The vital signs may reveal obvious hypotension and tachycardia, or more subtle manifestations such as a decreased pulse pressure or tachypnea. Clinicians should remember that some patients can tolerate substantial volume losses with minimal or no changes in vital signs. Similarly, paradoxical bradycardia can occur in the face of profound hypovolemia.
Skin findings should be noted. Cool, clammy skin is an obvious sign of shock. Spider angiomata, palmar erythema, jaundice, and gynecomastia suggest underlying liver disease. Petechiae and purpura suggest an underlying coagulopathy. Skin findings may be suggestive of the Peutz-Jeghers, Rendu-Osler-Weber, or Gardner syndromes. A careful ENT examination may occasionally reveal an occult bleeding source that has resulted in swallowed blood and subsequent coffee-ground emesis or melena. The abdominal examination may disclose tenderness, masses, ascites, or organomegaly. A rectal examination is indicated to detect the presence of blood, its appearance (bright red, maroon, or melanotic), and the presence of masses.
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