The first step in the physical examination is an evaluation of the patient's general appearance.
Our patient is a normally developed adolescent in no distress. He demonstrates mild cyanosis, evident in both the lips and the nail beds.
Cyanosis with clubbing
Further inspection of the fingers demonstrates clubbing, identified by observing obliteration of the normal obtuse angle between the base of the nail and the skin. The arrows indicate this angle in our patient on the left and in a normal individual on the right.
Clubbing
Clubbing of the fingers is characteristic of chronic hypoxemia. It takes many years to develop, as it represents hypertrophy of the distal phalanges. When mild, only loss of the angle appears. When severe clubbing, the distal phalanges demonstrates bulbous enlargement. Clubbing occurs in patients with cyanotic congenital heart disease, it may be seen also in patients with chronic lung disease that causes hypoxemia and in some forms of chronic liver disease.