Anemia — Complete History Taking & Clinical Examination

DEFINITION

• Men: Hb < 13 g/dL or Hct < 39%
• Non-pregnant women: Hb < 12 g/dL or Hct < 36%

HISTORY TAKING

1. Presenting Complaints (Symptoms of Anemia)

Harrison's: Patients who develop anemia gradually can tolerate remarkably low Hb levels due to compensation. Signs and symptoms are unreliable in predicting the hematocrit.

2. History of Present Illness (HPI)

• Acute vs. chronic (acute → blood loss or hemolysis; chronic → nutritional deficiency, chronic disease)
• Rate of progression — gradually worsening vs. sudden onset

• Epistaxis, hemoptysis
• Hematemesis, melena, hematochezia (GI source)
• Hematuria
• Menorrhagia, metrorrhagia (in females — duration of periods, number of pads/tampons used, passing large clots)
• Bleeding after trauma, injections, or tooth extractions
• Spontaneous purpura or petechiae

3. Past Medical History

• Previous episodes of anemia — treatment received (iron pills, transfusions), response to therapy
• Previous blood transfusions
• Underlying chronic diseases:
  • Renal failure (uremia → EPO deficiency)
  • Liver disease (decreased clotting factors, hypersplenism)
  • Hypothyroidism
  • Chronic inflammatory conditions: rheumatoid arthritis, SLE, IBD, cancer
  • Malabsorption syndromes (celiac disease, Crohn's disease → folate/iron/B12 malabsorption)
• Diarrhea (sign of celiac or IBD)
• Previous surgeries (gastrectomy → B12 deficiency; bowel resection → malabsorption)
• Hemolysis-associated conditions: SLE, renal failure, lymphoma, infectious mononucleosis, prosthetic heart valve

4. Drug & Toxin History

• NSAIDs, aspirin, anticoagulants → GI blood loss
• Chemotherapy, chloramphenicol, sulfonamides → bone marrow suppression
• Drugs causing hemolysis (especially in G6PD deficiency): antimalarials, nitrofurantoin, dapsone
• Alcohol (macrocytic anemia, folate deficiency)
• Drugs causing platelet inhibition
• Drug or toxic exposure history

5. Dietary History

• Vegetarianism / veganism → B12 deficiency (no animal products)
• Poor nutritional intake → iron or folate deficiency
• Tea/coffee excess → inhibits iron absorption
• Dietary history in infants (exclusively breast-fed without supplementation)

6. Family History

• Hereditary hemolytic anemias: sickle cell disease, thalassemia, hereditary spherocytosis, G6PD deficiency
• Family history of anemia or jaundice

7. Social & Occupational History

• Racial/ethnic background (thalassemia common in Mediterranean, Middle East, Southeast Asia; sickle cell in Africans)
• Occupation (toxin/heavy metal exposure)
• Travel history (malaria in endemic areas)
• Blood donations (frequent donors may deplete iron)

8. Menstrual & Obstetric History (in females)

• Last menstrual period
• Cycle regularity, duration, and flow
• Number of pads/tampons used per day
• Passing of large clots
• Number of pregnancies (increased iron demand)

PHYSICAL EXAMINATION

General Appearance

• Pallor (skin, mucous membranes)
• Jaundice (hemolytic anemia)
• Cachexia or malnourishment

Vital Signs (Measured Serially)

• Tachycardia — compensatory increase in cardiac output
• Hypotension / postural hypotension — volume depletion (acute blood loss)
• Tachypnea — compensatory increase in respiratory rate
• Low oxygen saturation — in severe anemia
• Raised respiratory rate

Skin

• Pallor of skin, nail beds — most reliable site in dark-skinned patients: palmar creases, conjunctivae
• Jaundice — hemolytic anemia (unconjugated hyperbilirubinemia)
• Petechiae, purpura, ecchymoses — thrombocytopenia, bleeding diathesis
• Angiomas, ulcerations (especially lower limbs in sickle cell)
• Diaphoresis (in acute severe anemia)
• Spooning of nails (koilonychia) — iron deficiency
• Brittle nails — chronic iron deficiency

Eyes

• Pallor of conjunctivae — look at the palpebral conjunctiva; pale pink instead of deep red
• Scleral icterus / conjunctival jaundice — hemolytic or megaloblastic anemia
• Retinal hemorrhages — severe anemia (Hb <5 g/dL)

Oral / Mouth

• Pallor of the tongue and oral mucosa
• Atrophic glossitis (smooth, beefy, depapillated tongue) — iron, B12, or folate deficiency
• Angular cheilosis / angular stomatitis — iron or B12 deficiency
• Papillary soreness of tongue

Lymph Nodes

• Lymphadenopathy — lymphoma, leukemia, infectious mononucleosis (causing anemia)

Cardiovascular

• Flow murmur (systolic ejection murmur) — due to decreased blood viscosity and increased cardiac output
• S3 or S4 gallop — high-output cardiac failure
• Quality of carotid and femoral pulses
• Heart size (cardiomegaly in chronic anemia)
• Signs of heart failure: raised JVP, lung crackles (pulmonary edema), peripheral edema

Abdomen

• Splenomegaly — hemolytic anemias (spherocytosis, thalassemia, sickle cell), hypersplenism, lymphoma, myeloproliferative disease
• Hepatomegaly — liver disease, infiltrative conditions, chronic hemolysis
• Hepatosplenomegaly — thalassemia major, lymphoma
• Ascites — chronic liver disease
• Abdominal masses — GI malignancy causing blood loss or marrow infiltration
• Rectal examination — stool hemoglobin testing (occult blood), masses

Nervous System

• Peripheral neuropathy (glove-and-stocking pattern) — B12 deficiency
• Loss of vibration sense and proprioception (posterior column signs) — subacute combined degeneration (B12 deficiency)
• Ataxia
• Altered level and content of consciousness — in severe acute anemia

Bone & Joints

• Bone tenderness (sternum, ribs) — marrow infiltration, leukemia, myeloma
• Leg ulcers (lower extremity ulcerations) — sickle cell disease

SUMMARY: CLUES FROM EXAMINATION TO ETIOLOGY

ALGORITHM FOR EVALUATION

1. CBC with peripheral smear → classify by MCV (microcytic / normocytic / macrocytic)
2. Reticulocyte count → assess bone marrow response (hyperproliferative vs. hypoproliferative)
3. Further targeted tests based on classification

Harrison's 22E: "The physical exam should be focused on the consequences of anemia (cardiac flow murmur) and clues to the cause, such as splenomegaly or blood in the stool. A review of the blood smear is a crucial part of any evaluation."

• Harrison's Principles of Internal Medicine, 22nd Ed. (2025) — Chapter 66
• Washington Manual of Medical Therapeutics — Hematologic Disorders
• Rosen's Emergency Medicine — Boxes 109.2, 109.3, 109.13