Anemia
Rationale
Anemia is a common finding, often identified incidentally in asymptomatic patients. It can be a manifestation of a serious underlying disease. Distinguishing among the many disorders that cause anemia, not all of which require treatment, is an important training problem for third-year medical students.
Knowledge
Students should be able to define, describe, and discuss the:
- classification of anemias
- morphological characteristics, pathophysiology and relative prevalence of:
- iron deficiency and other microcytic anemias (i.e., sideroblastic)
- macrocytic anemias
- anemia of chronic disease
- congential disorders
- sickle cell
- thalessemias
- hemolytic anemias
- laboratory tests used in evaluating anemia -- normal and abnormal values
- indications, contraindications and complications of blood transfusion
Skills
Students should demonstrate specific skills, including:
- History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including:
- constitutional and systemic symptoms:
- fatigue
- weight loss
- GI bleeding
- abdominal pain
- medications
- diet
- menstrual history
- family history
- past medical history
- Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including inspection of:
- skin
- eyes
- sclera
- conjunctiva
- fundi
- mouth
- heart
- abdomen
- rectum
- lymph nodes
- nervous system
- Differential Diagnosis: Students should be able to:
- generate a list of the most important and most common causes of anemia
- recognize specific history and physical exam findings that suggest a specific etiology of anemia
- Laboratory Interpretation: Students should be able to recommend when to order diagnostic tests and be able to interpret the following laboratory test results:
- hemoglobin and hematocrit
- red cell indices
- reticulocyte count
- iron studies
- serum iron
- TIBC
- ferritin
- transferrin
- serum B12 and folate
- haptoglobin
- LDH
- Schilling test
- hemoglobin electrophoresis
- blood smears
- Communication Skills: Students should be able to:
- counsel patients and their families with regard to:
- possible causes of the anemia
- appropriate further evaluation to establish the diagnosis of an underlying disease
- the impact on the family (genetic counseling)
- Basic and Advanced Procedure Skills: Students should be able to:
- interpret a peripheral blood smear.
- assist in performing a bone marrow aspiration.
- Management Skills:Students should be able to develop an evaluation plan to obtain appropriate diagnostic studies useful in establishing a specific diagnosis including:
- GI blood loss
- hemolytic anemia
- pernicious anemia
- chronic disease:
Students should be able to develop a treatment plan for the following:
- renal
- thyroid
- HIV
- malignancy
- inflammation
- iron deficiency anemia
Attitudes and Professional Behaviors
Students should be able to:
- recognize that constitutional symptoms, such as fatigue or malaise, may be caused by depression, rather than any underlying anemia or dietary deficiency.
- appreciate that anemia is not a disease by itself, but rather a common finding that requires further delineation and evaluation to identify the casual disorder and therefore the most appropriate management.
Resources
- Internal Medicine Clerkship Guide, Paauw et al, Mosby 2003, 64-72
- Clinical Management Conferences, E. Constance, MD and A. Varney, MD
- “Pernicious Anemia”, Ban-hock Toh, MBBS, DSc, Ian R. VanDriel, PhD, Paul A. Gleeson, PhD, New England Journal of Medicine, Vol. 337, No. 29, 1441-1448
- “Disorders of Iron Metabolism”, Nancy C. Andrews, MD, PhD, New England Journal of Medicine, Vol. 341, No. 26, 1986-1995
- "Diagnosis from the Blood Smear", Barbara J. Bain, F.R.A.C.P., F.R.C.Path., New England Journal of Medicine, 2005;353:498-507.
- "Anemia of Chronic Disease", Guenter Weiss, M.D., and Lawrence T. Goodnough, M.D., The New England Journal of Medicine, 2005;352:1011-23.
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