1. A peripheral blood smear
How to look at
A peripheral blood smear

2. Low Power
1- Scan the slide under low power (10x) 2- Find a good area 3- Evaluate red cell distribution 4- Evaluate the white count 1 WBC = mm3

4. Too thick area
Red cells appear as;
microcyte
hypochrome
rouleaux

5. Too thick area

6. Too thin
Red cells appear as
macrocyte
spherocyte
poikilocyte

7. Too thin area

8. Good area

9. What are you looking for at a peripheral smear (Oil immersion)
Red cell morphology
Platelet number and morphology
WBC differential and morphology
Blood parasite

10. RBC
MORPHOLOGY

11. Size
Shape
Color
Inclusion
Distribution

12. Evaluate red cells for size

13. Normocytes

14. Microcytes

15. Macrocytes

16. Macro-ovalocytes

17. Anisocytosis

18. Hb content & distribution
color
Hb content & distribution

19. Normochrome

20. Hypochrome

21. spherocyte

22. Microspherocyte

23. Dimorphic population

25. Target cells

26. Stomatocytes

27. shape

28. Normocyte

29. Tear-drop cells

30. Acanthocytes

31. Echinocytes

32. Ovalocyte - Elliptocyte

33. Sickle cells

34. Keratocyte (Horn cell)

35. Pincher cells

36. Schistocytes

37. Distribution

38. Erythrocyte antibody rosetting (EA-rosetting)

39. Rouleaux formation

41. Inclusions

42. HbH(Golf ball)

43. HbC crystal

44. Basophilic stippling

45. Howell Jolly bodies

46. Pappenheimer bodies

47. Cabot ring

48. babesia

50. Nucleated red blood cell (NRBC)

51. Beware of artifacts! 1) Water spots 2) Precipitated stain 3) Aged RBC
4) Refractiles

52. Refractiles: 
Humidity; under-fixation
late fixation
presence of water in alcohol used
excess buffer to stain
thick smear 

53. Refractiles: Increased central pallor but a normal thick rim of Hb.

54. Artifact(water spots)

55. Precipitated stain

56. Reference guide for grading red blood cell morphology
RBC type
Normal
Few (1+)
Moderate (2+)
Marked (3+)
Hypochromia
< 5
27-34 pg
5-15
22-26 pg
16-40
18-21 pg
> 40
< 18 pg
Polychromasia
< 3
3-5
6-20
> 20
Microcytes fl
70-79 fl
60-69 fl
< 60 fl
Macrocytes fl fl
> 125
Schistocytes
1-5
6-15
>15
Elliptocytes
<6
21-50
>50
Rouleaux
11-50
Spherocytes
>20
Target cells
<5
5-10
11-25
>25
Acanthocytes
1-10
11-30
>30
Report if present
Burr cells
>30%
Bite cells
>4%
Stomatocytes
Teardrop cells*
Agglutination
Dimorphic red cells
Dual population
Howell-Jolly bodies
Oval macrocytes
Pappenheimer bodies
Parasites
Sickle cell
*Teardrop cells accompanied by NRBCs can be reported even <4%.

57. Follow this system regularly then you won’t miss anything