Differential clubbing and cyanosis in a patient with pulmonary hypertension

A 41-year-old man was admitted with hemoptysis and a 10-year history of progressive exertional decline. He had a patent ductus arteriosus diagnosed in adult life that was unrepaired because of concomitant pulmonary hypertension. On examination, he had a sustained right ventricular impulse with a palpable second heart sound. The continuous murmur usually heard in patent ductus arteriosus was not audible. Cyanosis and clubbing were more profound in the toes compared with the fingers (Figure 1). Oxygen saturation in the toes on room air was 88% compared with 96% in the fingers.