Hands & Arms
Koilonychia (Spoon Nails)
Inspection: Nails
Iron Def AnemiaIndicates severe, chronic iron deficiency leading to structural thinning and concavity of the nail bed.
Leukonychia
Inspection: Nails
Reflects systemic hypoalbuminemia, predominantly pointing toward chronic liver disease. This is intrinsically linked to severe coagulopathies (vitamin K factor deficit) and portal hypertension, which causes splenic sequestration and marked Thrombocytopenia.
Clubbing & Cyanosis
Inspection: Nails / Capillary bed
Clubbing indicates chronic hypoxia driving erythropoietin production (Secondary Polycythemia/Erythrocytosis). Also seen in Inflammatory Bowel Disease (causing severe IDA) and thoracic Lymphomas. Cyanosis indicates unoxygenated hemoglobin.
Capillary Refill & Peripheral Pulsations
Inspection: Capillary bed / Palpation: Pulse
Delayed refill (>2s) indicates hypovolemia from acute bleeding. Tachycardia and bounding character indicate a hyperdynamic circulation compensating for severe systemic anemia, regardless of etiology.
Palmar Erythema, Dupuytren's, Spider Nevi
Inspection: Palms & Skin
Classic stigmata of chronic liver disease (estrogen excess). The liver synthesizes coagulation factors. Liver failure directly equals a severe bleeding diathesis, frequently coupled with Thrombocytopenia due to hypersplenism.
Flapping Tremors (Asterixis)
Action: Stretching hands
Platelet Dysfunction (Uremia)Indicates hepatic encephalopathy or Uremia. Uremia causes profound acquired platelet dysfunction by interfering with platelet-vessel wall interactions, leading to severe uremic bleeding despite potentially normal platelet counts on a CBC.
Tar Staining & Needle Tracks
Inspection: Fingers & Arms
Tar staining suggests heavy smoking leading to chronic CO exposure, causing carboxyhemoglobinemia and reactive Erythrocytosis (elevated RBC count). Needle tracks suggest IV drug use (HIV/Hep C), which triggers marrow suppression, leukemias, or lymphomas.
Skin & Mucous Membranes
Pallor
Inspection: Conjunctiva, palmar creases
The primary sign of anemia. Indicates decreased RBCs either from lack of production (IDA, MDS, Leukemic marrow replacement) or destruction (Hemolysis).
Petechiae, Purpura, Ecchymosis
Inspection: Skin integrity
Indicators of primary hemostasis defects. Non-blanching spots indicate capillary bleeding strictly due to severe Thrombocytopenia (e.g., ITP, leukemic marrow infiltration, or MDS).
Icterus (Jaundice)
Inspection: Sclera, mucous membranes
Indicates severe pre-hepatic jaundice caused by the rapid destruction of RBCs, leading to an overload of unconjugated bilirubin.
Head, Face & Mouth
Thalassemic Facies
Inspection: Frontal bossing, prominent jaws
Classic in Thalassemia Major and untreated Sickle Cell. Severe, chronic hemolytic anemia forces the bone marrow to expand massively to compensate, expanding the flat bones of the skull and face.
Moon Face & Muscle Wasting
Inspection: Facial contour
Moon face is highly associated with prolonged corticosteroid therapy, the first-line treatment for autoimmune cytopenias (AIHA, ITP). Wasting implies cachexia from advanced hematological malignancies.
Telangiectasia
Inspection: Face, lips, tongue
Iron Def AnemiaOsler-Weber-Rendu syndrome (HHT). These abnormal vascular malformations cause recurrent epistaxis and severe gastrointestinal bleeding, inexorably leading to profound Iron Deficiency Anemia.
Stomatitis, Ulcers, Glossitis
Inspection: Mouth cavity, tongue, breath
Angular stomatitis and pale glossitis pinpoint Iron Deficiency Anemia. Painful aphthous ulcers are common in profound Neutropenia (agranulocytosis, acute leukemias).
Gum Hypertrophy & Buccal Hyperpigmentation
Inspection: Gums and mucosa
Gum hypertrophy is an exquisite, high-yield sign of leukemic tissue infiltration (specific to monocytic AML). Buccal hyperpigmentation suggests Addison's, an autoimmune disease frequently overlapping with Pernicious Anemia.
The Neck
Cervical & Supraclavicular LNs
Palpation: Lymph Nodes
Painless, rubbery nodes suggest Lymphoma or CLL. Reactive nodes indicate viral infections causing absolute Lymphocytosis. A left supraclavicular node (Virchow's) signifies intra-abdominal malignancy (often causing occult bleeding/IDA).
Neck Veins (JVP)
Inspection: Jugular Venous Pressure
Elevated JVP reflects right heart failure. In hematology, this points to Cor Pulmonale resulting from recurrent Acute Chest Syndrome in Sickle Cell Disease, or from hyperdynamic high-output cardiac failure due to severe anemia of any cause.
The Chest
Chest Deformity, Gynecomastia & Hair Loss
Inspection: Chest wall structure & skin
Chest deformities (widened ribs) reflect bone marrow expansion from severe chronic hemolysis (Thalassemia). Gynecomastia and a paucity of axillary hair indicate estrogen excess from liver cirrhosis (pointing to systemic coagulopathies).
Palpate ribs for tender points
Palpation: Bony prominences
Exquisitely high-yield. Bony tenderness over the ribs or sternum indicates osteolytic bone lesions (classic for Multiple Myeloma / Plasmacytoma) or massive, acute bone marrow expansion pressing against the periosteum (Acute Leukemias).
Lower Limbs
Size, color, temperature, tender calf
Inspection & Palpation: DVT Signs
Asymmetric swelling and calf tenderness indicate DVT. Points to inherited thrombophilias, extreme Thrombocytosis (Essential Thrombocythemia), or acquired hypercoagulability (Multiple Myeloma lenalidomide treatment / active malignancy).
Trophic changes & Digital gangrene
Inspection: Distal extremities
Severe microvascular thrombosis blocking arterial supply. Indicates high-viscosity or platelet-plugging states like Polycythemia Vera, Thrombocytosis, or agglutination from Cold Agglutinin AIHA.
Edema (Dorsum of foot, Medial malleolus, Tibia)
Palpation: Pitting edema
Severe systemic anemia triggers fluid retention by the kidneys to maintain volume, combined with high-output cardiac strain, leading to frank right-sided heart failure and dependent edema.
Abdomen
Scars, Striae & Dilated Veins
Inspection: Abdominal surface & umbilicus
A LUQ scar suggests prior splenectomy (treatment for ITP/Thrombocytopenia or Hemolytic Spherocytosis). Purple striae suggest Cushing's syndrome (often iatrogenic from prolonged steroid use for ITP or AIHA).
Hepatomegaly (Liver)
Deep Palpation: Lower/Upper Borders, Span at MCL
Enlargement signifies extramedullary hematopoiesis (reactivation of fetal blood production in the liver due to severe chronic hemolysis/Thalassemia), or gross infiltration by Leukemia/Lymphoma cells.
Splenomegaly
Deep Palpation: Lower border / Percussion: Traube's area
The spleen is the graveyard of RBCs. Enlargement indicates massive red cell destruction (Hemolytic Anemia, Thalassemia), or neoplastic infiltration (Leukemia, Lymphomas). If soft and tender: Indicates acute capsular expansion.
Murphy's Sign
Palpation: Mid-point below 9th rib on deep inspiration
Detects acute cholecystitis. In hematology, patients with chronic Hemolytic Anemias (Sickle Cell, Thalassemia) have an extreme turnover of bilirubin, frequently leading to the formation of calcium bilirubinate (pigmented) gallstones.
Examining Lymph Nodes (Axillary/Epitrochlear)
Palpation: Site, size, consistency, fixation
Essential for staging. Diffuse, painless, rubbery node enlargement points to lymphoproliferative disorders like Lymphomas and CLL.
Neurological
Tone, Power, Reflexes & Sensation
Examination: Motor, Dorsal Columns, Cranial Nerves
Loss of position/vibration sense with abnormal reflexes is the absolute hallmark of B12 Deficiency (Macrocytic anemia, which can mimic MDS). Cranial nerve palsies can rarely indicate leukemic meningeal infiltration.
Joints
Target Joints (Knees & Elbows)
Inspection & Gentle Feel: Swelling, Redness
Hemophilia (Coagulation)Massive, painful joint swelling (Hemarthrosis) is the hallmark of secondary hemostasis defects (coagulation factor deficiencies like Hemophilia). Passive movement is avoided without prophylaxis.
Auscultation
Cardiac Murmurs & Prosthetic Clicks
Auscultation: Precordium
Mechanical valves mechanically shear red blood cells as they pass, causing intravascular Hemolytic Anemia. A soft Hemic murmur reflects the hyperdynamic, turbulent flow of severe underlying anemia (IDA/Hemolysis).
Lung Bases & Splenic Rub
Auscultation: Bases & Lt Hypochondrium
Basal crackles indicate pulmonary edema or leukemic lung infiltration. A splenic rub indicates severe capsular inflammation secondary to a localized splenic infarction (Classic in Sickle Cell Disease or CML).