Clinical Workup and Presentation of Anemias

Question 1

What diagnostic tools are used for diagnosing anemia? 8 things

Answer 1

History
Physical
CBC
Blood smear
Reticulocyte count
Direct Coombs
Confirmatory tests

Bone marrow exam if still confused

Question 2

Signs of anemia upon physical exam?

Answer 2

pallor, facial structure, oral mucosa, pale hands, hepatosplenomegaly, lymphadenopathy, telangiesctasia

Question 3

Smooth, shiny, and reddened tongue is classic of which anemia?

Answer 3

iron deficiency

Question 4

What is the normal hemoglobin level for men and women?

Answer 4

men- 14-17.4 g/dL

women- 12.3-15.3 g/dL

Question 5

What is the normal hematocrit level for men and women?

Answer 5

men- 42-50.5

women- 36-45

Question 6

What is the normal red cell count for men and women?

Answer 6

men- 4.5-6 x 10^6/ul

women- 4.5-5.1 x 10^6/ul

Question 7

What is the normal white cell count for men and women?

Answer 7

men- 4.4-11.3 x 10^3/ul

women- same

Question 8

What is the normal MCV for men and women?

Answer 8

both- 80-100 fl

Question 9

What is the normal platelet count for men and women?

Answer 9

150-400 K/ul

Question 10

What is the normal reticulocyte count for men and women?

Answer 10

both-

0.5-2.5% or 22,500-147,500/mm^3

Question 11

Equation for corrected reticulocyte count?

Answer 11

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

Question 12

How can you confirm hemolysis?

Answer 12

LDH (lactate dehydrogenase), indirect bilirubin, plasma free hemoglobin, and urine hemosiderin would be increased

and serum haptoglobin would be decreased

Question 13

When would a bone marrow draw be warranted?

Answer 13

Indications:
-Multiple cell lines affected

• Unresolved hypo-regenerative anemia (i.e. low reticulocytes)
• Abnormal cells in peripheral blood

Question 14

What are the main four causes of anemia?

Answer 14

• decreased production
• increased destruction
• blood loss
• sequestration (in an enlarged spleen)

Question 15

A decreased production anemia could be caused by what?

Answer 15

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.)

Question 16

If reticulocytes are appropriately elevated, what cause of anemia should you think?

Answer 16

increased destruction (immune or non-immune) or blood loss

Question 17

What are some immune causes of increased reticulocyte anemia?

Answer 17

warm or cold AHA. confirm with +DAT

Question 18

What are some non-immune causes of increased reticulocyte anemia?

Answer 18

microangiopathic or non-microangiopathic anemias

Question 19

What does microangiopathic mean?

Answer 19

schistocytes, or fragmented red cells

Question 20

What are some microangiopathic anemias?

Answer 20

DIC, TTP, HUS

prosthetic value

Malignant hypertension

Question 21

What are some non- microangiopathic anemias?

Answer 21

congenital- membrane, enzyme, or hemoglobin

acquired- infection, lead, PNH (identified via family history)

Question 22

So what is the first test you should do if you have an anemic patient?

Answer 22

reticulocyte count. If low, problem is productive. If elevated (as it should be)- problem is due to blood loss or destruction, etc.

Question 23

What tests would you consider if reticulocytes were low?

Answer 23

• 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

Question 24

What tests would you consider if reticulocytes were high?

Answer 24

1) DAT. If +, seek cause. If negative, look if microangiopathic or not
2) test appropriately after this

Question 25

If your cells are macrocytic (MCV is high), how would you go through the differential?

Answer 25

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)

Question 26

If your cells are microcytic (MCV is high), how would you go through the differential?

Answer 26

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

Question 27

What bcc parameter is most helpful in diagnosing iron deficiency?

Answer 27

MCV- should be small.

Question 28

When would reticulocytes be elevated?

Answer 28

hemolytic anemias.

Wouldn’t have enough time in acute GI blood loss but may in chronic GI blood loss