Clubbing

It's been some while since I last wrote. I have been busy with Neurology. Well, this patient is a 60 years old Malay man who was admitted to my ward with progressive L sided weakness over a week. He is non toxic looking and there is no stigmata of chronic liver disease. He has been a chronic smoker. To tell the truth, I was rather upset that 2 of my house officers could not come to a conclusion even after I mentioned the gross clubbing in this patient.

I hope medical students reading this will practice what has been learned in medical student years.

This is a clear cut case of Ca lung with metastasis to the brain.

What I would like to stress here is - Do not forget the causes of clubbing !

Respiratory :

Ca lung

Pulmonary fibrosis

Bronchiectasis

Chronic suppurative lung diseases

Cystic fibrosis

CVS :

Congenital cyanotic heart disease

Eisenmenger syndrome

Infective endocarditis

GI :

Chronic liver disease (Cirrhosis)

Inflammatory bowel disease

Thyrotoxicosis (pseudoclubbing - acropachy)

Superior Vena Cava Obstruction

I still remembered during my 2nd year as medical student that one of my lecturer who was an Anaesthesiologist(Dr. Murthy) who took us for Respiratory system showed us one case in Sarawak General Hospital.

His words : Look at this patient and remember this forever because you may not see it for a long time to come

He performed the Pemberton sign by asking the patient to lift his arms and immediately, the patient's face became plethoric and his voice became rather hoarse that he had to immediately put down his arms.

You may be asked to examine the respiratory system and you'll find

1) Dilated veins over the chest

2) Plethoric face, occasionally with congested eyes

3) Non-pulsatile raised JVP

4)Pemberton sign positive (you may not want to perform this but offer to the examiner because you may distress the patient which will then cause you to fail)

5) Talk to the patient to notice the hoarseness of voice

You are also expected to find the cause for this which almost always caused by lymph node compression due to malignancy. 

The above patient has Non-Hodgkin's lymphoma with SVC obstruction and is in respiratory distress.

Pleural effusion

This is a 80 years old Chinese gentleman with L pleural effusion.

Medical students will often be asked regarding the causes of pleural effusion.
You can divide it into unilateral and bilateral.

Question 1
What are the common causes of unilateral pleural effusion ?

Question 2
What is Light's criteria ?

Question 3
What are the clinical signs of an effusion ?


Question 4
What are the important investigations you would perform to ascertain the underlying aetiology ?

MCQ for Medical Students

Which of the following are causes of clubbing ?
a. Infective endocarditis
b. Inflammatory bowel disease
c. COPD(Chronic Obstructive Airway Disease)
d. Pulmonary fibrosis
e. Bronchiectasis