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Cardio Exam
 
 

The Nails

 
 
 
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Overview

In the context of the cardiovascular examination, inspection of the nails can aid in identifying evidence of anaemia, cyanosis and endocarditis.

Pallor of the Nail Bed

  • Look For

  • Whitening of the nail beds.
  • Causes of Nail Bed Pallor

  • Anaemia
  • Low cardiac output, due to cardiac disease
  • Peripheral shutdown, due to increased sympathetic activity.

Nail Bed Cyanosis

  • Look For

  • Blue discolouration of the nail beds
  • Significance

  • Nail bed cyanosis is a type of peripheral cyanosis, characterised by elevated levels of deoxygenated haemoglobin (hypoxaemia) in the peripheries. Always look for central cyanosis (under the tongue) when this is present.
  • Causes of Nail Bed Cyanosis

  • Central Cyanosis

  • High altitude
  • Obstructive lung disease, pulmonary oedema, pneumonia, pulmonary embolism
  • Congenital heart disease
  • Methaemoglobinaemia / sulfhaemoglobinaemia / carboxyhaemoglobinaemia
  • Peripheral Cyanosis

  • As for central cyanosis
  • Reduced cardiac output
  • Vasoconstriction

Splinter Haemorrhages

  • Look For

  • Painless, longitudinal, non-blanching red-brown streaks of 1-3mm in length beneath the fingernails or toenails.
  • Significance

  • A sign of infective endocarditis, though may also be caused by trauma, drugs or certain types of vasculitis.
  • Causes of Splinter Haemorrhages

  • Nail bed trauma
  • Infective endocarditis
  • Vasculitis - antiphospholipid syndrome, SLE, Behcet's disease, rheumatoid vasculitis
  • Skin conditions - psoriasis, lichen planus
  • Drugs - sunitinib, sorafenib
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