METHODICAL RECOMMENDATIONS

for independent work of the students

Topic: The main syndromes of anemia.

I. Importance of the topic. Hematopoietic diseases are very common in Ukraine and in
the world as a whole. These diseases are faced by doctors of various specialties: physicians,
surgeons, pediatricians and etc in their daily work. Anemia is the most common pathology of
the hematopoietic system. According to the WHO, anemia affects about 24.8% of the world's
population, of different ages and social groups. Anemia is caused by various reasons and has
symptoms which are resembling the pathology of other organs and systems. Taking into
account the vast majority of cases are diagnosed on the basis of laboratory tests, knowledge of
the diagnostic algorithm is relevant for doctors.

ІІ. Educational goals:

Know:
- Risk factors for anemia;
- Etiology and pathogenesis of anemia;
- Classification of anemias by etiology, laboratory changes and severity;
- The main clinical manifestations (symptoms) of anemia;
- The main syndromes in anemia;
- Laboratory diagnostic criteria for anemia;
- Additional instrumental research methods for anemia;
- Algorithm for diagnosing anemia.

Be able to:
- Conduct an interview (collection of medical history and life) and examination of the
patient;
- Analyze the data obtained during the survey, objective and laboratory examination of
the patient;
- Interpret the data of the general analysis of blood, biochemical research;
- Explain the causes of symptoms of anemia;
- Add the identified symptoms into syndromes;
- Make a plan for additional examination of patients with suspected anemia.

III. Basic level of training

№п / Names of Acquired skills

п previous
disciplines Know Be able to
1. Medical Know the basics of medical Apply moral and deontological
deontology ethics and deontology principles of a medical
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 specialist while communicating
with a patient
2. Normal anatomy Know the structure of Assess the anatomical structure
hematopoietic organs (liver, of hematopoietic organs.
spleen, bone marrow), their
blood supply and innervation,
and also
their topography.
3. Histology Cellular structure of
hematopoietic organs: liver,
spleen, bone marrow;
morphological characteristics of
erythron cells of different classes
and mature erythrocytes, normal
and in different types of anemia.
4. Human Know about the metabolism of Assess changes in laboratory
biochemistry iron and vitamin B₁₂, their role data
in hematopoiesis and non-
hematopoietic functions; know
the stages of hemoglobin
synthesis, and also the stages of
its degradation and bilirubin
metabolism.
5. Normal Know the neuroendocrine Assess the main physiological
physiology mechanisms of regulation of characteristics of the
hematopoiesis. hematopoietic organs
6. Pathological Know the etiopathogenetic Assess the main
physiology classification of anemia, and also pathophysiological
classification by morphological mechanisms and compensatory
characteristics of erythrocytes reactions in anemia.
and bone marrow regenerative
capacity;
7. Care for patients Know the features of care for Carry out basic measures for
patients with hematological the care of patients with
profile. hematological profile
8. Latin and Latin terminology. Use Latin medical terminology
medical to describe symptoms of anemia
terminology

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 IV. Contents of the lesson topic.

The list of the basic terms, parameters, characteristics which the student have to know
at preparation for lesson:

Term Definition
Anaemia - a condition in which there is a decrease in the number of
erythrocytes and hemoglobin per unit volume of blood
Facies puppe ceratae - "face of a wax doll" - slightly puffy, sharply pale with a yellowish
tinge on the face of a patient with Addison-Biermer`s anemia
Facies anemica - pale, "anemic" face of a patient with anemia
Erythrocytopenia - decrease in the number of erythrocytes per unit volume of blood
Anisocytosis - anisocytosis, erythrocytes of various sizes
Poikilocytosis - poikilocytosis, erythrocytes of various shapes
Macrocytosis - macrocytosis, an increase in the number of immature, large
erythrocytes in the peripheral blood
Microcytosis - microcytosis, an increase in the number of small erythrocytes in
the peripheral blood
Megalocytosis - megalocytosis, the appearance in the peripheral blood of immature
erythrocytes-megaloblasts
Hypochromaemia - hypochromia, decreased color index
Hyperchromaemia - hyperchromia, increase in color
MCV - mean corpuscular - the average volume of erythrocytes
volume
MCH - mean corpuscular - average hemoglobin content
hemoglobin
MCHC - mean - average hemoglobin concentration
corpuscular hemoglobin
concentration

Anemia is a pathological condition characterized by a decrease in hemoglobin and the

number of erythrocytes per unit volume of blood due to their absolute reduction in the body
and a decrease in oxygen supply to tissues. The World Health Organization (WHO) defines
anemia as a hemoglobin level below 130 g/l and erythrocytes less than 4 × 10 12/l in men and
less than 120 g/l and 3.5 × 1012/l in women.

Risk factors for anemia:

The primary risk factors are:
I. Belonging to a group of people who are characterized by iron deficiency:
• pregnant (due to increased blood volume);
• women of childbearing age (due to blood loss with menstruation);
• pregnant women and mothers under 18 years of age;
• women who gave birth 3 or more times, or with an interval between births less than a
year.

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 II. Conditions in which iron absorption decreases: intestinal pathology; conditions
after surgery on the stomach and intestines, including bariatric; peptic ulcer; H. pylori
infection; Whipple's disease; diarrhea.
III. Conditions that increase blood loss: heavy menstrual bleeding, donation,
inflammatory bowel disease, colon cancer, colorectal adenoma, worm infestations, erosive
gastritis, paroxysmal nocturnal hemoglobinuria, use of drugs that increase the risk of
gastrointestinal anti-inflammatory drugs.
IV. Toxic exogenous effects (chemical, physical, radiation factors), medication and
long-term use of antacids, H2-histamine receptor blockers, proton pump inhibitors,
nonsteroidal anti-inflammatory drugs, including acetylsalicylic acid, zinc preparations
hemodialysis);

Secondary risk factors include:

• low socio-economic status;
• donation (more than two annual blood donations for women and more than three annual
blood donations for men);
• postpartum period;
• vegetarianism.

Etiology of anemia:
• decrease in erythrocytes production;
• increasing the destruction of erythrocytes;
• loss of erythrocytes due to blood loss.

Classification of anemias

Classification of anemias by etiological factor:

I. Anemia due to blood loss (posthemorrhagic):
• acute posthemorrhagic anemia;
• chronic posthemorrhagic anemia.

ІІ. Anemia due to impaired hematopoiesis:

• iron deficiency anemia;
• B12-folate deficiency anemia;
• hypo- and aplastic anemias arising from the action on the bone marrow of
exogenous factors (physical, chemical, drug) or endogenous aplasia of the bone
marrow;
• metaplastic anemias that develop due to metaplasia (displacement) of the bone
marrow in hemoblastosis (leukemia) or cancer metastases to the bone marrow.

III. Anemia due to increased hemorrhage (hemolytic):

• congenital hemolytic anemias;
• acquired hemolytic anemia.

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 Classification by cell size (MCV):
• normocytic (average cell volume 80–100 fl);
• microcytic (average cell volume <80 fl);
• macrocytic (average cell volume> 100 fl).

Classification by hemoglobin content (or hemoglobin content in erythrocytes MCH):

• normochromic (color index 0.8–1.05; MCH 27-31);
• hypochromic (color index <0.8; MCH less than 27);
• hyperchromic (color index> 1.05; MCH more than 31).

Classification by type of hematopoiesis:

• normoblastic;
• megaloblastic;
• aplastic.

Classification by severity (decrease in hemoglobin concentration):

• light (women 110-119 g/l, men 110-129 g/l)
• average (female and male patient 80-109 g/l)
• heavy (female and male patient <80 g/l)

The clinical features are mainly due to the etiological factors of anemia which explains
the difference in the frequency of symptoms of anemia in different patients and forms in each
of them an individual palette of symptoms which the doctor later combines into syndromes.
When questioning a patient, it is important to collect the anamnesis correctly!

While collecting a medical history and life attention had to be paid to:
- the presence of ground or unchanged blood in the stool;
- distorted taste (tendency to consume inedible items);
- women are asked about information about the nature of menstruation (cyclicity,
duration, course) and pregnancy history;
- while collecting a medical history, information on drugs the patient had been receiving
(antacids, H2-histamine receptor blockers, proton pump inhibitors, long-term use of
nonsteroidal anti-inflammatory drugs, long-term use of acetylsalicylic acid, zinc or magnesium
drugs) is clarified;
- while collecting a life history, information about the presence of inflammatory bowel
disease in the past is specified; celiac disease; undergone operations on the stomach and
intestines; family history of coagulation disorders and colon cancer;
- about the peculiarities of the diet;
- social status;
- possible harmful factors in the workplace or at the place of residence.

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 The main clinical syndromes in anemia

• Circulatory-hypoxic;
• Anemic syndrome;
• Sideropenic syndrome;
• Funicular myelosis;
• Hemolysis syndrome;
• Anemic heart syndrome.

Circulatory-hypoxic syndrome.

Circulatory-hypoxic syndrome is the general reaction of an organism arising at

insufficient supply of tissue with oxygen against decrease in hemoglobin.

Clinical manifestations
• Weakness, fatigue, drowsiness
• Decreased efficiency
• Dizziness, tinnitus
• Increased sensitivity to cold
• Flickering flies in front of the eyes
• Palpitation
• Dyspnea
• Pale skin and visible mucous membranes

Anemic syndrome

Anemic syndrome is a hematological syndrome, the manifestation of which is a

decrease in hemoglobin and/or erythrocytes in the blood.

Reasons:
• Posthemorrhagic anemia;
• Anemia due to erythropoiesis disorders;
• Hemolytic anemias;
• Mixed anemia.

Laboratory diagnostics:
• Decreased hemoglobin and/or erythrocytes;
• Possible changes in erythrocyte volume, hemoglobin content in the erythrocyte:
decrease in MCV and MCH, or increase in MCV and MCH

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Microcytic/hypochromic
MCV <80fl
MCH <27 pg
MCNS <320 g / l
RDW rate or increased
Decreased hemoglobin (Hb)
Macrocytic/normo- or
Normocytic/normochromic
hyperchromic
MCV, MCH, MCHC, RDW MCV> 100fl
MCH> 32 pg
Usually within normal limits MCNS> 370 g / l
RDW increased

Calculation of erythrocyte indices in the absence of a hemanalyst

In the absence of a hematology analyzer, these indices can be calculated using
hemoglobin (Hb), erythrocytes (RBC) and hematocrit (Hct).

Erythrocyte indices include: mean erythrocyte volume (MCV), mean erythrocyte

hemoglobin (MCH), and mean erythrocyte hemoglobin concentration (MCHC).

MCV calculation formula:

where: Hct - hematocrit, expressed as a decimal fraction to the nearest hundredth; RBC -
the number of erythrocytes in 1 liter; MCV is the average erythrocyte volume expressed in
femtoliters (1 fl = 1015 l).

MCH calculation formula:

MCHC calculation formula:

The formula for calculating the color index:

3×𝐻𝑏 𝑔 ⁄𝑙
CP = 𝑡ℎ𝑒 𝑓𝑖𝑟𝑠𝑡 𝑡ℎ𝑟𝑒𝑒 𝑛𝑢𝑚𝑏𝑒𝑟𝑠 𝑜𝑓 𝑡ℎ𝑒 𝑐𝑜𝑛𝑡𝑒𝑛𝑡 𝑜𝑓 𝑒𝑟𝑦𝑡ℎ𝑟𝑜𝑐𝑦𝑡𝑒𝑠

Sideropenic syndrome

Sideropenic syndrome occurs in violation of iron-containing enzymes and proteins, due

to tissue iron deficiency.

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 Clinical manifestations:
• Pica chlorotica:
- Passion for unusual odors (gasoline, acetone, gutalin, varnishes, paints)
- Distortion of taste: an irresistible desire to eat unusual, inedible things (chalk, tooth
powder, coal, clay, sand)
• angular stomatitis ("bumps") - cracks in the corners of the mouth
• Glossitis, burning of the tongue, dysphagia due to atrophic changes of the mucous
membrane of the gastrointestinal tract.
• Feeling of heaviness, a foreign body in the pharynx - Plummer - Vinson syndrome
• Dryness and peeling of the skin
• Pale skin with "alabaster" or greenish tint and "blue" sclera (symptom of blue sclera)
• Transverse striation of nails, koilonihiya (spoon-shaped nails)
• Hair fragility, early graying of hair

Laboratory diagnostics:
• Decrease in serum iron content (N - 10,6-28,3 μmol/l)
• Reduction of ferritin (N - 11,0-306,8 ng/ml)
• Reduction in the percentage of transferrin saturation with iron (serum iron / transferrin *
100%) <16% (N - more than 20%)
• Increasing the total iron-binding capacity (N - 44,7-76,1 μmol/l)

NB! Ferritin is the most specific and sensitive indicator of iron stores in the body!

Funicular myelosis

Funicular myelosis are degenerative changes of the spinal cords, which occur due to a
lack of vitamin B12, which leads to demyelination of nerve fibers and destruction of CNS
structures.

Reasons:
• Impaired intake of vitamin B12 in the body
• Impaired absorption of Vitamin B12

Clinical manifestations:
• Numbness of the fingers of the lower extremities
• Feeling of ants crawling, tingling
• Postural instability
• Shaky walking
• Decreased physiological reflexes
• Visual acuity disorders
• Enuresis
• Mental disorders: irritability or apathy, depression

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 • Manifestations of circulatory-hypoxic syndrome

Laboratory tests:
• Decreased hemoglobin and red blood cell count;
• Erythrocyte hyperchromia (CP 1.7–1.8);
• Appearance of cells of pathological regeneration (megalocytes and megaloblasts);
• Occurrence of degenerative forms of erythrocytes - anisocytosis (macrocytosis),
Poikilocytosis (ovalocytosis);
• The presence of pathological inclusions (Jolly bodies, Kebot rings).
• Reduction of regenerative forms of erythrocytes (reticulocytes, polychromatophiles);

Change in blood biochemical parameters:

• Hyperbilirubinemia due to indirect fraction due to intraosseous destruction of
erythrocytes;
• Reduction of serum folate (in folate deficiency anemia)

Hemolysis syndrome
Hemolysis syndrome - is the increased destruction of erythrocytes due to the influence
of various factors.

Reasons:
 Hereditary
• membranopathy (structural disorders) of erythrocytes: spherocytosis
• enzymopathy (enzyme deficiency)
• hemoglobinopathies: sickle cell anemia, thalassemia.
 Purchased
• autoimmune
• infections
• mechanical damage to erythrocytes (prosthetic heart valves)
• toxic (drugs, hemolytic poisons)

Types of hemolysis:
• Intravascular: presence of mechanical valves, ICE syndrome, glucose-6-phosphate
dehydrogenase (G6FD) deficiency, incompatible blood transfusion, paroxysmal nocturnal
hemoglobinuria, thrombotic thrombocytopenic purpura
• Extravascular (intracellular): hereditary spherocytosis, autoimmune hemolytic anemia,
thalassemia.

Clinical manifestations
o General:
• Yellowing of the skin and sclera (color - lemon - yellow)
• Fever, chills
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 • Muscle pain of different localization
• Pain and heaviness in the abdomen, mainly on the left side
• Manifestations of circulatory-hypoxic syndrome
o Intracellular hemolysis:
• Splenomegaly, hepatomegaly
o Intravascular hemolysis:
• Fever, kidney pain, black urine (hemoglobinuria)

Laboratory data
• Decreased hemoglobin, erythrocytes
• Normochromia
• Reticulocytosis
• Hyperbilirubinemia due to indirect bilirubin
• Increased LDH activity
• Increase in the number of erythroblasts and normoblasts in the bone marrow
• At hemolysis - hemoglobinemia, hemoglobinuria, urgobilinogenuria
• Coombs' positive reaction

Anemic heart syndrome

Anemic heart syndrome is structural and functional changes of the heart due to
hypoxia in chronic anemia.

Clinical manifestations
• Shortness of breath at low load
• Cardialgia
• Palpitations, tachycardia
• Swelling of the lower extremities
• Systolic murmur on auscultation, mainly at the apex

Laboratory data
• Manifestations of anemic syndrome
Instrumental data
• ECHO-cardiography: high cardiac output, possible expansion of the heart cavities
•
Clinical blood test
Parameter Norm Units
Hemoglobin: Men 130-170
g/l
Women 120-160
Erythrocytes: Men 4-5
Women 3.9-5.0 x 1012/l
Hematocrit 39-49 %
MCV 80-100 fl

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 MCH 27-31 pg
Leukocytes 4-9 x109/l
Platelets 180-400 x109/l
Segmental neutrophils 40-78 %
Neutrophils are rod-shaped 0-6 %
Lymphocytes 19-37 %
Eosinophils 0.5-5 %
Basophils 0-1 %
Monocytes 3-11 %
Erythrocyte Sedimentation Rate 0-20 mm/h

Biochemical blood analysis

Parameter Norm Units
Iron 10.6-28.3 μmol/l
Ferritin 11.0-306.8 ng/ml
Total iron binding capacity 44.7-76.1 μmol/l
Total bilirubin 3-21 μmol/l
LDH 0-248 U/l

Additional instrumental research methods for anemia

• Puncture biopsy - lifelong study of the morphological structure of the bone marrow, lymph
nodes, spleen. It is appropriate to study the cell composition of the bone marrow in all
anemias, except iron deficiency;
• Fibrogastroduodenoscopy - is a mandatory study in patients with iron deficiency anemia,
to exclude the diagnosis of celiac disease. It also allows to detect structural changes in the
gastrointestinal mucosa, atrophic processes, ulcerative lesions of the mucous membrane,
which can lead to malabsorption and chronic blood loss;
• Rectoromanoscopy - allows you to detect ulcerative-dystrophic changes of the lower
gastrointestinal tract, as well as hemorrhoids, which can cause chronic blood loss;
• Ultrasound abdominal organs allows non-invasive detection of enlargement and structural
changes in the liver, spleen and lymph nodes;
• EchoCG allows you to detect structural and functional changes in the heart in patients with
anemia.

Algorithm of primary examination of a patient with suspected anemia

Patient with risk factors

Collection of complaints, anamnesis (disease, medication, life), physical

examination

Simple blood test: hemoglobin, erythrocytes, hematocrit, erythrocyte indices

(MCV, MCH, MCHC), leukocytes, leukogram, platelets, erythrocyte
sedimentation rate 12
 Anemia

Differential diagnosis of anemia

Microcytic anemia Normocytic anemia (MVC 80- Macrocytic anemia

(MCV <80 fl) 100 fl) (MVC> 100 fl)

Determination of ferritin Reticulocytes Megaloblasts

<15 μg/L <2% > 2%

15-30 mcg/L 30-100 mcg/L Yes No
Hypoproliferative Hyperproliferative

Diagnosis: IDA Hemorrhagic

Aplastic anemia Vitamin B12 Liver disease
Anemia of anemia Hemolytic folate deficiency Myelodysplastic
The diagnosis of IDA is not excluded. chronic diseases anemia anemia syndrome
Blood smear microscopy and Renal failure
determination of C-reactive protein

Assessment for the presence of an inflammatory or chronic process.

Conducting additional examination depending on the clinical situation.
Consider consulting a hematologist

MCV - average volume of erythrocytes; MCH - average hemoglobin content in the

erythrocyte; MCHC - the average concentration of hemoglobin in the erythrocyte mass, not in
whole blood; IDA - iron deficiency anemia.

V. Questions:

1. What risk factors should be considered when examining a patient with anemia?
2. What are the main etiological factors in the development of anemia?
3. What does the term "anemia" mean?
4. What classifications of anemia do you know?
5. What are the clinical symptoms of anemia?
6. What are the main symptoms of sideropenic syndrome?
7. Describe the anemic syndrome.
8. What are the main causes and manifestations of funicular myelosis?
9. List the changes in the simple blood test and in the biochemical blood test when anemic
syndrome.
10. What are the main diagnostic criteria for sideropenic syndrome?
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 11. What are the main laboratory indicators of iron metabolism disorders in the body?
12. Give a general clinical and laboratory characteristics of hemolytic anemia and highlight
the differences in the clinical picture patients with intravascular and intracellular types of
hemolysis.
13. What are the indications for clinical blood test and rules of patient preparation?
14. What is the diagnostic value of changes in basic blood parameters?
15. Describe the definitions: anisocytosis, anisochromia, poikilocytosis.
16. The essence of direct and indirect tests of Coombs.

VI. Practical work (tasks) performed in class:

1. Repeat the material in textbooks on physiology, patient care, Latin.
2. Get acquainted with the materials of the textbook, lectures, methodological development on
this topic.
3. Make a list (including in Latin) of the main terms, parameters, characteristics that need to be
learned in preparation for the lesson.
4. Answer control questions, test tasks and situational tasks.
5. Interviewing, history taking and general examination of patients with symptoms of anemic,
sideropenic, circulatory-hypoxic syndromes, as well as signs of gastrointestinal damage,
neurological manifestations.
6. Understand clinical problems and substantiate the algorithm for compiling clinical symptoms
into syndromes.
7. Interpret the data of simple blood test, biochemical blood test (including indicators of iron
metabolism, bilirubin metabolism).
8. Summarize all the results of objective and additional examination of the patient.

VII. Materials for self-control:

Situational task 1
Patient T., 78 years old, is preparing for surgery for atrophic ulcers of the lower
extremities. He has been suffering from type II diabetes mellitus for many years. A clinical
blood test was obtained.

Indicator Result
Hemoglobin (Hb) 84 g/l
Erythrocytes 3.00 T/l
Hematocrit (Ht) 25.8%
Mean erythrocyte volume (MCV) 86.0 fl.
The mean content of hemoglobin in the erythrocyte (MCH) 28.0 pg.
The mean concentration of hemoglobin in the erythrocyte (MCHC) 326 g/l
Erythrocyte distribution width (RWD) 14.3%
Reticulocytes 0.3%
ESR 63 mm/hour
Platelets 334 G/l

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 Platelet 0.22%
Leukocytes: 6.3 G/l
Basophils 0%
Eosinophils 3%
Neutrophils are rod-shaped 0%
Segmental neutrophils 68%
Lymphocytes 24%
Monocytes 5%
Plasma cells 0%
Atypical mononuclear cells 0%
Morphology of erythrocytes Without features

Question:
1. Evaluate changes in the general blood analysis.
2. Calculate the color index.
3. What do you think about the change in the general blood test?

Answer standard: The patient has the normocytic normochromic anemia of average
degree of severity according to the general blood analysis. Color index = 3*Hb/erythrocytes
(first three digits) = 3 * 84/300 = 0.84
The cause of anemia can be a chronic disease, namely diabetes.

VIII. Literature
sources: Main literature:
1. Propaedeutics of internal medicine: textbook. Kovaleva O.M., Safargalina - Kornilova
N.A. - K.: VSV "Medicine", 2010. - 720 p.
2. Propaedeutics of internal medicine: textbook. O.I. Decik, O.G. Yavorsky, R.Ya. Dutka
and others; for order. prof. O.G. Yavorsky. 3rd ed., Corrected. and add. – К.: ВСВ «
Medicine», 2013. - 552 с. + 12s. color. ill.
3. Propaedeutics of internal diseases/Detsyk Y.I., Neiko S.M., Pirig L.A. and others. For
order. Y.I. Detsyka. - K.: Health, 2000.
4. Dzyak G.V., Netyazhenko V.Z., Khomazyuk T.A. etc. Basics of examination of the
patient and the scheme of medical history (reference book). - Dnipropetrovsk. - Art press,
2002
5. Dzyak G.V., Khomazyuk T.A., Netyazhenko V.Z. Fundamentals of diagnostics of
internal diseases (reference book). – D-nsk, DSEA publishing house, 2001.
6. Recommendations of the Association of Cardiologists of Ukraine for the diagnosis and
treatment of chronic heart failure (2017)
7. Dzyak G.V., Drynovets J., Vasilieva L.I., Khanyukov A.A. Circulatory insufficiency.-
Methodical manual.-Dnepropetrovsk, DGMA publishing house, 1999.

Additional:
1. Fundamentals of internal medicine: propaedeutics of internal diseases + 2 CD / edited by
Professor O.G. Yavorsky. - Kyiv: Health, 2004. - 500 s.
2. Textbook "Propaedeutics of internal diseases in questions and answers" in Ukrainian
(278 pages) and Russian (301 pages) languages (authors O.G. Yavorsky, L.V. Yushchik).
Kyiv: Health. – 2003

15
3. Propaedeutics of internal diseases - ed. V.H. Vasilenko, A.L. Grebeneva. - M.: 2001 - 592p.

16
4. Propaedeutics of internal diseases with care for patients/For general. ed. Yepishina A.V. -
Ternopil: Ukrmedkniga 2001 5. Shklyar B.S., Diagnosis of internal diseases, - K.: Higher
school, 1972.
5. Strugynsky A.V., Baranov A.P., Roitberg G.E., Gaponenkov Yu.P. Fundamentals of
semiotics of diseases of internal organs. Atlas. - M., 1997.
6. Gubergritz A.Ya. Direct research of a patient, - M.: Medicine, 1972.
7. Encyclopedia of clinical examination of the patient: Per. with English - M.: GEOTAR
MEDICINA 1998.
8. Methods of examination of therapeutic patients: textbook. allowance / C.M. Andreychin,
Н.А. Bilkevich, T.Yu. Monk. - Ternopil: TSMU, 2015. - 260 p.

IX. Student self-preparation program on the topic:

Learn:
 Etiology, pathogenesis of anemia;
 Subjective symptoms of anemia;
 Objective symptoms of anemia;
 Features of examination of patients with anemia, methods of palpation of lymph nodes;
 Values of laboratory parameters that are important in the diagnosis of anemia.

Be able to:
1. Interviewing of the patient (collection of complaints and medical history) to identify
symptoms that make up the clinical picture of anemia;
2. Conduct a general examination of the patient to identify the symptoms that make up the
clinical picture of anemia;
3. Palpate the lymph nodes;
4. Evaluate the data of clinical blood tests, identify signs of anemia;
5. Justify the presence of the patient's set of symptoms of red blood diseases.

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