Anemia

Rationale

Anemia is a common condition, often identified incidentally in asymptomatic patients. It can be “benign” or a manifestation of a serious underlying disease. Distinguishing among the many disorders that cause anemia, not all of which are treatable, is an important training problem for third year medical students.

Prerequisites

Basic biochemistry and pathophysiology of the blood and bone marrow.

Specific Learning Objectives

1. Knowledge: Students should be able to describe and define the:
   1. classification of anemias
   2. morphological characteristics, pathophysiology, and relative prevalence of:
      1. iron deficiency and other microcytic anemias (i.e.,
         sideroblastic)
      2. macrocytic anemias
      3. anemia of chronic disease
      4. congenital disorders (sickle cell, thalessemias)
      5. hemolytic anemias
   3. available laboratory tests and normal values
   4. indications, contraindications, complications of blood transfusion
   5. describe steps in a critical pathway for anemia
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including:
      1. constitutional symptoms (fatigue, weight loss)
      2. GI bleeding
      3. abdominal pain
      4. drugs
      5. diet
      6. menstrual history
      7. family history
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including inspection of:
      1. skin
      2. eyes (sclera, conjunctiva, fundi)
      3. mouth
      4. heart
      5. abdomen
      6. rectum
      7. lymph nodes
      8. nervous system
   3. differential diagnosis: Students should be able to generate a list of the most importance and most common causes of anemia, recognizing specific history and physical exam findings that suggest a specific etiology of anemia
   4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
         • hemoglobin & hematocrit
         • red cell indices
         • reticulocyte count
         • iron studies (serum iron, TIBC, ferritin, transferrin)
         • serum B12 & folate
         • haptoglobin
         • LDH
         • Schilling test
         • hemoglobin electrophoresis
   5. communication skills: Students should be able to:
      1. explain the results of an initial evaluation to patients and their families, taking into consideration their knowledge about the condition
      2. counsel with regard to:
         • possible causes
         • appropriate further evaluation to establish the diagnosis of an underlying disease
         • the impact on the family (genetic counseling)
   6. basic procedural skills: Students should be able to perform and interpret:
      1. peripheral blood smear
      2. advanced procedural skills:
         • bone marrow aspiration
   7. management skills: Students should be able to develop an evaluation plan to obtain appropriate diagnostic studies useful in establishing a specific diagnosis including:
      1. GI blood loss
      2. hemolytic anemia
      3. pernicious anemia
      4. chronic disease (renal, thyroid, HIV, malignancy, inflammation)
      5. students should be able to develop a treatment plan for a specific diagnosis including:
         • iron therapy
         • vitamin B12
         • folic acid
         • accessing and utilizing appropriate information systems and resources to help delineate issues related to anemia
3. Attitudes: Students should be able to:
   1. recognize that constitutional symptoms, such as fatigue or malaise, may be caused by depression, rather than any underlying anemia or dietary deficiency