Initial Assessment

1. Is the patient anemic?

  • Hgb < 12 g/dL, Hct < 37% in females, Hgb < 14 g/dL, Hct < 42% in males

2. Is this anemia acute or chronic?

3. Is this dilutional anemia?(hematocrit)

4. What is the size of the RBC? (MCV)

5. Is body appropriately responding? (reticulocyte count)

6. What does the peripheral blood smear show?

MCV < 80

(hypochromic)

 normocytic (normochromic)

low reticulocytes

 normocytic

high reticulocytes

 MCV > 100
Fe deficiency

Anemia of chronic disease (ACD)

 chronic liver disease

thalassemia trait

liver disease

megaloblastic

marrow failure (pancytopenia)

myelodysplasia

leukemia

alcohol

myeloma

hypothyroidism

mets

infection

 blood loss

hemolysis

 lead overload

renal failure (uremia)

B12 lack

sideroblastic

endocrine (thyroid)

folate lack

ACD

hematinic lack

drugs

Microcytic

  • Fe deficiency - ↓ ferritin, ↑ TIBC
    • < 15 confirms, 15 - 25 suggests, 25 - 100 not helpful, > 100 rules out
  • Anemia of chronic disease (ACD)
    • associated with inflammation (RA, infection, carcinoma)
    • ↓ TIBC (Fe not transferred to developing RBCs)
  • Thalassemia
    • target cells, serum electrophoresis (↑ HbgA2)
  • Lead poisoning - ↑ serum Pb
  • Sideroblastic - ↑ in cellular iron uptake
    • ↑ ferritin, ring sideroblasts


Macrocytic

  • megaloblastic anemia - hypersegmented polymorphonucleocytes(PMNs)
  • defects in DNA synthesis that lead to hematologic abnormalities
  • ↓ folate or ↓ vit B12
  • drugs: methotrexate, azathioprine (Imuran - immunosuppressant)
  • myelodysplasia
    • dimorphic smear (micro/macrocytosis)
  • chronic liver disease
    • ↑ GGT, target cells


Normocytic

High reticulocyte

  • Hemolysis
    • hypersplenism, drugs, sepsis, autoimmune
    • cell morphology (from peripheral smear) is crucial: see below
      • ↑ LDH, ↑ bilirubin, ↑ serum Hbg, ↓ haptoglobin (Hgb scavenger), + Coombs

Low reticulocyte

  • bone marrow failure
    • pancytopenia (↓ WBC, ↓ plt)
    • BM aspirate (cell morphology), BM biopsy (structure)

Misc

Red cell distributuion width (RDW)

  • Normal:
    • ACD, thalassemia
  • Increased
    • iron deficiency
    • duel deficiency (fe, folate)
    • pernicious anemia
    • liver disease
    • AIHA

Blood smear

Shape

  • normal: biconcave
  • spherocyte - immune hemolytic anemia
  • schistocytes - MAHA: DIC, vasculitis, prosthetic heart valves, HUS/TTP
  • sickle cell - sickle cell disorders
  • target cell - liver disease, thalassemia, Fe deficiency
  • teardrop cell - myelofibrosis

Distribution

  • rouleaux formation - aggregates of RBC resembling stacks of coins
  • paraprotein (multiple myeloma)

Inclusion

  • nuclei (immature RBC)
    • serious medical disease
    • severe anemia, leukemia, bone marrow metastases
  • Heinz bodies (denatured hemoglobin)
    • G6PD deficiency
  • Howell-Jolly bodies
    • post-splenectomy, hyposplenism
  • basophilic stippling (blue granulations of variable size and number, aggregation of ribosomes)
    • lead intoxication, thalassemia

Other OSCE modules

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