Anemia WHO definition: a hemoglobin level <130g/L (13g/dL) in men and <120g/L (12g/dL) in women Reduction in below normal in the concentration of hemoglobin or RBC’s in the blood

Clinical Presentation: Acute anemia due to blood loss Acute blood loss – hypovolemia, hematocrit and hemoglobin level do not reflect volume loss, compensation due to Bohr effect Blood loss of 10-15% of total blood volume – signs of vascular instability Blood loss of >30% - remains supine, postural hypotension and tachycardia Blood loss >40% (>2L in average sized adult) – hypovolemic shock (confusion, dyspnea, diaphoresis, hypotension and tachycardia)

Clinical Presentation: Anemia due to Hemolysis Signs and symptoms dpend on the mechanism that led to the red cell destruction Intravascular hemolysis w/ release of free hemoglobin – associated with acute back pain, free hemoglobin in the plasma and urine, and renal failure

Clinical Presentation: Moderate anemia Fatigue, loss of stamina, breathlessness and tachycardia (with physical exertion)

Clinical Presentation: Chronic or Progressive anemia Depends on the age of the patient and the adequacy of blood supply to critical organs

Disorders commonly associated with anemia Chronic inflammatory states Lymphoproliferative disorders

3 Functional Categories Disorders of Proliferation Disorders in Erythrocyte Maturation Disorders due Primarily to Erythrocyte Destruction or Red Cell Loss

Approach to the Patient Do a careful and thorough history and physical examination Determine the Subjective and Objective data pertinent to anemia

Subjective Data Severity of the anemia Rapidity of onset Patient’s age and CV status Associated manifestations of the underlying disorder - Endocrine disorder - Renal disorder - Hepatic disorder

Onset & Duration of symptoms insiduous or acute Previous prescription for hematinics & response Medication history Occupation, household customs & hobbies Symptoms of hemolysis- jaundice, changes in urine color Symptoms of blood loss - melena, hematochezia, epigastirc pain

Geographic backgrounds and ethnic origin Obstetric & Gynecologic history # of pads/day duration # of pregnancies, abortions - interval Concomitant bleeding manifestations Dietary history Fever, Weight loss

Objective Data Cardiac Signs Hemic murmurs - mid or holosystolic often in the pulmonic or apical area, due to increased blood flow and turbulence Gallop rhythms Tachycardia/Cardiomegaly Strong peripheral pulses with wide pulse pressure

Integumentary Manifestation Pallor: <8 to 10 mg/dL hemoglobin Affected by: state of vasoconstriction/vasodilatation degree & nature of pigmentation nature & fluid content of the subcutaneous tissues Most constantly detected in: mucous membranes of the mouth, pharynx, conjunctivae, lips Nailbeds Palamar creases

Neuromuscular Sign Headache Vertigo Tinnitus Faintness Retinal hemorrhage Paresthesias Scotomas Lack of mental concentration Drowsiness Restlessness

GI Manifestations Glossitis Atrophy of the papillae of the tongue Dysphagia Oral ulcers Gingival hyperplasia Hepatosplenomegaly

Sternal Tenderness Genitourinary Sign lymphadenopathy Slight proteinuria Changes in urine color

Laboratory Evaluation – Complete Blood Count: Red cell count- hgb, hct, reticulocyte count RBC indices – MCV, MCH, MCHC, RDW White Blood cell count- cell differential, nuclear segmentation of neutrophils Platelet count Peripheral smear morphology – cell size, hemoglobin content, anisocytosis, poikilocytosis, polychromasia Iron Supply Studies – serum iron, total iron-binding capacity, serum ferritin Bone marrow examination – Aspirate: M/E ratio, Cell Morphology, iron stain; Biopsy: cellularity, morphology

Physiologic factors affecting CBC Age Sex Pregnancy Smoking Altitude

Red Blood Cell Indices Index Normal Value Mean Cell Volume(MCV): (hematocrit x 10)/(red cell ct. x 106) 90 + 8 fL Mean Cell Hemoglobin (MCH): (hemoglobin x 10)/ (red cell ct. x 106) 30 + 3 pg Mean Cell Hemoglobin Concentration: (hemoglobin x 10)/ hematocrit, 33 + 2% or MCH/MCV

MCV – reflects microcytosis and macrocytosis MCH and MCHC – reflectsdefects in hemoglobin synthesis

Changes in Normal Hemoglobin/Hematocrit Values with Age and Pregnancy Age/Sex Hemoglobin g/dl Hematocrit % At birth 17 52 Childhood 12 36 Adolescence 13 40 Adult man 16(+2) 47(+6) Adult woman 13(+2) 40(+6) (menstruating) Adult woman 14(+2) 42(+6) (postmenopausal) During pregnancy 12(+2) 37(+6)

Peripheral Blood Smear Provides important information about defects in red cell production It reveals: Anisocytosis – variations in cell size; correlates w/ increases in RDW or range of cell sizes Poikilocytosis – variations in cell shape; suggests a defect in maturation of red cell precursors in the bone marrow or fragmentation of circulating red cells Polychromasia – rbc that are slightly larger than normal and grayish-blue in color on the right-Giemsa stain

Normal Peripheral Smear

Microcytic Hypochromic RBC’s with anisocystosis and poikilocytosis

Macrocytosis

Howell-Jolly Bodies

Tear-drop shape cell and Nucleated RBC

Target Cell

RBC Fragmentation

Burr cell or Echinocytes

Spur Cell