• A 20-year-old woman who is a vegan with a history of heavy menses presents with fatigue.  She states that she barely has the energy to do anything anymore.  She denies substance abuse and states she gets a good 9 hours of sleep every night.  On exam you see a thin young woman who is tired appearing with palor of her conjunctivae on physical exam.  Her blood pressure is 95/60 mmHg and pulse is 88/minute.

  • Defined as low hematocrit and/or hemoglobin relative to normal values
  • Risk factors include
    • neoplasia
    • family history
    • alcoholism
    • GI bleeding
    • vegan diet
    • African-American descent
    • Mediterranean descent
  • Symptoms
    • weakness
    • fatigue
    • dyspnea on exertion
  • Physical exam
    • pallor
    • tachycardia
    • systolic flow murmor
    • jaundice
    • positive stool guiac
  • May present as angina
  • Initially assess 
    • hematocrit
    • MCV
    • reticulocyte count
    • peripheral blood smear
  • If microcytic follow with
    • ferritin
    • iron
    • TIBC
  • If macrocytic follow with
    • RBC folate
    • serum B12
  • If normocytic follow with
    • Coombs test
    • iron studies
    • bilirubin
  • Screen for malignancy, haptoglobin levels, and Guiac
Microcytic Anemias
Iron deficiency  
Low ferritin
Low serum Fe
Thalassemia HbF increased, low MCV, hemolysis
Sideroblastic Anemia
High ferritin
High serum Fe
Lead poisoning Low MCV, basophilic stippling, increased free erythrocyte porphyrins            
Macrocytic Anemia
Labs and Miscellaneous
B12 / Folate deficiency  Increased MCV, increased LDH, decreased haptoglobin
Hemolytic Anemia Mechanical Increased reticulocyte count
Immunologic Positive Coombs test
Drug exposure History of phenytoin, phenobarbital, or MTX
Diamond-Blackfan  Congenital "pure RBC anemia" with triphalangeal thumbs and a webbed neck
Labs and Miscellaneous
Hypoproliferative Anemia
Hemorrhage Watch CVP, not the Hct 
Chronic disease
High ferritin
Low serum Fe
Renal failure
Infection Osteomyelitis, HIV, Mycoplasma, or EBV
Bone marrow disease  Leukemia, lymphoma, or myelodysplasia
Intrinsic Hemolysis
G6PD Decreased serum haptoglobin
Hereditary spherocytosis Decreased serum haptoglobin
Extrinsic Hemolysis
Cold agglutinins Osteomyelitis, HIV, Mycoplasma, or EBV
Autoimmune  Increased LDH, K+ and bilirubin, decreased haptoglobin
Mechanical destruction Microangiopathic Hemolytic (TTP, HUS, or DIC)


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