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Haem Exam




  • Inspecting the patient's skin for evidence of pallor, plethora or jaundice provide information regarding the presence of anaemia, polycythaemia or haemolysis.


  • Skin pallor is a sign of anaemia.
  • General inspection of the patient may provide some clue regarding pallor, though it is more significant to assess pallor of the nail beds, palmar creases and conjunctivae.
    • Causes of Pallor

    • Physiologicaly pale skin
    • Anaemia
    • Chronic disease
    • Low cardiac output, due to cardiac disease
    • Peripheral shutdown, due to increased sympathetic activity


  • Plethora is a change of appearance in the skin due to increased blood flow.
    • Look For

    • Red discolouration, especially of the face.
    • Causes of Plethora

    • Cushing’s syndrome
    • Polycythaemia rubra vera


  • In the context of the haematology examination, jaundice may be an indicator of haemolytic anaemia.
    • Look For

    • Yellow discolouration of the skin and mucous membranes, due to deposition of bilirubin.
    • Causes of Jaundice

    • Haemolytic

    • Erythrocyte defects - sickle cell anaemia, thalassaemia, folate deficiency, pernicious anaemia, iron deficiency anaemia, sideroblastic anaemia, spherocytosis, lead poisoning
    • Excessive erythrocyte destruction - haemolytic anaemia, thermal injury, envenomation, DIC, haemodialysis, breast milk jaundice
    • Hepatocellular

    • Dysfunctional uptake - drugs
    • Dysfunctional conjugation - Crigler-Najar, Gilbert’s disease
    • Dysfunctional bilirubin storage / excretion - Dubin-Johnson
    • Hepatocyte damage - cirrhosis, hepatitis, tuberculosis, EBV, CMV, varicella, drug-induced hepatitis, autoimmunity, alpha-1 antitrypsin deficiency, Wilson’s disease
    • Cholestatic

    • Intrahepatic cholestasis - drugs, pregnancy, cystic liver disease, sepsis, total parenteral nutrition, Hodgkin’s disease, biliary cirrhosis, sclerosing cholangitis, liver cancer (primary / metastatic)
    • Extrahepatic cholestasis - cholangitis, cholelithiasis, pancreatitis, tumours (eg. pancreatic), bile duct (stenosis or extrinsic compression)
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