Dr. Huntley's
Diagnosis
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❑ Iron deficiency
❑ Chronic disease
❑ Vitamin B12 deficiency
❑ Subacute blood loss
❑ Thalassemia trait
❑ Folate deficiency
❑ Sickle cell trait
❑ Immune hemolytic anemia
❑ Myeloproliferative disease
❑ Aplastic anemia
❑ Sideroblastic anemia
Symptoms include dyspnea on exertion, fatigue, headache, palpitations, difficulty concentrating, and tinnitus. When blood loss occurs gradually, oxygen delivery can be maintained at rest to a hemoglobin as low as 5 g/dL.
Tachycardia and a systolic flow murmur occur when hemoglobin is less than 7.5 g/dL. Pallor is found in the conjunctivae and notably in the palmar creases with hand extension (they normally flush). Press the base of the nail to observe blanching and flushing, comparing with the color of your own nailbeds. Always test for orthostatic blood pressure changes to assess acuteness of blood loss. Check stools for occult blood. Splenomegaly is found in hemolysis, pernicious anemia, liver diseases, infection, and thalassemia. In chronic anemia, there will be bounding pulses with a wide pulse pressure and a midsystolic
murmur.
Heavy menses are recognized by clots and gushing of blood with tampon removal. A family history of anemia suggests hemoglobinopathy (e.g., sickle cell anemia or thalassemia). Drug or toxin exposure suggests aplastic anemia, myelodysplasia, or G6PD hemolysis. Glossitis is seen with iron, folate, or vitamin B12 deficiency. Lymphadenopathy is seen with marrow infiltration or infection.
Iron deficiency Specific symptoms include paresthesias, burning tongue, and dysphagia. Pica, which is a craving for dirt, clay, or more commonly ice may be seen in 50%. Findings include atrophic glossitis and angular cheilitis. Spoon nails with thinning and ridging are fairly specific. The most common cause is blood loss, either menstrual in young women or GI in older patients. Occult blood will usually be found concurrently in the stool if the source is the GI tract.
Chronic disease Chronic inflammatory diseases, chronic infections, neoplasms, cirrhosis, and renal failure are the common causes, and these causes are usually evident although they may be occult (e.g., pancreatic cancer).
Vitamin B12 deficiency This vitamin deficiency is usually caused by pernicious anemia, which may be associated with immune thyroiditis or vitiligo, or to blind loop syndrome. Symptoms include numbness in the extremities (the earliest sign), sore tongue, anorexia, diarrhea, memory impairment, and depression. Physical findings of glossitis, cheilitis, and loss of position and vibratory sense are common. The skin is lemon-yellow, which is caused by
a mild increase in bilirubin combined with the pallor of anemia.
Subacute blood loss Although presenting with anemia, subacute blood loss will usually have an evident source, such as black, sticky stools or a history of heavy menses. Bleeding into the thigh or retroperitoneum may not be obvious, but will be accompanied by pain or a palpable mass.
Thalassemia trait Consider in a patient with microcytic anemia and Medi-
terranean ancestry.
Folate deficiency No neurological deficits are present. Folate deficiency is recognized by the setting: dietary (alcohol abuse, no fruits or vegetables), increased metabolic demand (pregnancy, psoriasis, cancer), malabsorption (sprue, phenytoin), and direct antagonism (methotrexate, trimethoprim, triamterene). Sprue is recognized by weight loss, steatorrhea, hyperpigmentation, and circumoral fissuring.
Sickle cell trait Sickle crisis with abdominal pain may first occur with low oxygen tension, such as on an airplane flight. The patient is usually of African descent.
Immune hemolytic anemia Usually drug-related, quinidine, penicillin, or methyldopa are the most common agents. Splenomegaly is a hallmark. Jaundice with dark urine is also present.
Myeloproliferative disease Lymphadenopathy and splenomegaly are important clues. Bone tenderness, especially sternal, suggests marrow expansion in infiltrative diseases such as chronic myelogenous anemia, or lytic lesions in multiple myeloma.
Aplastic anemia Fatigue and bleeding are the initial symptoms. There is no splenomegaly. Chloramphenicol and propylthiouracil are classic causes.
Sideroblastic anemia A preleukemic type occurs in elderly patients. The liver and spleen are palpable in more than 50% of cases. A secondary type is associated with rheumatoid arthritis, polyarteritis, malabsorption, alcoholism, porphyria, lead poisoning, and pyridoxine deficiency.
Read excerpts from these other book chapters related to Fatigue:
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5 
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