Clinical examination and evaluation of anemia

There are many items for anemia testing, the aim of identifying one of the two causes

Clinical examination, i.

History collection

1.

In terms of anemia types, a variety of anemias, such as thalassemia, HS, abnormal hemoglobinopathy, G-6-PD deficiency, etc.

Figure 1 Genetic characteristics and phenotype of hereditary hemolytic anemia

*The probability of disease of the patient's offspring depends on the genetic characteristics of the patient's married woman, if the married woman is a homozygous (2 X chromosomes carry the defective gene), the sons born are all hemishematogens (1 X chromosome carries the defective gene, diseased), and the daughters are all homozygous (diseased)

Second, the history of medication

The pros and cons of drug treatment have received widespread attention

3.

Prolonged exposure to a variety of chemicals, such as lead, arsenic, benzene and its passes, pesticides, pesticides, dyes, and radioactive materials, can cause anemia

Fig.

Fourth, life history and regionality

With the improvement of living standards, the widely used materials used in interior decoration, as well as the materials in the car, often contain toxic substances, and in the slow distribution process, it is possible to cause hematological abnormalities in some people of specific qualities, including anemia

Although the anemia that occurs in strict vegetarians should also be considered due to folate deficiency, most of the MAs we currently diagnose and treat are caused by non-nutritive vitamin B12 deficiency, which is a good example

Some diseases are epidemic, such as certain parasitic diseases (especially malaria, kala-azale), and for patients from endemic areas, the possibility of anemia caused by these diseases also needs to be considered

V.

Diet and some of its habits are associated with the development of some anemias, and knowing nutritional information can help to speculate about the effect of a lack of a certain ingredient in the diet on

Knowing the dietary history can also provide some meaningful explanations for anemia: strict vegetarians are often prone to IDA due to the absence of certain vitamins and mineral salts, and patients are also underweight; People who have not eaten animal foods for many years are susceptible to nutritional anemia with vitamin B12 deficiency; Anorexia nervosa (caused by improper weight loss in quite a few cases) and cachexia due to long-term loss of necessary nutrient intake, often occur dystrophic degeneration (bone marrow tissue is purple-red, considered to be acidic mucopolysaccharide degeneration) bone marrow hematopoietic function, long-term partial eaters are also prone to malnutrition bone marrow hematopoietic function reduction; People who drink strong tea (excessive tannic acid intake) and continue to be vegetarian are more likely to affect the absorption of iron and suffer from IDA; Alcoholics and unreasonable diets are prone to macrocytic anemia or MA

6.

In the surgical history of surgical disorders, particular attention should be paid to gastrointestinal surgery, as anemia that occurs after gastrointestinal surgery may be related

7.
Other medical history

Many diseases can be accompanied by anemia
.
Therefore, the relationship between
the original disease and anemia needs to be understood in detail.
Autoimmune diseases (especially SLE), malignancies (especially gastrointestinal cancers and metastatic bone marrow tumors), endocrine diseases, chronic liver disease, chronic kidney disease, and chronic infectious diseases (eg, tuberculosis, subacute bacterial endocarditis, senile pneumonia) are common causes of anemia, and many are directly linked
.
With the improvement of people's living standards, at present, in middle-aged and elderly people, vitamin B12 deficiency MA caused by chronic gastrointestinal diseases has become a common underlying disease of MA, that is, the nutritional MA caused by vitamin B12 deficiency has exceeded the nutritional MA
of folate deficiency.

History of the present condition

Patiently listen to the patient's main complaint and sort out the correlation between the main complaint symptoms and past medical history and current blood abnormalities
.

1.
Skin and mucous membranes

The color of the skin is related
to the pigment contained in the skin and the amount of blood that passes through the capillaries of the skin.
Blood affecting the color of the skin has a guiding effect
on the diagnosis of anemia or polycythemia.
Because the hemoglobin is more significantly reduced, the skin is pale, and the increase in hemoglobin causes the skin to darken (dark red or crimson).

Pale and (wilted) yellow skin tones are common appearance characteristics of patients with anemia, but it is necessary to pay attention to changes in
skin tone caused by individual skin color differences.
At this point, it is more reliable
to check for changes in the color of the conjunctiva of the eyelids, oral mucosa, tongue, nails (nail bed), and palm lines (e.
g.
, pallor).
If the pink palm line of the original unfolded hand disappears and appears pale, it can indicate that the patient's hemoglobin has fallen below 70 g/L
.
Paleness and yellowing of the conjunctiva of the eyelids can indicate HA
.
The meaning of other changes in the tongue and nails is found in section
4 of this chapter.

2.
Bleeding

Acute blood loss or bleeding from the body surface (e.
g.
, skin, nose, and oral mucosa) is susceptible to the patient's attention, but upper GI bleeding is not easily recognized
by the patient.
For women of childbearing age, careful questioning of menstruation, number of pregnancies, and duration
of breastfeeding is required.
Excessive menstrual flow and/or a high number of pregnancies and long lactation are common causes
of IDA.

Careful examination of the skin and mucous membranes for petechiae and ecchymosis, typical of limb bruises characterized by thrombocytopenic bleeding, is seen in disorders with thrombocytopenia, such as idiopathic immune thrombocytopenia (ITP), AA, and acute leukemia
.

3.
Jaundice

When asking about the history and physical examination, it is necessary to pay attention to the past and present occurrence
of jaundice.
Jaundice is caused by the skin stained with bile pigment and is often one
of the manifestations of significant hemolysis.
Examination for jaundice should be seen in natural daylight and is readily observed in conjunctiva, mucous membranes, or in the absence of darker skin
.
Mild jaundice requires careful physical examination, such as mild jaundice that is common in anemia such as HA and MA; Acute episodes of intravascular hemolysis, such as PNH and G-6-PD deficiency, are common and often accompanied by significant deepening
of urine color.

Jaundice is more pronounced in AIHA (thermoreactive antibody autoimmune hemolytic anemia) and hereditary spherocythemia
.
In neonatal patients, G-6-PD deficiency and alloimmune anemia (caused by mother-to-child Rh or ABO blood group incompatibility) are common and have symptoms
of riddance.
Jaundice caused by hemolysis is mainly caused by an increase in indirect bilirubin levels, but direct bilirubin is more likely to cause jaundice than indirect bilirubin increase, which needs to be recognized
.

Fourth, the nervous system

Middle-aged and elderly patients with anemia, with gait instability and numbness (paresthesia), need to suspect vitamin B12 deficiency MA
.
This is due to vitamin B12 deficiency causing degeneration and dysfunction of peripheral nerves and posterior and lateral cords of the spinal cord, with decreased sensations of pain, touch, position and vibration, and abnormal tendon reflexes, and is more common in both lower extremities
.
Anemia is often evident by the time these symptoms occur, but some patients precede pathological changes in blood and bone marrow
.

5.
Urine color

Black tea, red wine, or soy sauce-like urine is suggestive of hemoglobinuria and is often characteristic of severe intravascular hemolysis, but needs to be distinguished from hematuria, myoglobinuria, porphyria (darkening in the light), or darkening of urine after taking certain medications
.
A positive urinary occult blood test and confirmation of hemoglobinuria require further understanding of the circumstances under which such urine occurs
.
There are four types of intravascular hemolytic anemia that are common in clinical practice: PNH (especially in acute exacerbations), paroxysmal cold hemoglobinuria (PCH), marching hemoglobinuria, and the special conditions of hemoglobinuria induced by taking drugs or eating fava beans are different, and can be combined with medical history to make (preliminary) diagnosis (Table 1).

Table 1 Manifestations of hemoglobinuria due to four types of intravascular hemolytic anemia are common

PNH is paroxysmal nocturnal hemoglobinuria; PCH paroxysmal cold hemoglobinuria; CAS is cold agglutinin syndrome; G-6-PD is a 6-phosphate glucose dehydrogenase deficiency

Sixth, bones

Children with severe thalassemia have a special face
formed by bone changes due to long-term hyperactivity of hematopoiesis in the bone marrow, resulting in thinning of the skull cortex, deep bone slits, bulging of the cheek bone, collapse of the bridge of the nose, and bone changes.
Fanconi anemia also has multiple skeletal deformities
.

Myeloid anemia due to hematologic tumors predisposes to bone pain, such as sternal tenderness (especially tenderness), which is the main sign
of leukemia.
Lumbosacral or hip pain when walking, bone tenderness in multiple areas (e.
g.
, ribs, sternum, collarbone, lumbosacral bone), common in plasma cell myeloma, and bone marrow infiltrative anemia caused by malignant tumors such as cancer infiltrating the bone marrow
.
However, the anemia associated with these diseases is not a major problem
in treatment.
Conversely, common anemia is often not without bone pain
.

7.
Spleen and lymphadenopathy

Splenomegaly is often accompanied by hypersplenism
.
Therefore, anemia with splenomegaly should further clarify the cause of splenomegaly and the relationship with
anemia.
Among them, it is most necessary to straighten out the primary and secondary relationship between hypersplenism and blood diseases in the diagnosis, such as splenomegaly HA and bone myeloid anemia caused by some blood tumors can be accompanied by hypersplenism, but HA and hematologic tumors are the main ones in diagnosis; In contrast, in patients with splenomegaly and cytopenia without significant hematopathic lesions (eg, cytopenia due to cirrhosis, cytopenia due to congestive splenomegaly), the diagnosis of hypersplenism is the
mainstay.

In principle, anemia does not have lymphadenopathy, accompanied by lymphadenopathy, especially in more obvious cases, almost all of which are secondary anemia, and most of them are anemia accompanied by hematological tumors such as lymphoma
.

8.
Basic data and individual status before illness

Patients see a haematology specialist and are eager for help, explanation, and diagnosis
from a doctor.
It is extremely important
to listen carefully and patiently to the patient's complaints.
Common complaints related to blood disorders: anemia, bleeding, fever and concomitant fatigue, insomnia, insomnia, malaise, weight loss, etc.
; There are also a considerable number of patients who have undergone initial examination without obvious explanation or after preliminary or general treatment without obvious effect of hemoglobin reduction, high or low white blood cells, mild abnormal cell classification, thrombocytopenia, etc
.
In addition, it needs to be linked
to the patient's other conditions and the patient's original basic data.

Understanding the patient's pre-morbid examination data and constitution, i.
e.
the underlying state (ground state), is very beneficial
for analyzing and assessing the dynamics of the disease or the likelihood of the presence of the disease.
In terms of the basic values of hematology, there is no history of sustained increase or decrease in values, such as slow-onset chronic anemia, hemoglobin reduction although severe, but its anemia symptoms due to adaptive compensation of the body may not be severe, due to acute blood loss or anemia occurring in a short period of time
, although the hemoglobin reduction is not serious, but its anemia symptoms can be obvious.
The presence or absence of anemia with or without a decrease in white blood cells and/or platelets is very closely related to the evaluation of the type of anemia, such as IDA is mostly simple anemia, and AA is a significant decrease
in platelets and/or white blood cells in addition to anemia.

In addition, the underlying changes (age and blood) caused by physiological changes should also be taken seriously, such as the growth and development of newborns to adolescents, blood red blood cells, white blood cells and lymphocytes from high to low until adults are in a stable state
.
After middle and old age, there may be some changes, such as lymphocytes tend to be high, bone marrow hematopoiesis has a tendency to centripetal atrophy, and the iliac bone marrow of people over 40 years old can undergo obvious fatification, that is, physiological hematopoiesis
.

9.
Others

Patients with moderate to severe anaemia often have a chronic outlook and a poor
mental state.
In addition to the red and smooth tongue (nipple atrophy), IDA patients can also see cheilitis (dry cleft corners of the mouth), MA can also see glossitis, etc
.
In lead poisoning, a lead line (a black line formed by the deposition of lead sulfide)
at the base of the tooth is visible.
Enlargement and hardness of the tongue, may be anemia caused by primary amyloidosis, etc
.