Pallor – Physical Examination

Synonyms: Paleness

Definition of Pallor

Pallor is the paleness of skin and mucous membranes, due to the reduced amount of oxyhemoglobin or decreased peripheral perfusion.

Sites to look for pallor

  1. Lower palpebral conjunctiva
  2. Tip and dorsum of the tongue
  3. Soft palate
  4. Nail beds
  5. Palmar or plantar creases
  6. General body skin

Pallor in lower palpebral conjunctiva:

Anemia in eye
A. Technique of exminaing for pallor in lower palpebral conjunctiva
B. Normal conjunctiva (Note the demarcation shown by arrow)
C. Pale conjunctiva (Loss of demarcation)


How (Technique)?
Pull the lower eyelid down and compare the color of anterior part of the palpebral conjunctiva (attached to the inner surface of the eyelid) with the posterior part where it reflects off the sclera. There is usually a marked difference between the red anterior and creamy posterior parts. This difference is absent when significant anemia is present.

Use both your thumb to retract eyelids downward on both the sides simultaneously and as you do so, ask the patient to look upwards.

Why(Reason)? The mucosa over this region is very thin and the underlying vessels are clearly seen and the pallor can be judged.

Pallor in palms:

How? As the patient to hyper-extend the fingers. Compare the color of palmar crease with that of the adjacent skin of palm. Pallor is said to be present if both are of same color.

Pallor in nailbeds:

How? Press the nail and note the color of nailbed after releasing the digital pressure.

Causes of pallor

1) Anemia (can be appreciated clinically when hemoglobin <8-9 g/dl)

2) Pallor without anemia:

  • Physiologic (“fair skinned”)
  • Shock
  • Hypoglycemia and other metabolic derangements
  • Respiratory distress
  • Skin edema
  • Pheochromocytoma

Pallor and Anemia

Although often used as synonyms, presence of pallor doesn’t always indicate anemia. Pallor is a sign, while anemia is a diagnosis based on laboratory results. Anemia is the qualitative or quantitative dimunition of RBC and/or hemoglobin concentration in relation to standard age and sex.

Clinical grading of anemia:

  1. Mild: Pallor of conjunctiva and/or mucous membrane
  2. Moderate: Above + Pallor of skin
  3. Severe: Above + Pallor of palmar creases

WHO grading of anemia:

  1. Mild: 10 g/dl to cut off point for ages
  2. Moderate: 7-10 g/dl
  3. Severe: <7 g/dl

Hemoglobin thresholds used to define anemia:

  • Men (>15 years): 13 g/dl
  • Teens (12-15 years): 12 g/dl
  • Women, non-pregnant (>15 years): 12 g/dl
  • Women, pregnant: 11 g/dl
  • Children (5-12 years): 11.5 g/dl
  • Children (0.5-5 years): 11 g/dl

Tips to aid assessment

Look for the coexistence of other signs, which may help to aid the diagnosis of the etiology of anemia.

  1. Tachycardia (Congestive Heart Failure/CHF)
  2. Edema (CHF, nephritic syndrome)
  3. Pulse volume (shock)
  4. Nail changes (koilonychia and paltyonychia in Iron Deficiency Anemia; splinter hemorrhages in associated thrombocytopenia)
  5. Skin changes (hyperpigmentation in megaloblastic anemia; petechiae in malignancies, aplastic anemia)
  6. Lymphadenopathy and hepatosplenomegaly (malignancy)
  7. Icterus (hemolytic anemia)

13 thoughts on “Pallor – Physical Examination

  1. It’s anemia. I’ve got the blood test from the hosiptal today.I had to be in a hosiptal to receive this diagnosis!:)It’s sad but we have to laugh otherwise we lose our minds.Tomorrow I’ll go to a GP who “hates physicians!”:)I told him I hate physicians on the first time we met and he reply: “Me too. My mother went to a doctor and when I arrived home she was having a drug that she can’t because of the other drug she takes. I almost prosecuted this…. !” -You’re right. Same of my colleagues are not supposed to medicate.”

    1. RDW (Red cell distribution width) is one of the RBC indices that is calculation of the variation in the size of RBCs. An increase in the RDW is observed when the size of the red blood cells vary within the red cell populations. This is physiologically a mix of different cell sizes and is known as anisocytosis. The reference range for RDW is as follows: RDW-SD 39-46 fL and RDW-CV 11.6-14.6% in adult.

      INTERPRETATION:

      Normal RDW and low MCV:

      1. Anemia of chronic disease
      2. Heterozygous thalassemia
      3. Hemoglobin E trait

      Elevated RDW and low MCV:

      1. Iron deficiency
      2. Sickle cell-β-thalassemia

      Normal RDW and high MCV:

      1. Aplastic anemia
      2. Chronic liver disease
      3. Chemotherapy/antivirals/alcohol

      Elevated RDW and high MCV:

      1. Folate or vitamin B12 deficiency
      2. Immune hemolytic anemia
      3. Cytoxic chemotherapy
      4. Chronic liver disease
      5. Myelodysplastic syndrome

      Normal RDW and normal MCV:

      1. Anemia of chronic disease
      2. Acute blood loss or hemolysis
      3. Anemia of renal disease

      Elevated RDW and normal MCV:

      1. Early iron, vitamin B12, or folate deficiency
      2. Dimorphic anemia (for example, iron and folate deficiency)
      3. Sickle cell disease
      4. Chronic liver disease
      5. Myelodysplastic syndrome

    2. Its red cell distribution width. It actually measures the degree of anisocytosis among red cells in perpheral smear. More the variation in sizes among RBCs more is the rcdw.

    1. The arrow shows the demarcation line between red anterior part and pale posterior part. If this demarcation line is unclear, it may be a sign of anemia.

    1. We don’t check palpebral conjunctiva for icterus. It is the upper bulbar conjunctiva. Bulbar conjunctiva is transparent and window to the sclera which is rich in elastin which readily binds the bilirubin. For more information: http://epomedicine.com/clinical-medicine/clinical-examination-icterus/

      Pallor is to be looked for in palpebral conjunctiva. We look for in lower palpebral conjunctiva because it is easier to retract compared to the upper one which requires eversion. The answer to why we look for pallor in palpebral conjunctiva has been mentioned in the article. The mucosa over this region is very thin and the underlying vessels are clearly seen and the pallor can be judged.

  2. excellent article on anemia. I have not found most of it on macleod’s, clinical exam. or hutchinson clinical methods or Bate’s physical exam.. So may i ask ur references please?

    1. Hello Shahriar,
      The text presented are derived from various sources. The classic textbooks don’t answer most of the reasoning questions` – however, they provide concise and “must know” information and are to be “referenced” for exam purposes. You can find most of the texts in books. Here, for examination of conjunctival pallor, comparison with the anterior and posterior part is recommended. This has been mentioned in around here – http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.1997.00014.x/pdf

      The posterior forniceal conjunctiva is pale compared to anterior and the author recommends comparing the two.

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