PICKLE - General Physical Examination

P - Pallor

• Definition: Abnormal paleness of the skin, mucous membranes, conjunctivae, or nail beds due to reduced hemoglobin or poor perfusion.
• How to check: Lower palpebral conjunctiva (best site), palmar creases, nail beds, tongue.
• Causes: Anemia (iron deficiency, B12/folate deficiency, hemolytic, aplastic), hemorrhage, shock, hypothyroidism.
• Grading: Mild, moderate, severe.

I - Icterus (Jaundice)

• Definition: Yellow discoloration of the sclera, skin, and mucous membranes due to elevated bilirubin (>2-3 mg/dL visible clinically).
• How to check: Sclera (best early indicator), under the tongue (sublingual), hard palate, skin.
• Types: Pre-hepatic (hemolytic), hepatic (hepatocellular), post-hepatic (obstructive/cholestatic).
• Note: Scleral icterus appears before skin jaundice.

C - Cyanosis

• Definition: Bluish discoloration due to >5 g/dL of deoxygenated hemoglobin in capillaries.
• Types:
  • Central cyanosis: Tongue, lips, oral mucosa - indicates systemic hypoxia (respiratory failure, cardiac shunting).
  • Peripheral cyanosis: Fingertips, toes, nail beds - indicates reduced peripheral circulation (cold, vasoconstriction, cardiac failure).
• How to check: Tongue first (for central), then periphery.

K - Clubbing

• Definition: Bulbous enlargement of the terminal phalanges (fingers and toes) with loss of the normal angle at the nail base (Lovibond angle >180°).
• Schamroth's sign: When two index fingers are apposed dorsally, the normal diamond-shaped window disappears in clubbing.
• Grading (Schamroth):
  • Grade 1: Loss of nail bed angle
  • Grade 2: Increased curvature of nail
  • Grade 3: Drumstick appearance
  • Grade 4: Hypertrophic pulmonary osteoarthropathy
• Causes (ABCDE mnemonic): Abscess/lung disease, Bronchiectasis/Bronchogenic carcinoma, Cyanotic heart disease/Crohn's/Cirrhosis, Diarrhea (IBD), Endocarditis.

L - Koilonychia

• Definition: Spoon-shaped nails (concave nail surface) where a drop of water can rest on the nail.
• Cause: Primarily iron deficiency anemia (most common cause).
• Other causes: Hemochromatosis, hypothyroidism, trauma, Plummer-Vinson syndrome.
• How to check: Hold the fingertip up to the light and look for the characteristic spoon shape.

E - Lymphadenopathy

• Definition: Enlargement of lymph nodes (>1 cm in most sites; >1.5 cm in inguinal region is abnormal).
• Sites to check: Cervical (anterior/posterior chain), submandibular, submental, axillary, inguinal, epitrochlear, popliteal.
• Characteristics to note: Size, consistency (soft/firm/hard/rubbery), tenderness, mobility, matting.
• Causes:
  • Tender + soft: Reactive/infective (viral, bacterial)
  • Hard + fixed: Metastatic carcinoma
  • Rubbery: Lymphoma

(E) - Edema (the final "E" in some versions)

• Definition: Abnormal accumulation of fluid in the interstitial spaces.
• Pitting vs. Non-pitting: Press for 5 seconds over bony prominence (tibia, sacrum).
• Sites: Pedal (dependent), sacral (bedridden patients), ascites (intra-abdominal), periorbital.
• Causes: Cardiac failure, hypoalbuminemia (liver disease, nephrotic syndrome, malnutrition), renal disease, venous obstruction.

Summary Table

Note on variants: The mnemonic appears in slightly different forms in different curricula - PICCKLE (adding a second C for Clubbing and Cyanosis separately), PICCLE, and PICKLE are all used. The full expanded version often includes edema as the final E, making it a 7-sign checklist. Always assess these signs as part of a head-to-toe general survey before proceeding to systemic examination.