A 74-year-old man with a history of upper gastrointestinal bleeding and iron deficiency anemia presented to clinic with three weeks of worsening fatigue, weakness, and dyspnea on exertion. He did not have melena, hematochezia, or hematemesis. He had stopped all medications including iron supplementation six months prior. Examination was notable for pallor of the conjunctivae, face, palms, and palmar creases (Fig. 1). The patient’s hemoglobin tested result was 4.7 g/dl and subsequent esophagogastroduodenoscopy demonstrated erosive gastritis. Palmar crease pallor has a positive likelihood ratio of 7.9 for the diagnosis of anemia,1 which increases the post-test probability of anemia by approximately 40 %.2 The physical exam cannot rule out anemia,3 but the presence of pallor in the hands, eyes, or mucosa should prompt the physician to send for a complete blood count and consider the diagnosis of anemia.
Figure 1.
Pallor of the palmar creases in the patient’s hand (red arrow) compared to the examiner’s hand (blue arrow).
Acknowledgements
We would like to thank Dr. Elmer Holzinger from the University of Pittsburgh for reviewing the initial version of this manuscript.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Funding
None.
REFERENCES
- 1.Stern S, Cifu A, Altkorn D. Symptom to Diagnosis: An Evidence Based Guide 2nd Edition. McGraw Hill Publishing Company; 2010.
- 2.McGee S. Simplifying Likelihood Ratios. J Gen Intern Med. 2002;17(8):647–650. doi: 10.1046/j.1525-1497.2002.10750.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Nardone D, Roth K, Mazur D, McAfee J. Usefulness of physical examination in detecting the presence or absence of anemia. Arch Intern Med. 1990;150(1):201–4. doi: 10.1001/archinte.1990.00390130165027. [DOI] [PubMed] [Google Scholar]