Clubbing
A nonspecific sign of pulmonary and cyanotic cardiovascular disorders, clubbing is the painless, usually bilateral increase in soft tissue around the terminal phalanges of the fingers or toes. (See Rare causes of clubbing.) It doesn’t involve changes in the underlying bone. In early clubbing, the normal 160-degree angle between the nail and the nail base approximates 180 degrees. As clubbing progresses, this angle widens and the base of the nail becomes visibly swollen. In late clubbing, the angle where the nail meets the now-convex nail base extends more than halfway up the nail.
History and physical examination
You’ll probably detect clubbing while evaluating other signs of known pulmonary or cardiovascular disease. Therefore, review the patient’s current plan of treatment because clubbing may resolve with correction of the underlying disorder. Also, evaluate the extent of clubbing in both the fingers and toes. (See Checking for clubbed fingers, page 182. )
Medical causes
Bronchiectasis
Clubbing commonly occurs in the late stage of this disorder. Another classic sign is a cough producing copious, foul-smelling, and mucopurulent sputum. Hemoptysis and coarse crackles heard over the affected area during inspiration are also characteristic. The patient may complain of weight loss, fatigue, weakness, and exertional dyspnea. He may also have rhonchi, fever, malaise, and halitosis.
Bronchitis
Clubbing may occur as a late sign in chronic bronchitis, but it doesn’t reflect the severity of the disease. The patient has a chronic productive cough and may display barrel chest, dyspnea, wheezing, increased use of accessory muscles, cyanosis, tachypnea, crackles, scattered rhonchi, and prolonged expiration.
Emphysema
Clubbing occurs late in this disease, which may also cause anorexia, malaise, dyspnea, tachypnea, diminished breath sounds, peripheral cyanosis, pursed-lip breathing, accessory muscle use, barrel chest, and a productive cough.
Endocarditis
In subacute infective endocarditis, clubbing may be accompanied by fever, anorexia, pallor, weakness, night sweats, fatigue, tachycardia, and weight loss. The patient may also develop arthralgia, petechiae, Osler’s nodes, splinter hemorrhages, Janeway lesions, splenomegaly, and Roth’s spots. Cardiac murmurs are usually present.
Heart failure
Clubbing is a late sign of heart failure along with wheezing, dyspnea, and fatigue. Other findings include jugular vein distention, hepatomegaly, tachypnea, palpitations, dependent edema, unexplained weight gain, nausea, anorexia, chest tightness, slowed mental response, hypotension, diaphoresis, narrow pulse pressure, pallor, oliguria, a gallop rhythm (a third heart sound),and crackles on inspiration.
Interstitial fibrosis
Clubbing occurs in almost all patients with advanced interstitial fibrosis. Typically, the patient also develops intermittent chest pain, dyspnea, crackles, fatigue, weight loss and, possibly, cyanosis.
Lung abscess
Initially, this disorder produces clubbing, which may resolve with resolution of the abscess. It can also cause pleuritic chest pain, dyspnea, crackles, halitosis, and a productive cough with a large amount of purulent, foul-smelling, and commonly bloody sputum. The patient may also experience weakness, fatigue, anorexia, headache, malaise, weight loss, and fever with chills. Auscultation may reveal decreased breath sounds.
Lung and pleural cancer
Clubbing occurs commonly in these cancers. Associated findings include hemoptysis, dyspnea, wheezing, chest pain, weight loss, anorexia, fatigue, and fever.
Special considerations
Don’t mistake curved nails—a normal variation—for clubbing. Remember that the angle between the nail and its base remains normal in curved nails, but not in clubbed nails.
Pediatric pointers
Clubbing usually occurs in children with cyanotic congenital heart disease or cystic fibrosis. Surgical correction of heart defects may reverse clubbing.
Geriatric pointers
Arthritic deformities of the fingers or toes may disguise clubbing in elderly patients.
Patient counseling
Inform the patient that clubbing doesn’t always disappear, even if the cause has been resolved.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Clubbing
Read excerpts from these other book chapters related to Clubbing:
Medical Books Excerpts
- Clubbing
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Clubbing
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Clubbing
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Clubfoot
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Clubbing
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Clubbing
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Clubbing
» Next page: Nail Phenomena/Clubbing (Field Guide to Bedside Diagnosis)
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