What is the approach to physical examination and diagnosis in a patient with suspected anemia?

Physical Examination and Diagnosis Approach for Suspected Anemia

The physical examination for suspected anemia should include assessment for pallor, jaundice, splenic enlargement, neurologic symptoms, petechiae, heart murmurs, and signs of blood loss, accompanied by comprehensive laboratory testing to confirm diagnosis and determine the underlying cause. 1, 2

Initial Assessment

History Taking

• Obtain a thorough drug exposure history, including use of NSAIDs, aspirin, and anticoagulants 3
• Document duration and onset of symptoms, comorbidities, family history of hematological disorders, and exposure to chemotherapy or radiation 2
• Assess for symptoms such as fatigue, weakness, exercise dyspnea, shortness of breath, syncope, headache, vertigo, and chest pain 1, 2
• Evaluate dietary history to identify potential iron-deficient diets, though this alone should not be presumed as the cause 3

Physical Examination Components

• General appearance: Look for pallor of skin, conjunctiva, and nail beds 1
• Cardiovascular system: Check for tachycardia, systolic flow murmurs, and signs of heart failure 1
• Respiratory system: Assess for exercise dyspnea and shortness of breath 1

Specific Physical Findings by Anemia Type

• Iron deficiency anemia:

  • Angular stomatitis (cracking at corners of mouth) 1
  • Glossitis (smooth, red, painful tongue) 1
  • Koilonychia (spoon-shaped nails) 1
  • Blue sclerae (bluish discoloration of eye whites) 1
  • Pagophagia (ice craving) 1

• Hemolytic anemia:

  • Jaundice 1, 2
  • Splenomegaly 1, 2

• Vitamin B12 deficiency:

  • Neurologic symptoms (paresthesias, ataxia) 1, 2

Diagnostic Testing

First-Line Laboratory Tests

• Complete blood count (CBC) with indices to characterize anemia and identify other cytopenias 2, 4
• Peripheral blood smear examination (and in some cases, bone marrow examination) 3
• Serum ferritin (most powerful test for iron deficiency, with level <45 ng/mL diagnostic) 3, 2
• Iron panel (iron level, TIBC, transferrin saturation) 2
• Reticulocyte count to assess bone marrow response 4
• Tests for folate and vitamin B12 deficiency 3
• Assessment for occult blood loss and renal insufficiency 3

Additional Testing Based on Clinical Suspicion

• Coombs' testing for patients with chronic lymphocytic leukemia, non-Hodgkin's lymphoma, or history of autoimmune disease 3
• Celiac disease screening with serology first, followed by small bowel biopsy only if positive 3
• Levels of lactate dehydrogenase, haptoglobin, and bilirubin if hemolysis is suspected 4

Gastrointestinal Evaluation for Iron Deficiency Anemia

• GI investigations should be considered in all patients with confirmed iron deficiency anemia unless there is significant non-GI blood loss 3
• Upper GI endoscopy should be performed first, with small bowel biopsies to rule out celiac disease (present in 2-3% of patients with iron deficiency anemia) 3
• Lower GI tract examination (colonoscopy or double contrast barium enema) should follow, as dual pathology occurs in 10-15% of patients 3
• Bidirectional endoscopy (upper and lower) is recommended for:
  • Asymptomatic postmenopausal women and men with iron deficiency anemia (strong recommendation) 3
  • Asymptomatic premenopausal women with iron deficiency anemia (conditional recommendation) 3

Common Pitfalls to Avoid

• Relying solely on physical examination findings without laboratory confirmation 1
• Assuming a single cause for anemia without comprehensive evaluation 2
• Accepting upper GI findings such as erosions or peptic ulcer as the sole cause of iron deficiency without lower GI evaluation 3
• Overlooking subtle physical signs of specific nutritional deficiencies 1
• Failing to consider non-GI causes of anemia 3

Diagnostic Algorithm

1. Initial evaluation:

   • Complete history and physical examination
   • CBC with differential and indices
   • Peripheral blood smear review 3, 4

2. Classification based on MCV:

   • Microcytic: Iron studies, hemoglobin electrophoresis
   • Normocytic: Reticulocyte count, LDH, haptoglobin
   • Macrocytic: B12, folate levels 4

3. For confirmed iron deficiency:

   • Test for occult blood loss
   • Bidirectional endoscopy (upper and lower GI evaluation)
   • Consider H. pylori testing 3

4. If initial workup is negative:

   • Consider small bowel evaluation in transfusion-dependent cases
   • Assess for non-GI causes (menstrual loss, frequent blood donation, etc.) 3

Remember that physical findings of anemia are neither sensitive nor specific to the type of anemia, and laboratory confirmation is essential for accurate diagnosis and management 1.