Clinical Assessment of Anemia



Signs and symptoms of anemia vary with the rapidity of onset and with underlying disease of the cardiovascular system (Table 51-2). Thus, rapid blood loss, especially if plasma volume de­creases rapidly, or brisk hemolysis may result in cardiovascular compensatory reactions, in­cluding tachycardia, postural hypotension, vaso­constriction in skin and extremities, dyspnea on exertion, and faintness. Slowly developing anemias, such as those resulting from nutritional deficiency, permit gradual expansion of the plasma volume so that increased cardiac output gradually compensates. The subject may remain asymptomatic, noting only slight exertional dysp­nea or, in the case of pre-existing coronary ar­tery disease, increased angina. Pallor of skin and mucous membranes, jaundice, cheilosis (fissuring of the angles of the mouth), a beefy red, smooth tongue, and koilonychia (spoon-shaped nails) are signs that accompany more advanced anemias of different types. The level of anemia at which signs of cardiovascular decompensation occur varies considerably with underlying disease, age, level of activity, and the individual’s stoicism. For ex­ample, in the sedentary elderly person, a change in mentation can be an important clue to anemia, whereas decreased activity can mask exercise in­tolerance.

Evaluation of the anemic patient is best served by a systematic evaluation of the clinical and lab­oratory findings together (Fig. 51-1). First, is the patient truly anemic? Increased plasma volume, fluid overload, or congestive heart failure may produce a dilutional anemia that disappears when fluid balance is restored. Second, is the anemia acquired or inherited? Family history is impor­tant, especially in hemolytic anemias, and a pos­itive family history of jaundice, splenomegaly, or gallstones may suggest such a condition. Hemo­globinopathies are frequent in Mediterranean, Af­rican, and Far Eastern populations, making ethnic background pertinent. For the immediate prob­lem, a lifelong history versus recent onset is a key differential point. Third, is there evidence for blood loss? The most common reason for anemia is iron loss and iron deficiency. While in growing children and pregnant women iron deficiency may result from dietary lack, the overwhelming cause of iron deficiency in adults is loss of blood from the gastrointestinal or genitourinary tract. Fourth, is there evidence for nutritional defi­ciency or malabsorption? In the urban Westerner, folic acid deficiency is a common form of mal­nutrition, seen especially in the elderly living alone and in alcoholics. Fifth, is there evidence for hemolysis? Inherited hemolytic anemias are common in certain populations, whereas acquired hemolytic anemia is rare, occurring mainly in set­tings of autoimmune disease and drug ingestion. Sixth, is there evidence for toxic exposure or drug ingestion that could cause bone marrow depres­sion and anemia? Finally, does the patient have a chronic inflammatory disease, renal insuffi­ciency, or cancer, each of which is associated with secondary mild anemias, the “anemia of chronic disease”?