Patients with cyanosis show bluish discolration of skin and mucous membranes. Common locations to look for cyanosis include tongue, buccal mucosa, lips, hands and feet.

• Physical examination of patients with cyanosis will show bluish discoration of lips, tongue, oral mucosa, nose tip, ear lobules, hands and feet. Because cyanosis is a symptom of disease process careful physical examination for associated symptoms include tachypnea, tachycardia, abnormal heart sounds or murmurs, wheezing, crackles, fever, clubbing, edema of extremities will be necessary to identify underlying disease process.

• Appearance of patients with cyanosis will vary depending to the underlying condition.
  • Lips, tongue, buccal mucosa, hands, and feet will appear blue in patients with cyanosis.

• Fever
• Tachypnea
• Tachycardia
• Bradycardia
• Hypertension / hypotension

• Skin usually appears blue in patients with cyanosis.
  • It is very difficult to find bluish discoration in dark-skinned individuals and in poor lighting conditions.
• Sites to look for central cyanosis: Tongue, inner aspect of lips, gums, soft palate, buccal mucosa, and sites of peripheral cyanosis.
• Sites to look for peripheral cyanosis: Nose tip, ear lobules, outer aspect of lips, fingertips, nail bed, extremities.
• Central cyanosis with gray appearance to the skin is characteristic of methemoglobinemia.
• Certain skin conditions and exposure to dyes may mimic cyanosis have to be ruled out(eg, Mongolian spot, tattoo, blue clothing dye, finger paints).

• Evidence of head trauma

• Jugular venous distension
• Hepatojugular reflux

• Cardiovascular examination of patients with cyanosis will show:^[2][3][4]
  • Tachycardia/ Bradycardia
    • Bradycardia is an ominous sign for imminent cardiovascular collapse.
    • Paradoxic pulse: Acute airway obstruction, Pulmonary embolism, cardiac tamponade, and asthma.
  • Auscultate for abnormal (loud, single or widely split S2) and additional heart sounds and murmurs (Grade, timing, location, radiation, intensity).

• Measure blood pressure in both upper and lower extremities

• Patients with cyanosis will show:^[3][5][6]
• Tachypnea is seen in patients with respiratory and cardiac diseases presenting with cyanosis.
• Nasal flaring, grunting, intercostal and substernal retractions, and prolonged breathing may indicate respiratory distress.
• Traumatic injury involving chest wall or lung will show following abnormalities:
  • Chest wall movement abnormalities
  • Chest wound (eg, open or sucking)
  • Abrasions
  • Ecchymosis
  • Focal tenderness can be elicited on palpation over ribs, sternum, or scapula.
  • Deviation of Trachea
  • Subcutaneous air with crepitus
• Stridor, voice changes, suprasternal retractions, drooling and prolonged inspiration can be found in patients with upper airway obstruction.
• Wheezing, rales / crackles and assymmetric breath sounds will suggest Intrinsic lung diseases.
• Tactile fremitus:
  • Increased: Consolidation by pneumonia ,atelactasis
  • Decresed: Pleural effusion, pneumothorax
• Lung sounds may be clear on auscultation in patients with
  • Cyanotic congenital heart disease
  • Methemoglobinemia
  • Neurologic conditions associated with hypoventilation (eg, muscle weakness, coma, and seizures)
  • Pulmonary embolism

• Clubbing is seen in some patients presenting with cyanosis.^[7][8]
  • Congenital heart diseases
  • Pulmonary diseases: COPD, bronchiectasis, cystic fibrosis, pulmonary fibrosis, pulmonary arteriovenous malformations.
• Edema of lower extremities due to congestive heart failure and pulmonary embolism, pulmonary edema, pulmonary hypertension.