anemia – an approach james czarnecki, d.o. internal medicine resident lecture series

Anemia – An Approach

James Czarnecki, D.O.James Czarnecki, D.O.Internal Medicine Resident Lecture SeriesInternal Medicine Resident Lecture Series

Background

Definition

Strictly defined as a decrease in red blood Strictly defined as a decrease in red blood cell (RBC) mass.cell (RBC) mass.

Usually discovered and quantified by Usually discovered and quantified by measurement of the RBC count, measurement of the RBC count, hemoglobin concentration, and hematocrit.hemoglobin concentration, and hematocrit.

Frequency

WHO chose 12.5 g/dL for both adult males and WHO chose 12.5 g/dL for both adult males and females.females.

In the US, limits of 13.5 g/dL for men and 12.5 In the US, limits of 13.5 g/dL for men and 12.5 g/dL for women – these values are more realistic.g/dL for women – these values are more realistic.

Using these values, approximately 4% of men and Using these values, approximately 4% of men and 8% of women have lower values.8% of women have lower values.

A significantly greater prevalence is observed in A significantly greater prevalence is observed in patient populations.patient populations.

Mortality / Morbidity

Varies greatly depending on etiology.Varies greatly depending on etiology. Acute hemorrhage has variable mortality Acute hemorrhage has variable mortality

depending on the site of bleeding (80% with aortic depending on the site of bleeding (80% with aortic rupture, 30-50% with bleeding esophageal varices, rupture, 30-50% with bleeding esophageal varices, approx. 1% with benign peptic ulcers).approx. 1% with benign peptic ulcers).

The 2-year fatality rate for severe aplastic anemia The 2-year fatality rate for severe aplastic anemia is 70% without bone marrow transplantation or a is 70% without bone marrow transplantation or a response to immunosuppressive therapy.response to immunosuppressive therapy.


Many symptoms associated with anemia are not Many symptoms associated with anemia are not caused by diminished RBC mass.caused by diminished RBC mass.

Patients with pernicious anemia are often Patients with pernicious anemia are often asymptomatic when they are detected incidentally asymptomatic when they are detected incidentally with an Hb of 6 g/dL.with an Hb of 6 g/dL.

Patients with iron deficiency anemia develop Patients with iron deficiency anemia develop symptoms at Hb of 10-11 g/dL because of symptoms at Hb of 10-11 g/dL because of depletion of iron-containing protein other than Hb.depletion of iron-containing protein other than Hb.


Tolerance of anemia is proportional to the Tolerance of anemia is proportional to the anemia’s rate of development.anemia’s rate of development.

Symptoms and mortality associated with Symptoms and mortality associated with rapidly developing anemia are more rapidly developing anemia are more profound than in slowly developing anemia.profound than in slowly developing anemia.

Race

Certain races and ethnic groups have an Certain races and ethnic groups have an increased prevalence of genetic factors increased prevalence of genetic factors associated with certain anemias. For associated with certain anemias. For example:example: HemoglobinopathiesHemoglobinopathies ThalassemiaThalassemia G6-PD deficiencyG6-PD deficiency

Sex

Anemia is twice as prevalent in females than in Anemia is twice as prevalent in females than in males. This difference is significantly greater males. This difference is significantly greater during the childbearing years due to pregnancies during the childbearing years due to pregnancies and menses.and menses.

Approximately 65% of body iron is incorporated Approximately 65% of body iron is incorporated into circulating Hb. Each gram of Hb contains into circulating Hb. Each gram of Hb contains 3.46 mg of iron. 3.46 mg of iron.

Each healthy pregnancy depletes a mother of Each healthy pregnancy depletes a mother of approximately 500 mg of iron.approximately 500 mg of iron.

Sex

A male must absorb about 1 mg of iron to A male must absorb about 1 mg of iron to maintain equilibrium, a premenopausal maintain equilibrium, a premenopausal female must absorb an average of 2 mg female must absorb an average of 2 mg daily.daily.

Females have a markedly lower incidence Females have a markedly lower incidence of anemia from X-linked anemias such as of anemia from X-linked anemias such as G6PD deficiency and sex-linked G6PD deficiency and sex-linked sideroblastic anemia.sideroblastic anemia.

Age

Severe genetically acquired anemias (ie, Severe genetically acquired anemias (ie, sickle cell disease, thalassemia, Fanconi sickle cell disease, thalassemia, Fanconi Syndrome) are more commonly found in Syndrome) are more commonly found in children because they do not survive to children because they do not survive to adulthood.adulthood.

During the childbearing years, women are During the childbearing years, women are more likely to become iron deficient.more likely to become iron deficient.

Age

Neoplasia increased the prevalence with Neoplasia increased the prevalence with each decade of life and can produce anemia each decade of life and can produce anemia fromfrom bleedingbleeding from the replacement of bone marrow from the replacement of bone marrow

with tumor with tumor from the development of anemia from the development of anemia

associated with chronic disordersassociated with chronic disorders

Age

Use of aspirin, NSAIDs, and coumadin Use of aspirin, NSAIDs, and coumadin increases with age and can produce increases with age and can produce gastrointestinal bleeding.gastrointestinal bleeding.

Clinical Approach

History

Carefully obtain a history and perform a Carefully obtain a history and perform a physical examination in every patient with physical examination in every patient with anemia because the findings usually provide anemia because the findings usually provide important clues to the etiology of the important clues to the etiology of the underlying disorder.underlying disorder.

Areas of inquiry found valuable are the Areas of inquiry found valuable are the following.following.

History

The duration can be established by obtaining a The duration can be established by obtaining a history of previous blood examinationhistory of previous blood examination

Obtain a careful family not only for anemia but Obtain a careful family not only for anemia but also for jaundice, cholelithiasis, splenectomy, also for jaundice, cholelithiasis, splenectomy, bleeding disorders, and abnormal Hbs. bleeding disorders, and abnormal Hbs.

Carefully document pregnancies, abortions, and Carefully document pregnancies, abortions, and menstrual loss.menstrual loss.

History

Patients do not appreciate the significance of tarry Patients do not appreciate the significance of tarry stools. Changes in bowel habits can be useful in stools. Changes in bowel habits can be useful in uncovering neoplasms of the colon.uncovering neoplasms of the colon.

Hemorrhoidal blood loss is difficult to quantify, Hemorrhoidal blood loss is difficult to quantify, and it may be overlooked or overestimated from and it may be overlooked or overestimated from one patient to another.one patient to another.

Seek a careful history of gastrointestinal Seek a careful history of gastrointestinal complaints that may suggest gastritis, peptic complaints that may suggest gastritis, peptic ulcers, hiatal hernias, or diverticula.ulcers, hiatal hernias, or diverticula.

History

Abnormal urine color can occur in renal and Abnormal urine color can occur in renal and hepatic disease and in hemolytic anemia.hepatic disease and in hemolytic anemia.

A thorough dietary history is important in a A thorough dietary history is important in a patient who is anemic. It must include foods that patient who is anemic. It must include foods that the patient both eats and avoids, as well as an the patient both eats and avoids, as well as an estimate of their quantity.estimate of their quantity.

Nutritional deficiencies may be associated with Nutritional deficiencies may be associated with unusual symptoms that can be elicited by a unusual symptoms that can be elicited by a history.history.

History

Obtain a history or presence of fever Obtain a history or presence of fever because infections, neoplasms, and collagen because infections, neoplasms, and collagen vascular disease can cause anemia. vascular disease can cause anemia.

Cold intolerance can be an important Cold intolerance can be an important symptom of hypothyroidism or lupus symptom of hypothyroidism or lupus erythematosus.erythematosus.

History

Relation of dark urine to either physical Relation of dark urine to either physical activity or time of day can be important in activity or time of day can be important in march hemoglobinuria, or paroxysmal march hemoglobinuria, or paroxysmal nocturnal hemoglobinuria.nocturnal hemoglobinuria.

Explore the presence or the absence of Explore the presence or the absence of symptoms suggesting an underlying symptoms suggesting an underlying disease, such as cardiac, hepatic, and renal disease, such as cardiac, hepatic, and renal disease; chronic infection, or malignancy.disease; chronic infection, or malignancy.

Physical

Physical

Too often, the physical is rushed without Too often, the physical is rushed without looking at the patient for an unusual habitus looking at the patient for an unusual habitus or appearance of underdevelopment, or appearance of underdevelopment, malnutrition, or chronic illness.malnutrition, or chronic illness.

Examine optic fundi carefully, but not at the Examine optic fundi carefully, but not at the expense of the conjunctivaie and the expense of the conjunctivaie and the sclerae, which can show pallor, icterus, sclerae, which can show pallor, icterus, petechia, or telangiectasia.petechia, or telangiectasia.

Physical

Perform systematic examination for Perform systematic examination for palpable enlargement of lymph nodes for palpable enlargement of lymph nodes for evidence of infection or neoplasia.evidence of infection or neoplasia.

Carefully search for both hepatomgaly and Carefully search for both hepatomgaly and splenomegaly. Their presence or absence is splenomegaly. Their presence or absence is important, as are the size, the tenderness, important, as are the size, the tenderness, the firmness, and the presence or absence of the firmness, and the presence or absence of nodules.nodules.

Physical

A rectal and pelvic examination cannot be A rectal and pelvic examination cannot be neglected because tumor or infection of neglected because tumor or infection of these organs can be the cause of anemia.these organs can be the cause of anemia.

The neurologic examination should include The neurologic examination should include tests of position sense and vibratory sense, tests of position sense and vibratory sense, examination of the cranial nerves, and examination of the cranial nerves, and testing for tendon reflexes.testing for tendon reflexes.

Physical

The heart should not be ignored because The heart should not be ignored because enlargement may provide evidence of the enlargement may provide evidence of the duration and severity of an underlying duration and severity of an underlying anemia, and murmurs may be the first anemia, and murmurs may be the first evidence of a bacterial endocarditis, which evidence of a bacterial endocarditis, which could explain an etiology of an underlying could explain an etiology of an underlying anemia.anemia.

Causes

Causes

GeneticGenetic HemoglobinopathiesHemoglobinopathies ThalassemiasThalassemias Defects of the RBC cytoskeletonDefects of the RBC cytoskeleton Rh null diseaseRh null disease Hereditary xerocytosisHereditary xerocytosis Fanconi anemiaFanconi anemia

Causes

NutritionalNutritional Iron deficiencyIron deficiency Vitamin B-12 deficiencyVitamin B-12 deficiency Folate deficiencyFolate deficiency Starvation and generalized malnutritionStarvation and generalized malnutrition

HemorrhageHemorrhage Immunologic – Antibody-mediated abnormalitiesImmunologic – Antibody-mediated abnormalities

Causes

Physical effectsPhysical effects TraumaTrauma BurnsBurns FrostbiteFrostbite Prosthetic valves and surfacesProsthetic valves and surfaces

Drugs and chemicalsDrugs and chemicals Aplastic anemiaAplastic anemia Megaloblastic anemiaMegaloblastic anemia

Causes

Chronic diseases and malignanciesChronic diseases and malignancies Renal diseaseRenal disease Hepatic diseaseHepatic disease Chronic infectionsChronic infections NeoplasiaNeoplasia Collagen vascular diseasesCollagen vascular diseases

Causes

InfectionsInfections Virals – Hepatitis, infectious Virals – Hepatitis, infectious

mononucleosis, cytomegalovirusmononucleosis, cytomegalovirus Bacterial – Clostridia, gram-negative Bacterial – Clostridia, gram-negative

sepsissepsis Protozoal – Malaria, leishmaniasis, Protozoal – Malaria, leishmaniasis,

toxoplasmosistoxoplasmosis

Differentials

Differentials

Aplastic AnemiaAplastic Anemia Cooley AnemiaCooley Anemia Hemolytic AnemiaHemolytic Anemia Iron Deficiency AnemiaIron Deficiency Anemia Low LDL CholesterolLow LDL Cholesterol Megaloblastic AnemiaMegaloblastic Anemia Pernicious AnemiaPernicious Anemia

Differentials

Sickle Cell AnemiaSickle Cell Anemia Spur Cell AnemiaSpur Cell Anemia Thalassemia, AlphaThalassemia, Alpha Thalassemia, BetaThalassemia, Beta

Work Up

Work Up

Detection of anemia involves the adoption Detection of anemia involves the adoption of arbitrary criteria. In the US:of arbitrary criteria. In the US: Anemia is suggested in male with Hb Anemia is suggested in male with Hb

levels less than 13.5 g/dL and in females levels less than 13.5 g/dL and in females with Hb levels less than 12.5 g/dL.with Hb levels less than 12.5 g/dL.

Once the existence of anemia is established, Once the existence of anemia is established, investigate the pathogenesis.investigate the pathogenesis.

Work Up

A rational approach is to begin by A rational approach is to begin by examining the peripheral smear and examining the peripheral smear and laboratory values obtained on the blood laboratory values obtained on the blood count. If the anemia is either microcytic count. If the anemia is either microcytic (MCV < 84) or macrocytic (MCV > 96), the (MCV < 84) or macrocytic (MCV > 96), the investigative approach can be then limited.investigative approach can be then limited.

Work Up

A rapid method of determining whether A rapid method of determining whether cellular indices are normocytic and cellular indices are normocytic and normocromic is to multiply the RBC and normocromic is to multiply the RBC and Hb by 3. The RBC multiplied by 3 should Hb by 3. The RBC multiplied by 3 should equal the Hb, and the Hb multiplied by 3 equal the Hb, and the Hb multiplied by 3 should equal the Hct.should equal the Hct.

Work Up

In microcytic hypochromic anemia, seek a In microcytic hypochromic anemia, seek a source of bleeding. source of bleeding.

The appropriate lab tests are serum iron The appropriate lab tests are serum iron level and TIBC and serum ferritin level. level and TIBC and serum ferritin level.

If the serum iron level is decreased and If the serum iron level is decreased and TIBC is increase, a diagnosis of iron TIBC is increase, a diagnosis of iron deficiency can be made.deficiency can be made.

Work Up

When a normocytic, normochromic anemia When a normocytic, normochromic anemia is encountered, classify the anemia into 3 is encountered, classify the anemia into 3 possible etiologies (ie, blood loss, possible etiologies (ie, blood loss, hemolysis, or decreased production). hemolysis, or decreased production).

In most anemias, one of these causes is the In most anemias, one of these causes is the dominant factor, however in some, more dominant factor, however in some, more than a single cause may play an important than a single cause may play an important role (ie, pernicious anemia).role (ie, pernicious anemia).

Microcytic Hypochromic Anemia (MCV < 83; MCHC < 31)

Serum IronSerum Iron TIBCTIBC Bone Marrow IronBone Marrow Iron CommentComment

Iron DeficiencyIron Deficiency -- ++ 00Responsive to iron Responsive to iron

therapytherapy

Chronic Chronic inflammationinflammation

-- -- ++++Unresponsive to iron Unresponsive to iron

therapytherapy

Thalassemia majorThalassemia major ++ NN ++++++++Reticulocytosis and Reticulocytosis and

indirect indirect bilirubinemiabilirubinemia

Thalassemia minorThalassemia minor NN NN ++++++++ Target CellsTarget Cells

Lead poisoningLead poisoning NN NN ++++Basophilic stippling Basophilic stippling

of RBCsof RBCs

SideroblasticSideroblastic ++ NN ++++++++Ring sideroblasts in Ring sideroblasts in

marrowmarrow

HemoglobinHemoglobin NN NN ++++Hemoglobin Hemoglobin

electrophoresiselectrophoresis

Macrocytic Anemia (MCV > 95)

Megaloblastic bone marrowMegaloblastic bone marrow Deficiency of vitamin B-12Deficiency of vitamin B-12 Deficiency of folic acidDeficiency of folic acid Drugs affecting DNA synthesisDrugs affecting DNA synthesis Inherited disorders of DNA synthesisInherited disorders of DNA synthesis

Macrocytic Anemia (MCV > 95)

Nonmegaloblastic bone marrowNonmegaloblastic bone marrow Liver diseaseLiver disease Hypothyroidism and hypopituitarismHypothyroidism and hypopituitarism Accelerated erythropoiesis (reticulocytes)Accelerated erythropoiesis (reticulocytes) Hypoplastic and aplastic anemiaHypoplastic and aplastic anemia Infiltrated bone marrowInfiltrated bone marrow

Various Forms of RBCs

Macrocyte – Larger than normalMacrocyte – Larger than normal Microcyte – Small than normalMicrocyte – Small than normal Hypochromic – less hemoglobin in cellHypochromic – less hemoglobin in cell Spherocyte – Loss of central pallor, stains Spherocyte – Loss of central pallor, stains

more densely, often microcytic.more densely, often microcytic. Target cell – hypochromic with central Target cell – hypochromic with central

“target” of hemoglobin (liver disease)“target” of hemoglobin (liver disease)


Leptocyte – Hypochromic cell with a normal Leptocyte – Hypochromic cell with a normal diameter and decreased MCVdiameter and decreased MCV

Elliptocyte – Oval to cigar shaped (B-12, folate)Elliptocyte – Oval to cigar shaped (B-12, folate) Schistocyte – Fragmented helmet-shaped RBCSchistocyte – Fragmented helmet-shaped RBC Stomatocyte – Slitlike area of central pallor in Stomatocyte – Slitlike area of central pallor in

erythrocyte (liver disease, acute alcoholism)erythrocyte (liver disease, acute alcoholism)


Tear-shaped RBCs – Drop-shaped erythrocyte, Tear-shaped RBCs – Drop-shaped erythrocyte, often microcytic.often microcytic.

Acanthocyte – Five to 10 spicules of various Acanthocyte – Five to 10 spicules of various lengths and at irregular intervals on the surface of lengths and at irregular intervals on the surface of RBCs.RBCs.

Echninocyte – Evenly distributed spicules on Echninocyte – Evenly distributed spicules on surface of RBCs, usually 10-30 (uremia, peptic surface of RBCs, usually 10-30 (uremia, peptic ulcer, carcinoma)ulcer, carcinoma)

Sickle Cell – Elongated cell with pointed ends. Sickle Cell – Elongated cell with pointed ends. Hemoglobin S and certain types of hemoglobin C.Hemoglobin S and certain types of hemoglobin C.

Imaging Studies

Imaging Studies

Useful in the workup for anemia when a Useful in the workup for anemia when a neoplastic etiology is suggested.neoplastic etiology is suggested.

Permit discovery of the neoplasm or Permit discovery of the neoplasm or centrally located adenopathy.centrally located adenopathy.

Occasionally, they are useful in detecting or Occasionally, they are useful in detecting or confirming the existence of splenomegaly.confirming the existence of splenomegaly.

Procedures

Procedures

Investigate gastrointestinal bleeding by endoscopy Investigate gastrointestinal bleeding by endoscopy and radiographic studies to identify the bleeding and radiographic studies to identify the bleeding site. site.

May leave the source of GI bleeding undetected if May leave the source of GI bleeding undetected if the lesion is small.the lesion is small.

Bone marrow aspirates and biopsy finding are Bone marrow aspirates and biopsy finding are particularly useful in establishing the etiology of particularly useful in establishing the etiology of anemia in patients with decreased production of anemia in patients with decreased production of RBCs.RBCs.

Treatment

Medical Care

Transfusion of packed RBCs should be Transfusion of packed RBCs should be reserved for patients who are actively reserved for patients who are actively bleeding and for patients with a severe and bleeding and for patients with a severe and symptomatic anemiasymptomatic anemia

Nutritional therapy is used to treat iron Nutritional therapy is used to treat iron deficiency, vitamin B12, and folic acid.deficiency, vitamin B12, and folic acid.

Corticosteroids are useful in the treatment Corticosteroids are useful in the treatment of autoimmune hemolytic anemia.of autoimmune hemolytic anemia.

Medical Care

Treatment of aplastic disorders includes Treatment of aplastic disorders includes removal of the offending agent whenever it removal of the offending agent whenever it can be identified, supportive therapy for the can be identified, supportive therapy for the anemia, and prompt treatment of infection.anemia, and prompt treatment of infection.

Surgical Care

Surgical Care

Surgery is useful to control bleeding in patients Surgery is useful to control bleeding in patients who are anemic. who are anemic.

Most commonly, bleeding is from the GI tract, the Most commonly, bleeding is from the GI tract, the uterus, or the bladder.uterus, or the bladder.

Patients should be hemodynamically stable before Patients should be hemodynamically stable before and during surgery.and during surgery.

Splenectomy has been advantageous in hereditary Splenectomy has been advantageous in hereditary spherocytosis and hereditary elliptocysosis.spherocytosis and hereditary elliptocysosis.

Surgical Care

Bone marrow and stem cell transplantation Bone marrow and stem cell transplantation have been used in patients with:have been used in patients with: LeukemiaLeukemia LymphomaLymphoma Multiple myelomaMultiple myeloma MyelofibrosisMyelofibrosis Aplastic diseaseAplastic disease

Consultations

Consultations

Surgical consultation is indicated to control Surgical consultation is indicated to control bleeding, for splenectomy when necessary, and for bleeding, for splenectomy when necessary, and for biopsies to establish the presence of neoplasiabiopsies to establish the presence of neoplasia

Consultation with gastroenterologists is frequently Consultation with gastroenterologists is frequently sought to identify a bleeding site in the gut.sought to identify a bleeding site in the gut.

Urologic consultation may be needed to Urologic consultation may be needed to investigate hematuria.investigate hematuria.

Diet

Iron deficiency anemia is prevalent in geographic Iron deficiency anemia is prevalent in geographic locations where little meat is in the diet.locations where little meat is in the diet.

A strict vegetarian diet requires iron and vitamin A strict vegetarian diet requires iron and vitamin B-12 supplementation.B-12 supplementation.

Folic acid deficiency occurs among people who Folic acid deficiency occurs among people who consume few leafy vegetables.consume few leafy vegetables.

Coexistence of iron and folic acid deficiency is Coexistence of iron and folic acid deficiency is common among Third World nations.common among Third World nations.

Activity

Activity

The activity of patients with severe anemia should The activity of patients with severe anemia should be curtailed until the anemia is partially corrected.be curtailed until the anemia is partially corrected.

Transfusion can often be avoided by ordering bed Transfusion can often be avoided by ordering bed rest.rest.

March hemoglobinuria is a rare hemolytic disorder March hemoglobinuria is a rare hemolytic disorder usually observed in young males. Individuals usually observed in young males. Individuals develop hemoglobinuria after marching or running develop hemoglobinuria after marching or running on hard surfaces. Can be treated by curtailing the on hard surfaces. Can be treated by curtailing the precipitating exercise.precipitating exercise.

Follow Up

Follow Up

Patients with chronic anemia can usually be Patients with chronic anemia can usually be cared for on an outpatient basis. cared for on an outpatient basis.

Follow-up care is necessary to ensure that Follow-up care is necessary to ensure that therapy is being continued and to assess the therapy is being continued and to assess the efficacy of treatment.efficacy of treatment.

The most serious complications of severe The most serious complications of severe anemia arise from tissue hypoxia.anemia arise from tissue hypoxia.

Follow Up

Shock, hypotension, or coronary and Shock, hypotension, or coronary and pulmonary insufficiency can occur.pulmonary insufficiency can occur.

This is more common in older individuals This is more common in older individuals with underlying pulmonary and with underlying pulmonary and cardiovascular disease.cardiovascular disease.

Hemolytic transfusion reactions and Hemolytic transfusion reactions and transmission of infectious disease are risks transmission of infectious disease are risks of blood product transfusions. of blood product transfusions.

Medical / Legal Pitfalls


Negligence in transfusion of either incompatible Negligence in transfusion of either incompatible blood or blood containing a potentially blood or blood containing a potentially identifiable infectious agentidentifiable infectious agent

Failure to recognize a hemolytic transfusion Failure to recognize a hemolytic transfusion reaction and to initiate prompt and appropriate reaction and to initiate prompt and appropriate therapytherapy

Delayed diagnosis, investigation, and treatment of Delayed diagnosis, investigation, and treatment of a neoplastic disorder because the etiology of an a neoplastic disorder because the etiology of an anemia was not pursued in a timely manneranemia was not pursued in a timely manner


Failure to provide appropriate therapy and Failure to provide appropriate therapy and to ensure that the patient has adequate to ensure that the patient has adequate follow-up carefollow-up care

Underestimating the potential severity of an Underestimating the potential severity of an anemia.anemia.

Histopathology

Decreased Production of RBCs

Microcytic Anemia

Peripheral Smear

Bone Marrow Aspirate

Competency Exam

Question #1

All of the following are matched correctly, except:All of the following are matched correctly, except:

(A)(A) Macrocyte – Larger than normalMacrocyte – Larger than normal

(B)(B) Microcyte – Smaller than normalMicrocyte – Smaller than normal

(C)(C) Spherocyte – Loss of central pallorSpherocyte – Loss of central pallor

(D)(D) Schistocyte – Hypochromic cell with a normal Schistocyte – Hypochromic cell with a normal diameterdiameter

(E)(E) Stomatocyte – Slitlike area of central pallor in Stomatocyte – Slitlike area of central pallor in an erythrocyte.an erythrocyte.

Question #2

Which of the following deficiencies would Which of the following deficiencies would most likely lead to megaloblastic anemia?most likely lead to megaloblastic anemia?

A) vitamin E deficiencyA) vitamin E deficiency

B) vitamin BB) vitamin B66 deficiency deficiency

C) iron deficiencyC) iron deficiency

D) folic acid deficiencyD) folic acid deficiency

E) Vitamin B12 deficiencyE) Vitamin B12 deficiency

Question #3

The peripheral blood of a patient with iron The peripheral blood of a patient with iron deficiency anemia will most likely show deficiency anemia will most likely show what picture?what picture?

a) microcytic, hypochromic red cells a) microcytic, hypochromic red cells b) microcytic, normochromic red cells b) microcytic, normochromic red cells c) macrocytic, hypochromic red cells c) macrocytic, hypochromic red cells d) normocytic, hypochromic red cells d) normocytic, hypochromic red cells e) normocytic, normochromic red cellse) normocytic, normochromic red cells

Question #3

The peripheral blood of a patient with iron The peripheral blood of a patient with iron deficiency anemia will most likely show deficiency anemia will most likely show what picture?what picture?

a) microcytic, hypochromic red cellsa) microcytic, hypochromic red cells b) microcytic, normochromic red cells b) microcytic, normochromic red cells c) macrocytic, hypochromic red cells c) macrocytic, hypochromic red cells d) normocytic, hypochromic red cells d) normocytic, hypochromic red cells e) normocytic, normochromic red cellse) normocytic, normochromic red cells

End of Lecture

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anemia – an approach james czarnecki, d.o. internal medicine resident lecture series

Documents

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