Age/sex
|Age/sex |Normal Hemoglobin, g/dL |Normal Hematocrit, % |
|Adolescents |13.0 |40 |
|Adult men |16.0 (±2.0) |47 (±6) |
|Adult women |13.0 (±2.0) |42 (±5) |
|Adult women (postmenopausal) |14.0 (±2.0) |42 (±6) |
|Pregnant women (third trimester) |12.0 (±2.0) |37 (±6) |
Normal Values for Red Blood Cell Indices
| | | |
|Mean cell volume (MCV) |80-95 fL | |
|Mean cell hemoglobin (MCH) |32 ± 2 pg | |
|Mean cell hemoglobin concentration (MCHC) |33 ± 3% | |
|RDW-CV |13 ± 1% | |
|RDW-SD |42 ± 5 fL | |
RDW, red-cell distribution width (a numerical index of the distribution of red blood cell volumes); RDW-CD, ratio of the width of the histogram of the distribution of red blood cell volumes at one standard deviation divided by the MCV; RDW-SD, width of the histogram of the distribution of red blood cell volumes at 20% frequency level
Classification of Anemia by Mean Corpuscular Volume
|Microcytic |Macrocytic |Normocytic |
|Iron deficiency |Megaloblastic: |Many causes, including early stages of all |
|Thalassemia |Vitamin B12 deficiency |anemias |
|Sideroblastic anemia |Folate deficiency |Early stages of iron deficiency |
|Anemia of chronic disease |Myelodysplasia, anemias caused by | |
| |chemotherapy | |
| |Nonmegaloblastic: | |
| |Liver disease | |
| |Increased reticulocytes | |
| |Myxedema/hypothyroidism | |
| |Cold agglutinin | |
Classification of Anemias by Pathophysiology
|Decreased RBC production |Increased destruction of RBC |
|Hemoglobin synthesis: Iron deficiency, thalassemia, anemia |Blood loss from hemolysis (inherited): |
|of chronic disease, sideroblastic anemia |Membrane: Hereditary spherocytosis, elliptocytosis |
|DNA synthesis: Megaloblastic anemia |Hemoglobin: Sickle cell (SC) disease, unstable hemoglobin |
|Stem cell: Aplastic anemia |RBC enzyme abnormalities: Pyruvate kinase, glucose-6-phosphate |
|Bone-marrow infiltration: Carcinoma, lymphoma |dehydrogenase (G6PD) deficiency |
|Pure red-cell aplasia |Blood loss from hemolysis (acquired): |
| |Immune: warm antibody, cold antibody |
| |Traumatic hemolysis: thrombotic thrombocytopenic purpura, |
| |hemolytic-uremic syndrome, mechanical cardiac valve |
| |Infection: clostridial, malarial |
| |Copper toxicity in Wilson's disease |
| |Hypersplenism |
Causes of Iron Deficiency
|Deficient diet (rare) |
|Decreased absorption (rare) |
|Increased iron requirements: |
| Pregnancy |
| Lactation |
|Blood loss: |
| Gastrointestinal |
| Menstrual |
| Blood donation |
|Hemoglobinuria |
|Iron sequestration: |
| Pulmonary hemosiderosis (rare) |
Key Findings from Patient History for Anemia Diagnosis
|Finding |Condition(s) to consider |Comments |
|Change in bowel habits or dark stools, or |Carcinoma of the colon |Chronic blood loss leading to iron-deficiency anemia |
|both | | |
|Menorrhagias or metrorrhagia |Iron deficiency |Anatomic or functional lesions of the uterus causing excessive bleeding |
|Dark urine |Hemolytic anemia |Hemoglobinuria |
|Poor diet and high alcohol intake |Megaloblastic |Reduced intake and diminished absorption of dietary folate |
| |anemia | |
|Alteration in mental status,paresthesias, |Pernicious |Vitamin B12 deficiency |
|and numbness of the feet |anemia | |
|Recent infections |Primary bone-marrow disorder causing pancytopenia |Bone-marrow aplasia |
| |(aplastic anemia) | |
|Bleeding into skin or mucus membranes |Primary bone marrow disorder causing pancytopenia |Bone-marrow aplasia or replacement by leukemic tissue |
| |(aplastic anemia or acute leukemia) | |
|Leg ulcers |Hereditary spherocytosis, sickle cell disease |Hemolytic anemia |
|Unexplained deep vein thrombosis |Paroxysmal nocturnal hemoglobinuria, occult |Hypercoagulable state |
| |malignancy | |
|Drug use |Drug-induced immune hemolysis |Immunologic destruction caused by binding of antigen or antigen-antibody |
| | |complexes to the RBCs |
| |Oxidant hemolysis |Oxidant injury to hemoglobin and RBC membrane in susceptible patients |
| | |(G6PD deficiency and related conditions) |
| |Blood loss |Gastric irritation or bleeding (nonsteroidal anti-inflammatory drugs) |
| |Drug-induced cytopenia |Bone-marrow suppression or aplasia |
|Family history of anemia, splenomegaly, or |inherited hemolytic anemia |Membrane protein mutations and deficiencies, RBC enzyme deficiencies |
|gallstones | | |
|Occupational history |Lead poisoning, aplastic anemia |Toxic effect on the bone marrow |
|Back pain |Multiple myeloma |Bone-marrow plasmacytosis and osteolytic bone lesions |
Key Physical Examination Findings in Patients with the Diagnosis of Anemia
|Finding |Important diagnostic considerations |
|Pallor without jaundice |Iron deficiency, anemia of chronic disease, aplastic anemia |
|Pallor with jaundice |Hemolytic anemias |
| |Megaloblastic anemias or other conditions associated with ineffective erythropoiesis (intramedullary hemolysis)|
| |Anemia in liver disease |
|Petechiae, ecchymoses |Primary bone-marrow disorder affecting production of both red blood cells and platelets (aplastic anemia, acute|
| |leukemia, and related disorders) |
|Koilonychia (spoon nails) |Longstanding iron deficiency |
|Spider hemangiomas |Anemia of chronic liver disease |
|Telangiectasias |Gastrointestinal blood loss |
|Adenopathy |Lymphoproliferative disorders |
| |Tuberculosis |
| |Disseminated fungal infections |
| |AIDS/advanced HIV infection |
|Splenomegaly |Myeloproliferative or lymphoproliferative disorders |
| |Hemolytic anemias |
| |Liver disease |
|Dry skin |Anemia of hypothyroidism |
|Palmar erythema, loss of body hair, |Anemia of chronic liver disease |
|gynecomastia | |
|Atrophy of tongue mucosa |Vitamin B12 or iron deficiency |
Diagnostic Criteria For Various Types of Anemia
|Cause of anemia |Essentials of diagnosis |
|Iron-deficiency anemia |Absent bone-marrow iron stores or serum ferritin ................
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