lecture of 88 slides

1. .
How to Read
Complete Blood Picture
Prof. Ahmad Mansour
Professor of Pediatrics,
Hematology Oncology
Faculty of Medicine,
Mansoura University

2. BY
Eman Shalaby
Eman Hatem
Prof : Ahmed Mansour

3. CONTENTS
 Definition ,
 Hematopoiesis,
 Purpose ,
 Preparation ,
 WBCs , it’s differentials ,
 RBCs , it’s indices ,
 Platelets ,
 Absolute neutrophil count(ANC) ,
 Examples ,
Refrences.

4. Definition
 A complete blood count (CBC) ,also known
as full blood count( FBC )
, full blood exam
(FBE ro )blood panel , is a series of tests
used to evaluate the composition and
concentration of the cellular components of
blood.
Alexander Vastem is widely regarded as being
the first person to use the complete blood
count for clinical purposes in the early 1960s.

5. Haemocytopoiesis
Definition : Formation of blood
Hematopoetic Stem Cell : Origin of all blood cells
Hematopoetic Organs :
o Bone Marrow (myeloid tissue) ;
Location: long bones, ribs, sternum , vertebrae.
Primary site of blood cell formation.
T Lymphocytes are formed here and then migrate to the
lymphatic system for maturation .
o Lymphatic System;
Lymph nodes, spleen, thymus, and tonsils.
Young fetus: site of haemocytopoiesis is most of bone together
with the liver and the bone marrow .

8. Blood
Plasma
o Fluid Component: 90%
water .
o Solutes : 10% (electrolytes
and proteins)
Formed Elements
o Cellular component (WBC,
RBC, Plt)

9. CBC measures the following:
• The number of red blood cells (RBCs)
• The number of white blood cells (WBCs)
• The total amount of hemoglobin in the blood .
• The fraction of the blood composed of red blood cells
(hematocrit)
• The mean corpuscular volume (MCV) — the size of the
red blood cells .
• The platelet count is also usually included in the CBC.
CBC also includes information about the red blood
cells that is calculated from the other measurements:
• MCH (mean corpuscular hemoglobin).
• MCHC (mean corpuscular hemoglobin concentration).

10. Purpose:
The CBC provides valuable information about the blood and to
some extent the bone marrow, which is the blood-forming
tissue.
The CBC is used for the following purposes:
A- as a preoperative test: to ensure both adequate
oxygen carrying capacity and hemostasis.
B- to identify persons who may have an infection.
C- to diagnose anemia.
D- to identify: acute and chronic illness, bleeding
tendencies, and white blood cell disorders such as
leukemia.
E- to monitor treatment for anemia and other blood
diseases.
F- to determine the effects of chemotherapy
and radiation therapy on blood cell production.

11. Preparation:
There is no special preparation needed.
How the Test is Performed:
 Blood is drawn from a vein, usually
from the inside of the elbow or
the back of the hand. The
puncture site is cleaned with
antiseptic. An elastic band is
placed around the upper arm to
apply pressure and cause the vein
to swell with blood.
 A needle is inserted into the vein,
and the blood is collected in an air-
tight vial or a syringe. During the
procedure, the band is removed to
restore circulation. Once the blood
has been collected, the needle is
removed, and the puncture site is
covered to stop any bleeding.

12. In infants or young children, the
area is cleansed with antiseptic
and punctured with a sharp
needle or a lancet.
The blood may be collected in a
pipette (small glass tube), on a
slide, onto a test strip, or into a
small container.
A bandage may be applied to the
puncture site if there is any
bleeding.

15. White Blood Cell
 Fight infection
 Attack foreign material
 4,500 – 11, 000 mm3 (abbreviated as 4.5
– 11)
 Lifespan = hours – days
 Clinical implications for an Increased
WBC (leukocytosis):
o Infection, tissue necrosis, bone marrow
malignancies, and inflammation .
 Clinical implications for a Decreased
WBC (leukopenia):
o Infections, conditions or medications
that suppress or weaken the immune
system or exhaust the bone marrow .

16. WBC Differential
o Breaks down the WBC into their type (5 specific
types).
o (neutophil , basophil , monocyte , lymphocyte and
eosinophil)
o Each type is expressed as a percentage (%) of the
total WBC count.
o “Informative” component of the WBC.
o Sum of the components of the WBC differential must
add up to 100.

17. Normal Values:
NORMAL
VALUES
TEST
4.5-11.0
Adult
% (total WBC
count)
Neutrophils
3-5%
Bands
54-62%
Segs
25-33%
Lymphocytes
3-7%
Monocytes
1-3%
Eosinophils
0-0.75%
basophils
NORMAL
VALUES
TEST
X1000 cells/mm³
(µL)
Leukocyte (White
Blood Cell)
9.0-30.0
Birth
9.4-34.0
24 hours
5.0-19.5
1 month
6.0-17.5
1-3 years
5.5-15.5
4-7 years
4.5-13.5
8-13 years

19. Clinical implications for neutrophilia :
o Bacterial infection, some inflammatory conditions, tissue damage, and
malignancies of the bone marrow (leukemia) .
 A rise in neutrophils in general is consistent with a bacterial Infection,
 A rise in bands in particular is highly suggestive of bacterial infection.
Clinical implications for neutropenia :
o Some viral conditions, overwhelming infection that exhausts the bone marrow,
cancer treatment drugs,
o certain antibiotics and psychotropic drugs, some hereditary disorders,
o Newborns with sepsis are at higher risk for developing neutropenia.
First line of defense against infection.
Two types:
oBands or stabs (3-5% ) - immature
oSegs ( 54-62% ) – mature

20. “Left Shift”
 Increase in bands
 Many consider it to be an increase
in the combined bands an segs.
 Indicates a bacterial infection .
“Right Shift”
 Technically, there is no such thing
as a right shift.
 Practically, it indicates a rise in
the monocytes and lymphocytes.
 Indicates a viral infection .

21. Monocytes ( 3-7% )
 Second line of defense against infection .
 Indicates a viral infection .
Clinical implications for monocytosis :
 Monocytic leukemia, ulcerative colitis,
 viral diseases such as mononucleosis and herpes
zoster,
 Parasitic diseases such as Rocky Mountain Spotted
Fever and glandular fever .
 Bacterial diseases ,TB ,syphilis ,malaria ,typhus.
Clinical implications for monopenia :
 Some forms of leukemia, bone marrow failure or
suppression .

22. Lymphocytes (25-33 %)
 Produced in the Lymphatic System .
o B Lymphocytes (B Cells): humoral immunity .
o T Lymphocytes (T cells): cell-mediated immunity .
 Indicates a viral infection .
Clinical implications for lymphocytosis :
 viral infections (most common),
 bacterial or allergic conditions (less common) as TB ,
syphilis .
 Clinical implications for lymphopenia :
 Corticosteroid therapy,
 adrenocortical hyperfunction,
 stress,
 shock .

23. Eosinophils (1-3 %)
Indicates allergic disorders and parasitic
infections .
Clinical implications for eosinophelia :
 Asthma,
 hay fever,
 drug reaction .
Clinical implications for eosinopenia :
 Corticosteroid therapy,
 adrenocortical hyperfunction,
 stress,
 shock .

24. Basophils (0.0-0.75%)
o Indicated systemic allergic reactions
(inflammatory states) .
o Responsible for histamine release .
Clinical implications for basophilia :
 Chronic inflammatory and
hypersensitivity reactions .
Clinical implications for basopenia :
 Corticosteroid therapy,
 adrenocortical hyperfunction,
 stress,
 shock .

25. Red Blood Corpuscels
(Erythrocytes)
RBCs

27.  Transports oxygenated Hgb to the tissues of the
body .
 Contributes to maintenance of acid-base equilibrium .
 Lifespan : 120 days .
Production is regulated by 2 things:
(1) Tissue oxygenation ,
(2) Renal production of erythropoietin .
Tissue hypoxia stimulates the kidneys to produce
erythropoietin, which then stimulates the bone
marrow to release RBC’s.
NB** It is the ability of the RBC’s to transport
oxygen to the tissues of the body that regulates
the production of RBC’s NOT the number of
circulating RBC’s.

28. Clinical implications for polycythemia :
 Congenital heart disease,
 chronic hypoxia,
 high altitudes,
 polycythemia vera .
Clinical implications for decreased
hemoglobin :
 Renal disease,
 hematological conditions involving RBC
destruction, iron deficiency, vitamin B12
deficiency,
 blood loss/hemorrhage,
 bone marrow suppression .

29. 3.9-5.5
Cord
4.0-6.6
1-3 days
3.9-6.3
1 week
3.6-6.2
2 weeks
3.0-5.4
1 month
2.7-4.9
2 months
3.1-4.5
3-6 months
3.7-5.3
0.5-2 years
3.9-5.3
2-6 years
4.0-5.2
6-12 years
4.5-5.3
12-18 years(male)
4.1-5.1
12-18years(female)
RBCs count
(Million/mm³)

30. RBC Indices
 Measures the size and Hgb content of the RBC .
 Calculated based on mathematical formulas that
reflect the relationships among the RBC, Hgb,
and Hct .
 Primarily used to differentiate between different
types of anemia .
 It includes :
o Mean Corpuscular Volume (MCV) ,
o Mean Corpuscular Hemoglobin (MCH) ,
o Mean Corpuscular Hemoglobin Concentration (MCHC)
o Red Cell Distribution Width (RDW) ,
o Hematocrit (Hct) .

31. Mean Corpuscular Volume (MCV)
 Indicates the average size of the RBC .
 Three (3) Size Descriptions:
(1) Normocytic: normal cell size (75-94µm³ );
varies with age and gender .
(2) Macrocytic: large cell size (>94µm³) .
(3)Microcytic: small cell size (<75µm³) .
 Clinical implications for increased MCV:
 folate or vitamin B12 deficiency,
 aplastic anemia,
 immune hemolytic anemia .
 Clinical implications for decreased MCV:
 iron deficiency anemia,
 lead poisoning,
 thalassemia .

32. MCV
Age
95-121µm³
1-3 days
70-86 µm³
0.5-2 years
77-95 µm³
6-12 years
78-98 µm³
12-18 years
(male)
78-102 µm³
12-18 years
(female)

33. Mean Corpuscular Hemoglobin
(MCH)
Measures average weight of Hgb
per RBC {25-33 pg (picrograms)}.
Clinical implications for increased
MCH:
same as for MCV
Clinical implications for decreased
MCH:
same as for MCV

34. MCH
ِAge
31-37 pg/cell
At birth
31-37 pg/cell
1-3 days
28-40 pg/cell
1 week – 1 month
26-34 pg/cell
2 months
25-35 pg/cell
3-6 months
23-31 pg/cell
0.5-2 years
24-30 pg/cell
2-6 years
25-33 pg/cell
6-12 years
25-35 pg/cell
12-18 years

35. Mean Corpuscular Hemoglobin
Concentration (MCHC)
Measures average concentration of Hgb per RBC .
Three (3) Hgb Concentration Descriptions:
(1) Normochromic: normal Hgb concentration (33-36%);
varies with age .
(2) Hyperchromic: increased concentration of Hgb per
RBC (>36%) .
( 3) Hypochromic: decreased concentration of Hgb per
RBC (<33%) .
Clinical implications for increased MCHC:
 hereditary spherocytosis .
Clinical implications for decreased MCHC:
 iron deficiency, thalassemia .

36. MCHC
Age
30-36 g Hg/dL RBC
Birth
29-37 g Hg/dL RBC
1-3 days
28-38 g Hg/dL RBC
1-2 weeks
29-37 g Hg/dL RBC
1-2 months
30-36 g Hg/dL RBC
3 months – 2
years
31-37g Hg/dL RBC
2-18 years

37. Red Cell Distribution Width (RDW)
 Measures the uniformity of RBC size (11.5 – 14.5 )
Anisocytosis (increased RDW):
indicated greater cell size variability .
Clinical implications for increased RDW:
 iron deficiency anemia,
 folic acid deficiency anemia,
 vitamin B12 deficiency anemia .

38. Hemoglobin (Hgb)
Component of the RBC that binds oxygen and
delivers it to the tissues of the body (11.5 – 14.5 g/dl,
varies based on age and gender).
Types: dependent on stage in life and an abnormalities
of the genes which regulate hemoglobin.
Composed of four (4) globin chains:
 Hgb F (Fetal Hemoglobin): 2 alpha and 2 gamma chains.
 Hgb A (Adult Hemoglobin): 2 alpha and 2 beta chains.

39. Haemoglobin
Age
14.5-22.5 g/dL
1-3 days
9-14 g/dL
2 months
11.5-15.5 g/dL
6-12 years
13-16 g/dL
12-18 years
(male)
12-16 g/dL
12-18 years
(female)

40.  Clinical implications for increased hemoglobin:
 congenital heart disease,
 chronic hypoxia,
 high altitudes,
 polycythemia vera,
 fluid loss (dehydration) .
 Clinical implications for decreased
hemoglobin (anemia);(4) 
1- Decreased Production: 
aplastic anemia, renal disease, iron deficiency,
bone marrow suppression.
2- Increased Destruction: 
sickle cell disease, hereditary spherocytosis.
3- Blood Loss:  hemorrhage.
4- Other: fluid volume overload.

41. Hematocrit (Hct)
Percentage of packed RBC to whole blood .
Expressed the ratio of cells to blood .
The relationship between Hct and Hgb is constant/fixed.
 Hct = 3 X Hgb
 Hct rises and falls in the same direction and for the
same clinical reasons as does Hgb.
Clinical implications for increased hematocrit ;
 More cells , Less fluid.
 Dehydration,
 Burns,Diarrhea,
 Polycythemia vera,
 Low oxygen tension (smoking, congenital heart disease, living at
high altitudes)

42. Clinical implications for
decreased hematocrit:
 Fewer cells , More fluid
 Anemia (various types),
 Blood loss (hemorrhage),
 Bone marrow failure (for example, due to
radiation, toxin, fibrosis, tumor)
 Hemolysis (RBC destruction) related to
transfusion reaction,
 Leukemia,
 Malnutrition or specific nutritional deficiency,
 Multiple myeloma,
 Rheumatoid arthritis.

43. Hematocrit
Age
48-69%
1 day
48-75%
2 days
44-72%
3 days
28-42%
2 months
35-45%
6-12years
37-49%
12-18years (male)
36-46%
12-18years (female)

44. Reticulocyte (Retic Count)
o Immature RBC (0.5% - 1.5%).
o Indicates active RBC production from the
bone marrow.
o An indirect measure of hematopoiesis.
Clinical implications for increased reticulocytes
(reticulocytosis):
 acute anemia,
 chronic hemolytic anemia <<< (sickle cell
disease, hereditary spherocytosis)

45. Reticulocyte
Count
Age
2-5% of
RBCs
Infants
0.5-4% of
RBCs
Children
0.5-1% of
RBCs
12-18 years
(male)
0.5-2.5% of
RBCs
12-18 years
(female)

46. Clinical implications for decreased
reticulocytes (reticulocytopenia):
 bone marrow failure syndrome,
 infectious bone marrow
suppression,
 iron deficiency anemia,
 vitamin B12 deficiency anemia,
 folate deficiency anemia.

49. Cellular components needed to form a clot (150,000 –
450,000; abbreviated 150-450).
Regulated by thrombopoietin;
<< mechanism of action is largely unknown.
 Clinical implications for increased platelets
(thrombocytosis):
 acute blood loss, platelet count
 myeloproliferative disease,
polycythemia vera.
84,000-
478,000/mm³
Birth-1
week
150,000-
400,000/mm³
Thereafter

50. Clinical implicates for decreased platelets
(thrombocytopenia): 3 Causes 
Decreased Production: 
 leukemias,
 other primary bone marrow failure syndromes.
Increased Destruction: 
 idiopathic thrombocytopenia purpura (ITP),
 certain drugs.
Abnormal Pooling: 
 splenic sequestration,
 splenomegaly.

52.  Definition:
o Represent the actual number rather than the % of
neutrophils.
 Clinical Implication:
o Indicates the degree of immune system functioning.
 Range:
> 1000
 Neutropenia:
ANC < 1000
500 – 1000: indicates a moderate risk for infection,
< 500: indicates a severe risk of life-threatening
infection.
 Etiology:
 Chemotherapy,
 Immunosupression (Steroid Therapy),
 Chronic Benign Neutropenia of Childhood,
 Syndromes affecting the immune system.

53. Calculation
Three calculation methods:
Learn 1 and forget the other 2…
 Method #1: (Bands + Segs)% X true WBC = ANC
 Method #2: {(Bands + Segs) X WBC} / 100 = ANC
 Method #3: (Bands + Segs) X (Abbreviated WBC X 10)
= ANC

55. Normal range
units
Low/high
Results
Test
CBC WITH
DIFFERENTIAL
4.1 - 5.1 /
4.70 - 6.10
x 10-6/μl
3.5 (L)
Red Blood Count
12.0 - 16.0
/ 14.0 -
18.0
g/dl
10.8 (L)
Hemoglobin
37.0 - 48.0
/ 42.0 –
52.0
%
31.1 (L)
Hematocrit
140 - 415
x 10-3/μl
302
Platelets
4.5 - 11
x 10-3/μl
7.2
White Blood
Count
17 – 44
%
48 (H)
Lymphocytes
3 - 10
%
7.0
Monocytes
45 - 76
%
43 (L)
Neutrophils
0 - 4
%
2.0
Eosinophils
0 - 2
%
0
Basophils

56. Refrence interval
Units
Result
Test
5.0-10.0
x 103/mm3
1.5 L
White Blood Count
4.1-5.3
x 106/mm3
3.50 L
Red blood count
12.0-18.0
g/dL
10.8 L
Hemoglobin
37.0-52.0
%
31.1 L
Hematocrit
150-400
x 103/mm3
302
platelets
45-76
%
23L
Polys (neutrophils)
17-44
%
68 H
Lymphocytes
3-10
%
7
Monocytes
0-4
%
2
Eosinophils
0.2
%
0.6
basophils
1.8-7.8
x 103/mm3
0.34L
Polys (absolute)
0.7-4.5
x 103/mm3
1.0
Lymphocytes (absolute)
0.1-1
x 103/mm3
0.1
Monocytes (absolute)
0-0.4
x 103/mm3
0.1
Eosinophils (absolute)
0.0-0.2
x 103/mm3
0.0
Basophils (absolute)

57. CASE
S

59. 4 years female
CBC:
HB=5 gm/dl
MCV=75 fl
MCH=35 pg
WBC:150,000 /mm3
PLAT: 35,000 /mm3
Anemia
Normocytic
normochromic
Leucocytosis
Thrombocytopenia
Clinical Examination: ill
Purpura rash on the face, forearm + HSM,
generalized LN, high fever
What Do you recommend
Next Lab Investigation???

60. Case of Acute Lymphoblastic Leukemia
Bone Marrow aspiration
Lymphoblasts =80%

62. 4 years male
CBC:
HB=13 gm/dl
MCV=75 fl
MCH=35 pg
WBC:15,000 /mm3
PLAT: 35,000 /mm3
Thrombocytopenia
Clinical Examination: well
ecchymosis on the face, purpura upper and lower limbs +
No HSM, No generalized LN, No fever , + preceding viral infection
What Do you recommend Next Lab

63. Case of ITP
Bone Marrow aspiration
Megakaryocytes abundunt, hyperactive, decresed budding seen (so
rapid budding cant be seen in film)

65. 10 years male
CBC:
HB=5 gm/dl
MCV=75 fl
MCH=35 pg
WBC:1,000 /mm3
PLAT: 35,000 /mm3
Anemia
Normocytic
normochromic
Leucocytopeni
a
Thrombocytopeni
a
Clinical Examination:
Purpura rash all over the body, No HSM, No generalised
LN, high fever, mouth ulcers
What Do you recommend Next Lab
Investigation???

66. Case of Aplastic anemia
Bone Marrow aspiration and biopsy
Empty bone marrow. Increased fat cell and lymphocytes

68. 7 years male
CBC:
HB=14 gm/dl
MCV=75 fl
MCH=35 pg
WBC:10,000 /mm3
PLAT: 200,000 /mm3
Clinical Examination:
Purpura rash on the lower limbs, buttocks + no HSM, no
generalized LN, no fever , abdominal pain, arthritis ,
hematuria
What Do you recommend Next Lab
Investigation???
Do You Recommend Bone Marrow aspiration

69. A case of
Henoch-Schönlein Purpura
(Anaphlactoid Purpura)
• Clinical Diagnosis
• Renal function evaluation
• Surest Investigation (Skin Biopsy (IgA
vasculitis))

71. 5 years male
CBC:
HB=5 gm/dl
MCV=55 fl
MCH=25 pg
WBC:10,000 /mm3
PLAT: 250,000 /mm3
Anemia
Microcytic
hypochromic
Clinical Examination: pallor, jaundice , mongoloid
facies,
received blood 10 times
No Purpura + huge spleen, No generalized LN, No
fever
What Do you recommend Next Lab
Investigation???

72. DD: Chronic Hemolytic
Anemia
Investigations:
Reticulocytic count: increase
Hb electrophoresis: for Thalassemia
Osmotic fragility: for spherocytosis
Sickling test: for sickle cell anemia

73. Case Scenario
•
A 3 years old black male developed
painfull tender swelling of his foot
•
Temp : 39 C
•
CBC : H 8.4
•
Rbcs 3 mill / cmm
•
Hct 25
•
Mcv 83 fl
•
Mch 28 ngm
•
Mchc 33 %

74. •
T L C : 10,600 / cmm
•
Neut 72 %
•
Lymph 20 %
•
Monocyte 8 %
•
P 400 000 / cmm
•
ESR 26 / hour
•
X ray >> periosteal new bone formation
•
>> cortical destruction of the
•
fourth metatarsal bone

75. •
May Salmonella Organism be
found in his blood ??

76. •
Is Sodium Metabisulfite test
•
likely to be abnormal ??

77. •
May Polyvalent pneumococcal
vaccine reduce his future
morbidity ??

78. •
Is intravenous oxacillin is
the treatment of choice ??

79. 1
Reticulocytic Count 5%

80. 2

81. 2

82. 1

83. 1
Reticulocytic Count 1%

84. 2

85. 2

87. Refrences
(Pediatric Nursing Annual Conference 2010)
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with Nursing Diagnosis (5th ed.) Upper Saddle River, New Jersey:
Prentice Hall Health.
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ed.). Philadelphia: W. B. Saunders Company.
Hazinski, M. F. (1988). Understanding fluid balance in the seriously ill
child. Pediatric Nursing, 14, 231-236.
Jakubik, L. D., Cockerham, J., Altmann, A., & Grossman, M. B. (2003). The
ABCs of pediatric laboratory interpretation:
Understanding the CBC with differential and LFTs. Pediatric Nursing,
29(2), 97-103.
Jakubik, L. D., Deatrick, J. A., & Woodring, B. C. (2002). Pediatric
complete blood count, reticulocyte count, WBC differential,and absolute
neutrophil count. In, Pediatrics Mastering New Clinical Specialties: A
Competency Based Approach toCross-training and Skill Enhancement (module
8: pp. 1-38). Cypress, CA: Medcom Trainex.

88.  Jakubik, L. D. & Thompson, M. (2000). Care of the
child with sickle cell disease: Acute complications.
Pediatric Nursing, 26(4),373-379.
 Kee, J. L. (1999). Laboratory and Diagnostic Test with
Nursing Implications (5th ed.). Stamford, Connecticut:
Appleton and Lange.
 Lilleyman, J., Hann, I., & Blanchette, V. (1999).
Pediatric Hematology (2nd ed.). London: Churchill
Livingstone.
 Malarkey, L.M. & McMorrow, M. E. (Eds.) (2000). Nurse’s
Manual of Laboratory Tests and Diagnostic Procedures (2nd
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 Muscari, M. E. (2004). Lippincott’s Review Series:
Pediatric Nursing (4th ed.). Philadelphia: Lippincott
Williams & Wilkins.
 Nathan, D. G. & Oski, F. A. (1999).Hematology of Infancy
and Childhood (5th ed.) Philadelphia: W. B. Saunders
Company.