My Patient has Anemia. WHY? Family Medicine Specialist CME Oct 15-17 2012

“If my patient has anemia I just give a transfusion.” Before we transfuse we should look for clues to answer WHY there is anemia. Do a history and physical exam. Use simple laboratory information. Blood count, RBC size, examine the blood with a microscope. Special tests help sometimes. A way of thinking about anemia Will a transfusion fix the problem? Does the patient need a transfusion?

Normal RBC

When you see ANEMIA think about THREE ways to have anemia. Bleeding. Fast bleeding. Slow bleeding. Red Blood Cell destruction Decreased RBC production.

THREE ways to have Anemia. 1. Bleeding. Fast bleeding. trauma, surgery, melena, hematemesis, menometrorrhagia. Slow bleeding (slowly bleeding ulcer or carcinoma). Induced bleeding (, repeated diagnostic testing, hemodialysis, excessive blood donation).

If your patient has slow bleeding do you use up any blood ingredients?

Case 1 Hgb 98, MCV 72, retics not elevated. Morphology classification Kinetic classification. what do you suspect? What more info do you want Hx, Px, lab. (Dx PUD) Management plan?

Case 2 Hgb 82, MCV 74, retics not elevated. Morphology class. (note stacking artifact for hypo/micro) Kinetic class. Suspect? What hx, px, lab (DX = CA, note ACD) Management?

THREE ways to have Anemia. 2. Red Blood Cell Destruction Something is wrong inside the red blood cell that makes it break easily. Sickle cell anemia is a common example of this.  Something is wrong outside of the red blood cell that breaks the red blood cell. Infection of RBC. Malaria is a common example of this. Antibodies against the RBC.

Abnormal RBC Shapes

Schistocytes: Mechanical RBC Destruction

Spherocytes: Immunological RBC Destruction

THREE ways to have Anemia. 3.Decreased RBC production Making RBC is like making a cake. You need: Ingredients. Iron, folate, vitamin B12 are RBC ingredients. A good Recipe to tell you what to do with the ingredients. The genes for all the parts of the RBC are the recipe. Thalassemia is an example of this. An Oven that works. What is the “oven” for making blood cells?

Folate or Vitamin B12 deficiency. Compare RBC size to lymphocyte nucleus.

Normal Neutrophil

Folate or Vitamin B12 deficiency: Hypersegmented Neutrophil

Case 3

Case 4 Hgb 78, MCV 65, retics elevated Morphol class Kinetic class What do you suspect? More info Hx, Px, lab

Case 5 Discussion of inclusions

Thalassemia

My Patient Has Anemia. Always ask yourself “Why?”. Think about the different ways that a patient can become anemic. Look for clues in the history, physical exam and try to get simple lab information. Think before you transfuse.