Anemia - Fitzgerald

What is the reticulocyte percentage?

% of immature blood cells in circulation The body's normal response to anemia is to attempt correction via increasing the number of young RBC cells (reticulocytes). In healthy persons normal reticulocyte % = 1-2% of RBCs A normal response to anemia is reticulocytosis (>2%) The body releases the reticulocytes early to attempt to increase % of circulating reticulocytes. compensate for the anemia.

Anemia defined

A complex of signs and symptoms characterized by decreases in numbers od RBCs or Hgb content caused by blood loss, deficient erythropoiesis, excessive hemolysis or a combination of these changes Anemia occurs when the insult is severe enough to disturb normal homeostatic mechanism and exceed reserves

One of the earliest laboratory markers in evolving macrocytic or microcytic anemia A. An increase in RBC distribution width (RDW) B. A reduction in measurable hemoglobin C. A low MCH level D. an increased platelet count

A. An increase in RBC distribution width (RDW)

65 yo with Rheumatoid arthritis hgb 10.1 RBC 3.2 MCV 82 RDW 12.8 Retic 0.7 (1-2) Findings consistent with: IDA- (RDW tends to be high) Folate deficiency ACD Alpha minor

ACD

What is the RDW (RBC distribution width)? RDW is when the bone marrow releases cells of different sizes

An index variation in RBC size- (NL=11.5-15%) Abnormal Value = greater than 15% indicating that new cells differ in size (larger or smaller) when compared with older cells ~~ This is one of the earliest laboratory indicators of an evolving microcytic or macrocytic anemia Qualification of anisocytosis, or abnormal variation in RBC size

Rule number 1- anemia

Anemia is a decrease in the RBCs (85% of iron is stored), Hgb, and or Crit. If anyone are low your patient has anemia.

Rule number 2- Anemia

Anemia is not a diagnosis it is a sign of an underlying problem that you must figure out

Microcytic hypochromic/w normal RDW Alpha or beta thalassemia minor

At risk ethnic groups for alpha minor is Asian, african ancestry (AAA) At risk for beta minor African Mediterranean, middle eastern ancestry (BAMME) through inherited genetic variation, small microcytic, pale hypochromic cells that are all around the same size NL RDW Hgb-decreased Hct=decreased RBC increased MCV decreased MCHC decreased RDW WNL next step test= hgb electrophoresis for evaluation of hemoglobin variants 27 yo man of African ancestry w beta minor (CBC results reflect younger adult male norms) HGB= 11.6 (14-16) Hct=36.7 (42-48) RBC=6.38 (4.7-6.10) MCV=69.5 (81-100) microcytic MCH=22 (27-33) RDW=13.8 (11.5-15) In bone marrow suppression they look at RBCs

you advise a 28 yo vegan (female) to supplement with Vitamn A Iron B-12 Folic Acid

B-12

You examine a 47-year-old man who presents with difficulty initiating and maintaining sleep and chronic pharyngeal erythema with the following results on hemogram: Hgb = 15g (normal 14 - 16) Hct = 45% (normal 42% to 48%) RBC = 4.8 million mm3 (normal 4.7 to 6.1 million mm3) MCV = 108 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL (normal 31 to 37 g/dL) These values are most consistent with: A. Pernicious anemia B. Alcohol abuse C. Thalassemia minor D. Fanconi disease

B. Alcohol abuse

A 40-year-old woman with pyelonephritis is taking two medications: ciprofloxacin and ferrous selfate (for iron-deficiency anemia). She asks about taking both medications. You advise that: A. Should should take the medications with a large glass of water. B. An inactive drug compound is potentially formed if the two medications are taken together. C. She can take the medications together to enhance adherence to therapy. D. The ferrous sulfate potentially slows gastrointestinal motility and results in enhanced ciprofloxacin absorption.

B. An inactive drug compound is potentially found if the two medications are taken together

You examine a 57-year-old woman with rheumatoid arthritis who is on a disease-modifying antirheumatic drug (DMARD) but continues to have poor disease control and find the following results of hemogram: Hgb = 10.5 g Hct = 33% RBC = 3.1 million mm3 MCV = 88 fL MCHC = 32.8 g/dL RDW = 12.2% Reticulocytes = 0.8% The laboratory findings are most consistent with: A. Pernicious anemia B. Anemia of chronic disease C. Beta thalassemia minor D. Folate-deficiency anemia

B. Anemia of chronic disease

Risk factors for folate-deficiency anemia include: A. Menorrhagia B. Chronic ingestion of overcooked foods C. Use of nonsteroidal anti-inflammatory drugs D. Gastric atrophy

B. Chronic ingestion of overcooked foods

Two months into therapy for pernicious anemia, you wish to check the efficacy of the intervention. The best laboratory test to order at this point is a: A. Schilling test B. Hemoglobin measurement C. Reticulocyte count D. Serum Cobalamin

B. Hemoglobin measurement

When counseling a patient about the neurological alterations often associated with vitamin B12 deficiency, the NP advises that: A. These usually resolve within days with appropriate therapy B. If present for longer than 6 months, these changes are occasionally permanent C. The use of parenteral vitamin B12 therapy is needed to ensure symptom resolution D. Cognitive changes associated with vitamin B12 deficiency are seldom reversible even with appropriate therapy

B. If present for longer than 6 months, these changes are occasionally permanent

Pernicious anemia is usually caused by: A. Dietary deficiency of vitamin B12 B. Lack of production of intrinsic factor by the gastric mucosa C. RBC enzyme deficiency D. A combination of micronutrient deficiencies caused by malabsorption

B. Lack of production of intrinsic factor by the gastric mucosa

Which of the following is most consistent with iron-deficiency anemia? A. Low mean corpuscular volume (MCV), mornal mean corpuscular hemoglobin (MCH) B. Low MCV, Low MCH C. Low MCV, elevated MCH D. Normal MCV, normal MCH

B. Low MCV, low MCH

A 68-year-old man who is usually healthy presents with new onset of "huffing and puffing" with exercise for the past 3 weeks. Physical examination reveals conjunctiva pallor and a hemic murmur. Hemogram results are as follows: Hgb = 7.6 g Hct = 20.5% RBC = 2.1 million mm3 MCV = 76 fL MCHC = 28 g/dL RDW = 18.4% Reticulocytes = 1.8% The most likely cause of these findings is: A. Poor nutrition B. Occult blood loss C. Malabsorption D. Chronic inflammation

B. Occult blood loss

Which of the following conditions is unlikely to result in anemia of chronic disease? A. Rheumatoid arthritis B. Peripheral vascular disease C. Chronic renal insufficiency D. Osteomyelitis

B. Peripheral vascular disease

Most of the body's iron is obtained from: A. Animal-based food sources B. Recycled iron content from aged red blood cells (RBCs) C. Endoplasmic reticulum production D. Vegetable-based food sources

B. Recycled iron content from aged red blood cells (RBCs).

Common physical examination findings in patients with pernicious anemia include: A. Hypoactive bowel sounds B. Stocking-glove neuropathy C. Thin, spoon-shaped nails D. Retinal hemorrhages

B. Stocking-glove neuropathy

When prescribing erythropoietin supplementation, the nurse practitioner considers that: A. The adrenal glands are its endogenous source. B. The addition of micronutrient supplementation needed for erythropoiesis is advisable C. Its use is as an adjunct in treating thrombocytopenia D. With its use, the RBC life span is prolonged

B. The addition of micronutrient supplementation needed for erythropoiesis is advisable

Intervention in anemia of chronic disease most often includes: A. Oral vitamin B12 B. Treatment of the underlying condition C. Transfusion D. Parenteral iron

B. Treatment of the underlying condition

32 yo well female of Mediterranean ancectry HB10.6 (12-14) hct 32%(36-42) *RBC 6.2 (4.2-5.4) MCV 71 (80-96) microcytic MCHC 25.2 (31-37)hypochromic *RDW 12% (not iron not lead) Findings are consistent with IDA Cooleys Anemia (if you never heard of it its not your answer) Beta Thal minor Acute blood loss

Beta Thalassemia Minor

Rule number 3 -3 causes of anemia

Blood loss deficient erythropoietin (90% comes from kidney) excessive hemolysis

78 year woman presents with fatigue, spoon shaped nails and the following laboratory hgb9 Hct 28.1 RBC 2.4 MCV 70 microcytic MCHC 24.2 hypochromic RDW19% elevated - GI blood loss (85% of iron stored in RBC) -Micronutrient malabsorption -Chronic ileitis (Chrons dx) - Folic acid deficiency NEVER Microcytic

Bone marrow working Is it: ID- Thalassemia- No because RDW is elevated TH=RDW WNL P- (Lead tox) - usually young children in geographical areas- old buildings etc. GI Bleed

In health, the ratio of hemoglobin to hematocrit is usually: A. 1:1 B. 1:2 C. 1:3 D. 1:4

C. 1:3

You examine a 22-year-old woman of Asian ancestry. She has no presenting complaint. Hemogram results are as follows: Hgb = 9.1 g (normal 12 - 14) Hct = 28% (normal 36% to 43%) RBC = 5.6 million mm3 (normal 4.2 to 5.4 million mm3) MCV = 68 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL (normal 31 to 37 g/dL) RBC distribution width (RDW) = 13% (normal <15%) Reticulocytes = 1.5% (normal 1% to 2%) This is most consistent with: A. Iron-deficiency anemia B. Cooley anemia C. Alpha-thalassemia minor D. Hemoglobin Barts

C. Alpha-thalassemia minor

An increase in the normal variation of RBC size is known as: A. Poikilocytosis B. Granulation C. Anisocytosis D. Basophilic strippling

C. Anisocytosis

A woman who is planning a pregnancy should increase her intake of which of the following to minimize the risk of neural tube defect in the fetus? A. Iron B. Niacin C. Folic acid D. Vitamin C

C. Folic acid

Which of the following is not consistent with anemia of chronic disease (ACD)? A. NL RDW B. NL MCHC C. Hct less than 24% D. Nl to slightly elevated serum ferritin

C. Hct less than 24%

In the first weeks of anemia therapy with parenteral vitamin B12 in a 68-year-old woman with hypertension who is taking a thiazide diuretic, the patient should be carefully monitored for: A. Hypernatremia B. Dehydration C. Hypokalemia D. Acidemia

C. Hypokalemia

When the cause of macrocytic anemia is uncertain, the most commonly recommended additional testing includes which of the following: A. Haptoglobin and reticulocyte count B. Schilling test and gastric biopsy C. Methylmalonic acid and homocysteine D. Transferrin and prealbumin

C. Methylmalonic acid and homocysteine

A 48-year-old woman developed iron-deficiency anemia after excessive perimenopausal bleeding, successfully treated by endometrial ablation. Her hematocrit level is 25%, and she is taking iron therapy. At 5 days into therapy, one possible observed change in laboratory parameters would include A. A correction of mean cell volume B. An 8% increase in Hct level C. Reticulocytosis D. A correction in ferritin level

C. Reticulocytes

Results of hemogram in a person with anemia of chronic disease include: A. Microcytosis B. Anisocytosis C. Reticulocytopenia D. Macrocytosis

C. Reticulocytopenia

Poikilocytosis refers to alterations in a red blood cell's: A. Thickness B. Color C. Shape D. Size

C. Shape

Which of the following is the best advice on taking ferrous sulfate to enhance iron absorption A. "Take with other medications" B. "Take on a full stomach" C. "Take on an empty stomach" D. "Do not take with vitamin C"

C. Take on an empty stomach

A healthy 34-year-old man asks whether he should take an iron supplement. You respond that.. A. This is a prudent measure to ensure health. B. Iron-deficiency anemia is a common problem in men of his age C. Use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload D. Excess iron is easily excreted

C. Use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload

Chronic low volume blood loss

Chroninc low volume blood loss from erosive gastritis, menorrhagia, GI malignancy- others Iron from RBC wasted via blood loss cannot be recycled. Clinically significant blood loss can be as little as a few mL/d

In children younger than age 6 years, accidental over-dose of iron-containing products is: A. Easily treated B. A source of significant gastrointestional (GI) tract upset C. Worrisome but rarely causes significant harm D. A leading cause of fatal poisoning in the age-group

D. A leading cause of fatal poisoning in the age-group

Worldwide, which of the following is the most common type of anemia? A. Pernicious anemia B. Folate-deficiency anemia C. Anemia of chronic disease D. Iron-deficiency anemia

D. Iron deficiency anemia

Folate-deficiency anemia causes which of the following changes in the RBC indices? A. Microcytic, normochromic B. Normocytic, normochromic C. Microcytic, hypochromic D. Macrocytic, normochromic

D. Macrocytic, normochromic

Pernicious anemia causes which of the following changes in the RBC indices? A. Microcytic, normochromic B. Normocytic, normochromic C. Microcytic, hypochromic D. Macrocytic, normochromic

D. Macrocytic, normochromic

You examine a 27-year-old woman with menorrhagia who is otherwise well and note the following results on hemogram: Hgb = 10.1 g Hct = 32% RBC = 2.9 million mm3 MCV = 72 fL MCHC = 28.2 g/dL RDW = 18.9% Physical examination is likely to include: A. Conjunctive pallor B. Hemic murmur C. Tachycardia D. No specific anemia-related findings

D. No specific anemia-related findings

Erythropietin is a glycoprotein that influences a stem cell to become a: A. Lymphocyte B. Platelet C. Neutrophil D. Red blood cell

D. Red blood cell

Macrocytic (MCV>96 fl) normochromic anemia w/ elevated RDW FAT RBC

F=Fetus pregnancy rare A=Alchol excess T=Thyroid disease (hypothyroidism) R=Reticulocytosis B= B12 and folate deficiency C=Cirrhosis and chronic liver disease Abnormally large macrocytic cells due to altered RNA:DNA ratio- Hemoglobin content WNL normochromic new cells larger thanolder cells (elevated RDW) HB=decreased Hct= Decreased RBC= decreased MCV= increased MCHC WNL RDW= increased Next step test Vit b-12 and RBC folate 72 yo woman w/ untreated pernicious anemia (most common form of B12 deficiency) HGb=8.2 (12-14) Hct= 25% (36-43) RBC=2.7 (4.2-5.4) MCV=125.5 (81-96)macrocytic MCH= 31 (27-33) normochromic RDW 18.8 (11.5-15%) BM pumping out cells that are big

Nutritional supplements associated with bleeding and should be used with caution in pre surgery 7-10 days and patients who take asa and anticoagulants include Ginseng Ginko Fish oils Vitamin D TorF

G=true G=true Fish=true Vitamin D=false

What is the most common type of Anemia in childhood during Pregnancy In females during productive years In the elderly

ID ID ID Anemia of chronic dx

Microcytic, hypochromic (MCV<80)anemia w/ elevated RDW (LIT)

Lead toxicity Iron deficiency Thalassemia Small cell microcytic due to insufficient hemoglobin (hemo-iron, globin protein)(hypochromic) with new cells smaller than the old cells elevated RDW HB= decreased HCT=decreased RBC= decreased MCV= decreased MCHC= decreased RDW=INCREASED Next step to test for ferritin level for estimated of iron stores lead testing in younger children, testing for thalassemia 68yo man w/ erosive gastritis (IDA) 48 yo female w/ mennorhagia (IDA) 3 yo with plumbism (lead tox) HGB=10.1(12-14) Hct 32% ((36-43) RBC3.2 (4.2-5.4) MCV 72 (81-96) Microcytic MCHC 26.8 (31-37) Hypochromic RDW 18.1 (11.5-15) Bone marrow pumping out cells not thalassemia Lead or ID

Match the best next test to order in an adult with anemia based on hemogram results

MCV decreased, MCHCdecreased RDW increased= Ferritin (MVC decreased) MCV decreased, MCHC decreased, RDW WNL= Vitamin b12 and folate MCV increase MCHC NL RDW increase= Hemoglobin electrophoresis

In an evolving microcytic anemia....... The MCV______and the RDW______.

MCV decreases and RDW increases

In an evolving macrocytic anemia as the MCV___ the RDW____.

MCV increase the RDW increases

Anemia Type- Normocytic (MCV= 80-96) normochromic anemia with NL RDW MR B Calm

Marrow failure Renal failure Blood loss Chronic disease Aplastic Anemia Leukemia Metastasis Cancer 1) ACD 2)Acute blood loss 3) Early Iron deficiency Cells made with sufficient Iron, B12, folate, other micronutrients Hb- decreased HCT- decreased RBC decreased MCV WNL MCHC WNL RDW WNL 72 yo male w an acute GI bleed (ABL)and a 32 yo female with a new dx of lupus erythematosus (ACD) Hgb- 10.1 (12-14) HCT 32% (36-43) RBC 3.2 (4.2-5.4) MCV- 82 (81-100) Normocytic MCHC 34.8 (31-370 ) normochromic RDW- 12.1% (11.5-15) =bone marrow suppresion

Drug induced macrocytosis usually w/o anemia Alchol excess, antiepileptic drugs(AED) including carbamazepine Tegretol phenytoin Dilantin, methotrexate

Most common etiology >5 alcoholic drinks per day in men and >3 in women 1 beer=12oz 5oz glass of wine 1.5oz of 80 proof liquor HGB,HCT,RBC all WNL MCV=increased MCHC and RBC= WNL Reversible when use of offending medication is stopped but usually not a reason to curtail the drugs use EXEPT excessive alcohol intake 32 yo female taking phenytoin 38 yo woman who drinks 5 glasses of wine per day Hgb= 12 Hct=37 RBC 4.2 MCV=105.5 (81-96) macrocytic MCH= 31 (27-33) RDW 12.8 11.5-15) drug induced macrocytic anemia

Premature destruction anemia

Most uncommon Hemolysis, shortened RBC lifespan (Normal life span is 90-120 Days) Shortened RBC lifespan= pat of mechanism in anemia of chronic disease. Hemolysis= uncommon in primary care

68 year old woman presents with 6 month hx of increasing sever peripheral numbness and oral irritation Hgb=6.2 Hct= 20% RBC= 2.1 MCV=132- MACRO MCHC=32.4 NORMOchromic RDW 19% pumping out big cells PE= pale conjunctiva, grade 2/6 systolic ejection murmur over the precordium without radiation and a smooth red tongue

Peripheral numbness pale conjunctiva smooth red tongue are classic signs of B-12 deficiency ID is NEVER macrocytic Hemolysis- presents like acute bleed Chronic disease is NEVER MACRO B12 def is the answer the murmur was never heard before and will likely resolve with treatment of anemia - It s likely a _________murmur -Pathologic- valve problem(no) -Hemic- Physiologic murmur turbulent blood!! YES -Venus hum and Congenital are pediatrics-no

What is red blood cells hemoglobin content (RBC color remains unchanged during rbcs 90-120 lifespan)

Reflected by mean cell hemoglobin MCH- mean cell hemoglobin concentration MCHC= (color) Hemoglobin RBCs color source (-chromic) Hemoglobin= 90% of RBC volume Normochromic =normal color=MCHC+31-37g/dL (310-370) Hypochromic = Pale=MCHC <31 (310)

What are hematocrit, hemoglobin and RBC values

Values should be proportionately decreased Normally Hbg to hematocrit ratio is 1:3 10g/dL (100g/L)= 30% 10x3=30 12g/dL (120g/L)= 36% 12x3=36 15g/dL (120g/L)= 45% 15x3=45

What is the red blood cell size? (rbc size remains unchanged guring the 90-120 day lifespan)

Wintrobes classification of anemia by evaluation of mean corpuscle volume (MCV) (SIZE) microcytic- small cell- MCV=<80fl normocytic normal cell size- MCV= 80-100fl macrocytic abnormally large cell size >100fl

Oral iron therapy maximizes efficacy

by taking on an empty stomach and take w/ oj on an empty stomach

Acute blood loss

mechanism- In adult >1L blood loss before clinically significant drop in hemoglobin - Uncommon in Primary care Hemorrhage most likely cause of sudden dangerous drop in HCT and Hb. Canusually be rued out/in by Health history and or physical exam.

reduced RBC production

most common in primary care setting Nutritional deficit- B12, folic acid, iron deficiency anemia of chronic disease (ACD), bone marrow suppression, use of certain meds like PPI (B12 and Iron), Metformin (B12), reduced erythropoietin production (Chronic renal failure) Also associated with the use of select medications that prevent micronutrient absorption including chronic PPI use (B12 and iron malabsorption) metformin( B12 malabsorption

Primary care of a 27 to w beta thalassemia minor should include

offering genetic counseling prior to pregnancy

intervention in anemia

treat the underlying cause- for this to be effective, etiology of anemia must be accurately determined. In severe and or chronic anemia's consider multiple causes replace the micronutrients like Fe or B12 and folate vitamins Micronutrients requirements increase reticulocytosis EPO or Procrit: as indicated. Biologically identical to endogenous erythropoietin, indices erythropoiesis helpful in severe anemia, especially if renal failure- erythropoietin supply is diminished in advancing renal failure (check GFR if needed) GFR<49 (normal 90-120)