Cyanosis physical examination

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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 [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

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 of patients with [disease name] is usually normal.

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

• Patients with [disease name] usually appear [general appearance].

Vital Signs

• High-grade / low-grade fever
• Hypothermia / hyperthermia may be present
• Tachycardia with regular pulse or (ir)regularly irregular pulse
• Bradycardia with regular pulse or (ir)regularly irregular pulse
• 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 examination of patients with [disease name] is usually normal.

OR

• Cyanosis
• Jaundice
• Pallor
• Bruises

• Description (Adapted from Dermatology Atlas)

  Description (Adapted from Dermatology Atlas)

• 

  Description (Adapted from Dermatology Atlas)

HEENT

• HEENT examination of patients with [disease name] is usually normal.

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 examination of patients with [disease name] is usually normal.

OR

• 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

Heart

• Cardiovascular examination of patients with cyanosis will show:
  • Tachycardia/ Bradycardia
    • Bradycardia is an ominous sign for imminent cardiovascular collapse.
    • Paradoxic pulse: Acute airway obstruction, Pulmonary embolism, cardiac tamponade
  • Auscultate for abnormal (loud, single or widely split S2) and additional heart sounds and murmurs (Grade, timing, location, radiation, intensity).

	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

• Tachypnea is seen in patients with respiratory and cardiac diseases presenting with cyanosis.
• Nasal flaring, grunting, intercostal and substernal retractions, and prolonged breathing may indicate respiratory distress.
• Traumatic injury involving chest wall or lung will show following abnormalities:
  • Chest wall movement abnormalities
  • Chest wound (eg, open or sucking)
  • Abrasions
  • Ecchymosis
  • Focal tenderness can be elicited on palpation over ribs, sternum, or scapula.
  • Deviation of Trachea
  • Subcutaneous air with crepitus
• Stridor, voice changes, suprasternal retractions, drooling and prolonged inspiration can be found in patients with upper airway obstruction.
• Wheezing, rales / crackles and assymmetric breath sounds will suggest Intrinsic lung diseases.
• Tactile fremitus:
  • Increased: Consolidation by pneumonia ,atelactasis
  • Decresed: Pleural effusion, pneumothorax
• Lung sounds may be clear on auscultation in patients with
  • Cyanotic congenital heart disease
  • Methemoglobinemia
  • Neurologic conditions associated with hypoventilation (eg, muscle weakness, coma, and seizures)
  • Pulmonary embolism

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

• Pulses in all extremities need to be evaluated.
• Check capillary refill.
• Clubbing of the toes or fingers may be indicative of chronic pulmonary disease or congenital heart disease.

• 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

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