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==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with [[cyanosis]] show bluish discolration of [[skin]] and [[Mucous membrane|mucous membranes]]. Common locations to look for [[cyanosis]] include [[tongue]], [[buccal mucosa]], [[Lip|lips]], [[Extremities|hands and feet.]]
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3]
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


==Physical Examination==
==Physical Examination==
* Physical examination of patients with [disease name] is usually normal.
* [[Physical examination]] of [[Patient|patients]] with [[cyanosis]] will show bluish discoration of [[Lip|lips]], [[tongue]], [[oral mucosa]], [[nose]] tip, [[ear]] lobules, [[Hand|hands]] and [[Lower limb|feet]]. Because [[cyanosis]] is a [[symptom]] of [[disease]] process careful [[physical examination]] for associated [[Symptom|symptoms]] include [[tachypnea]], [[tachycardia]], abnormal [[heart sounds]] or [[Heart murmur|murmurs]], [[Wheeze|wheezing]], [[Rales|crackles]], [[fever]], [[clubbing]], [[edema]] of extremities will be necessary to identify underlying [[disease]] process.
OR
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*[[Human physical appearance|Appearance]] of [[Patient|patients]] with [[cyanosis]] will vary depending to the underlying condition.
**[[Lip|Lips]], [[tongue]], [[buccal mucosa]], [[Hand|hands]], and feet will appear blue in [[Patient|patients]] with [[cyanosis]].


===Vital Signs===
===Vital Signs===
 
*[[Fever]]
*High-grade / low-grade fever
*[[Tachypnea]]
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]]
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]]
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Hypertension]] / [[hypotension]]
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
*Skin usually appears blue in patients with [[cyanosis]].
OR
**It is very difficult to find bluish discoration in dark-skinned individuals and in poor lighting conditions.
*[[Cyanosis]]  
*Sites to look for central [[cyanosis]]: [[Tongue]], inner aspect of [[Lip|lips]], [[Gingiva|gums]], [[soft palate]], [[buccal mucosa]],  and sites of [[Cyanosis|peripheral cyanosis]].
*[[Jaundice]]
*Sites to look for peripheral [[cyanosis]]: [[Nose|Nose tip]], [[Ear|ear lobules]], outer aspect of [[Lip|lips]], [[Finger|fingertips]], [[Nail (anatomy)|nail bed]], [[Limb|extremities]].
* [[Pallor]]
*Central [[cyanosis]] with  gray appearance to the skin is characteristic of [[methemoglobinemia]].
* Bruises
*Certain [[skin]] conditions and exposure to dyes may mimic [[cyanosis]] have to be ruled out(eg, Mongolian spot, tattoo, blue clothing dye, finger paints).
 
[[File:Cynosis.JPG|center|thumb|Hand with cyanosis - By James Heilman, MD - Own work, CC BY-SA 3.0, <ref>https://commons.wikimedia.org/w/index.php?curid=17978808</ref>]]
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
*Evidence of head trauma
OR
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
OR
*[[Jugular venous distension]]
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
*[[Hepatojugular reflux]]


=== Heart ===
=== Heart ===
*Cardiovascular examination of patients with cyanosis will show:
*Cardiovascular examination of patients with [[cyanosis]] will show:<ref name="pmid15852070">{{cite journal |vauthors=Berg A, Greve G, Hirth A, Rosland GA, Norgård G |title=[Evaluation of cardiac murmurs in children] |language=Norwegian |journal=Tidsskr. Nor. Laegeforen. |volume=125 |issue=8 |pages=1000–3 |date=April 2005 |pmid=15852070 |doi= |url=}}</ref><ref name="pmid15275985">{{cite journal |vauthors=Sasidharan P |title=An approach to diagnosis and management of cyanosis and tachypnea in term infants |journal=Pediatr. Clin. North Am. |volume=51 |issue=4 |pages=999–1021, ix |date=August 2004 |pmid=15275985 |doi=10.1016/j.pcl.2004.03.010 |url=}}</ref><ref name="pmid8772770">{{cite journal |vauthors=Ammash N, Warnes CA |title=Cerebrovascular events in adult patients with cyanotic congenital heart disease |journal=J. Am. Coll. Cardiol. |volume=28 |issue=3 |pages=768–72 |date=September 1996 |pmid=8772770 |doi= |url=}}</ref>
**Tachycardia/ Bradycardia  
**[[Tachycardia]]/ [[Bradycardia]]
***Bradycardia is an ominous sign for imminent cardiovascular collapse.
***[[Bradycardia]] is an ominous [[Medical sign|sign]] for imminent [[Shock|cardiovascular collapse]].
**Auscultate for abnormal (single or widely split S2) and additional heart sounds and murmurs (Grade, timing, location, radiation, intensity).
***[[Pulsus paradoxus|Paradoxic pulse]]:  Acute airway obstruction, [[Pulmonary embolism]], [[cardiac tamponade]], and [[asthma]].
**Signs of heart failure:
**[[Auscultation|Auscultate]] for abnormal (loud, single or widely split S2) and additional [[heart sounds]] and [[Heart murmur|murmurs]] (Grade, timing, location, radiation, intensity).
***Parasternal heave and palpable P2 (pulmonary hypertension)
{| class="wikitable"
***Elevated JVP
!
***Hepatomegaly
!S2
***Peripheral edema
!Murmur
***Displaced apical impulse
|-
**Measure blood pressure in both upper and lower extremities
|TOF
 
|single
|systolic
|-
|Tricuspid atresia
|single
|with or with out systolic
|-
|Ebstein's anomaly
|split
|systolic
|-
|TGA
|single
|none
|-
|Truncus arteriosus
|single
|systolic murmur/ with or with out diastolic murmur
|-
|Pulmonary stenosis
|single
|systolic
|-
|Pulmonary atresia
|single
|systolic
|-
|TAPVC
|split
|systolic
|-
|HLHS
|single
|with or with out systolic
|-
|Tricuspid atresia
|single
|with or with out systolic
|}
*Measure blood pressure in both upper and lower extremities


=== Lungs ===
=== Lungs ===
*Patients with cyanosis will show:<ref name="pmid15275985">{{cite journal |vauthors=Sasidharan P |title=An approach to diagnosis and management of cyanosis and tachypnea in term infants |journal=Pediatr. Clin. North Am. |volume=51 |issue=4 |pages=999–1021, ix |date=August 2004 |pmid=15275985 |doi=10.1016/j.pcl.2004.03.010 |url=}}</ref><ref name="pmid8575588">{{cite journal |vauthors=Maitre B, Similowski T, Derenne JP |title=Physical examination of the adult patient with respiratory diseases: inspection and palpation |journal=Eur. Respir. J. |volume=8 |issue=9 |pages=1584–93 |date=September 1995 |pmid=8575588 |doi= |url=}}</ref><ref name="pmid19462358">{{cite journal |vauthors=Kosacka M, Brzecka A, Jankowska R, Lewczuk J, Mroczek E, Weryńska B |title=[Combined pulmonary fibrosis and emphysema - case report and literature review] |language=Polish |journal=Pneumonol Alergol Pol |volume=77 |issue=2 |pages=205–10 |date=2009 |pmid=19462358 |doi= |url=}}</ref>
*[[Tachypnea]] is seen in [[Patient|patients]] with [[Lung|respiratory]] and [[Heart|cardiac diseases]] presenting with [[cyanosis]].
*[[Tachypnea]] is seen in [[Patient|patients]] with [[Lung|respiratory]] and [[Heart|cardiac diseases]] presenting with [[cyanosis]].
*[[Nasal]] flaring, grunting, intercostal  and substernal retractions, and  prolonged [[breathing]]  may indicate respiratory distress.
*[[Nasal]] flaring, grunting, intercostal  and substernal retractions, and  prolonged [[breathing]]  may indicate respiratory distress.
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*[[Stridor]], [[Human voice|voice]] changes, [[Sternum|suprasternal]] retractions, [[drooling]] and prolonged [[inspiration]] can be found in patients with [[Airway obstruction|upper airway obstruction]].
*[[Stridor]], [[Human voice|voice]] changes, [[Sternum|suprasternal]] retractions, [[drooling]] and prolonged [[inspiration]] can be found in patients with [[Airway obstruction|upper airway obstruction]].
*[[Wheeze|Wheezing]], [[Rales|rales / crackles]] and assymmetric [[breath sounds]] will suggest Intrinsic lung diseases.
*[[Wheeze|Wheezing]], [[Rales|rales / crackles]] and assymmetric [[breath sounds]] will suggest Intrinsic lung diseases.
*[[Tactile fremitus]]:
**Increased: [[Consolidation (medicine)|Consolidation]] by [[pneumonia]] ,[[atelactasis]]
**Decresed: [[Pleural effusion]], [[pneumothorax]]
*Lung sounds may be clear on auscultation in patients with
*Lung sounds may be clear on auscultation in patients with
**[[Congenital heart disease cyanotic|Cyanotic congenital heart disease]]
**[[Congenital heart disease cyanotic|Cyanotic congenital heart disease]]
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**Neurologic conditions associated with [[hypoventilation]] (eg, [[muscle weakness]], [[coma]], and [[Seizure|seizures]])
**Neurologic conditions associated with [[hypoventilation]] (eg, [[muscle weakness]], [[coma]], and [[Seizure|seizures]])
**[[Pulmonary embolism]]
**[[Pulmonary embolism]]
===Abdomen===
Abdominal examination of patients with [disease name] is usually normal.
OR
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
===Back===
* Back examination of patients with [disease name] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


=== Extremities ===
=== Extremities ===
* Pulses in all extremities need to be evaluated.
*[[Clubbing]] is seen in some patients presenting with [[cyanosis]].<ref name="pmid24001503">{{cite journal |vauthors=Srinivas SK, Manjunath CN |title=Differential clubbing and cyanosis: classic signs of patent ductus arteriosus with Eisenmenger syndrome |journal=Mayo Clin. Proc. |volume=88 |issue=9 |pages=e105–6 |date=September 2013 |pmid=24001503 |doi=10.1016/j.mayocp.2013.02.016 |url=}}</ref><ref name="pmid20421356">{{cite journal |vauthors=Wald R, Crean A |title=Differential clubbing and cyanosis in a patient with pulmonary hypertension |journal=CMAJ |volume=182 |issue=9 |pages=E380 |date=June 2010 |pmid=20421356 |pmc=2882471 |doi=10.1503/cmaj.091003 |url=}}</ref>
* Check capillary refill.
**[[Congenital heart disease|Congenital heart diseases]]
* [[Clubbing]] of the toes or fingers may be indicative of chronic pulmonary disease or [[congenital heart disease]].
**Pulmonary diseases: [[COPD]], [[bronchiectasis]], [[cystic fibrosis]],  [[Idiopathic pulmonary fibrosis|pulmonary fibrosis]], [[Arteriovenous malformations|pulmonary arteriovenous malformations]].
*[[Edema]] of [[Human leg|lower extremities]] due to [[congestive heart failure]] and [[pulmonary embolism]], [[pulmonary edema]], [[pulmonary hypertension]].


* Extremities examination of patients with [disease name] is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
[[Category:Primary care]]
 
{{WH}}
{{WS}}
[[Category: (name of the system)]]

Latest revision as of 04:12, 26 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]

Overview

Patients with cyanosis show bluish discolration of skin and mucous membranes. Common locations to look for cyanosis include tongue, buccal mucosa, lips, hands and feet.

Physical Examination

Appearance of the Patient

Vital Signs

Skin

Hand with cyanosis - By James Heilman, MD - Own work, CC BY-SA 3.0, [1]

HEENT

  • Evidence of head trauma

Neck

Heart

S2 Murmur
TOF single systolic
Tricuspid atresia single with or with out systolic
Ebstein's anomaly split systolic
TGA single none
Truncus arteriosus single systolic murmur/ with or with out diastolic murmur
Pulmonary stenosis single systolic
Pulmonary atresia single systolic
TAPVC split systolic
HLHS single with or with out systolic
Tricuspid atresia single with or with out systolic
  • Measure blood pressure in both upper and lower extremities

Lungs

Extremities

References

  1. ↑ https://commons.wikimedia.org/w/index.php?curid=17978808
  2. ↑ Berg A, Greve G, Hirth A, Rosland GA, Norgård G (April 2005). "[Evaluation of cardiac murmurs in children]". Tidsskr. Nor. Laegeforen. (in Norwegian). 125 (8): 1000–3. PMID 15852070.
  3. ↑ 3.0 3.1 Sasidharan P (August 2004). "An approach to diagnosis and management of cyanosis and tachypnea in term infants". Pediatr. Clin. North Am. 51 (4): 999–1021, ix. doi:10.1016/j.pcl.2004.03.010. PMID 15275985.
  4. ↑ Ammash N, Warnes CA (September 1996). "Cerebrovascular events in adult patients with cyanotic congenital heart disease". J. Am. Coll. Cardiol. 28 (3): 768–72. PMID 8772770.
  5. ↑ Maitre B, Similowski T, Derenne JP (September 1995). "Physical examination of the adult patient with respiratory diseases: inspection and palpation". Eur. Respir. J. 8 (9): 1584–93. PMID 8575588.
  6. ↑ Kosacka M, Brzecka A, Jankowska R, Lewczuk J, Mroczek E, Weryńska B (2009). "[Combined pulmonary fibrosis and emphysema - case report and literature review]". Pneumonol Alergol Pol (in Polish). 77 (2): 205–10. PMID 19462358.
  7. ↑ Srinivas SK, Manjunath CN (September 2013). "Differential clubbing and cyanosis: classic signs of patent ductus arteriosus with Eisenmenger syndrome". Mayo Clin. Proc. 88 (9): e105–6. doi:10.1016/j.mayocp.2013.02.016. PMID 24001503.
  8. ↑ Wald R, Crean A (June 2010). "Differential clubbing and cyanosis in a patient with pulmonary hypertension". CMAJ. 182 (9): E380. doi:10.1503/cmaj.091003. PMC 2882471. PMID 20421356.
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