This document discusses the approach to evaluating a patient presenting with pallor. It begins by outlining the learning objectives which are to understand the importance of history and exam in workup of pallor, learn about causes and classification of anemia, how to interpret lab tests, and management of anemia. It then provides details on evaluating pallor, the definition of anemia, essential initial lab tests, and an approach to diagnostic workup of anemia based on mean corpuscular volume. Case examples are presented and discussed to demonstrate examples of iron deficiency anemia, vitamin B12/folate deficiency anemia, and sickle cell anemia. Management of iron deficiency anemia is also reviewed.

1. Approach to patient with Pallor

2. Learning objectives
1. To understand the importance of proper history and
clinical examination in the workup of a patient presenting
with pallor in various age groups.
2. Causes and classification of Anemia
3. Interpretation of Lab. Investigations for diagnostic
purposes.
4. understanding of ordering specific investigations for
confirmation and finding out the cause of Anemia.
5. To describe the management plan of anemia in various
conditions and to ensure proper replacement therapy.

3. Pallor
• Pale color of the skin and mucous membrane
due to deficiency of hemoglobin. (hemoglobin
in carried in the RBCs)
There are many causes of pallor :
Anemia : Most common
Heart disease
Sleep deprivation
Shock : septic , Anaphylactic, Cardiogenic,
Neurogenic or hypovolemic

4. Pallor is also seen in case of
Endocrine defect :
1.long standing diabetes leading to keratin deposition
in the skin
2. Hypothyroidism with or without anemia
3.Hypopituitarism leading to decrease in the melanin
stimulatory hormone
Pallor is seen in : * Palm creases * Conjunctiva.
* And mucous membranes

5. Pallor in mucus membrane of lower
eye lid and conjunctive

6. Angular cheilitis (AC) is inflammation
of one or both corners of the mouth.

7. Angular chelosis & Glossitis

8. Koilonychia in Iron def.

9. Iron Deficiency Anemia - koilonychia

10. Case Presentation
• HISTORY: A 60- year- old male presented with marked
pallor, easy fatigability and breathlessness on exertion.
On questioning he revealed that he is taking pain killers
for his joint pains for the last 3 years. He mentioned
about passing dark colored stools off and on.
• On examination, he was markedly pale, tachycardia and
having spoon shaped deformity of nails.
• Blood examination: Hemoglobin 7 g/dl
• MCV: 68 fl, MCHC:
• Raised Iron binding capacity with serum Ferritin 12ug/l
(Normal range 60 or above ug/l)

12. Anemia is defined by
• Reduction in Hg Concentration,
•Hct Concentration or
• RBC count according to the age & sex of the
individual

13. 13
Considerations by Age, Sex, and Other
Factors 1 of 2
• Newborns less than one week old have hemoglobin
of 14-22 g/dl.
• By six months , hemoglobin levels are11 and 14 g/dl.
• 1 year and 15 years hemoglobin is 11-15 g/dl.
• Normal adult hemoglobin depends on gender:
– ♀ 12-16 g/dl
– ♂ 14-18 g/dl
• In geriatric age group, men and women have same
hemoglobin range: 12-16 g/dl.

14. Symptoms
• Exertional dyspnea and Dyspnea at Exertion
• Headaches
• Fatigue
• Bounding pulses and Roaring in the Ears
• Palpitations
• PICA is an eating disorder typically defined as the persistent ingestion of nonnutritive substances
for at least 1 month at an age for which this behavior is developmentally inappropriate.

15. Etiology of anemia
• Iron deficiency 25%
• Anemia of inflammation 25%
• Hemoglobinopathy 25%
• Hemolytic anemia/marrow failure 15%
• Myelodysplasia 10%

16. First Step in Evaluation
Clinical PresentationClinical Presentation

17. 17
Approach
• Detailed History
• Review of Systems
• Physical Exam
• Laboratory Evaluation
– Prior documentation of CBC’s
– CBC with RETICULOCYTE COUNT
– Review peripheral blood smear

18. 18
History
Family historyFamily history
Spherocytosis
Sickle cell
anemia
Thalassemia
DietDiet
Vegetarian
Drugs/Toxins
Infection
Alcohol AbuseAlcohol Abuse
Folate
deficiency
Liver disease
MalabsorptionMalabsorption
B12
Folate
Iron
Exposure
Lead
Chemotherapy
Peptic UlcerPeptic Ulcer
DiseaseDisease
DiverticulitisDiverticulitis
Colonic PolypsColonic Polyps
GI MalignancyGI Malignancy
colorectal
esophageal
Recent SurgeryRecent Surgery
TravelTravel

19. Symptoms
Weakness
Fatigue
Dizziness
Headache
Chest pain
SOB / DOE
Palpitations
Cold intolerance
Dysphagia
Jaundice
Hematemesis
Diarrhea
Constipation
Melena
Hematuria
Menorrhagia
Pica (clay, dirt,
chalk, ice)
Hematoma

20. Physical Exam

21. 21
Physical Exam
Ophtho exam
Flame hemorrhage
Papilledema
Exudates
Pallor
Blue sclera
Angular Cheilitis
Iron Deficiency
GlossitisGlossitis
B12 / Folate / Iron
Tachycardia
Jaundice
Liver Disease
Hemolysis
Guiaic positive (gFOBT)
Splenomegaly
Malignancy
Infection
Liver disease
Chronic Hemolysis
Adenopathy
SkinSkin
Pallor
Ulcerations
Scars
Thin/Brittle, Spoon-
shaped nails
Edema
Neurologic
Headache, fatigue
Lack of concentration
Syncope
Paresthesias
Ataxia
Dementia

22. Essential laboratory tests in the evaluation
of anemia
• Hemoglobin – amount of lysed pigment in a volume
of blood
• Mean corpuscular volume – size of red blood cells
• Red cell distribution width – measure of variation of
cell size
• Red blood cell count – absolute number of red
blood cells per volume
• Platelet count
• White blood cell count
• Peripheral blood smear

23. Diagnostic approach to anemia
1. Review prior CBCs
2. Take comprehensive history and physical
3. Classify anemia by MCV
– Microcytic (MCV <80 fL)
– Normocytic (MCV 80-100 fL)
– Macrocytic (MCV >100 fL)
• Mild macrocytosis MCV 100-110 fL
• Marked macrocytosis MCV >110 fL
1. Reticulocyte Count (classification of proliferation)
2. Order appropriate additional tests

24. Case 1
• 52 year old male construction worker with
presenting complaint of fatigue for 2 months. He
now reports getting dyspnea when climbing stairs or
carrying heavy loads at work. He says, “I never go to
doctors.”
• Physical exam unremarkable
• ROS occasional crampy abdominal pain

25. Case 1
• Hgb 10.2 gm/dl, MCV 68 fL, Platelets
450,000/dL
• How do you classify the anemia?

26. Case 1
• Serum Iron is low
• Fecal occult blood test is positive
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27. Features of iron deficiency anemia
• Clinical
– Symptoms of anemia
– Evidence of blood loss
– Pica (very specific)
• Laboratory
– Microcytic anemia (occasionally normocytic)
– Elevated RDW
– Elevated platelet count
– Low serum iron, ferritin and elevated TIBC

28. 28
Fe Deficiency Anemia

29. 29
Iron Deficiency – Etiologies
• History –History – GI (blood loss, diarrhea/constipation),GI (blood loss, diarrhea/constipation),
menses, coagulopathy, urine color (menses, coagulopathy, urine color (cokecoke-colored-colored
[bilirubin] OR[bilirubin] OR redred [hematuria, hemoglobinuria])[hematuria, hemoglobinuria])
• Guaiac stoolsGuaiac stools
– Office DRE
– Hemocult cards as outpatient
• Colonoscopy / EGDColonoscopy / EGD
• PT / APTT, UAPT / APTT, UA

30. Case 2
• 48-year-old white man is referred for pallor and
unexplained tierdness. He is an executive in a
software company and reports fatigue and dyspnea
during brisk walk
• Physical examination: He is a normal, healthy-looking
man, perhaps pale, with a clean tongue. The results
of his chest, abdomen, and neurologic exams are all
normal.

31. Case 2
• Hemoglobin 9.2 gm/dl
• Mean corpuscular volume (MCV) 112 fL
• White blood cells 3,400/ul normal differential
• Platelets 89,000/ul

32. Case 2 laboratory results
• B12 level 100 pg/mL, folate >20 ng/mL
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Schrier, S. ASH Image Bank 2001;2001:100231

33. Case 3
• 45 year old African-American female presents with fatigue for
6 months. She now only works 6 hours a day at her
secretarial job and is now dyspneic climbing 2 flights of stairs
at home.
• PMH: Hypertension, depression, G6P6
• PSH: C-section x 2, breast biopsy – benign
• FH: Father – multiple myeloma, Mother – DM2 on
hemodialysis, 2 younger siblings are well
• SH: No tobacco or alcohol
• ROS: Joint pains for about 6 months, intermittent chest pain
worse with deep breathing
• Medications: Lisinopril, aspirin, venlafaxine

34. Case 3
• Hemoglobin 8.0 gm/dL
• MCV 81 fL
• WBC 3,200/uL
• Platelets 450,000/uL

35. Management of iron deficiency
• Rule out blood loss, reason for negative iron
balance
– Gastrointestinal
– Genitourinary
– Poor iron absorption
– Pregnancy

36. Oral iron supplementation
• Goal: 150-200 mg elemental iron daily
• Administration
– DO NOT give with food
– Give 2 hrs from antacids
– May give with ascorbic acid 250 mg
• Gastrointestinal intolerance (~20%)
– Decrease daily elemental iron dose
• Switch from sulfate to gluconate or elixir
– Give with food (will decrease absorption)

37. Reticulocytes

38. Interpreting reticulocyte counts
• Reticulocytes are erythrocytes new to peripheral
circulation
• Need to correct for degree of anemia
– Reticulocyte index = Retic % x [Pt Hct/NlHct]
– Absolute reticulocyte count = Retic % x RBC number
• Appropriate reticulocytosis
– Reticulocyte index >2%
– Absolute reticuocyte count >100,000/mcl

39. Anemia in the elderly
10-30% of elderly are anemic
• Consequences
– Decreased physical performance
– Increased mortality in CHF patients
– EPO improved LV function in elderly CKD patients
treated with EPO
• About 30% have “unexplained anemia”
Guralnik J Hematology: ASH Education Book 2005