Sandbox: HS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Differential diagnosis

Abbreviations: COPD= Chronic obstructive pulmonary disease,

Causes of cyanosis Disease Cyanosis Clinical manifestations/association Diagnosis Additional findings Symptoms Signs Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Respiratory Airway disorder Croup ✔ + + Epiglottitis ✔ + − − − − Foreign body aspiration + + − − − Airway trauma + + ± − − Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Parenchymal disorder Pulmonary embolism − − − − ABGs D-dimer CXR V/Q scan Spiral CT pulmonary angiogram Dyspnea Tachycardia Pleuretic chest pain Pneumonia − − − − − ABGs Leukocytosis Pancytopenia CXR CT chest Bronchoscopy Shortness of breath Cough Asthma (Late) + − − − − Cystic fibrosis ± ± − − − COPD (Emphysema) ± + Empyema ± + − − − Thoracentesis Chest X-ray Pleural opacity Localization of effusion Physical examination Crackles Egophony Increased tactile fremitus Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Chest wall disorders Flail chest − ± − − − Pneumothorax − ± − − − Hemothorax − + ± − − Cardiovascular Congenital heart diseases Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Atrioventricular canal defect ✔ + + Ebstein anomaly ✔ Hypoplastic left heart syndrome ✔ Pulmonary atresia ✔ Tetralogy of Fallot ✔ Pulmonic stenosis ✔ Total anomalous pulmonary venous drainage ✔ Transposition of the great vessels ✔ Truncus arteriosus ✔ Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Heart failure ✔ ✔ + + + + (S3) CBC Complete metabolic profile Cardiac enzymes BNP Thyroid profile Renal function tests EKG Exercise stress test ABG's Lipid profile CXR Increase in heart size compared to the old film. Pleural fluid Interstitial edema Echocardiography Angiography Cardiac MRI Nuclear imaging Endomyocardial biopsy can be used when a specific diagnosis is suspected that would influence therapy in heart failure patients. Valvular heart disease ✔ ✔ ± − + + CBC Complete metabolic profile Cardiac enzymes BNP Thyroid profile Renal function tests EKG CXR To assess pulomary congestion or other lung pathology. Echocardiography Doppler echocardiography Angiography To assess the need for concomitant coronary artery bypass surgery in elderly people. Myocardial infarction ✔ ✔ − + + + CBC Complete metabolic profile Cardiac enzymes BNP Thyroid profile Renal function tests EKG Lipid profile CXR Normal or may show signs of CHF Echocardiography Angiography Central Nervous system Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Methemoglobinemia ✔ + + + CBC Peripheral smear Complete metabolic profile Hemoglobin electrophoresis Serum nitrite levels Pulse oximetry ABG's Drug screen LDH CXR EKG Family history of methemoglobinemia or glucose-6-phosphate dehydrogenase (G6PD) deficiency is important to determine. Polycythemia ✔ + + CBC Pulse oximetry Erythropoietin levels (EPO) ABG's Increased leukocyte alkaline phosphatase B12 levels JAK 2 mutation CXR EKG Tenderness in the sternum may indicate transformation to acute myeloid leukemia and should be properly investigated. Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Breath holding spells ✔ No confirmatory study CBC Serum ferritin Blood lead level video-EEG monitoring can be use in non diagnostic cases. Cyanotic breath-holding spells most commonly occur around 1 year of age with a range of six months to four years. Iron deficiency anemia is more prevalent in children with breath-holding spells.  Miscellaneous Shock ✔ + + (septic shock) + + (Cardiogenic shock) Complete metabolic profile CBC Cardiac enzymes ABG's Lactate BNP Renal function tests Coagulation studies and D-dimer level Echocardiography Chest radiography Angiography Smoke inhalation + + +  CBC Electrolytes BUN and CR, Lactate levels Toxicology screen CO-oximetry  CXR ECG Serial cardiac enzymes (in patients with chest pain)\ Pulmonary function testing Direct laryngoscopy and fiberoptic bronchoscopy CO toxicity should be suspected in any patient who presents following smoke inhalation unless co-oximetry shows normal carboxyhemoglobin. Cold exposure ✔ − − − − − − Fingerstick glucose (Hyperglycemia) Electrocardiogram (ECG) may show J wave, sinus bradycardia and prolongation of all ECG intervals. Serum electrolytes (including potassium and calcium) BUN and creatinine Serum hemoglobin, white blood cell, and platelet counts ( Raised HCT due to volume contraction) Coagulation profile (clotting factors impairment) Serum lactate ( lactic acidosis) Creatine kinase (Rhabdomylosis) Arterial blood gas CXR Mild hypothermia: core temperature 32 to 35°C ; patient presents with confusion, tachycardia, and increased shivering. Moderate hypothermia: 28 to 32°C patient presents with lethargy, bradycardia and arrhythmia and decreased shivering. Severe hypothermia: below 28°C patient presents with coma, hypotension, arrhythmia, pulmonary edema, and rigidity.