History-Taking in Anemia

1. Presenting Complaint & Symptoms of Anemia

• Fatigue and weakness - most common complaint
• Dyspnea - especially on exertion
• Decreased exercise tolerance
• Chest pain / angina - in severe or cardiac-compromised patients
• Dizziness, lightheadedness, or syncope
• Palpitations
• Headache

Rosen's Emergency Medicine, Box 109.3

2. Duration and Course

• Is the anemia lifelong (suggests hereditary cause), chronic, intermittent, or acute?
• Onset of symptoms - gradual vs. sudden
• Previous episodes of anemia

3. Sites of Blood Loss

4. Dietary History

• Vegetarianism or strict vegan diet - risk of B12 deficiency
• Poor nutrition or food insecurity - risk of iron, folate deficiency
• Pica (craving for ice, dirt, chalk) - classic clue for iron deficiency
• Alcohol intake - causes folate deficiency, bone marrow suppression, liver disease

5. Drug Use and Toxin Exposure

• NSAIDs / aspirin - GI blood loss, platelet inhibition
• Chemotherapeutic agents, hydroxyurea, AZT - macrocytic anemia/bone marrow suppression
• Chloramphenicol, sulfonamides, dapsone - aplastic or hemolytic anemia
• Alcohol
• Lead exposure (occupational or environmental)
• Recent blood transfusions

6. Clues to Specific Anemia Types

Iron Deficiency / Blood Loss

• Change in bowel habits, occult or frank GI bleeding
• Surgical procedures (past operations)
• Pica (craving for ice = pagophagia)
• Restless leg syndrome

Hemolysis

• Jaundice - episodic or sustained; family history of jaundice
• Hemoglobinuria - dark/tea-colored urine, especially with cold, drugs, or sleep (paroxysmal nocturnal hemoglobinuria)
• Cholelithiasis or cholecystectomy in early adulthood (pigment stones from chronic hemolysis)
• Association with cold exposure (cold agglutinin disease)
• Ethnic background - African, Mediterranean, Southeast Asian heritage (sickle cell, G6PD deficiency, thalassemia)
• Family history of anemia or jaundice

B12 / Folate Deficiency (Megaloblastic)

• Neurological symptoms: tingling/numbness in hands and feet, unsteady gait, memory problems
• Dietary habits (veganism for B12; alcoholism or poor diet for folate)
• Prior gastric surgery (gastrectomy removes intrinsic factor)
• Malabsorption disorders (Crohn's disease, celiac disease)

Hemolytic - Specific Triggers

• Drug or toxic exposure
• Association with infection (e.g., EBV/infectious mononucleosis)
• Underlying disease: SLE, renal failure, lymphoma, prosthetic heart valve

7. Underlying Diseases

Goldman-Cecil Medicine, Table 144-4

8. Family History

• Family history of anemia, jaundice, or splenectomy
• Known hemoglobinopathies (sickle cell, thalassemia) in family
• Hereditary spherocytosis or other RBC membrane disorders
• G6PD deficiency (X-linked - maternal family history important)

9. Surgical and Obstetric History

• Previous surgeries (especially GI surgeries causing malabsorption)
• Gastrectomy (B12 deficiency due to loss of intrinsic factor)
• Number of pregnancies (iron depletion from repeated pregnancies)
• Recent blood transfusions

10. Social History

• Occupation (lead exposure, chemical exposure)
• Dietary habits and food security
• Alcohol use
• Travel history (malaria-endemic areas - cause of hemolytic anemia)

Bonus: Evaluation Algorithm

Quick Summary Mnemonic - "ANEMIA"

• Rosen's Emergency Medicine, Box 109.2, 109.3, 109.13
• Goldman-Cecil Medicine, Table 144-4 & 144-5