Physical examination plays a crucial role in patient evaluation by confirming the hypotheses during history taking, suggesting new clues, and directing investigations. We describe how the recognition of a nail abnormality led us to the recognition of the cause of long-standing lymphedema and pleural effusion.
Clinical Summary
A 41-year-old male farmer presented with dyspnea and cough of 4 years duration and bilateral pedal edema of 20 years duration. Pedal edema was bilateral, gradual in onset, persistent, and painless, and had reduced in intensity over the last 3 years. Breathlessness had increased gradually, and he was breathless on performing daily work at the time of evaluation. He denied any smoking, drug abuse, significant family history, or high-risk behavior. He was married with no children. He was evaluated in another hospital earlier where investigations had revealed bilateral pleural effusions. On the basis of the pleural fluid characteristics, antitubercular therapy was administered for 6 months. However, pleural effusion and breathlessness had increased on this treatment, and bilateral intercostal tube drainage was performed. The patient’s course was complicated by persistent drainage, empyema, loculated pleural collections, and worsening respiratory distress. He was referred to this center for evaluation.
On evaluation, the patient was febrile, drowsy, normotensive with a respiratory rate of 26 breaths/min, pulse rate of 110 beats/min, and central cyanosis. Examination showed bilateral nonpitting edema with skin thickening and left-sided hydrocele. He had yellow dystrophic nails with subungual hyperkeratosis in both upper limbs. There was no evidence of fungal infection of the fingers (Figure 1).
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— Srinivas Rajagopala, MD, Navneet Singh, MD, DM, Dheeraj Gupta, MD, DM, FCCP
This article was originally published in the December 2009 issue of The American Journal of Medicine.
