Pallor is almost invariably caused by anemia and is best analyzed with the application of pathophysiology.Anemia may be caused by decreased production of blood, increased destruction of blood, or loss of blood. Decreased production results from poor nutrition particularly, poor absorption or intake of B12 (pernicious anemia), iron (iron deficiency anemia), and folic acid (malabsorption syndrome). It may also result from suppressed bone marrow (aplastic anemia) or infiltrated bone marrow (leukemia or metastatic carcinoma). Increased destruction is caused by hemolysis from intrinsic defects in the red cells (e.g., sickle cell anemia and thalassemia) or extrinsic defects in the circulation (autoimmune hemolytic anemia of many disorders). Blood loss may result from peptic ulcers and carcinomas of the gastrointestinal (GI) tract, excessive menstruation or metrorrhagia from tumors of the uterus, or dysfunctional uterine bleeding. These are the principal causes of anemia, but the reader will be able to think of several more. What is important here is to have a systematic method to recall them. If anemia is ruled out, the less frequent causes of pallor should be considered. Shock, congestive heart failure (CHF), and arteriosclerosis cause pallor by poor circulation of blood to the skin. Patients who have hypertension may be pale from reflex vasomotor spasms of the arterioles supplying the skin. Aortic regurgitation and stenosis, as well as mitral stenosis, cause pallor for the same reasons, but the malar flush of mitral stenosis may negate this. The reason that tuberculosis, rheumatoid arthritis, carcinomatosis, and glomerulonephritis cause pallor even when their victims are not anemic or hypertensive is not known.
The approach to the diagnosis of pallor is obviously to check for anemia first; then to examine for the other chronic disorders. Chest x-ray, electrocardiogram (ECG), sedimentation rate, and a check for rheumatoid factor are all appropriate in specific cases.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8 
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