APPROACH TO A PATIENT WITH ANEMIA

Anemia Reduction below normal in the concentration of hemoglobin or RBC’s in the blood Anemia is not a diagnosis in itself, but merely an objective sign of disease.

Signs and symptoms depend on Severity of the anemia Onset Patient’s age and compensation mechanisms Associated disorder/s

History Questions to address HPI Onset (date,age) and duration of symptoms, symptoms of hemolysis or blood loss, fever or weight loss, co-existing disease Past Medical History Previous anemia, renal disease, infections, ileal surgery Family History Anemia in the family, jaundice, gallstones OB-Gyne History Menarche, Menstrual Cycle (Duration, # of pads used), # of pregnancies/ abbortions (bleeding) Personal History Diet, Occupation, Medications, Recent travel Others Gender, race/ethnicity Hemolysis: jaundice, changes in urine color Blood loss: hematochezia, melena, epigastric pain Existing disease: renal or any chronic disease Recent travel: acquisition of schistosomiasis Gender: X-linked disorders Race/ ethnicity: genetic predisposition

Physical Examination Vital Signs BP Hypotension, presence of orthostatic hypotension PR Tachycardia, pulse may be weak or strong RR Tachypnea Temp Cold extremities/ skin

Physical Examination/ ROS System Manifestation Integumentary Skin pallor, pale conjunctivae, lack-luster hair, brittle/ spooning of nails, purpura Cardiac Heart murmurs, palpitations, cardiomegaly Respiratory Dyspnea or shortness of breath GI Glossitis, atrophy of the papillae of the tongue, dysphagia, oral ulcers, gingival hyperplasia, hepatosplenomegaly , sternal tenderness GU Slight proteinuria, changes in urine color Neurologic Headache, vertigo, tinnitus, faintness, retinal hemorrhage, paresthesias, scotomas, lack of mental concentration, drowsiness, restlessness, pica Heart murmurs: hemic murmurs (mid or holosystolic often in the pulmonic or apical area, due to increased blood flow and turbulence), gallop rhythms Pallor: <8 to 10 mg/dL hemoglobin

Laboratory Tests Tests Parameters Red blood cell count Count, Hgb, Hct, reticulocyte count, RBC indices White blood cell count Differential count, nuclear segmentation of neutrophils Platelet count Peripheral smear morphology Check for size and morphology Iron studies Serum iron, serum ferritin, TIBC Bone marrow examination Others Vitamin B12 and Folate Assays, Coombs test, Hemoglobin assays, Occult Blood test, Endoscopy (if indicated for bleeding)

Normal Blood Count Normal Values Hb M: 135-175 g/L F: 129-160g/L RBC M: 4.5-6.5 x 1012 L F: 3.9-5.6 x 1012L Hct M: .40 - .52 F: .36-.48 MCV 80-95 fl MCH 26-34 pg MCHC 30-35 g/dL Reticulocytes 0.5-20% WBC Total: 4.0-11.0 x 109/L Neutro 2.5 – 7.5 x 109/L Lympho 1.5- 3.5 x x109/L Mono 0.2-0.8 x 109/L Eosino 0.04-0.44 x 109/L Baso 0.01 – 0.1 x 109/L Platelets 150-400 x 109/L

RBC Indices Index Normal Value Mean Cell Volume(MCV) = (hematocrit x 10)/(red cell ct. x 106) 90 + 8 fL Mean Cell Hemoglobin (MCH) =(hemoglobin x 10)/ (red cell ct. x 106 30 + 3 pg Mean Cell Hemoglobin Concentration: =(hemoglobin x 10)/ hematocrit or MCH/MCV 33 + 2%

Reticulocyte Count NV: 5 – 15 x 10-3 (SI) Correction: Patient’s Hct x Reticulocyte count % = corrected 45 reticulocyte Corrected Reticulocyte = RPI 2 Measure of bone marrow compensation for anemia

Normal Peripheral Blood Smear

Normal BM Histology LPO HPO

Algorithm for Anemia

Iron studies Parameter tested Significance Serum iron amount of circulating iron bound to transferrin Total iron binding capacity indirect measurement of bound transferrin Serum ferritin estimate of iron stores

Stages of Iron Deficiency Normal Negative iron balance Iron deficient erythropoiesis Iron deficiency anemia Marrow iron stores 1–3+ 0-1+ Serum ferritin (ug/L) 50- 200 <20 <15 TIBC (ug/dL) 300-360 >360 >380 >400 SI (ug/dL) 50-150 NL <50 <30 Saturation (%) 30-50 <10 Marrow sideroblasts (%) 40-60 RBC morphology Microcytic hypochromic

Classification of Anemias Based on Etiology Increased Blood Loss Acute and Chronic Hemorrhage Excessive Blood Destruction (Hemolytic Anemia) A. Congenital 1. Red Cell Morphologic Defects (e.g. Congenital Spherocytosis) 2. Hemoglobinopathies (e.g. Thalassemias) 3. Enzyme Defects (e.g. G6PD Deficiency)

Classification of Anemias Based on Etiology B. Acquired 1. Immune Disorders (e.g. LE) 2. Non-Immune Disorder (e.g. Infections, Allergy, etc.) Marrow production defects a. Hematinic deficiencies – iron, Vit. B12, Folic Acid b. Infiltrative Diseases – Leukemias, lymphomas, Cancer c. Aplasia d. Miscellaneous – Endocrine, Renal, Infections

Classification of Anemisa based on RBC size Microcytic (<80fl) - IDA, Pb poisoning, Thalassemia syndromes, Chronic Disease, Sideroblastic Anemia Macrocytic (>100fl) - Vit B12 and Folic acid deficiency, aplastic anemia, liver disease, hypothyroidism Normocytic - Hemolytic anemias, acute blood loss, splenic pooling, chronic renal disease

Treatment Depends on the etiology

Table IDA vs Megaloblastic Anemia Hct Hgb MCV MCH MCHC Neutro Peripheral Smear IDA ↓ N Hypochromic, microcytic with anicystosis and pikilocytosis Megaloblastic Anemia ↑ ↓ with hyper segmentation Macrocytic JAY PACHECK NALANG, DI KO SURE TOH EH Serum Fe Ferritin TIBC RBC Count RPI Ret count IDA ↓ ↑ N Megaloblastic Anemia