3. Hematological
CBC: Hb, Hct, RBC, WBC and diff,
plts, retic count
MCV: useful <80, 80-100, >100
MCH: not useful
MCHC g/dl if high suggests
hereditary spherocytosis
RDW: helpful in ddx of iron
deficiency vs thalassemia minor
11. DDX of Microcytosis
Iron deficiency anemia Familial telangiectasia (OWR)
idiopathic pulmonary
hemosiderosis, PNH
- thalassemia No simple test, trial of iron therapy
- thalassemia Thal minor - elevated Hb A2 if not
iron deficient
Anemia of chronic disease MCV 75-82; inadequate
erythropoietin response
Hb CC African-American, splenomegaly,
mild anemia MCV 65, many target
cells
Hb EE Southeast Asian, no anemia or
minimal anemia. MCV 65 many
target cells
14. Lab Test for DDx of Common Microcytic Hypochromic Anemias
Iron
Deficiency
Thalassemia
Minor
Chronic
Disease
Scrum Iron N or
TIBC N or N or
% Iron
Saturation
(< 10%) N or
Serum Feritin
FEP N
15. Important points in iron therapy
Determine the underlying cause
Ferrous sulfate orally, parenteral
iron IV or IM rarely
Start with one tablet (300 mg-60mg
Fe) daily then bid until Hgb
normalizes
Then reduce to one tablet daily for a
year to replete iron stores
Grey/black iron stools vs tarry
stools
Avoid tea with iron, encourage
16. Normocytic anemia with a normal or
reduced retic count
Anemia of chronic disease (reutilization
defect)
Megaloblastic anemia with thalassemia or
iron deficiency
Hypoendocrine states
Chronic renal failure
AIDS
Bone marrow infiltration
Myelodysplastic syndromes
34. MCV > 115 fl DDX Folate or B12 Deficiency
Folic Acid
Deficiency
B12 Deficiency
Peripheral smear & BM
morphology
Same Same
Dietary Cause Common, in 3-
4 months
Rare, except pure
vegans, 3-4 yrs
Drugs interfering with
absorbtion
Dilantin, oral
contraceptives
Omeprazole
(Prilosec)
Neurologic findings No May be present
Methylmalonic acid level Normal Elevated
Schilling test Useful for
etiology
Obtain after Rx
35. Important Points About Anemia
Retic peak occurs 1 week after
Rx
Fe, B12, folate
Hb/Hct increases to normal in 6-
8 weeks
If not, complications
1% reticulocytosis increases MCV
1fl
(Chronic reticulocytosis)
High LDH suggests megaloblastic
anemia
(1000-3000 U/ml)
High MCHC suggests hereditary
spherocytosis
(or acquired spherocytosis)
Bilirubin not over 4mg/dl with
hemolysis
Higher values = complications
36. Case 1
27 yo female with a history of lupus
presents with a one week history of
worsening dyspnea on exertion
Reports dark urine
Labs: hgb 8, mcv 101, rdw 19, total
bili 1.9
37.
38.
39. Case 2
62 yo white male presents with
worsening fatigue for 3 months.
He reported anginal pain to his PCP
and was referred to cardiology and
had an abnormal stress test
Underwent cardiac cath which was
unremarkable
Labs done post- cath showed a hgb
of 6, hct 20, MCV 62, RDW 20,
platelets 500K
40.
41. Case 3
84 yo female living in an assisted
living facility admitted for “failure to
thrive”
Admission labs: WBC 3.2 with
normal diff, hgb 8.7, mcv 112,
platelets 92K, LDH 1800
42.
43. Case 4
68 yo white female with a 10 year
history of poorly controlled type II
DM, HTN, CAD presents for routine
follow-up.
CBC: wbc 7.2 with normal diff, hgb
9.8, hct 28, mcv 82, rdw 11,
platelets 252K
BMP: creatinine 3.4
44.
45. Case 5
28 yo AAM with a h/o HIV brought
to the ER for altered mental status
Found to have a temp of 101.2
Labs: wbc 2.2, ANC 1200, hgb 7.2,
mcv 80, rdw 18, platelets 52K,
creatinine 3.2, LDH 4200, bili 2.2
47. Case 6
55 yo female with metastatic breast
cancer reports worsening fatigue for
a few weeks
CBC: wbc 6.8 with 1% blasts, hgb
9.1,mcv 102, platelets 86K
48.
49. Case 7
72 yo female with no significant PMH is
brought for a routine physical by her
daughter
She has not seen a doctor in 20 years
Daughter notes that mom is increasingly
tired and has abdominal distension
On exam, patient is pale and has marked
splenomegaly
CBC: wbc 4.2, hgb 7, hct 20, mcv 94,
platelets 72K
