PE in polycythemia

Q: 44 years old cab driver with a history of lung disease secondary to smoking, who also works as an auto mechanic on weekends is admitted to the ICU with sepsis due to community-acquired pneumonia. Lab exam shows polycythemia with Hemoglobin level of 17 g/dL. In polycythemia, retinal veins would be? (selected one)

A) constricted

B) dilated

Answer: B

The objective of this question is to emphasize the art of history taking and perform detailed physical examinations in the light of patient history. Determination of the core cause of polycythemia is essential as management is different between relative, primary, and secondary causes of polycythemia.

Smoking, exposure to carbon monoxide (as in auto mechanics), lung disease, and volume contraction (as possible in this patient who now presented with pneumonia) are all well-known causes of secondary reasons. Possible findings in the physical exam are:

• Cyanosis in the lips, earlobes and fingers
• Clubbing in the nailbeds
• Plethoric facies
• Dilated lingual or retinal veins
• Areas of painful erythema
• Cardiac murmurs or bruits from pulmonary arteriovenous shunts or right-to-left cardiac shunts
• Hepatomegaly and/or splenomegaly 

#physical-exam

#hematology

References:

1. Lee G, Arcasoy MO. The clinical and laboratory evaluation of the patient with erythrocytosis. Eur J Intern Med. 2015 Jun;26(5):297-302. doi: 10.1016/j.ejim.2015.03.007. Epub 2015 Mar 31. PMID: 25837692.

2. Hocking WG, Golde DW. Polycythemia: evaluation and management. Blood Rev. 1989 Mar;3(1):59-65. doi: 10.1016/0268-960x(89)90026-x. PMID: 2650777.