Clinical Nail Changes - Nail Signs Suggesting Disease - Dr Gill

Hello and welcome back to the channel. You join myself, Dr. James Gil, for a clinical skills adjacent video. Today, we're going to have a look at changes that we might see in the hand on an examination. Note, I didn't say we're going to be doing the examination of the hand, but in fact, we're going to be looking at changes that we might see during other examinations that become apparent in the hand. Now when we'll do an examination for example respiratory examination in OSKI examinations we will have a series of check uh check boxes that we're looking for students to identify. However there are things that we might see in the real world that don't directly connect to an examination that we've asked a student to do. An example there being coilia. Now this isn't technically part of the respiratory examination because its presence doesn't indicate a respiratory problem. However, coilia which is due to iron deficiency anemia may therefore be the explanation for why a patient has shortness of breath. So, it's something that we may see and actually want to put into our diagnostic civ as it were to work out where we are. However, as you're going to see with many of these clinical signs, coilia on its own may also simply be idiopathic. So, we can see it actually in young children who may be born such as my son with these spoon-shaped nails. And that really does highlight the name as much as anything. Coanikia from the Greek spoon, nikia from nails. And we know because uh my son had to have an operation when he was younger that he doesn't have any issues with iron deficiency anemia and therefore it's hoped that this is something that he'll grow out of. However, bizarrely, coal here as well has been due to iron deficiency anemia can also be associated with other conditions. For example, hemocchromattosis where we've paradoxically got increased levels of iron. It could potentially be due to uh rears disease or may be seen in SLE or lupus. There's lots of things that can um explain some of the symptoms we'll see in the hand. So it's very important we don't fixate on this sign means this. A good example of that is clubbing. Now this is a massive um sign that we're going to look for at medical school because it's so um spread across different aspects. So with regard to clubbing, it could be due to abdominal causes, it could be due to respiratory causes, it could be due to cardiovascular causes, it could be due to endocrine causes. Oh, and also idiopathic. It can be one of those things. So clubbing is where we lose the nail fold angle for whatever reason. And that ends up with a bulbous curvature of the nail. looks a little bit like a chicken drumstick. And the way we're going to identify that with a patient is get them to put their fingers together like so. Looking for a diamond window between the two nails. This is shamrock window. And if it's present means that the patient does not have clubbing. Now I go back to the fact that these are things we may notice in passing on other bits of an examination. We might also notice them out in the real world. As an example, from when I was at medical school, I was in a shop uh being served by somebody and I saw that their fingers looked quite visibly clubbed and I kept on looking at them and we finished the transaction. I said, "I do hope you don't mind. I you know, your your fingers look uh uh um particularly um obvious." And the the guy paused and said, "Don't worry about it. I am very aware of this. I've got clubbing. It's something that runs in my family. We've all been investigated for it's idiopathic, but thank you for actually mentioning it. Obviously, you were concerned. Thank you for that. So, you know, we've highlighted there that these are things we want to pay attention to, but we're not going to necessarily hinge all of our diagnostic work on that. And I cannot underline that enough with regard to the course of clothing. So let's have a look at those. Now if we're talking about respiratory problems, we could be dealing with um fibrosine alvolitis, lung abscesses or empa, bronchiacttois, cystic fibrosis, lung cancers. Um it it has a very broad range of things with the the respiratory system which perhaps explains a lot because we think that this swelling at the nail fold is due to release of vascular endothelial growth factor i.e. the body releasing a chemical that causes the production or growth of more blood vessels in response to reduced oxygen levels. So kind of makes sense that it's mainly lung related conditions but not always. The next condition group um or next system group is abdominal problems. So for example cystic fibrosis um ulcerative colitis, cerosis of the liver and celiac disease can all present with clubbing which in a lot of cases aren't having a massive impact with regard to hypoxia. So with regard to clubbing in the heart, we could have bacterial endocarditis. We can also have cyanotic congenital heart disease where the blood vessels have been transposed ending up with high levels of deoxxygenated blood moving around the body. All of which linking to that production of vascular endothelial growth factor. From an endocrine perspective, we can also have um a Graves disease which can cause um clubbing perhaps due to a peripheration of uh tissue because we may also see Palmer erythemma a redness to the palm which can be associated with cerosis and can be associated with endocrine issues such as Graves disease as well. So hopefully you can see with that the connection perhaps with clubbing and perhaps liver issues and certainly um tissue produ uh blood vessel production that there's definitely going to be some overlap with a lot of these signs with coilia where we're saying the coil indicating spoon shaping of the nails with encholyis we're talking about splitting of the nails as suggested in the name and there we're dealing with classically psoriasis but we can have it connected with literal other connective tissue disorders including SLE so lupus it can also be present in saridosis hyperthyroidism and crucially common things being common trauma you bang your nail you get a hematoma under it you're probably going to have the nail fall off because of that damage and hopefully it'll regrow one of the other signs we can see in the hand is kind of looking backwards. Um, if we if we look at the nails from somebody who's been very unwell or maybe admitted to ITU, we can see Bose lines, horizontal ridges on the nail where the nail has stopped growing during that time of severe illness. Now, I've actually got them on several of my fingers at the moment because I was quite unwell a few months ago with flu. And literally the body says, "I'm too busy keeping you alive to worry about making, you know, hair and nails." So those things stop. Hence why it's possible after severe illnesses, people can also lose hair. Now, I say it's about looking backwards because these ridges are in the middle of my nail. That means that I've actually recovered and I've had new nail pushing forwards. And eventually, as I cut down my nails, these Bose lines will disappear. It might be worthwhile asking if you do see a patient with both lines, what happened? Why do you have these? Do you remember being particularly unwell? Very similar to enculis is pitting of the nails where it looks like literally somebody's gone at the nail with a small pin. It can also be seen in psoriasis and potentially issues with the hair because it's the same type of substance, the nails, uh, alopecia areata. And there's a bit of a rheumatological syndrome called writer syndrome where you have problems with the eyes, problems with the joints and also problems with the urinary tract infection which can have pitting as well. So writers often has that medical school aid memoir of the patient can't see, can't pee, can't bend the knee. And in our case, we're also potentially going to see changes to the nail. Splinter hemorrhages are a little bit like um clubbing. It's a it's a medical school big um condition and we see these vertical um black marks in the nail like little splinter hemorrhages that have gone under the nail. So this can be like a lot of these conditions to do with trauma. You bang your nail, there's a little bit of bleed under the skin, there's your vertical mark. Now the reason why we can see those with things like bacterial endocarditis is we get an infection in the heart with the leaflets of the valve. They break off fly through the circulation and lodge in the end capillary which we can see underneath the nail. So where that small clot lodges, we get a little bit of death of cells around that um now infaction causing these splinter hemorrhages. We actually see them quite often because simply banging your hand can cause them these little bleeds. So, it's something we can get particularly twitchy about, but in reality are often explained by very unconcerning issues and particularly with all of these signs. We want to connect them with our history and with other parts of the examination. So if we've got splinter hemorrhages and no issues with fever, no issues with palpitations, no weight loss, no night sweats, no new murmurss, no potential uh high-risk individuals with regard to endocarditis, we're probably going to say, "Yeah, that's a clinical sign. I'm paying attention to it, but I'm going to deemphasize it if it doesn't clearly follow with the evidence that we have." No, not our thinking, but the evidence we have to support what might have explained it. One of the other changes to nail that we talk about a lot at medical school is lucania. So, white patches in the nail. And I say an awful lot because there are many many students will normally have these little white dots on some of their nails. I don't have any on myself at the moment, but it's not unusual for me. The crucial bit is there. That is pseudo or partial lucineia. And these white patches are often due to a little bit of trauma. Now, if you flip it round, proper lucaneia, the whole nail turns white, almost as if somebody's put sort of tipex under the tissues there. And this is often normally associated with low protein states. So, for example, renal failure might cause that. I hope this has been a useful overview of some of the things that we might see in the hands. We've very much focused on the nails at this point, but if you perhaps like me to do a volume two to dig into the clinical signs that we can see in the hand moving a little bit more approximately, please do put in the comments and we'll certainly look to do a second video. With that in mind, take care and I'll see you in the next one. Cheerio.