How to check for icterus (jaundice), pallor (paleness), cyanosis (blue discoloration), clubbing (finger enlargement), edema (swelling), and lymphedema (lymph node swelling) in a patient?

How to Examine for Icterus, Pallor, Cyanosis, Clubbing, Edema, and Lymphadenopathy

Begin with a systematic head-to-toe examination focusing on specific anatomical sites for each finding, using natural lighting when possible and documenting characteristics of any abnormalities identified. 1

General Appearance and Vital Signs

• Document vital signs including height, weight, and blood pressure in both arms to establish baseline data and identify systemic abnormalities 1, 2
• Assess overall appearance for evidence of obesity, wasting, lipodystrophy, frailty, and ambulatory ability as these provide invaluable clues to underlying disease 1
• Observe for dyspnea during conversation or with minimal activity, Cheyne-Stokes respiration, poor nutritional status, skeletal deformities, tremor, and anxiety which indicate underlying cardiopulmonary or systemic disease 1

Icterus (Jaundice) Examination

• Inspect the sclera and conjunctiva in natural lighting for yellow discoloration, as this is the most sensitive site for detecting icterus 1
• Examine the skin for yellow discoloration, though scleral icterus is more reliable than skin assessment alone 1, 2
• Ask specifically about dark urine and changes in stool color (clay-colored stools suggest biliary obstruction) 1, 2
• Note that jaundice is NOT commonly associated with intrahepatic cholestasis of pregnancy and suggests other hepatic diseases when present 1

Pallor Assessment

• Examine the conjunctivae, oral mucosa, and palmar creases for pallor, as mucous membranes are more reliable than skin color alone 1, 2
• Assess for generalized versus localized pallor and document any associated findings 2
• In patients with suspected pulmonary hypertension, examine for retinal pallor during fundoscopic examination 1

Cyanosis Detection

• Examine the lips, tongue (central cyanosis), and nail beds (peripheral cyanosis) to differentiate arterial desaturation from reduced peripheral perfusion 1, 2
• In suspected congenital heart disease, check for differential cyanosis affecting lower extremities more than upper when shunting occurs at the ductal level 3
• Document whether cyanosis is present at rest or only with exertion 1
• Note that cyanosis requires adequate hemoglobin levels to be visible and may be absent in severe anemia 1

Clubbing Examination

• Perform systematic nail examination assessing for loss of the normal angle between the nail bed and nail fold (Schamroth sign) 1, 3
• When clubbing is present, immediately evaluate for pulmonary veno-occlusive disease, cyanotic congenital heart disease, interstitial lung disease, or liver disease 3
• Obtain focused history including progressive exertional dyspnea, chronic cough, smoking history, occupational exposures (asbestos), and cardiac symptoms 3, 2
• Critical pitfall: Digital clubbing is rare in idiopathic pulmonary arterial hypertension—its presence should redirect evaluation toward PVOD, congenital heart disease, interstitial lung disease, or cirrhosis 3
• The absence of clubbing does NOT exclude serious pulmonary or cardiac disease 3

Edema Assessment

• Examine dependent areas (ankles, pretibial region, sacrum in bedridden patients) for pitting edema by applying firm pressure for 5 seconds 1, 2, 4
• Document the location (unilateral vs bilateral), extent (ankle only vs extending to thigh), and severity (depth of pitting) 2, 4
• Assess for associated findings:
  • Hemosiderin deposition and skin changes suggest chronic venous insufficiency 4
  • Brawny, nonpitting edema characterizes lymphedema 4, 5
  • Spider nevi, testicular atrophy, and palmar erythema suggest liver disease 1, 2
• In chronic heart failure, elevated jugular venous pressure or positive hepatojugular reflux are more reliable than peripheral edema alone 1
• Peripheral edema is NOT a reliable indicator of heart failure unless jugular venous pressure is elevated 1

Lymphadenopathy Examination

• Systematically palpate all nodal regions: cervical (anterior and posterior chains), supraclavicular, axillary, epitrochlear, inguinal, and femoral 1, 2
• Document specific characteristics:
  • Size (measure largest dimension in centimeters) 1
  • Consistency (soft, firm, rubbery, hard) 2
  • Mobility versus fixation to underlying structures 2
  • Tenderness 2
  • Whether nodes are discrete or matted together 2
• Differentiate generalized lymphadenopathy (≥2 non-contiguous regions) from localized enlargement 1
• In HIV-infected patients, generalized lymphadenopathy is common and should be documented at baseline 1

Integration with History

• For each positive finding, ask about onset, duration, progression, aggravating/alleviating factors, and associated symptoms 2
• Assess timing and chronicity, as acute versus chronic findings fundamentally change the differential diagnosis 2
• Correlate physical findings with review of systems:
  • Unexplained weight loss, night sweats, fever 1
  • Skin rash, ulcers, or lesions 1
  • Cardiopulmonary symptoms (chest pain, dyspnea, orthopnea) 1
  • Gastrointestinal symptoms (diarrhea, nausea, abdominal pain) 1

Common Pitfalls to Avoid

• Do not rely on single findings in isolation—correlate all physical examination findings with history and laboratory data 2
• Do not assume absence of these signs excludes serious underlying disease, particularly for clubbing and cyanosis 3, 2
• In suspected biliary obstruction, skin examination alone is insufficient—always examine sclera 1
• Peripheral edema without elevated jugular venous pressure should not be attributed to heart failure 1