Physical Exam to Detect Anemia

I was in ambulatory GIM clinic seeing a patient referred for chronic anemia. She had been worked up over many years, including a bone marrow aspirate years prior which confirmed a diagnosis of iron deficiency anemia. She had been on iron supplementation and her hemoglobin improved for a time. However, recently it had dropped again and this was why she was representing. The patient's chief symptom was fatigue. I spent a lot of time working through the lab tests and identified a normocytic anemia. I built a differential diagnosis and presented this to my preceptor. During the presentation, I was asked about any physical exam findings for anemia. I realized I hadn't focused on this, and other than a vague idea about skin pallor didn't have a good approach to this aspect of the presentation of anemia. I was thankful to have my preceptor demonstrate the different physical exam findings with me and the patient. I learned that the best place to look for pallor is the conjunctiva, nail beds, and palms. My preceptor looked at the nail beds and explained that thinning, flattening, and spooning of the nails can occur with iron deficiency anemia. Other findings more specific to iron deficiency anemia include: glossitis, and angular stomatitis. This was an excellent learning experience. I realized I had focused too heavily on the lab tests in my workup of anemia. The physical exam can provide useful clues as to severity and chronicity of the problem. I was thankful for bedside teaching that helped me build my approach and competence for recognizing signs of anemia and iron deficiency on physical exam.

- MH