Clinical Workup and Presentation of Anemias Flashcards
What diagnostic tools are used for diagnosing anemia? 8 things
History Physical CBC Blood smear Reticulocyte count Direct Coombs Confirmatory tests
Bone marrow exam if still confused
Signs of anemia upon physical exam?
pallor, facial structure, oral mucosa, pale hands, hepatosplenomegaly, lymphadenopathy, telangiesctasia
Smooth, shiny, and reddened tongue is classic of which anemia?
iron deficiency
What is the normal hemoglobin level for men and women?
men- 14-17.4 g/dL
women- 12.3-15.3 g/dL
What is the normal hematocrit level for men and women?
men- 42-50.5
women- 36-45
What is the normal red cell count for men and women?
men- 4.5-6 x 10^6/ul
women- 4.5-5.1 x 10^6/ul
What is the normal white cell count for men and women?
men- 4.4-11.3 x 10^3/ul
women- same
What is the normal MCV for men and women?
both- 80-100 fl
What is the normal platelet count for men and women?
150-400 K/ul
What is the normal reticulocyte count for men and women?
both-
0.5-2.5% or 22,500-147,500/mm^3
Equation for corrected reticulocyte count?
reticulocyte count% x hct/45 to adjust for anemia to evaluate bone marrow
also need to account for RMT (maturation time)
RPI: Corrected retake count/RMT
less an 1= decreased response
greater than 2= good response
How can you confirm hemolysis?
LDH (lactate dehydrogenase), indirect bilirubin, plasma free hemoglobin, and urine hemosiderin would be increased
and serum haptoglobin would be decreased
When would a bone marrow draw be warranted?
Indications:
-Multiple cell lines affected
- Unresolved hypo-regenerative anemia (i.e. low reticulocytes)
- Abnormal cells in peripheral blood
What are the main four causes of anemia?
- decreased production
- increased destruction
- blood loss
- sequestration (in an enlarged spleen)
A decreased production anemia could be caused by what?
reticulocytes will NOT be elevated
- Nutritional (B12, folate)
- Infection (HIV, bacteria)
- Inflammatory (chronic osteomyelitis)
- Endocrine (hypothyroidism)
- Metabolic
- Toxins that suppress bone marrow
- Bone Marrow Failure
- Infiltration (by tumors, fibrosis, etc.)
If reticulocytes are appropriately elevated, what cause of anemia should you think?
increased destruction (immune or non-immune) or blood loss
What are some immune causes of increased reticulocyte anemia?
warm or cold AHA. confirm with +DAT
What are some non-immune causes of increased reticulocyte anemia?
microangiopathic or non-microangiopathic anemias
What does microangiopathic mean?
schistocytes, or fragmented red cells
What are some microangiopathic anemias?
DIC, TTP, HUS
prosthetic value
Malignant hypertension
What are some non- microangiopathic anemias?
congenital- membrane, enzyme, or hemoglobin
acquired- infection, lead, PNH (identified via family history)
So what is the first test you should do if you have an anemic patient?
reticulocyte count. If low, problem is productive. If elevated (as it should be)- problem is due to blood loss or destruction, etc.
What tests would you consider if reticulocytes were low?
- B12 and folate levels
- ferritin (for iron)
- Spe (serum protein electrophoresis for MM)
- TSH (hypothyroidism)
- LDH (malignancies)
- ESR or CRP for inflammation
if still not clear, might want to consider bone marrow exam
What tests would you consider if reticulocytes were high?
1) DAT. If +, seek cause. If negative, look if microangiopathic or not
2) test appropriately after this
If your cells are macrocytic (MCV is high), how would you go through the differential?
1) reticulocyte count.
2) If high, hemolysis or acute blood loss.
3) If low, check B12/folate.
3a) If B12/folate low, thats the cause. If normal, check TSH (hypothyroidism), ETOH (alcohol intoxication), and do a standard evaluation (liver disease and primary bone marrow disorders)
If your cells are microcytic (MCV is high), how would you go through the differential?
1) check ferritin (b/c iron deficiency is most common cause)
2) If ferritin is low, look for source of blood loss (GI tract)
3) If ferritin is normal, do a hgb electrophoresis.
3a) If abnormal, it may show b-thalassemia or sickle cell
3b) If normal, may have a-thalassemia (will look healthy and have high rbc counts) or if low rbc need to do anemia workup again
What bcc parameter is most helpful in diagnosing iron deficiency?
MCV- should be small.
When would reticulocytes be elevated?
hemolytic anemias.
Wouldn’t have enough time in acute GI blood loss but may in chronic GI blood loss
