Snapshot 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. Introduction 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 Presentation Symptoms weakness fatigue dyspnea on exertion Physical exam pallor tachycardia systolic flow murmor jaundice positive stool guiac May present as angina Evaluation 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 Differential Microcytic Anemias Findings Iron deficiency Low ferritin Low serum Fe High TIBC Thalassemia HbF increased, low MCV, hemolysis Sideroblastic Anemia High ferritin High serum Fe Low TIBC Lead poisoning Low MCV, basophilic stippling, increased free erythrocyte porphyrins Diamond Blackfan Anemia Megaloblastic anemia with triphalangeal thumbs and a webbed neck 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 Normocytic Labs and Miscellaneous Hypoproliferative Anemia Hemorrhage Watch CVP, not the Hct Chronic disease High ferritin Low serum Fe Low TIBC 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)