Hands Examination - Patient Management

Hands

·        Nails:

o  Takes ~ 6 months for fingernails to grow out

o  Clubbing:

§  Respiratory: carcinoma, fibrosis, cystic fibrosis, TB, chronic suppuration (eg bronchiectasis), idiopathic pulmonary fibrosis, NOT asthma or CORD alone

§  Cardiovascular: infective endocarditis

§  Other (uncommon): cirrhosis, IBD, coeliac disease, thyrotoxicosis

o   Blue: cyanosis, Wilson‟s disease

o   Red: Polycythaemia (red-blue), carbon monoxide poisoning (cherry red)

o   Pale nail bed: anaemia

o   Koilonychia: spoon shaped nails in Fe deficiency

o   Leuconychia: white nails in hypoalbuminaemia

o   Mee‟s lines: single white transverse line in renal failure

o   Splinter haemorrhages: usually trauma (especially manual workers) or infective endocarditis, rarely vasulitis (eg in rheumatoid arthritis), polyarteritis nodosa, sepsis, blood malignancy or profound anaemia

o   Check capillary refill: squeeze nail and see how long it takes to return to red – sign of peripheral circulation. Normal < 2 sec

·        Hands:

o   Palmar erythema: pink spots on pale background – should be bilateral - Chronic liver disease, pregnancy, rheumatoid arthritis, polycythaemia, thyrotoxicosis, SLE

o   Skin: subcutaneous bleeding: petechiae small, purpura bigger, ecymosis – biggest. Petechiae caused by a platelet problem, not due to coagulopathy

o   Dupuytren‟s Contracture: extend fingers back – shortening of palmar aponneurosis – in alcoholic liver disease, epilepsy, manual workers and idiopathic

o   Asterixis: metabolic flap – coarse, non-symmetrical – neural inhibition ® encephalopathy in renal failure (­urea), respiratory failure (­CO2), liver failure (­nitrogenous material), hypoglycaemia, barbiturate poisoning

o   Raynaud‟s Syndrome: intermittent attacks of ischaemia of fingers or toes due to intense arterial vasospasm, often precipitated by cold or emotional stimuli

o   Tendon Xanthomata: lipid deposits in tendons of hands or arms in hyperlipidaemia