1. APPROACH TO A PATIENT WITH ANEMIA

2. 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.

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

4. 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

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

6. 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

7. 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)

8. Normal Blood Count Normal Values Hb M: 135-175 g/L F: 129-160g/L RBC
M: x 1012 L F: x 1012L
Hct
M: F:
MCV
80-95 fl
MCH
26-34 pg
MCHC
30-35 g/dL
Reticulocytes
0.5-20%
WBC
Total: x 109/L
Neutro – 7.5 x 109/L
Lympho x x109/L
Mono x 109/L
Eosino x 109/L
Baso – 0.1 x 109/L
Platelets
x 109/L

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

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

11. Normal Peripheral Blood Smear

12. Normal BM Histology
LPO
HPO

13. Algorithm for Anemia

14. 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

15. 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)
<20
<15
TIBC (ug/dL)
>360
>380
>400
SI (ug/dL)
50-150 NL
<50
<30
Saturation (%)
30-50
<10
Marrow sideroblasts (%)
40-60
RBC morphology
Microcytic hypochromic

16. 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)

17. 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

18. 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

19. Treatment
Depends on the etiology

20. 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