Sunday, October 19, 2008


I think in medical school and residency I saw clubbing once that I can remember. According to Harrison's (Harrison's Principles of Internal Medicine) clubbing is "selective bullous enlargement of the distal sement of a digit due to an increase in soft tissue." All that to say, the fingernail isn't flat, but curves. I always thought that it only signified hypoxemia (low oxygen saturation in the blood), but have found out that it can be associated with much more. It is found with pulmonary, cardiac, gastrointestinal, and dermatological conditions as well as with different cancers, can be genetic or idiopathic (no reason for it). The majority of patients that I have seen here with clubbing typically have had bronchiectasis. This, again, is something I saw once in residency and didn't remember much about. Bronchiectasis occurs when the bronchioles (in our lungs) dilate, usually secondary to an infection like pneumonia or TB. As a result, the patients don't exchange oxygen as well and are hypoxemic. They also are unable to clear secretions, which leads to multiple infections in these patients. The hands above belong to a guy who came to our hospital with the diagnosis of TB at another facility. Once I saw his hands, I knew it wasn't TB. I have seen a lot of TB here, and despite what I have read which says clubbing can occur in TB, I haven't seen it yet. So when I see clubbing, it leads me to look for another cause. This guy was saturating only 60%, and that was on O2, when I saw him in the ER. I also noticed a smell from his mouth when he talked, this is typical of patients who have an anaerobic infection, which often occurs in bronchiectasis. He told me that he previously had TB about 4 yrs ago, but now has been sick for a year with coughing and hemoptysis. I could be wrong, but to try and put it all together he could have had posttuberculosis bronchiectasis secondary to the destruction in his lungs from the TB prior to the treatment he received. As a result, he now gets multiple lung infections causing lots of coughing and shortness of breath, which is why he came to see us, and why I am writing this.