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There's never none of these demure boys come to any proof; for their drink doth so over cool their blood, and making many fish-meals, that they fall into a kind of male green-sickness.

William Shakespeare (1564–1616), King Henry IV


Anaemia is a label, not a specific diagnosis. Anaemia is defined as a reduction in red blood cell numbers or a haemoglobin (Hb) level below the normal reference level for the age and sex of that individual.


The WHO defines anaemia as haemoglobin <130 g/L for men, <120 g/L for women and <110 g/L in pregnant women and school-aged children.

Anaemia: a masquerade

Anaemia is regarded as a masquerade because the problem can develop surreptitiously and the patient may present with many seemingly undifferentiated symptoms before the anaemia is detected. Once identified, a cause must be found.


Key facts and checkpoints

  • In Australia, most people with anaemia will have iron deficiency ranging from up to 5% for children to 20% for menstruating females.1

  • The remainder will mainly have anaemia of chronic disorders.

  • The incidence of haemoglobinopathy traits, especially thalassaemia, is increasing in multicultural Western societies.

  • If a patient presents with precipitation or aggravation of myocardial ischaemia, heart failure or intermittent claudication, consider the possibility of anaemia.

  • The serum ferritin level, which is low in cases of iron-deficiency anaemia, is probably the best test to monitor iron-deficiency anaemia as its level reflects the amount of stored iron.

  • Normal reference values for peripheral blood are presented in Table 22.1.

Table Graphic Jump Location
Table 22.1

Normal reference values for peripheral blood: adults


Diagnostic triad

DxT fatigue + palpitations + exertional dyspnoea ➜ anaemia

++ Clinical features

Patients with anaemia may be asymptomatic. When symptoms develop they are usually nonspecific. Symptoms can include:


  • tiredness/fatigue

  • muscle weakness

  • headache and tinnitus

  • lack of concentration

  • faintness/dizziness

  • dyspnoea on exertion

  • palpitations

  • angina on effort

  • intermittent claudication

  • pica—usually brittle and crunchy food, e.g. ice (iron-deficiency anaemia)

++ Signs

Non-specific signs include pallor, tachycardia, systolic flow murmur and angular cheilosis.


If severe, signs can include ankle oedema and cardiac failure.


Specific signs include jaundice—haemolytic anaemia, and koilonychias (spoon-shaped nails)—iron-deficiency anaemia.

++ History

The history may indicate the nature of the problem:


  • iron deficiency: inadequate diet, pregnancy, GIT loss, menorrhagia, NSAID and anticoagulant ingestion

  • folate deficiency: ...

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