ANEMIA: LOOK AT THE TONGUE, EYES, AND HANDS

A patient presents with a gastrointestinal hemorrhage. Can you predict anemia from the physical examination? The short answer is yes, but not very well.

A review of the current literature reveals that the results are mixed. Sensitivity is often below 50% and specificity varies enough that we can’t totally trust the bedside finding of pallor. Most of these studies were done on outpatient populations with varying hemoglobin levels defining anemia.

At the bedside, you look at the conjunctival rim, the palms, the nailbeds, and the tongue. The conjunctiva has color but the palms and nailbeds are pallid. The tongue appears slightly pallid. The hemoglobin turns out to be normal. After IV fluids the extremity pallor has resolved. In this case the pallor seems to be the result of vasoconstriction. Perhaps that is also the explanation in those patients whose pallor did predict anemia? If that is true it explains why, after decades of research and dozens (hundreds?) of studies, we still can’t establish the diagnosis of anemia on physical examination alone

TAKE HOME POINTS:

-Physical diagnosis for anemia has mixed results

-If you are going to look for it, look at multiple areas (hands, eyes, tongue)

-Whether you do or don’t find pallor, order confirmatory hemoglobin levels

BEDSIDE DIAGNOSIS OF COAGULOPATHY

A patient presents found in the rural backcountry after a motor vehicle accident. She has a grade V liver laceration and is not stable for transfer. Your general surgeon is getting ready to take her to the operating room for damage control laparatomy and packing. You notice she is oozing from her central line site. Could this indicate a consumptive coagulopathy? How reliable is the bedside diagnosis of coagulopathy?

There is not sufficient evidence to answer this question in an ED context. There are two types of assessment: in vivo and ex vivo. In vivo assessment of clotting is to a standardized challenge, such as a 1cm long 1mm deep incision or a needlestick. We do not generally use these tests in the ED. However, we are doing procedures and should note any abnormal bleeding and order clotting studies or even empiric FFP.

The ex vivo assessment is more variable because coagulation time is relative to volume. The clotting reaction is initiated at the surface of contact and spreads inward, so smaller volumes clot faster. A droplet of blood during a fingerstick glucose test often clots before the nurse can get the result. That is why the nurse has to do a second stick, rather than continue to squeeze the first. Punguyire, in the Journal of Emergency Medicine recently published an article for resource-limited situations for assessing whether a snakebite is a dry bite. He used a 5mL syringe full of blood and waited 20 minutes to see whether it clotted. The absence of clot was taken to indicate coagulopathy. 

I have sometimes noticed during procedures that rubbing the fingers together enables one to sense how sticky the blood appears to be. I recall a trauma patient with consumptive coagulopathy who kept oozing from the wound, and it felt more like wine than blood. When I felt that, I became a lot more aggressive on FFP transfusion, and made decisions based on bedside findings ahead of pending laboratory results.

Take home points:

-Abnormal bleeding after needlesticks may be the first sign of coagulopathy

-Normal blood in a 5mL syringe should clot within 20 minutes

SPLENOMEGALY: PALPATE FOR THE SPLENIC EDGE

A patient presents with fever.  After the history, you suspect leukemia.  Is there splenomegaly?

 

Percussion: The chest wall should be tympanitic at the costal margin of the anterior axillary line. Dullness is abnormal and is taken to indicate splenomegaly. This test is neither sensitive nor specific but it does have some value.

 

Palpation: Any palpation of the spleen is abnormal.  It is easiest to feel the edge as it ballots against the volar fingers.  Approach from the left or right lower quadrants and move inward. Place your left hand on the affected area and then place the right hand above it, balloting for the edge. This is more specific than dullness to percussion

 

Maneuvers to increase detection include putting the patient’s left hand behind the back  and rolling the patient onto the right side.  Obesity limits the examination.

 

Take home points:

Palpation of the splenic edge is the most specific sign of splenomegaly

PHYSICAL DIAGNOSIS OF PURPURIC LESIONS

You evaluate a patient with a rash, and as you look, you notice small patches of purple lesions that are circular in distribution.  You recognize what appears to be purpura.  The differential diagnosis is long, and includes hematologic, infectious, and immune mediated conditions.  How can we use physical diagnosis to narrow the differential diagnosis at the bedside?

Blanching: Intravascular vrs extravascular

First, apply pressure to see if it blanches.  Dermatologists use glass and call it diascopy.  In the ED we just press, let go, and we have a quick look to see if it had blanched.  Blanching indicates the color is intravascular, like erythema from a rash.  If it blanches, it is not purpura.  Nonblanching indicates the problem is extravascular.  Your patient’s lesion does not blanch.

Palpable purpura: Inflammation

Next, is it palpable? Nonpalpable purpura is caused by blood leaking out of a normal blood vessel, either because of trauma or a hematologic problem.  The most common benign cause is senile or actinic purpura in the elderly, where a thin dermis renders the capillaries vulnerable to minor trauma.  A normal bruise is not palpable, nor is the purpura from thrombocytopenia and coagulation defects.

In contrast, palpable purpura means there is inflammation around the blood vessels.  Your patient’s lesions are palpable.  You have now narrowed the differential diagnosis to a vasculitis, or an infection causing inflammation around the blood vessels.  The most common cause in children is Henoch-Schonlein purpura.  The most common in adults is leukocytoclastic vasculitis, a small vessel vasculitis with various causes.

Meningococcemia is palpable in later stages of the disease but in the early stages may not be palpable, and in very early stages may actually blanch (Riordan 1996).  Petechial lesions restricted to the area above the clavicles generally signifies a benign cause, generally precipitated by coughing or vomiting (Wells 2001).

Physical diagnosis narrows the differential diagnosis of purpura to a more manageable degree. With the use of pressure to check for blanching, one can confirm whether the purple hue is intravascular or extravascular.  If it is extravascular then this suggests purpura. One can then check for palpable purpura to decide if inflammation is present.  In this manner, one can pursue this diagnosis to the highest degree at the bedside.  Depending on the findings, a phone call to the local dermatologist, rheumatologist, or hematologist and oncologist can expedite this patient’s definitive care.

TAKE HOME POINTS

-Blanching suggests a vascular cause.  Nonblanching supports purpura.

-Palpable purpura supports an inflammatory cause such as vasculitis or a systemic infection