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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