1. 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

2. 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)

3. 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

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

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

6. Disorders commonly associated with anemia
Chronic inflammatory states
Lymphoproliferative disorders

7. 3 Functional Categories
Disorders of Proliferation
Disorders in Erythrocyte Maturation
Disorders due Primarily to Erythrocyte Destruction or Red Cell Loss

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

9. 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

10. 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

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

12. 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

13. 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

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

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

16. Sternal Tenderness Genitourinary Sign lymphadenopathy
Slight proteinuria
Changes in urine color

17. 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

18. Physiologic factors affecting CBC
Age
Sex
Pregnancy
Smoking
Altitude

19. Red Blood Cell Indices Index Normal Value Mean Cell Volume(MCV):
(hematocrit x 10)/(red cell ct. x 106) fL
Mean Cell Hemoglobin (MCH):
(hemoglobin x 10)/ (red cell ct. x 106) pg
Mean Cell Hemoglobin Concentration:
(hemoglobin x 10)/ hematocrit, %
or MCH/MCV

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

21. Changes in Normal Hemoglobin/Hematocrit Values with Age and Pregnancy
Age/Sex Hemoglobin g/dl Hematocrit %
At birth
Childhood
Adolescence
Adult man (+2) (+6)
Adult woman (+2) (+6)
(menstruating)
Adult woman (+2) (+6)
(postmenopausal)
During pregnancy (+2) (+6)

22. 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

23. Normal Peripheral Smear

24. Microcytic Hypochromic RBC’s with anisocystosis and poikilocytosis

25. Macrocytosis

26. Howell-Jolly Bodies

27. Tear-drop shape cell and Nucleated RBC

28. Target Cell

29. RBC Fragmentation

30. Burr cell or Echinocytes

31. Spur Cell