Anaemia: facial, conjunctival and palmar pallor were helpful in diagnosing.

Clinical bottom line (level 4)

  1. In-patients with facial pallor (LR+3.6) , conjunctival pallor (LR+3.1) or palmar pallor (LR+2.2) were more likely to have anaemia.
  2. The risk of anaemia increased the more of these signs patients had; all three (LR+5.5) .
  3. Absence of all these signs did not exclude anaemia.
  4. Nailbed pallor and palmar crease pallor were unhelpful in diagnosing or excluding anaemia.
Nardone et al: Archives of Internal Medicine 1990; 150: 201-204
Expires June 2003

The study

Setting: university hospital, USA

103 patients (aged range 27 to 80 years; mean 60, 95% male) medical and surgical in-patients

Independent blinded reference standard, applied in all patients from a non-consecutive inappropriate spectrum.
Reference standard:
  • haemocrit within two days of examination- considered anaemic if <0.41 in men; <0.36 in women
Diagnostic test: pallor of conjunctivae, face, nailbeds, palms and palmer creases
  • The clinical examination was performed during summer months in natural light by three examiners.

The evidence


diagnostic test anaemia no anaemia LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
conjunctival pallor 27 6 3.1
(1.4 to 6.8) 		82% 0.65
(0.50 to 0.84) 		49%
facial pallor 21 4 3.6
(1.3 to 9.8) 		84% 0.72
(0.59 to 0.89) 		51%
nailbed pallor 30 15 1.4
(0.85 to 2.2) 		67% 0.79
(0.57 to 1.1) 		53%
palmar pallor 32 10 2.2
(1.2 to 4.0) 		76% 0.62
(0.46 to 0.85) 		48%
palmar crease pallor 4 0 inf
(0.95 to inf) 		100% 0.93
(0.87 to 1.0) 		58%
conjunctivae, face or palm pale 40 12 2.3
(1.4 to 3.8) 		77% 0.48
(0.32 to 0.72) 		41%
two of conjunctivae, face or palm pale 26 6 3.0
(1.4 to 6.6) 		81% 0.67
(0.52 to 0.86) 		49%
conjunctivae, face and palm pale 16 2 5.5
(1.3 to 23) 		89% 0.77
(0.66 to 0.91) 		53%
total 61 42

Comments

  1. Given the limited population, it is difficult to generalize with comfort these results to other populations.
  2. Pre- and post-test probabilities are meaningless in a group of pre-selected patients.

Citation

  1. Nardone DA, Roth KM, Mazur DJ, et al: Usefulness of physical examination in detecting the presence or absence of anemia. Archives of Internal Medicine 1990; 150: 201-204
Contributor: Chris Ball and Clare Wotton, June 2000
Reviewer: Malcolm Man-Son-Hing

Clinical Question.
Patient medical and surgical in-patients
Intervention or Exposure clinical signs
Comparison haemocrit levels
Outcome diagnosis of anaemia