IM9.3-5 | Anaemia Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

The clinical evaluation of anaemia comprises three integrated skills: structured history-taking, systematic physical examination, and construction of a prioritised differential diagnosis.

History — seven domains: (1) presenting symptoms (pica, glossitis, paraesthesias, dark urine, pain crises); (2) dietary history (vegetarian, tea/coffee with meals, green vegetables, phytates); (3) GI bleeding history (melaena, haematemesis, change in bowel habit — mandatory in males and postmenopausal women); (4) menstrual and obstetric history (menorrhagia, inter-pregnancy interval); (5) prior illness, medications, family history (NSAIDS, methotrexate, primaquine, haemoglobinopathy family history); (6) occupational/travel history (hookworm, TB exposure); (7) systems review (weight loss, lymphadenopathy, bleeding from multiple sites).

Examination — four pallor sites + aetiology-specific signs:
- IDA signature: pallor + koilonychia + smooth tongue + angular stomatitis (no jaundice)
- Haemolysis signature: pallor + jaundice + splenomegaly
- Aplasia signature: pallor + purpura + infection (no organomegaly)
- B12 signature: glossitis (beef-red) + neurological signs (SACD — vibration/proprioception loss, Romberg positive)
- Hyperdynamic circulation: tachycardia + flow murmur + wide pulse pressure

Differential diagnosis: Build from morphological hypothesis → rank by epidemiological probability → safety-net the dangerous diagnoses (GI malignancy in IDA, aplastic anaemia/leukaemia in pancytopenia).

Referral triggers: Pancytopenia, haematological malignancy signs, haemodynamic compromise, Hb <6 g/dL, haemolytic anaemia requiring specialist typing, IDA non-responsive to 8–12 weeks iron therapy.

REFLECT

Return to Meena and Ramesh from the opening hook. Meena's story — months of fatigue, fainting at the well, pica, smooth tongue, pallor without jaundice — builds a coherent IDA narrative from history and examination before a single test is ordered. Ramesh's story — 52 years old, melaena, IDA — forces you to hold a more dangerous diagnosis in your differential: the melaena cannot be dismissed as haemorrhoids in a man of his age, and IDA in this demographic is GI malignancy until proven otherwise. Think about the last patient you saw with 'weakness': what specific questions did you ask to distinguish the seven history domains? Which of the four pallor assessment sites did you check, and in what order? Did you formally construct and document a ranked differential? The discipline of the structured clinical evaluation — however busy the clinic — is what separates a safe physician from an efficient note-taker. Begin practising this structure in every patient encounter from today.