History (1 of 10 slides)

History (2 of 10 slides)

A 26 year-old woman presented to her primary care physician with compaints of increasing fatigue over the past 4 months. She had a complete blood count that showed anemia and iron studies that suggested iron deficiency. She is referred to you for further workup. When you question her, she admits to shortness of breath on exertion, which is new. She was diagnosed with iron deficiency 10 years earlier and was treated at the time with oral iron for about 6 months. She is currently not taking any medications. She does not drink alcohol and has never smoked. You next ask her about other general symptoms of anemia (choose from the list on the next slide).

History (3 of 10 slides)

What symptoms are associated with anemia, regardless of its cause?

Correct. A reduction in hemoglobin in anemia results in a compensatory increase in cardiac output with increased stroke volume and heart rate, both of which may contribute to palpitations.
Decreased exercise tolerance
Correct. The reduced oxygen carrying capacity of blood that occurs in anemia results in reduced oxygen delivery to the tissues, hence reduced exercise capacity.
Yes. The headache is often frontal and throbbing.
Diarrhea is not generally associated with anemia.

History (4 of 10 slides)

Your patient admits to having palpitations on exertion. She is experiencing throbbing headaches, especially in the temporal and frontal regions. She is no longer able to exercise like she used to.

History (5 of 10 slides)

Let’s take a look at symptoms of anemia from a pathophysiological standpoint:

Oxygen delivery = cardiac output x oxygen content of blood

  • Cardiac output (L/min) = stroke volume (ml/beat) x heart rate (beats/min)
  • Oxygen content of blood = Hb (g/dL) x oxygen saturation (%) x 1.34 ml O2/g Hb + (0.0031 x PaO2)
  • (0.0031 x PaO2) is the amount of oxygen dissolved in plasma and is so negligible that we can ignore it

So, now we can rewrite the formula:

Oxygen delivery = [stroke volume x heart rate] x [Hb (g/dL) x oxygen saturation x 1.34 ml O2/g Hb]

In anemia, the hemoglobin is low. That means reduced oxygen content and oxygen delivery to tissues. Low oxygen delivery accounts for the fatigue (and sometimes listlessness, somnolence and chest pain). As a result, the body tries to compensate by improving oxygen saturation, causing shortness of breath on exertion and increasing stroke volume and heart rate, leading to palpitations.

History (7 of 10 slides)

In addition to general symptoms of anemia, there are symptoms that are specific to different causes of anemia. What specific symptoms of iron deficiency anemia would you ask the patient about (next slide)?

History (8 of 10 slides)

Which symptoms are caused by iron deficiency (even in the absence of anemia)?

Headache is reported in about 60% of patients with iron deficiency, but it also occurs as a general feature of anemia.
Restless legs
Correct. Restless leg syndrome is reported in about 25% of patients with iron deficiency anemia. Patients may use wide range of descriptive terms to describe their leg paresthesia, which include crawling, tingling, restless, cramping, creeping, pulling, painful, electric, tension, itching, burning, and prickly.
Pica is the ingestion of non-nutritive material. It is reported in up to 55% of patients with iron deficiency. The patient will rarely volunteer this symptom. It must be specifically asked about. Click on NOTES page below for details of different types of pica.
Hair loss
Yes, all rapidly dividing cells in the body require iron. Hair follicle matrix cells are among the most rapidly dividing cells in the body. Thus, iron deficiency may lead to alopecia.
Brittle nails
All rapidly dividing cells in the body require iron. The nail cuticle is rapidly dividing. Thus, iron deficiency may lead to brittle nails and, at the extreme, spoon-shaped nails (koilonychia). The latter is present in about 5% of patients with iron deficiency anemia.

History (9 of 10 slides)

Your next line of questioning should be:

Family history of iron deficiency
That won’t get you too far in this clinical context.
Source of bleeding
YES! We are suspicious that the patient has iron deficiency anemia. Now we want to question her about symptoms related to underlying causes of iron deficiency. The most common cause is blood loss, especially menstrual blood loss in premenopausal women.
History or symptoms of Celiac disease
Celiac disease is diagnosed in about 10%-15% of patients with symptomatic iron deficiency anemia. So, it is certainly worth asking about.
Previous bariatric surgery
Iron deficiency anemia occurs in more than 30% of patients after 5 years from bariatric surgery.

History (10 of 10 slides)

You ask about a history of symptoms of causes of iron deficiency. In general terms, these include causes associated with increased loss (bood loss), decreased gastroinotestinal absorption or increased demands (for example in patients with multiple pregancies).

Your patient states that her periods are regular but heavier than usual (she uses about 8 tampons on her heavy days). She has no other bleeding symptoms. She has not had stomach bypass surgery. She has never been pregnant.

Now we are ready for the physical exam!