The purpose of this paper is to briefly describe the initial core diagnostic questioning and core set of diagnostic testing related to the patient presenting with anemia. Subjective information and recommended testing are written with consideration of the scope of practice of the family nurse practitioner. In addition, three specific case studies are examined.
Core set of subjective questions
The healthcare provider should initially obtain a history of any previous anemia or blood disorders and records, if possible, providing results of any previous blood tests as these can help determine the duration of the disorder. It will be important to examine any family medical history, particularly questioning about jaundice, cholelithiasis, splenectomy, bleeding disorders, and abnormal blood test results (Maakaron, 2011). Questions regarding occupation, hobbies, prior medical history, medications including over the counter preparations, and household product exposure can help identify possible noxious agents (Maakaron, 2011). Specifically ask questions regarding medical conditions known to cause anemia such as rheumatoid arthritis and renal disease (Schrier, 2012). Questions addressed to medication use should include intake of NSAIDS and corticosteroids as both are associated with anemia due to gastrointestinal damage (Zaiden & Rana, 2012). In addition, some antibiotics are associated with lowered platelet levels (Zaiden & Rana, 2012). Alcohol intake should also be explored. If the patient is female and the healthcare provider is concerned about possible blood loss, specific questions regarding menstrual periods and details regarding previous pregnancies and/or abortions are important to ask. “Estimates of menstrual losses are notoriously inaccurate if only routine inquiry is made” (Maakaron, 2011). Inquiries regarding the color of stools and urine assist in identifying gastrointestinal blood loss, hepatic disease, and/or hemolytic anemia. It is essential to carefully examine the diet and eating habits of any person presenting with anemia. It may be helpful to include a close family member in the discussion as they can often provide more objective information regarding intake. The healthcare provider needs to determine very specifically what nutrients the patient is eating in sufficient amounts and identify potential deficiencies. Specifically question the patient regarding possible intake of substances such as clay or laundry detergent (pica) as these substances interfere with the absorption of iron (Maakaron, 2011). Patients with iron deficiency may frequently chew ice (pagophagia), complain of dysphasia, brittle fingernails, fatigue, and leg cramps (Maakaron, 2011). B12 deficiency may present with complaints of greying hair, burning sensation of the tongue, and a loss of proprioception (Maakaron, 2011). Patients with a folate deficiency may have a sore tongue, cheilosis, and/or steatorrhea (bulky, floating stools often indicate poor absorption) (Maakaron, 2011). Other questions are asked to ascertain if systemic disorders such as infections, neoplasms, or autoimmune conditions are at the root of the anemia. Has the patient had a fever? Has the patient noticed any purpura, easy bruising, or petechiae? A positive answer could indicate thrombocytopenia or another bleeding disorder (Maakaron, 2011). Cold intolerance can occur with hypothyroidism, lupus, and certain macroglobulinemias which are all associated with anemia (Maakaron, 2011). The healthcare providers should be aware that many patients may have anemia without any presenting symptoms. Diagnostic testing
Initial laboratory tests should include a complete blood count (CBC). Due to differences in labs, the healthcare provider should specifically request a CBC with platelets, WBC differential, and reticulocytes (Schrier, 2012). Blood testing may be performed by automated machines and it is important to recognize the limits...