Anemia

Ways to work-up anemia, MCV (normocytic, macrocytic, microcytic, mixed), reticulocyte count.

Objectives

1. Assess the risk of decompensation of anemic patients (e.g., volume status, the presence of congestive heart failure [CHF], angina, or other disease states) to decide if prompt transfusion or volume replacement is necessary.
2. In a patient with anemia, classify the anemia as microcytic, normocytic, or macrocytic by using the MCV (mean corpuscular volume) or smear test result, to direct further assessment and treatment.
3. In all patients with anemia, determine the iron status before initiating treatment.
4. In a patient with iron deficiency, investigate further to find the cause.
5. Consider and look for anemia in appropriate patients (e.g., those at risk for blood loss [those receiving anticoagulation, elderly patients taking a nonsteroidal anti-inflammatory drug]) or in patients with hemolysis (mechanical valves), whether they are symptomatic or not, and in those with new or worsening symptoms of angina or CHF.
6. In patients with macrocytic anemia:
   • Consider the possibility of vitamin B12 deficiency.
   • Look for other manifestations of the deficiency (e.g., neurologic symptoms) in order to make the diagnosis of pernicious anemia when it is present.
7. As part of well-baby care, consider anemia in high-risk populations (e.g., those living in poverty) or in high-risk patients (e.g., those who are pale or have a low-iron diet or poor weight gain).
8. When a patient is discovered to have a slightly low hemoglobin level, look carefully for a cause (e.g., hemoglobinopathies, menorrhagia, occult bleeding, previously undiagnosed chronic disease), as one cannot assume that this is normal for them.
9. In anemic patients with menorrhagia, determine the need to look for other causes of the anemia.