2. New anemia: H&P
History
• Fatigue
• Exertional dyspnea,
palpitations, angina,
claudication
• Dizziness/Syncope
• Remember to ask about:
– Ethnicity
– Medications (NSAIDs)
– EtOH use
Physical
• VS/General
– Orthostasis, hypotension,
– Lethargy, dizziness
– Back or leg pain
• Skin:
– Conjunctival rim pallor
– Delayed capillary refill
– Petechiae or purpura
• CV:
– Bounding pulses
– Ejection murmur
– Clinical heart failure
3. New Anemia: Labs (Basic)
What lab What’s normal Who cares
Hgb >12 (F), >13 (M) You do – it’s the topic of this lecture
WBC 3.5-10.5 Increase may indicate MPD
Decrease may indicate bone marrow failure
Platelets 150-450 Decrease may indicate bone marrow failure or
platelet consumption (TTP)
Red Cell Indices
MCV 80-96 fL Identifies microcytic/macrocytic anemia
MCHC 27.5-33.2 pg Decreased when there is less Hgb/cell (IDA,
thalassemia), increased when there is more
Hgb/cell (hemolytic anemia, spherocytosis)
RDW 11.5-14.5 Microcytic/normal RDW: suspect thalassemia
Microcytic/high RDW: suspect IDA
Macrocytic/high RDW: suspect B12/Folate def.
4. My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Check MCV
5. Step 1: the reticulocyte index
• How do I calculate the RI?
– RI = retic count x [Pt Hct/45] x correction factor
– Correction factor is determined by pt Hct
• RI normal (>2): normal production
– Evaluate for occult blood loss
– Evaluate for hemolysis
• RI decreased (<2): impaired production
– Evaluate RBC morphology
6. My approach to anemia
Reticulocyte
Index
RI>2
(normal)
RBC loss
RBC
destruction
RI<2 (low)
Check MCV
7. Step 1b (normal RI): look for blood loss
Other areas: menorrhagia, post-surgical, traumatic, iatrogenic
8. Step 1b (normal RI): workup RBC
destruction
Test Interpretation
LDH Elevated in any hemolysis
Haptoglobin Decreased with intravascular hemolysis
Coombs Positive in any immune-mediated hemolysis
(includes drugs that induce immune-mediated
hemolysis)
Smear
Review
Can reveal microspherocytes (hemolytic
anemia), schistocytes (MAHA)
Soluble transferrin receptor: cleaved extracellular domain whose production varies with iron body stores but is not affected by inflammation. In particular, a ratio of STFR/Ferritin (reflects ratio of iron availability to iron stores) >1 reflects IDA in a patient with ACD