insulation or production of
tiles, shingles, gaskets, or textiles).
• May lead to a number of respiratory diseases, including lung cancer, pleural plaques, benign pleural
effusions, and malignant mesotheliomas.
• Risk of lung cancer increased in patients exposed to cigarette smoke.
Pleural mesothelioma
• Classified into 3 types based on thoracoscopic biopsy and cytology samples: epithelial, sarcomatoid,
and mixed.
• About 80% of patients have had occupational exposure to asbestos.
Lipoid pneumonia
• Rare form of pneumonia that may be due to release of endogenous lipids in the lung (when lung tissue
breaks down distal to an obstruction: e.g., lung carcinoma, bronchiolitis obliterans, or following lung
necrosis after chemotherapy and radiotherapy) or caused by inhalation of exogenous lipids (e.g.,
aspiration of ingested oil, including mineral and vegetable oil).[11]
Pulmonary artery sarcoma
• Rare sarcoma arising from the intima of the pulmonary artery.
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
• Is the result of non-IgE mediated immunological inflammation of the alveoli and distal bronchioles
caused by repeated inhalation of non-human protein, such as from plant, bacteria, or animal, or the
result of a chemical conjugated to a human airway protein, such as albumin.
• Clubbing occurs in approximately half of those with chronic hypersensitivity pneumonitis.[12] [13]
Cardiovascular
Congenital heart disease
• Clubbing is a common sign of cyanotic congenital heart disease (e.g., tetralogy of Fallot, double outlet
right ventricle, transposition of great vessels).
• May also occur in association with other cardiac causes of right-to-left shunting such as patent ductus
arteriosus, coarctation of the aorta, and in ventral septal defects.[14]
Infective endocarditis
• Infection of the endocardial surface of the heart, including the valvular structures, chordae tendineae,
site of septal defects, or the mural endocardium.[15]
9
• May be acute, typically developing over a period of days to weeks, or subacute, typically developing
over the course of weeks to months.
Atrial myxoma
THEORY
• Most common of the rare benign primary cardiac tumours.

• Usually found in the left atrium and typically attached to the septum.
Axillary artery aneurysm
• Rare but potentially life-threatening cause of unilateral clubbing.

• Majority are pseudoaneurysms that arise after trauma or injuries. True aneurysms seldom occur.
Brachial arteriovenous malformations
• Abnormal connection between veins and arteries occurring in the arm.

• Rare condition causing unilateral clubbing.
• Usually congenital.
Hepatobiliary
Primary biliary cholangitis
• Autoimmune disease of the liver marked by slow and progressive destruction of bile canaliculi within
the liver.
• More common in women than men, and marked by intense itching.
Cirrhosis of the liver
• Pathological end-stage of any chronic liver disease.

• Most commonly results from chronic hepatitis B and C infection, alcohol misuse, and non-alcoholic
fatty liver disease.
• Leads to portal hypertension, liver insufficiency, and hepatic failure.
• Generally considered to be irreversible in its advanced stages.
Gastrointestinal
Ulcerative colitis
• Form of inflammatory bowel disease that affects the rectum and extends proximally.
• Characterised by diffuse inflammation of the colonic mucosa and a relapsing, remitting course.
Crohn's disease
• Inflammatory bowel disease that may involve the entire gastrointestinal tract.
• Strictures, abdominal pain, and fistulae common.
Leiomyoma of the oesophagus
• Rare benign tumour arising from the smooth muscle of the oesophageal submucosa, jutting into the
oesophageal lumen.
Achalasia
• Oesophageal motor disorder characterised by loss of peristalsis in the distal third and failure of the
lower oesophageal sphincter to relax in response to swallowing.
Ulcerative oesophagitis
THEORY
• May be caused by alcohol, drugs, GORD, or peptic ulceration.
Coeliac disease
• Systemic autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley, and
related grains.
• Immune activation in the small intestine leading to villous atrophy, hypertrophy of the intestinal crypts,
and increased numbers of lymphocytes in the epithelium and lamina propria.
• Locally, causes gastrointestinal symptoms and malabsorption.
• Diverse systemic manifestations, potentially affecting almost every organ system.
Tropical sprue
• Acquired malabsorptive condition of probable infectious aetiology.

• Features include altered small-bowel mucosa, chronic diarrhoea, and signs and symptoms of multiple
vitamin and nutrient deficiencies.
• Seen in both natives of, and long-term visitors to, specific endemic areas in the tropics.
Endocrine
Acromegaly
• Rare chronic disease caused by excessive secretion of growth hormone, usually due to a pituitary
somatotroph adenoma.
Severe secondary hyperparathyroidism
• Most commonly caused by chronic renal insufficiency.

• Characterised by excessive secretion of parathyroid hormone in response to hypocalcaemia.
Thyroid acropachy
• Extreme manifestation of Graves' disease or autoimmune thyroiditis, causing soft-tissue swelling and
digital clubbing.
Non-pulmonary malignant
Hodgkin's lymphoma (Hodgkin's disease)
• Uncommon haematological malignancy arising from mature B cells.

• Characterised by orderly spread of tumour from one group of nodes to the other and the presence of
Reed-Sternberg cells on histopathology.
Disseminated chronic myelogenous leukaemia
• Malignant clonal disorder of haematopoietic stem cells.

• Multiple organ system involvement regarded as disseminated disease.
11
Thyroid cancer
• Most commonly presents as an asymptomatic thyroid nodule detected by palpation or ultrasound in a

woman in her 30s or 40s.
THEORY
• Histological variants include papillary, follicular, medullary, and anaplastic neoplasms.
Thymus cancer
• Rare form of cancer.

• Myasthenia gravis, lupus, and rheumatoid arthritis possible predisposing factors.
Hereditary
Familial clubbing
• Clubbing without any associated signs or symptoms.

• Exact genetics undefined; most likely inherited as an autosomal-dominant trait.[16]
• Sometimes regarded as incomplete form of primary hypertrophic osteoarthropathy (HOA).[17] [18]
• Important to exclude other causes of clubbing before reaching this diagnosis.
Pachydermoperiostosis
• Rare autosomal-dominant inherited condition.

• Regarded as primary HOA[19] and accounts for 5% of all cases of HOA.
• Characterised by the combination of pachydermia (elephant-like skin), periostosis (swelling around the
joints, especially the wrists and knees), and clubbing.
Pachydermoperiostosis: furrowed and thickened forehead

THEORY
Pachydermoperiostosis: wrist joint swelling
13
THEORY Assessment of clubbing Theory
Pachydermoperiostosis: finger clubbing

Other
Secondary hypertrophic osteoarthropathy (HOA)
• Syndrome characterised by proliferative changes in the skin and skeleton.

• Enlargement of the extremities due to periarticular and osseous proliferation as well as digital clubbing
are common.
• Associated with cardiopulmonary diseases and malignancies (e.g., lung cancer, lung abscess,
bronchiectasis, emphysema, Hodgkin's lymphoma, metastatic disease, cystic fibrosis, cirrhosis,
inflammatory bowel disease, biliary atresia).
• Presence of an underlying condition differentiates HOA from pachydermoperiostosis (considered
primary HOA), which does not require immediate attention or intervention.[20]
Palmoplantar keratoderma
• May be inherited (either autosomal dominant or autosomal recessive) or acquired (due to changes in
an individual's health or environment).
• Characterised by an abnormal thickening of the palms and soles.
• Fischer's syndrome and Volavsek's syndrome (also called Buschke-Fischer-Brauer syndrome)
considered variants of palmoplantar keratoderma.
Pregnancy
• In rare cases, increased vascular demand of peripheries and hormonal factors can induce clubbing in
pregnancy.
Pseudoclubbing
THEORY
• Lovibond's angle (the angle made by the proximal nail fold and nail plate) between 160° and 180°
possibly reflects early stages of clubbing or a pseudoclubbing phenomenon.
• Unlike digital clubbing there is no clear definition of pseudoclubbing.[21] In addition, there is no
convincing aetiopathogenic mechanism for pseudoclubbing. Asymmetrical finger involvement has
been observed in the majority of cases. Acro-osteolysis is also seen, but is not a discriminatory feature
as it also occurs in true clubbing.[21]
Myelofibrosis
• Reactive process common to many malignant and benign disorders.

• Clubbing has been described in myelofibrosis.[22]
15
Assessment of clubbing Emergencies
Urgent considerations
(See Differentials for more details)
A number of conditions associated with clubbing require urgent evaluation and treatment.
Pulmonary
Lung cancer
• Emergency care may be necessary depending on the presentation. If the patient has upper airway
obstruction, urgent admission to the intensive care unit (ICU) is required. Fibre-optic laryngoscopy or
intra-operative tracheostomy may be necessary to help relieve the obstruction. Sometimes patients
present with severe haemoptysis. In such cases, immediate suctioning is indicated. If respiratory
failure is imminent, an endotracheal tube should be placed. The patient will require an urgent blood
transfusion, and a pulmonologist may have to perform fibre-optic bronchoscopy. All patients, except
those with the most minor bleed, need intensive care.
EMERGENCIES
Empyema
• Respiratory failure can occur, requiring assisted ventilation in an ICU. Intubation may be necessary. If
pulse oximetry shows low saturation, supplemental oxygen should be started immediately.
• The extent and position of metastases are important considerations. Metastases impinging on major
airways or eroding into major intrathoracic vessels can result in massive haemoptysis and shock.
These patients require emergency management in an intensive care ward. Establishment of venous
access, transfusion of blood products, management of shock with fluids, and cardiosupportive
measures are usually the initial steps. A thoracic surgery team should be on standby for an emergency
thoracotomy if indicated.
Pulmonary tuberculosis
• This is infectious and requires administration of antituberculous drugs immediately. The patient may
require respiratory isolation if there is open discharge of bacilli. Notification to appropriate healthcare
agencies is mandatory.
• Patients can present with a pleural effusion. All patients with rapidly collecting effusions need
evaluation in the emergency department. Urgent placement of an intercostal drain may be required.
Lipoid pneumonia
• Hypoxia and respiratory distress, although rare, can occur in severe cases. Urgent ventilatory support
is required.
• Patients may present to the emergency department with a massive bleed, shock, and collapse.
Haemoptysis is a warning sign. Thoracotomy and intervention by a pulmonary care intensivist and
thoracic surgeon will be required.
Cardiovascular
Right-to-left shunting
• Infants with cyanotic congenital heart disease (e.g., tetralogy of Fallot, double outlet right ventricle,
transposition of great vessels) or other causes of right-to-left shunting (e.g., patent ductus arteriosus
and coarctation of the aorta) may present with symptoms and signs of congestive heart failure.
Digoxin, diuretics, and afterload reduction therapy should be given promptly before surgical
interventions are considered.
• Patients may present to the emergency department with congestive heart failure or even renal failure
requiring urgent therapy and possibly dialysis.
Atrial myxoma
• This can occasionally cause a stroke due to embolisation. In such cases, urgent medical attention is
EMERGENCIES
required, as a successful outcome depends on rapid evaluation, diagnosis, and intervention.
• This can sometimes result in a pulmonary embolism. Fibrinolysis, heparin, oxygen, and intravenous
fluids may be required. In severe cases, emergency bypass is necessary.
• This may result in embolisation, pain, or distal gangrene. Urgent admission, delineation of the
aneurysm and possible resection, or resolution of embolic episodes are required.
Hepatobiliary
Cirrhosis
• May result in the alteration of clotting parameters or varices causing an acute bleed, requiring urgent
sclerotherapy, transfusion, and endoscopic assistance. Deterioration of metabolic status can lead to
coma and hepatorenal shutdown, requiring intensive care.
Gastrointestinal
Ulcerative colitis
• Ulcers can occasionally cause severe haematochezia and rectal bleeding. These patients need an
emergency colonoscopy and sometimes resection of the affected bowel segment.
Crohn's disease
• Intestinal obstruction can develop due to bowel wall thickening by acute inflammation. Presents with
abdominal pain, nausea, vomiting, abdominal distension, and dilated bowel loops and air-fluid levels
on x-ray. Treatment involves bowel rest with nasogastric suctioning and may require corticosteroid
therapy. Patients not responding to these measures require surgical resection.
17
• Patients can present with vomiting and haematemesis if the ulcer erodes into the wall of the
oesophagus. Emergency assistance is required, with oesophagoscopy to arrest bleeding and possible
transfusion of blood products.
Non-pulmonary malignant
• Advanced cases can occasionally alter the coagulation cascade and produce disseminated
intravascular coagulation. This requires urgent replacement with plasma and anticoagulant therapy
immediately after evaluation.
Other
Secondary hypertrophic osteoarthropathy
• May be due to a sinister underlying cause (including adenocarcinoma of the lung, as well as other
EMERGENCIES
malignancies including metastatic disease); thus, its presence should alert the physician to the need
for a thorough and urgent investigation.
Assessment of clubbing Diagnosis
Approach
Clubbing is described as bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit, with
subsequent loss of the normal angle between the nail and the nail bed. It is usually bilateral, although
unilateral clubbing does exist (e.g., with axillary artery aneurysm or brachial arteriovenous malformations).
On clinical examination, in profile, the normal distal digit shows an angle made by the junction of the proximal
nail fold and nail plate (Lovibond's angle) typically ≤160°. With clubbing this angle flattens, and then rises
as the severity of the clubbing increases. If the angle is >180°, definitive clubbing exists. An angle between
160° and 180° possibly reflects early stages of clubbing or a pseudo-clubbing phenomenon.
Clubbing of nails showing loss of the classic Lovibond's angle (normally

≤160° in a normal distal digit, but >180° with definitive clubbing)
DIAGNOSIS
The Schamroth window test can be used to identify or confirm clubbing. If two opposing fingers are held back
to back against each other, a diamond-shaped space should normally appear between the nail beds and the
nails of the two fingers. In clubbing, this space (or window) is missing.
19
Schamroth window test demonstrating a diamond-shaped window when fingers are not clubbed
DIAGNOSIS
Schamroth window test demonstrating lack of window with clubbed fingers

Once clubbing has been identified, the examination should then focus on excluding all the possible
underlying causes, because clubbing is a sign rather than a condition.
DIAGNOSIS
21
Finger clubbing
DIAGNOSIS
Pachydermoperiostosis: toe clubbing

History
DIAGNOSIS
A detailed history is necessary to exclude organic causes of clubbing.[18]
The presence of shortness of breath, chest pain, and cough (acute or chronic) on history-taking usually
indicates an underlying pulmonary aetiology. A cough may also be a symptom of hypersensitivity
pneumonitis, congenital heart disease, thymus cancer, or Hodgkin's lymphoma. Production of purulent
sputum is particularly suggestive of lung abscess, empyema, or bronchiectasis. Haemoptysis may indicate
underlying lung cancer, pulmonary tuberculosis (TB), pulmonary artery sarcoma, or interstitial pulmonary
fibrosis, as well as bronchiectasis, lung abscess, or myelofibrosis. Smoking is considered a risk factor
for lung cancer, asbestosis, and interstitial pulmonary fibrosis.[23] Asbestos exposure is suggestive of
asbestosis, lung cancer, or pleural mesothelioma. A known TB contact, travel to an endemic area, and/or a
history of immunosuppression (particularly HIV infection) should arouse suspicion of cavitating pulmonary
TB. A history of mineral or vegetable oil ingestion (e.g., laxative use) in a patient with respiratory symptoms
supports a diagnosis of lipoid pneumonia.
Failure to thrive in children, shortness of breath, diaphoresis, irritability, and recurrent lung infections, with
or without cyanosis, strongly suggest a cardiac aetiology. Adults who survive congenital heart disease may
23
have symptoms of heart failure (dyspnoea, peripheral oedema, and fatigue) or differential cyanosis (pink
upper extremities and cyanotic lower extremities, as can occur in coarctation of the aorta).
Abdominal pain may occur in cystic fibrosis, ulcerative colitis, Crohn's disease, tropical sprue, or coeliac
disease. Ulcerative oesophagitis can present with epigastric pain. In addition, diarrhoea may be a symptom
of both cystic fibrosis and coeliac disease.
Fever often suggests an underlying infectious aetiology such as pulmonary TB, infective endocarditis,
empyema, or lung abscess. Other conditions presenting with fever include pulmonary artery sarcoma,
hypersensitivity pneumonitis, Hodgkin's lymphoma, disseminated chronic myelogenous leukaemia, atrial
myxoma, Crohn's disease, and tropical sprue. When considering tropical sprue as an underlying cause, a
history of travel to endemic areas should be established.
Loss of weight is a fairly non-specific symptom and may occur with pulmonary TB, ulcerative colitis,
Crohn's disease, tropical sprue, malignancy, metastatic disease, interstitial pulmonary fibrosis, chronic
hypersensitivity pneumonitis, and achalasia. Generalised weakness is associated with most conditions,
particularly TB, lung cancer, congenital heart disease, inflammatory bowel disease, liver cirrhosis, cystic
fibrosis, interstitial pulmonary fibrosis, and primary biliary cholangitis. Night sweats are a common presenting
symptom of pulmonary TB and Hodgkin's lymphoma. Patients with infective endocarditis may also complain
of night sweats.
Jaundice suggests underlying liver cirrhosis. Nausea and vomiting are symptoms of early pregnancy and
of ulcerative oesophagitis. Paraesthesias may occur in association with lung metastases due to associated
hypercalcaemia, paraproteinaemia, or vasculitis. Arthralgia is a feature of pachydermoperiostosis,[19]
sarcoidosis, and infective endocarditis.
A history of dysphagia should arouse suspicion of an oesophageal condition such as achalasia or leiomyoma
of the oesophagus.
In thymus cancer almost one third of patients are asymptomatic. Chest pain, myasthenia gravis, cough, and
dyspnoea may occur with equal frequency. Fatigue is common, as are weakness and weight loss.[24]
DIAGNOSIS
Patients with thyroid acropachy usually have a history of thyrotoxicosis (Graves' disease, but it may also be
present in Hashimoto's thyroiditis) and complain of related symptoms including heat intolerance, sweating,
weight loss, palpitations, scalp hair loss, or irritability.
Physical examination
When examining the skin and nails, the following signs should be sought:
• Thickened palms and soles suggestive of palmoplantar keratoderma

• Cutis verticis gyrata (thickened skin of the scalp manifesting as folds and furrows), associated with
various conditions such as acromegaly and pachydermoperiostosis[19]
• Coarse skin indicative of acromegaly or pachydermoperiostosis[19]
• Acne, which may be associated with pachydermoperiostosis[19]
• Skin changes of liver disease including jaundice, spider naevi, and skin excoriations
• Pallor suggesting anaemia (present in disseminated myelogenous leukaemia, Crohn's disease,
ulcerative colitis, coeliac disease, tropical sprue, and infective endocarditis)
• Swellings that could indicate an aneurysm, such as axillary artery aneurysm and brachial
arteriovenous malformations
• Rashes, which may indicate a compromised immune state, such as underlying malignancy
• Erythema nodosum, which may be a feature of sarcoidosis, Crohn's disease, and ulcerative colitis
• Unilateral clubbing, which may indicate an axillary artery aneurysm or brachial arteriovenous
malformation.
Pachydermoperiostosis: furrowed and thickened forehead

DIAGNOSIS
Pachydermoperiostosis: finger clubbing

25
A complete physical examination of the lungs should be undertaken, looking for signs suggestive of fluid
collection in the pleura (pleural effusion, empyema), consolidation, or collapse (pneumonia, TB). Pulmonary
malignancies, including metastatic lesions, may also present with signs suggestive of fluid collection,
consolidation, and/or collapse. Areas of hyper-resonance on the lung fields and evidence of cavitation (TB) or
fibrosis (suggestive of interstitial pulmonary fibrosis, chronic hypersensitivity pneumonitis, or cystic fibrosis)
should also be excluded.
A thorough cardiovascular examination should also be performed to evaluate for signs suggestive of a right-
to-left shunt (cyanosis together with a cardiac murmur indicates cyanotic congenital heart disease), infective
endocarditis (cardiac murmur, Janeway's lesions, Osler's nodes, splinter haemorrhages, Roth's spots), and
an atrial myxoma (systolic murmur, loud first heart sound, opening snap, embolic manifestations).
Hepatomegaly may be present on abdominal examination, indicating an underlying malignancy or the

early stages of primary biliary cholangitis. Splenomegaly is almost always present in myelofibrosis. The
presence of splenomegaly and ascites suggests advanced liver disease. Epigastric tenderness may be due
to ulcerative oesophagitis. Ulcerative colitis, Crohn's disease, tropical sprue, coeliac disease, and cystic
fibrosis can all present with varying degrees of abdominal pain.
Thyroid gland examination should focus on the presence of enlargement, nodules, and tenderness. This
helps to exclude endocrine conditions associated with clubbing, such as thyroid acropachy.
Tender, swollen joints may suggest pachydermoperiostosis[19] or secondary hypertrophic osteoarthropathy.

In addition to joint pain, patients with severe secondary hyperparathyroidism experience bone tenderness.
DIAGNOSIS
Pachydermoperiostosis: wrist joint swelling

Baseline investigations
When clubbing is identified, baseline investigations may include a full blood count (FBC) with peripheral
smear and an erythrocyte sedimentation rate. These tests are useful when an underlying infectious or
inflammatory cause (e.g., hypersensitivity pneumonitis, TB, empyema, ulcerative colitis, Crohn's disease) or
malignancy (both pulmonary and non-pulmonary) is suspected. An FBC will show anaemia in myelofibrosis,
and a peripheral blood smear will show teardrop-shaped red blood cells (RBCs) and the presence of
metamyelocytes, myelocytes, promyelocytes, myeloblasts, and nucleated RBCs in the circulation. In addition
to an FBC, a complete metabolic panel is necessary when evaluating for chronic illness (e.g., cystic fibrosis,
sarcoidosis, liver disease).
A chest x-ray is also considered a baseline investigation, as an underlying pulmonary condition commonly
exists. In addition, pulmonary metastases may be detected on chest x-ray.
Liver function tests may be part of the initial work-up if the history or examination suggests a possible
hepatobiliary cause. Estimations of serum free T3/total T3, serum free T4, and thyroid-stimulating hormone
levels have prognostic and diagnostic value in thyroid disease and should also be included in the initial tests.
Blood cultures may be included in the initial investigation when a possible infectious aetiology is suspected
(e.g., lung abscess, infective endocarditis).
A urinalysis is easy to perform and is also considered a baseline investigation. In cases of infective
endocarditis, urinalysis may demonstrate active sediment (indicating septic emboli), assisting in the clinical
diagnosis.
Specific investigations
Further investigation is guided by the above results coupled with findings on physical examination and a
suggestive history.
Plain film x-rays of the hands and other joints may be helpful in confirming a diagnosis of secondary
hypertrophic osteoarthropathy or pachydermoperiostosis.[19]
DIAGNOSIS
Sputum microscopy and culture, as well as cytology, should be requested where there is an underlying
pulmonary cause associated with clubbing. If history or clinical examination suggests pulmonary TB, a
tuberculin skin test is necessary.
Spirometry helps to assess lung function and often supports various pulmonary diagnoses, particularly
interstitial lung disease. Bronchoalveolar lavage is useful in confirming the diagnosis of lipoid pneumonia
or hypersensitivity pneumonitis, and may be indicated in difficult-to-prove cases of TB. A diagnostic
thoracentesis may be necessary when empyema or pleural mesothelioma is suspected.[25]
A chest computed tomography (CT) scan may be required to clarify or localise chest x-ray findings,
especially where a pulmonary malignancy is the concern. Some centres perform a high-resolution chest
CT, as this provides an enhanced definition of the lesion when compared with a routine chest CT. It is also
considered more useful when interstitial lung disease is suspected. In addition, CT scan is necessary to
detect metastases and helps to diagnose lymphoreticular malignancies such as Hodgkin's lymphoma.
A magnetic resonance imaging scan is useful to localise lesions. It may be combined with angiography to
visualise the vascularity of the lesion or the relationship of the lesion to blood vessels.
27
A positron emission tomography scan is a useful investigation, especially when combined with CT scan for
accurate definition of lesions. It is particularly helpful in detecting lymphomas of the chest or body.
Once the site of the lesion has been identified, a confirmatory tissue diagnosis is desirable. This may be
achieved via bronchoscopy, aspiration techniques, tumour resection, or simple biopsy through endoscopy, all
depending on lesion location.
When a structural heart defect is suspected, trans-thoracic echocardiogram is usually the first test
performed. Trans-oesophageal echocardiogram is considered a more sensitive assay to detect structural
defects and vegetations in infective endocarditis. Cardiac catheterisation is a specialised investigation, done
to confirm an echocardiogram finding or, rarely, to sample an intracardiac mass. It is also a useful tool to
measure pressure changes in the heart accurately. Intravascular ultrasonography is useful for preoperative
diagnosis of a pulmonary artery sarcoma. A final diagnosis is confirmed with histopathology following
surgery.
When an arteriovenous malformation is present, Doppler ultrasonography detects the flow across a shunt
and the direction of flow of blood in a vessel. This is considered especially helpful in delineating the origins
of an aneurysm. Angiography or magnetic resonance angiography is useful, particularly when planning
treatment of an arteriovenous anomaly.
The size and texture of the liver is easily assessed with ultrasonography and, therefore, this is usually one of
the initial tests ordered when evaluating liver disease, including cirrhosis.
Barium studies may be necessary when the underlying diagnosis is thought to be due to inflammatory
bowel disease or an oesophageal abnormality. Colonoscopy is indicated when signs and symptoms suggest
inflammatory bowel disease. This technique also allows tissue sampling for histopathology, which further
confirms the diagnosis.
When cystic fibrosis is suspected, a sweat test is performed. Gene analysis may be indicated if the sweat
test is inconclusive.
When acromegaly is suspected, growth hormone levels, coupled with measurement of insulin growth factor
DIAGNOSIS
1, confirms the diagnosis. Levels of serum parathyroid hormone, calcium, and vitamin D are indicated when
the possibility of secondary hyperparathyroidism is a concern. Determining lactate dehydrogenase level and
immunohistochemical studies may be necessary when evaluating for Hodgkin's lymphoma. A prolonged
prothrombin time is often associated with coeliac disease or liver cirrhosis. Coeliac disease may also result in
iron deficiency; thus, iron studies should be sent. Serum folate and B12 analysis is necessary when tropical
sprue is suspected, as malabsorption may reduce levels.
A 72-hour faecal fat collection to assess for steatorrhoea may assist in the diagnosis of tropical sprue.
If thyroid cancer is suspected, thyroid ultrasonography helps determine the structure and nature of the thyroid
mass. A fine needle aspiration biopsy of the suspicious lesion may be performed under ultrasound guidance
for accurate tissue sampling. Cytology results confirm the diagnosis.
Cytogenetic testing (e.g., fluorescent in situ hybridisation) may be indicated in cases of disseminated chronic
myelogenous leukaemia.
Skin biopsy is rarely necessary. However, in some conditions it may help to establish a diagnosis, including
sarcoidosis, thyroid acropachy, and pachydermoperiostosis.[19]
Differentials overview
Common
Lung cancer
Bronchiectasis
Lung abscess
Empyema
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Uncommon
Cystic fibrosis
Interstitial pulmonary fibrosis
Sarcoidosis
Asbestosis
DIAGNOSIS
Cavitating pulmonary tuberculosis (TB)
Atrial myxoma
Thyroid acropachy
Acromegaly
29
Uncommon
Hodgkin's lymphoma
Ulcerative colitis
Crohn's disease
Cirrhosis
Thyroid cancer
Thymus cancer
Lipoid pneumonia
Achalasia
Coeliac disease
Tropical sprue
DIAGNOSIS
Leiomyoma of the oesophagus
Familial clubbing
Pachydermoperiostosis (primary hypertrophic osteoarthropathy)
Palmoplantar keratoderma
Pregnancy
Pseudoclubbing
Myelofibrosis
DIAGNOSIS
31
Differentials
Common
Lung cancer
History Exam 1st Test Other tests
cough, shortness weight loss, respiratory »chest x-ray: nodule, »bronchoscopy and
of breath, history of distress common; mass, infiltrates, biopsy: confirms
smoking, asbestos may be absent or pleural effusion, hilar tissue diagnosis
exposure, haemoptysis, decreased breath lymphadenopathy Yields lung tissue for
chest pain, wheezing; sounds, dullness to Done in symptomatic accurate diagnosis.
with spread into percussion, mediastinal patients. Findings
the neck, may have shift; other signs Indicated if imaging or
features of superior depend on spread and of a mass, although cytology is abnormal.
vena cava syndrome type of tumour[26] [27] suggestive of cancer,
(facial plethora and must be confirmed Recommended mainly
distended neck veins with cytology or tissue for central lesions.
when arms raised
study.[27] Peripheral lesions can
above the head) or
even hoarseness be difficult to access,
»chest CT: nodule, and thus trans-thoracic
mass, infiltrates,
pleural effusion, hilar aspiration may be
lymphadenopathy necessary.[28]
Required to clarify or
»PET scan chest:
localise chest x-ray
further evaluates
findings. location and extent
of primary tumour;
Findings of a mass, evaluates for distant
although suggestive metastases
of cancer, must be PET scan is
DIAGNOSIS
confirmed with cytology complementary to CT,

or tissue study.[27] facilitating accurate
Some centres perform assessment of the
high-resolution chest extent of local, regional,
CT, as this provides an and distant disease.
enhanced definition of
the lesion compared
with routine CT scan.
»sputum cytology:
malignant cells in
sputum
Can detect abnormal
cells even in the
presence of normal
imaging studies.
Diagnostic yield
depends on several
Common
Lung cancer

variables, including
location and type of
cancer. Squamous cell
carcinoma and small
cell carcinoma, which
are larger and centrally
located, have good
yield and diagnostic
value. Sputum cytology
detects 71% of
central tumours,
<50% of peripheral
tumours. Peripheral
tumours are usually
adenocarcinomas,
which exfoliate as
easily as the squamous
tumours occurring
centrally.[28]
At least 3 samples
should be analysed.
Samples can be
obtained by bronchial
DIAGNOSIS
brush, wash,
bronchoalveolar lavage,
and transbronchial
fine needle aspiration
(the most accurate).
Overall, larger lesions
and peripheral tumours
show best sensitivity.
Adding molecular
diagnostic techniques
enhances the value of
sputum cytology for all
types of lung cancer.
33
Common
◊ Bronchiectasis
history of recurrent crackles and wheezes, »chest x-ray: »spirometry:

respiratory tract predominantly over thickening of bronchi irreversible obstructive
infections; cough lower lobes and bronchioles, defect, with
producing large seen as ill-defined FEV₁:forced vital
amounts of perihilar linear densities capacity ratio <70%
mucopurulent sputum, associated with
diurnal variation (e.g., indistinctness of central
worse in the morning), pulmonary artery
positional worsening; margins
dyspnoea, wheezing, Simulates interstitial
haemoptysis pulmonary oedema.
Bronchus seen
on end shows ill-
defined ring shadows.
Presence of tram
lines or parallel lines
along the expected
courses of the bronchi
indicates more severe
disease, where the
dilated bronchial lumen
becomes visible.[6]
Sensitive but not

specific findings.
DIAGNOSIS
Should be the first

examination if high-
resolution CT not
available.
»high-resolution CT
scan chest: bronchial
dilation (internal
bronchial diameter
greater than diameter
of accompanying
bronchial artery,
known as signet ring
formation) and lack of
bronchial tapering on
sequential slices[29]
Can detect airway
anomalies of
bronchiectasis. Should
Common
◊ Bronchiectasis

be the first examination
if available.[30]
Lung abscess
presence of risk factors tachypnoea, fever, »chest x-ray: cavitary »chest CT: localises
(immunosuppression, dyspnoea, dullness to lesion with air fluid position and size of
poor oral hygiene, drug percussion, whispered level, usually in collection
abuse, alcohol misuse, pectoriloquy and posterior segment of »bronchoscopy:
seizure disorder, bronchophony on right upper lobe localises position and
cerebrovascular auscultation »FBC: leukocytosis size of collection
accident, lung cancer);
»blood culture: Fibre-optic
cough with purulent
sputum and foul odour, positive for infectious bronchoscopy using
fever, chills and sweats, organism bronchial brushings or
pleuritic chest pain, bronchial lavage, used
possibly haemoptysis
to obtain specimens
from the cavity, is
sent for cultures and
cytology.
Empyema
DIAGNOSIS
recent pneumonia, febrile, toxic patient; »chest x-ray: »chest CT:

fever, cough, purulent dullness on percussion, anteroposterior and associated pulmonary
sputum production, absence of breath lateral films show fluid consolidation or
chest pain sounds over affected collection abscess
area Useful screening tool. Useful in detecting
Required to determine parenchymal disease
indication for diagnostic or loculations,
thoracentesis. characterising pleural
surfaces, and guiding
»sputum culture:
therapy.[31]
positive growth of
offending organism
»chest
ultrasonography:
distinguishes loculated
effusions from an
infiltrate
35
Common
Empyema

Provides guidance for
thoracentesis or pleural
catheter placement. It is
portable and therefore
easier to perform than
a CT scan.
»diagnostic
thoracentesis:
aspiration of purulent
fluid; may be positive
Gram stain or culture of
pleural fluid[25]
Confirmatory test. At
least 10 mL fluid is
needed.
poor feeding in various; cardiac »chest x-ray: may »cardiac

infants, failure to murmur, central reveal abnormal catheterisation:
thrive, shortness of cyanosis, dyspnoea, cardiac silhouette pulmonary stenosis
breath, diaphoresis, failure to thrive Normal cardiac and ventricular septal
DIAGNOSIS
irritability, recurrent lung silhouette does not rule defects may be seen
infections; adults who on angiogram; provides
survive have symptoms out congenital heart haemodynamic data
of heart failure disease. such as systemic right
(dyspnoea, peripheral ventricular pressure
oedema, fatigue) or »trans-thoracic and right-to-left shunt
differential cyanosis echocardiogram: Provides additional
(pink upper extremities variable; findings
information that is
and cyanotic lower depend on underlying
extremities, as can cardiac condition useful in planning
occur in coarctation of Vital non-invasive treatment, especially
the aorta) early diagnostic test. when surgery is being
Echocardiogram considered.
reveals any associated
structural lesions (e.g.,
ventricular septal
defect) and illustrates
direction of blood
flow. For example,
in transposition
Common

of great vessels,
echocardiogram
confirms transposed
ventricular arterial
connections and size of
interatrial connection;
ductus arteriosus can
also be visualised.
Surgical intervention,
if required, can
be planned after
echocardiogram (e.g.,
coarctation of aorta
with widely patent
ductus arteriosus).
Echocardiogram is
helpful if ductus is
closed or partially
restrictive and
demonstrates a high-
velocity jet.
Pulsed and colour
DIAGNOSIS
Doppler may also be
used to assess degree
of mixing.
fever, fatigue, chills, majority febrile, new or »blood cultures:

anorexia, night sweats, changing heart murmur, growth of infecting
myalgia, and/or petechiae on mucosae organism
arthralgia and extremities, Three sets of blood
splinter haemorrhages cultures obtained 1
below nails, Osler's
nodes on digits, hour apart prior to
Janeway's lesions, initiating antibiotic
hepatosplenomegaly therapy ensures
greatest yield.
37
Common

»FBC: anaemia and
leukocytosis
»erythrocyte
sedimentation rate:
markedly elevated
»urinalysis: abnormal
sediment
Septic emboli
are common
complications of
infective endocarditis;
urinalysis may
demonstrate active
sediment, assisting in
the clinical diagnosis.
»echocardiogram:
vegetations in mitral,
tricuspid, aortic, or
pulmonary valve; seen
as nodular structures
If routine trans-thoracic
echocardiogram
fails to detect
valvular vegetations,
DIAGNOSIS
trans-oesophageal
echocardiogram is
recommended.
◊ Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
exposure to non-human dyspnoea, cough, »immunological »bronchoalveolar

protein or chemicals febrile, malaise, weight response to lavage: positive
such as epoxy resins, loss, bibasilar or diffuse causative antigen: antibody and
shortness of breath, rales on auscultation antibody to the putative lymphocytosis (elevated
non-productive or antigen positively CD8+ cells)
productive cough, fever, identified through »lung biopsy:
malaise, weight loss, immunological blood bronchocentric
bibasilar or diffuse rales test infiltrate consisting of
»FBC: leukocytosis; lymphocytes, plasma
normocytic, cells, neutrophils,
normochromic anaemia foamy macrophages,
and non-caseating
Common
◊ Hypersensitivity pneumonitis (extrinsic allergic alveolitis)

»erythrocyte granulomas; in later
sedimentation rate: stages interstitial
elevated fibrosis predominates
»albumin: low
»chest x-ray: patchy,
nodular infiltrates
are observed in
acute and subacute
hypersensitivity
pneumonitis; fibrosis in
chronic hypersensitivity
pneumonitis
scan chest: ground-
glass shadowing/
attenuation and poorly
defined micronodules;
features of chronic
hypersensitivity
pneumonitis include
mosaic attenuation,
centrilobular nodules,
and relative basal
sparing
»pulmonary
function tests:
restricted pattern in
acute hypersensitivity
DIAGNOSIS
pneumonitis; mixed
restrictive and
obstructive features in
subacute or chronic
hypersensitivity
pneumonitis
»diffusing lung
capacity of carbon
monoxide: decreased
Uncommon
◊ Cystic fibrosis
variable; mainly variable; rhinitis, nasal »sweat test: increased »gene analysis:
presents in infancy polyps, tachypnoea, chloride in sweat; >60 mutations in the CFTR
or childhood; chronic respiratory distress, mmol/L is diagnostic gene
cough, sputum wheeze, cough,
39
Uncommon
◊ Cystic fibrosis

production, persistent hyper-resonance on Sweat chloride levels Screening for CFTR
chest symptoms, chest percussion; between 30 and 59 mutations detects about
wheezing; failure abdominal distension,
to thrive, diarrhoea, organomegaly, rectal mmol/L prompt gene 68% of cases.[33]
abdominal pain, prolapse, signs analysis or repeat
prolonged neonatal of malabsorption Useful if sweat chloride
of sweat test. Cystic
jaundice; infertility due (failure to thrive, test not conclusive.
fibrosis is very unlikely
to azoospermia[32] abdominal tenderness,
steatorrhoea), salivary if sweat chloride is ≤29
gland swelling, and/or mmol/L.[32]
scoliosis may also be
present
◊ Interstitial pulmonary fibrosis
history of smoking, tachypnoea, end- »chest x-ray: reticular »spirometry:

progressive exertional expiratory rales and/or nodular restrictive pattern with
dyspnoea, chronic at the bases, opacities are typical; low forced vital capacity
cough (occasionally wheezing; pulmonary honeycombing and cyst (FVC) and normal or
productive), hypertension and right formation in advanced increased FEV₁:FVC
haemoptysis, fatigue, heart failure occurs in disease ratio
weakness, weight loss severe disease First test done. Helps »lung biopsy: variable
to exclude other Done if a firm diagnosis
causes.[34] cannot be reached from
earlier tests.
DIAGNOSIS
Sometimes changes
are too fine to be
detected on chest x-
ray. May need high-
resolution CT scan.[35]
scan chest: fibrosis
of alveoli and lung
parenchyma
Coupled with
clinical history and
examination, the best
way to diagnose the
condition short of a
biopsy.[36] [37]
Uncommon
◊ Sarcoidosis
chronic cough, variable; »chest x-ray: hilar »biopsy from

dyspnoea; usually lymphadenopathy, and/or paratracheal viscera: non-caseating
extra-pulmonary wheezing, rhonchi, adenopathy with upper- granuloma
symptoms: arthralgia, uveitis, arthritis lobe-predominant, If no specific cutaneous
eye pain, blurred vision, or periarthritis, bilateral infiltrates lesion is evident, then a
painful skin lesions organomegaly, painful Valuable diagnostic
skin papules or tissue biopsy from any
tool.[38]
nodules, erythema affected viscera (e.g.,
nodosum »high-resolution CT lung, liver) should be
scan chest: delineates performed following
type of hilar shadows; chest x-ray or high-
detects interstitial lung
resolution CT scan.
disease and pulmonary
fibrosis
High-resolution
CT scan is an
accurate method of
diagnosis.[39]
»biopsy of specific
cutaneous lesion
(if evident): non-
caseating granuloma
Strongly and often
convincingly suggests
the diagnosis of
sarcoidosis by
DIAGNOSIS
showing non-caseating
granuloma.
Asbestosis
history of prolonged rales, described as »chest x-ray: basal »tissue biopsy via
asbestos exposure; cellophane or velcro reticulonodular bronchoscopy:
progressive dyspnoea; rales, initially heard in infiltrates, pleural asbestos bodies
dry cough with chest end-inspiratory phase thickening; honeycomb Have a protein coat
discomfort appearance in and long, beaded
advanced disease
body. Absence of
Essential for diagnosis.
an asbestos body in
»high-resolution tissue sample does not
CT scan chest: exclude asbestosis.[41]
delineates pleural-
based anomalies;
subpleural linear
41
Uncommon
Asbestosis

opacities parallel to
pleura, pleural plaques
Can be seen even in
absence of chest x-ray
findings.[40]
history of asbestos dullness on percussion, »chest x-ray: pleural- »chest MRI: degree
exposure; older adult absence of breath based mass; unilateral of tumour extension,
patient; recent-onset sounds over affected pleural effusion; especially to the chest
shortness of breath and area irregular pleural wall and diaphragm
non-pleuritic chest pain; thickening Required for
cough, weight loss, Non-specific findings. staging.[42]
weakness may also Useful screening tool.
occur
MRI has the potential
»thoracentesis for to differentiate
pleural biopsy and
cytology: variable between benign
Thoracoscopic biopsy fibrous mesothelioma
using video-assisted (low signal intensity
thoracoscopy has a on T2-weighted
yield of >90% and images) and malignant
mesothelioma (high
DIAGNOSIS
is becoming the first

investigation of choice. signal intensity).
Although this is a good

first test, cytology
from this method
is often unreliable,
because reactive
mesothelial cells
and cells from other
malignant tumours
such as sarcomas and
adenocarcinomas are
often very difficult to
distinguish from pleural
mesotheliomas.
Uncommon
fever, chills, chronic variety of chest signs, »chest x-ray: miliary »tuberculin skin
cough, weight loss, depends on severity of mottling, cavitary and/ test (purified protein
night sweats; history lung involvement: may or apical fibrocavitary derivative test):
of travel to endemic include tachypnoea, changes positive: >15 mm if no
areas, HIV infection, or decreased breath »sputum Gram stain: risk factors
immunosuppression[43] sounds, crackles, All patients residing
positive staining for
[44] dullness to percussion in or having travelled
acid-fast bacilli
»sputum culture: to endemic areas for
growth of acid-fast TB should be tested.
bacilli Causes of positive
Provides definitive test include current TB
diagnosis if acid-fast infection, resolved TB,
bacilli identified, but or being immunised.
takes 6-8 weeks for
growth. Three negative Cut-off applies
morning sputum irrespective of previous
samples required to BCG.
provide negative result.
>10 mm considered
positive if diabetes,
renal failure, healthcare
worker, intravenous
drug user, prior
gastrectomy, history
DIAGNOSIS
of head or neck
malignancies, >10%
below ideal body
weight, haematological
malignancy, from high-
risk country.
>5 mm considered
positive in presence
of HIV infection, on
corticosteroids, close
contact with infected
patient, previous TB on
chest x-ray.
»bronchoalveolar
lavage: growth of acid-
fast bacilli
43
Uncommon

May be useful in
difficult cases to obtain
specimens for further
studies such as culture
and even a biopsy in
endobronchial TB.
symptoms may be dyspnoea, wheezing, »chest x-ray: nodules »high-resolution CT

absent in multiple respiratory distress or infiltration scan chest: delineates
metastases; dyspnoea small nodules
common; sudden- Best method to detect
onset dyspnoea lymphangiomatosis
indicates haemorrhage
or pneumothorax; carcinomatosa (a
wheezing or grave consequence of
haemoptysis suggests lymphatic infiltration).
endobronchial
metastases; extension »trans-thoracic
to pleura may cause biopsy: histology of
pleuritic chest pain; the primary tumour
patients may have Access to metastases
paraesthesias
is by bronchoscopy or
DIAGNOSIS
(due to associated
hypercalcaemia, resection. Sometimes
paraproteinaemia, or a wedge resection is
vasculitis) needed to reach the
tumour mass.[28]
Atrial my xoma
dyspnoea, paroxysmal raised jugular venous »FBC: haemoglobin »cardiac

nocturnal dyspnoea, pressure, loud first and haematocrit catheterisation:
fatigue, dizziness, heart sound, delayed decreased; variable
syncope, fever, weight pulmonic component leukocytosis, Rarely necessary
loss, haemoptysis, of the second heart thrombocytopenia in myxomas, except
sudden death (due to sound, tumour plop Decreased
embolisation anywhere (early diastolic sound), to obtain a tissue
haemoglobin and
in arterial system) fever, cyanosis, rash, diagnosis if mass
petechiae haematocrit found
is sessile. Tissue
Uncommon
Atrial my xoma

in almost half of sample is sent for
patients.[45] histopathology.[46]
»chest x-ray: »biopsy: gelatinous

cardiomegaly, growth with nests of
pulmonary oedema, spindle cells
occasionally
calcification in cardiac
myxoma
»echocardiogram:
seen as a dumbbell-
shaped configuration;
possibly associated
lipomatous hypertrophy
of interatrial septum
Tumour location,
size, attachment,
and mobility can be
assessed. Helps to plan
treatment.
Trans-oesophageal
echocardiogram
is preferred over
trans-thoracic
echocardiogram, as it
DIAGNOSIS
is far more sensitive
in detecting smaller
lesions.
A xillary artery aneurysm
usually sudden unilateral clubbing, »Doppler »CT arteriography:

onset; coolness and pallor, coolness of ultrasonography: exact level of
numbness of affected affected arm and hand, turbulent, pulsatile flow bifurcation and
hand, weakness and slow capillary refill, within the structure, extent of aneurysm
heaviness in affected peripheral pulses in contiguous with demonstrated
arm, symptoms worsen affected arm and hand brachial artery distally 3-dimensional
on exercise may be normal tomography delineates
exact aneurysm
character. Useful
45
Uncommon
A xillary artery aneurysm

for preoperative
planning.[47]
limb hypertrophy if unilateral clubbing, »Doppler »magnetic

chronic, discoloration of soft boggy swelling ultrasonography: resonance
affected limb on affected limb, bruit vascular anomalous angiography:
heard over swelling, flow abnormal early venous
partially compressible filling during arterial
phase of imaging
Non-invasive technique
to assess extent of
anomaly. Arteriovenous
malformation is easily
recognised.
May be used in
preoperative screening.
»angiography:
delineation of
arteriovenous anomaly
DIAGNOSIS
Useful for treatment

planning.
◊ Thyroid acropachy
history of autoimmune soft-tissue swelling »thyroid-stimulating »serum free or total

thyrotoxicosis (usually of hands and feet, hormone (TSH): T3: elevated
Graves' disease, signs of thyrotoxicosis suppressed Elevated free T3
but may be present (exophthalmos, pretibial and suppressed
»serum free T4:
in Hashimoto's myxoedema, goitre, elevated TSH suggest
thyroiditis); symptoms tachycardia, tremor)
of thyrotoxicosis hyperthyroidism.
(heat intolerance, Ordered if
sweating, weight loss, TSH suggests
palpitations, scalp hair
loss, irritability) hyperthyroidism but
free T4 is normal, to
differentiate clinical
Uncommon
◊ Thyroid acropachy

hyperthyroidism
(T3 toxicosis)
from subclinical
hyperthyroidism.
TSH and free T4 are
diagnostic tests for
hyperthyroidism in 95%
cases.[48]
Acromegaly
headache, snoring, acromegalic facies »serum insulin- »pituitary MRI or CT

visual field defects, (frontal bossing, like growth factor 1 scan: characteristic
hyperhidrosis, thickening of nose, levels: elevated features of pituitary
coarsening of facial prognathism, Influenced by several adenoma
features, joint pain and macroglossia), factors including age, Gadolinium-enhanced
dysfunction, fatigue, hirsutism, oily skin, MRI of pituitary
increased appetite, enlarged hands with sex, time of collection,
polyuria/polydypsia sausage-shaped insulin levels, T4, can detect small
fingers, organomegaly, corticosteroid levels. microadenomas
hypertension, (<10 mm diameter)
arrhythmias, thyroid In acromegaly, the and define extent of
anomalies, arthritis
mean levels are 8-10 macroadenomas (>10
DIAGNOSIS
times higher than age- mm diameter).
adjusted population
norms. Diagnostic »chest and/or
abdominal CT scan:
difficulty exists in tumour localisation
adolescents 13-18 Imaging the chest and/
years of age, as they or abdomen with CT
have considerably scan can be used to
higher baseline values. look for ectopic GH
Complements the GH or GnRH-secreting
measurement, and tumours.
laboratories should
standardise for region
and race.[49]
»random serum
growth hormone
(GH): >0.4 micrograms/
L
47
Uncommon
Acromegaly

GH levels in normal
people generally <0.4
micrograms/L with a
few bursts of secretion
during the day when
GH levels rise up to
30 micrograms/L,
overlapping with values
seen in acromegaly.
GH concentrations in
patients with active
acromegaly rarely drop
to <1 microgram/L.
Therefore, random GH
level <0.4 micrograms/
L is useful to exclude
acromegaly.[50] [51]
Random GH levels
considered unreliable in
patients with diabetes
or renal disease.[52]
[53]
DIAGNOSIS
bone and joint pain, myopathy, »serum parathyroid

muscle weakness, osteomalacia, xerosis hormone levels:
history of renal disease elevated
Values may change
depending on primary
cause, or with
associated renal failure.
Severity of renal failure
may alter calcium
metabolism, which in
turn can cause reflex
hyperparathyroidism.
Uncommon

»serum calcium:
reduced or normal
»vitamin D levels:
reduced
Hodgkin's lymphoma
may be asymptomatic; rubbery lymph nodes »FBC with »PET scan: delineates
fever, chills, night in neck, axillae, differential: low lymphoid tissue
sweats, weight loss, and inguinals; haemoglobin, WBC Routine radiology is
chest pain, cough, hepatosplenomegaly, count, and platelets largely being replaced
dyspnoea, pruritus, Waldeyer's ring Secondary to bone
bone pains involvement (tonsils, by PET scans. Pre-
marrow involvement.
nasopharynx, base of treatment PET scan is
tongue) »erythrocyte also useful to monitor
sedimentation rate response to therapy.
(ESR): elevated
ESR >50 without B »lymph node and/or
symptoms or >30 with bone marrow biopsy:
Hodgkin's cells
B symptoms is an within an appropriate
adverse prognostic background cellular
factor. milieu
Biopsy is the
»LDH: elevated definitive test.[54]
DIAGNOSIS
Although non- Hodgkin's lymphoma
specific, elevations
can be classified
point to activation into lymphocyte-
of lymphoreticular predominant and
system, as occurs with classic Hodgkin's
lymphomas. Cannot be lymphoma. The latter
taken in isolation. may be lymphocyte-
»chest x-ray: rich, mixed cellular,
mediastinal mass; large nodular sclerosing,
mediastinal adenopathy lymphocyte-depleted,
Large mediastinal or unclassifiable.
adenopathy (exceeding
one third of the Hodgkin's cell can be
intrathoracic characteristic Reed-
measurement on an Sternberg cell or one
upright posteroanterior of its variants, such as
film at the T5-T6 lacunar cell in nodular
sclerosis subtype; in
49
Uncommon
Hodgkin's lymphoma

interspace) is a nodular lymphocyte-
negative prognostic predominant
factor. Hodgkin's lymphoma,
characteristic cell
is lymphocytic
and histiocytic cell
('popcorn' cell).
»immunohistochemical
studies: classically
CD30-positive
Hodgkin's lymphoma
can be diagnosed
using morphological
assessment
alone. However,
immunohistochemical
studies are sometimes
invaluable in
differentiating
Hodgkin's lymphoma
from other lymphomas
as well as non-
haematological
DIAGNOSIS
processes.
fatigue, anorexia, pallor, plethora, »FBC: elevated »fluorescent in situ

weight loss, abnormal abdominal distension WBC, anaemia, hybridisation test:
bleeding or bruising; due to splenomegaly, thrombocytosis detects BCL-ABL gene
left shoulder bruising; occasionally rearrangements
»peripheral blood
pain (indicates tender purple This cytogenetic
smear: myelogenous
splenic infarction or papules on the body, test has expanded
maturing cells,
perisplenitis) accompanied by fever elevated basophils and sensitivity of standard
(Sweet's syndrome) eosinophils
karyotype and
Almost all WBCs are
permits detection
myelogenous maturing
of submicroscopic
cells. Can be used for
abnormalities.[55]
Uncommon

subsequent disease »bone marrow
monitoring. biopsy and
karyotyping:
granulocytic
hyperplasia; presence
of Philadelphia
chromosome
Bone marrow
aspiration required for
cytogenetic analysis
and confirmation of
diagnosis. Reticulin
stain rules out
myelofibrosis.[55]
Ulcerative colitis
age 15-45 years, abdominal tenderness »colonoscopy and »FBC: microcytic

bloody diarrhoea, and distension, biopsy: continuous anaemia,
abdominal pain, and extra-intestinal uniform inflammation thrombocytosis
bloating manifestations that always involves »erythrocyte
including peripheral the rectum; normal sedimentation rate:
arthritis, sacroiliitis, terminal ileum (or mild elevated
pyoderma 'backwash' ileitis in
DIAGNOSIS
gangrenosum, pancolitis) »autoantibodies:
erythema nodosum Biopsy should be negative anti-
Saccharomyces
obtained at time of
cerevisiae antibody
colonoscopy and shows and positive perinuclear
typical inflammation of antineutrophilic
mucosa and crypts. cytoplasmic antibody
Crohn's disease
crampy abdominal pain, aphthous ulcers, »upper »colonoscopy and

intermittent diarrhoea, evidence of weight gastrointestinal biopsy: aphthous
bloody diarrhoea if loss, pallor, abdominal and small-bowel ulcers, mucosal
colitis a feature, weight tenderness, abdominal series: thickening and oedema, cobblestoning,
loss, fatigue mass, perianal fistula, distortion of valvulae luminal narrowing;
perirectal abscess, anal conniventes due to discontinuous, with
fissure, perianal skin oedema and ulceration intermittent areas of
tags; extra-intestinal
51
Uncommon
Crohn's disease

manifestations Demonstrates features normal-appearing
including iritis, arthritis, suggestive of Crohn's bowel (skip lesions)
sacroiliitis, erythema Indicated if imaging
nodosum, pyoderma disease and aids in
alone is not sufficiently
gangrenosum defining its distribution
informative. Tissue
and severity.
specimen should be
If patient is too ill, obtained at same time
radionuclide scans may to confirm diagnosis
be used instead. histologically. Biopsies
demonstrate transmural
involvement with non-
caseating granulomas.
»FBC: anaemia;
leukocytosis
Anaemia can be due to
chronic inflammation,
chronic blood loss, iron
malabsorption, and/
or malabsorption of
vitamin B12 or folate.
Leukocytosis is
associated with
acute or chronic
DIAGNOSIS
inflammation, abscess,
or corticosteroid
treatment.
»erythrocyte
sedimentation rate:
elevated
»autoantibodies:
positive anti-
Saccharomyces
cerevisiae antibody
and negative
perinuclear
antineutrophilic
cytoplasmic antibody
Uncommon
middle-aged hepatomegaly, skin »LFTs: elevated

women, personal hyperpigmentation, bilirubin, gamma
or family history of splenomegaly, glutamyl transferase,
autoimmune disease jaundice, and alk phos
or primary biliary xanthelasmata »anti-mitochondrial
cholangitis, history of antibodies: present
hypercholesterolaemia,
Found in 95% of
pruritus, fatigue, sleep
disturbance, dry eyes patients with primary
and mouth (sicca biliary cholangitis and
syndrome), postural specific for 98% of
dizziness/blackouts,
patients.[56] [57]
right upper quadrant
discomfort
Presence of antibodies
established by
immunofluorescence
or enzyme-linked
immunosorbent assay
(ELISA).
Cirrhosis
presence of risk factors jaundice, »LFTs: deranged »liver biopsy:
DIAGNOSIS
(alcohol misuse, hepatomegaly, Aspartate architectural distortion
intravenous drug nodularity of liver on aminotransferase of liver parenchyma
use, unprotected palpation, ascites, with formation of
intercourse, obesity, signs of end-stage liver (AST) and alanine regenerative nodules
blood transfusion); failure aminotransferase (ALT) Liver biopsy remains
may be asymptomatic levels increase with the most specific
or have non-specific hepatocellular damage.
constitutional and sensitive test for
symptoms such as Normal AST and ALT diagnosis of cirrhosis,
fatigue, weakness, levels do not preclude but is not necessary in
weight loss diagnosis of cirrhosis. patients with advanced
liver disease and typical
Cholestasis (resulting
clinical, laboratory,
from primary biliary
and/or radiological
cholangitis and primary
findings of cirrhosis,
sclerosing cholangitis)
unless degree of
increases alk phos
inflammation needs to
and gamma glutamyl
be determined.
transferase with
53
Uncommon
Cirrhosis

minimal derangement
of AST and ALT.
Total bilirubin may be

normal in patients with
compensated cirrhosis;
as cirrhosis progresses,
serum levels generally
rise.
Values vary depending

on stage and extent of
cirrhosis.
»albumin: reduced
»prothrombin time:
prolonged
Marker of hepatic
synthetic dysfunction.
»abdominal
ultrasound: early
stages: enlarged
smooth liver;
subsequently: coarse
echotexture; advanced
DIAGNOSIS
disease: small liver

with surface nodularity,
ascites, splenomegaly,
increased diameter of
portal vein (≥13 mm) or
collateral vessels
Stages of cirrhosis
can be monitored
on ultrasound. Early
intervention can arrest
disease progress.
In combination
with strong clinical
suspicion, the above
findings suffice for
diagnosis of cirrhosis
without need of
Uncommon
Cirrhosis

confirmatory liver
biopsy.
Thyroid cancer
most commonly affects palpable thyroid nodule »thyroid

women; painless (particularly if hard ultrasonography:
palpable solitary thyroid and fixed), cervical detects cysts and
nodule; hoarseness or lymphadenopathy structure of thyroid
dysphagia may occur mass
if recurrent laryngeal »fine needle
nerve involved or vocal aspiration (FNA)
cord compressed; biopsy: cytology
history of head and confirms malignant
neck irradiation features
FNA biopsy may be
performed under
ultrasound guidance
for accurate tissue
sampling. Findings
highly sensitive and
specific. Histological
variants include
DIAGNOSIS
papillary, follicular,
medullary, and
anaplastic neoplasms.
Lymphoma may also be
identified.
Thymus cancer
history of myasthenia dyspnoea, loss »chest x-ray: »chest PET

gravis, fatigue, of weight; rarely posteroanterior view: scan: reveals a
generalised weakness, produces clubbing lesion typically appears hypermetabolic mass
weight loss, persistent (usually present as a smooth mass in Indicated once CT scan
cough, chest pain, when associated upper half of chest has defined location
dyspnoea common with hypertrophic Mass usually projects
early symptoms; one osteoarthropathy) of the mass. PET
into one of the
third of patients are scan can also exclude
hemithoraces.
55
Uncommon
Thymus cancer

asymptomatic at time of Most thymic cancers extramediastinal
diagnosis[24] [58] are confirmed at time involvement.
of surgical resection.
Invaluable in confirming
Therefore, tests
invasive malignant
ordered are to stage
thymoma.
the tumour and get a
histological type and Emphasises the
prognostic bearing.[24] value of multiple
[59] imaging methods
»chest CT scan: before deciding on a
demonstrates management protocol
relationship between for this tumour.
thymoma and
surrounding vascular
structures
Regarded as imaging
procedure of choice.
Usually used with a
contrast dye. Aids
surgical resection.
Lipoid pneumonia

DIAGNOSIS
history of mineral oil variable and non- »chest x-ray: alveolar »chest CT: necrosis
(e.g., in laxatives) specific signs including infiltrates, consolidation and pulmonary
or vegetable oil fever, tachypnoea, collections
ingestion; history crackles Indicated if chest
of lung cancer or x-ray findings
bronchiolitis obliterans,
recent chemotherapy inconclusive.[60]
or radiotherapy; may
»bronchoalveolar
be asymptomatic or
lavage: identifies
present with non-
aspirated agent
specific symptoms
(cough, chest pain, Useful to confirm
dyspnoea) diagnosis.[61]
Uncommon
dyspnoea, chest and/ systolic ejection »chest x-ray: »chest CT: non-
or back pain, cough, murmur, cyanosis, solid sarcomatous specific uniform
haemoptysis, weight extremity oedema, expansions of proximal mass consistent with
loss, malaise, syncope, jugular vein distension, pulmonary artery are organised thrombi
fever, rarely sudden hepatomegaly highly suggestive, Enhanced with
death especially if there gadopentetate
are pulmonary
nodules; decreased studies.[63]
vascularity, and cardiac
»intravascular
enlargement
ultrasonography:
By itself chest x-ray is
unique echogenic
not diagnostic unless mass with irregular
specific features are surface, string-shaped
seen as stated.[62] projection, mosaic
pattern containing
flecked echolucent and
increased echogenic
areas
Uses a specially
designed catheter
with a miniaturised
ultrasound probe
attached to distal end
of catheter. Proximal
end of catheter is
attached to ultrasound
DIAGNOSIS
equipment.
Intravascular
ultrasound and
PET studies can
aid preoperative
diagnosis. Final
diagnosis confirmed by
histopathology.
»PET scan chest:

shows heterogeneous
soft-tissue density
from areas of necrosis,
haemorrhage, and
ossification
Intravascular
ultrasound and PET
studies can aid
57
Uncommon

preoperative diagnosis;
final diagnosis is by
histopathology.
burning retrosternal minimal findings, »barium studies: »biopsy: epithelial

pain, nausea, vomiting occasional epigastric ulceration seen in hyperplasia, infiltration
tenderness barium shadow by inflammatory cells,
and sometimes focal
»endoscopy: direct
necrosis possible in
visualisation of
early lesions; presence
ulceration
of intra-epithelial
eosinophils common
May progress to
superficial ulceration
and spread of
inflammation to the
wall.
◊ Achalasia

DIAGNOSIS
dysphagia, weight loss »barium studies:

regurgitation, chest dilated oesophagus,
pain, heartburn contrast passes slowly
into stomach, distal
oesophagus narrowed
and resembles a bird's
beak
»oesophageal
manometry:
incomplete relaxation
of lower oesophageal
sphincter in response to
swallowing; high resting
pressure of lower
oesophageal sphincter;
absent oesophageal
peristalsis
Uncommon
◊ Coeliac disease
diarrhoea, flatulence, protuberant abdomen »anti-tissue »FBC: microcytic

steatorrhoea, weight (may be tympanic due transglutaminase anaemia
loss, weakness, to bowel distension); antibodies: elevated Anaemia is due to
fatigue; abdominal pallor, easy bruising, titre chronic disease,
pain not common aphthous stomatitis Results correlate
in uncomplicated malabsorption, or low
with degree of tissue
cases; extra-intestinal serum iron.
symptoms may be damage. If patient is
present (dermatitis serum IgA deficient, »iron studies: iron
herpetiformis, history of tissue transglutaminase deficiency
bone pain, or previous IgG can be measured. »prothrombin time:
fracture suggesting prolonged
osteoporosis) Due to altered
Older patients with
severe disease can be coagulation parameters
seronegative. as a result of impaired
vitamin K absorption.
»small-bowel biopsy:
presence of intra-
epithelial lymphocytes,
villous atrophy, and
crypt hyperplasia
Small-bowel histology
is the most specific and
sensitive test.
◊ Tropical sprue
DIAGNOSIS
prolonged exposure glossitis, stomatitis, »FBC: macrocytic »72-hour faecal fat

to an endemic area; weight loss, anaemia collection: >6 g of
diarrhoea, fever, dehydration, pallor, More than half faecal fat in 24 hours
fatigue, malaise, pedal oedema of patients have Fat content of stool
anorexia is measured over 72
megaloblastic
anaemia and reduced hours based on 80- to
folate levels due to 100-g fat diet.
malabsorption.
»D-x ylose
absorption test: low
»serum folate: low
serum and urine levels
More than half of D-xylose following
of patients have a 25 g oral dose of D-
megaloblastic xylose
anaemia and reduced Indicates
folate levels due to malabsorption. Patients
malabsorption. have to be well
59
Uncommon
◊ Tropical sprue

»serum B12: low hydrated and have
Folate deficiency, normal renal function
vitamin B12 deficiency, for this test to be valid.
and megaloblastic
anaemia virtually define
tropical sprue.
◊ Leiomyoma of the oesophagus
young patients, weight loss and wasting »barium studies: »oesophageal

dysphagia, retrosternal in severe cases smooth concave mass ultrasonography:
discomfort, chest pain, underlying intact mass located in
regurgitation; bleeding mucosa, encroaching muscularis
is rare lumen of oesophagus »oesophagoscopy:
uniform smooth
mass growing out of
muscularis into lumen
Biopsy should not be
performed, as it would
cause scarring at the
biopsy site and hamper
definitive excision.
DIAGNOSIS
»brush cytology:
interlacing smooth
muscle cells well
demarcated by
adjacent tissue or a
capsule
Done via
oesophagoscopy to rule
out carcinoma.
◊ Familial clubbing
positive family absence of signs »none: diagnosis is

history; absence of suggesting an clinical
symptoms suggesting underlying organic
an underlying organic condition
condition
Uncommon
◊ Pachydermoperiostosis (primary hypertrophic osteoarthropathy)
onset often at puberty; combination of »chest x-ray: usually »plain film x-rays: x-
excessive sweating, pachydermia (elephant- normal ray of the hands shows
acne, arthralgia, like skin), periostosis Done to exclude acro-osteolysis of the
coarsening of facial (swelling around the pulmonary findings, terminal phalanges;
features, enlargement joints, especially films of other joints
of fingers and toes, wrists and knees), the presence show periosteal
cutaneous thickening, and clubbing is of which would reactions
and furrowing of scalp typical;[19] possibly suggest secondary Confirms the diagnosis,
also seborrhoea, pulmonary hypertrophic although rarely
acne, hyperhidrosis,
cutis verticis gyrata osteoarthropathy. indicated, as diagnosis
(thickened skin of the is largely clinical.
scalp manifesting as
folds and furrows),
haemarthrosis or
hydrarthrosis[64]
painful joints with enlarged extremities »plain film x-rays: »chest CT scan:
limited range of due to periarticular and x-ray of hands shows delineates the nature of
movement; pulmonary, osseous proliferation, acro-osteolysis of pulmonary involvement
hepatic, or endocrine tender and swollen terminal phalanges; (if present)
symptoms[65] [66] joints; signs suggesting films of other joints Helps in deciding
underlying cause show periosteal therapy and the need
DIAGNOSIS
(lung cancer, abscess, reactions
bronchiectasis, for further investigation
Confirms diagnosis
emphysema, Hodgkin's into the underlying
in most cases, but is
lymphoma, metastatic cause. MRI is not yet
disease, cystic fibrosis, not used in isolation.
well defined but can
cirrhosis, inflammatory Nuclear scanning can
bowel disease, biliary augment CT findings.
pick up early signs
atresia) of joint inflammation
but needs clinical
correlation.
»chest x-ray: may

reveal associated
pulmonary signs
Indicated in all cases,
as hypertrophic
osteoarthropathy can
exist in the absence of
pulmonary involvement.
61
Uncommon
◊ Palmoplantar keratoderma
thickening of palms hyperkeratosis »none: diagnosis is

and soles; may be clinical
hereditary but more
commonly acquired
◊ Pregnancy
amenorrhoea, nausea, breast enlargement, »urine beta-hCG: »pelvic ultrasound:

vomiting, weight gain abdominal distension, positive visualisation of fetal
palpation of abdominal parts
or uterine mass
◊ Pseudoclubbing
asymptomatic Lovibond's angle »none: diagnosis is

between 160° and clinical
180°; clubbing may
be localised to a
single digit; subungual
tumour, cyst, or osteoid
osteoma may be
present; if clubbing
DIAGNOSIS
is generalised, acro-
osteolysis (loss of
terminal tufts of digits)
may be present[18]
◊ Myelofibrosis
may be a history of splenomegaly with or »FBC with »JAK2 V617F

exposure to radiation without hepatomegaly, differential: anaemia mutation: positive in
or industrial chemicals; progressive dyspnoea, 50% of cases
»peripheral blood
non-specific symptoms cutaneous petechiae smear: teardrop-
are common (e.g., shaped red blood cells
weight loss, low- (RBCs), presence
grade fever and of metamyelocytes,
night sweats, fatigue, myelocytes,
anorexia, pruritus); promyelocytes,
gastrointestinal myeloblasts, and
bleeding, haemoptysis, nucleated RBCs in the
haematuria, ascites, circulation
Uncommon
◊ Myelofibrosis

and pericardial effusion »bone marrow
may be present aspiration: may be
'dry'
»bone marrow
biopsy: fibrosis
DIAGNOSIS
63
Assessment of clubbing Guidelines
Guidelines
Europe
Suspected cancer: recognition and referral (ht tps://www.nice.org.uk/

guidance/ng12)
Published by: National Institute for Health and Care Excellence

Last published: 2017
International
Diagnosis of idiopathic pulmonary fibrosis (ht tps://www.thoracic.org/

statements/)
Published by: American Thoracic Society; European Respiratory Society; Japanese Respiratory Society;
GUIDELINES
Latin American Thoracic Society

North America
Consensus guidelines for the management of empyema (ht tps://

www.jtcvs.org/article/S0022-5223(17)30152-6/fulltext)
Published by: American Association for Thoracic Surgery

Diagnosis clinical care guidelines (ht tps://www.cff.org/Care/Clinical-Care-

Guidelines/)
Published by: Cystic Fibrosis Foundation

Diagnosis and management of lung cancer (ht tp://www.chestnet.org/

Guidelines-and-Resources)
Published by: American College of Chest Physicians

Assessment of clubbing References
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2008 Apr;22(2):233-44;vi. Abstract
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71
Assessment of clubbing Images
Images
IMAGES
Figure 1: Schamroth window test demonstrating a diamond-shaped window when fingers are not clubbed
IMAGES
Figure 2: Schamroth window test demonstrating lack of window with clubbed fingers
73
IMAGES Assessment of clubbing Images
Figure 3: Finger clubbing

IMAGES
Figure 4: Pachydermoperiostosis: toe clubbing
75
Figure 5: Clubbing of nails showing loss of the classic Lovibond's angle (normally ≤160° in a normal distal
digit, but >180° with definitive clubbing)
Figure 6: Pachydermoperiostosis: furrowed and thickened forehead

IMAGES
Figure 7: Pachydermoperiostosis: wrist joint swelling
77
Figure 8: Pachydermoperiostosis: finger clubbing

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Contributors:
// Authors:
Murlidhar Rajagopalan, MD
Senior Consultant Dermatologist and Coordinator
Apollo Hospitals, Chennai, India
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Robert A. Schwart z, MD, MPH, DSc (Hon), FRCP Edin, FACP, FAAD
Professor & Head
Dermatology, Rutgers New Jersey Medical School, Newark, NJ
DISCLOSURES: RAS declares that he has no competing interests.
// Peer Reviewers:
Krishna Sundar, MD, FCCP

Associate Professor (Clinical)
Department of Medicine, University of Utah, Director, Pulmonary and Critical Care Research, IHC Urban
South, Utah Valley Pulmonary Clinic, UT
DISCLOSURES: KS declares that he has no competing interests.
Santhanam Lakshminarayanan, MD
Assistant Professor of Medicine
Director, Rheumatology Fellowship, University of Connecticut Health Center, Farmington, CT
DISCLOSURES: SL declares that he has no competing interests.

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Straight to the point of care

Last updated: Aug 11, 2020

Schamroth window test demonstrating lack of window with clubbed fingers

Pachydermoperiostosis: toe clubbing

• Clubbing may be seen with any cell type of lung cancer.

• Chronic granulomatous disorder, characterised by accumulation of lymphocytes and macrophages in

• Rare sarcoma arising from the intima of the pulmonary artery.

Hypersensitivity pneumonitis (extrinsic allergic alveolitis)

• Most common of the rare benign primary cardiac tumours.

Axillary artery aneurysm

• Rare but potentially life-threatening cause of unilateral clubbing.

Brachial arteriovenous malformations

• Abnormal connection between veins and arteries occurring in the arm.

Cirrhosis of the liver

• Pathological end-stage of any chronic liver disease.

Leiomyoma of the oesophagus

• Acquired malabsorptive condition of probable infectious aetiology.

• Most commonly caused by chronic renal insufficiency.

• Uncommon haematological malignancy arising from mature B cells.

• Malignant clonal disorder of haematopoietic stem cells.

• Most commonly presents as an asymptomatic thyroid nodule detected by palpation or ultrasound in a

• Histological variants include papillary, follicular, medullary, and anaplastic neoplasms.

• Rare form of cancer.

• Clubbing without any associated signs or symptoms.

• Rare autosomal-dominant inherited condition.

Pachydermoperiostosis: furrowed and thickened forehead

Pachydermoperiostosis: finger clubbing

• Syndrome characterised by proliferative changes in the skin and skeleton.

• Reactive process common to many malignant and benign disorders.

Clubbing of nails showing loss of the classic Lovibond's angle (normally

Schamroth window test demonstrating lack of window with clubbed fingers

Pachydermoperiostosis: toe clubbing

• Thickened palms and soles suggestive of palmoplantar keratoderma

Pachydermoperiostosis: furrowed and thickened forehead

Pachydermoperiostosis: finger clubbing

Hepatomegaly may be present on abdominal examination, indicating an underlying malignancy or the

Tender, swollen joints may suggest pachydermoperiostosis[19] or secondary hypertrophic osteoarthropathy.

Pachydermoperiostosis: wrist joint swelling

Congenital heart disease

Hypersensitivity pneumonitis (extrinsic allergic alveolitis)

Interstitial pulmonary fibrosis

Cavitating pulmonary tuberculosis (TB)

Axillary artery aneurysm

Brachial arteriovenous malformations

Severe secondary hyperparathyroidism

Disseminated chronic myelogenous leukaemia

Primary biliary cholangitis

Pulmonary artery sarcoma

Leiomyoma of the oesophagus

Pachydermoperiostosis (primary hypertrophic osteoarthropathy)

Secondary hypertrophic osteoarthropathy

History Exam 1st Test Other tests

confirmed with cytology complementary to CT,

History Exam 1st Test Other tests

History Exam 1st Test Other tests

history of recurrent crackles and wheezes, »chest x-ray: »spirometry:

Sensitive but not

Should be the first

History Exam 1st Test Other tests

History Exam 1st Test Other tests

recent pneumonia, febrile, toxic patient; »chest x-ray: »chest CT:

History Exam 1st Test Other tests