Anemia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Chetan Lokhande, M.B.B.S [2]; Asra Firdous, M.B.B.S.[3]


Anemia is defined as a decrease in the oxygen-carrying capacity of the blood causing tissue hypoxia. It presents with a decrease in volume concentrations of hemoglobin (Hb), hematocrit, red blood cell indices like (MCV), and red blood cell count (RBC count). Anemia is defined as a hemoglobin concentration (Hb) of less than 12 g/dL in women and less than 13 g/dL in men, or alternatively, hematocrit of less than 36% in women and less than 40% in men.


Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.[1][2]

Common causes

Common causes of anemia include:[3][4][5]

For a complete list of hemolytic anemia causes, click here

For a complete list of anemia causes, click here


Characterise anemia symptoms
Dyspnea on exertion
Normocytic anemia[9]

❑ Increased reticulocyte count

Blood loss
Hemolytic anemia

❑ Decreased reticulocyte count

Aplastic anemia

Diagnostic Work-up

Anemia Diagnostic work-up
Iron deficiency anemia
Iron studies
❑ Decreased serum ferritin
❑ Decreased serum iron
❑ Increased total iron binding capacity
❑ Increased serum transferrin/ total iron binding capacity
❑ Increased transferrin saturation
❑ Increased RDW
❑ Elevated erythrocyte (RBC) zinc protoporphyrin
Iron stain (prussian blue stain) on bone marrow aspirate


❑ Elevated lactate dehydrogenase (LDH)
❑ Low haptoglobin
❑ Abnormal bands on hemoglobin electrophoresis
Target cells on peripheral blood smear

Lead poisoning

Basophilic stippling of red blood cells
❑ Elevated venous blood lead levels

Sideroblastic anemia

Iron studies
❑ Increased serum ferritin
❑ Increased serum iron
❑ Decreased total iron binding capacity
❑ Increased transferrin
Prussian Blue stain of RBC in bone marrow, shows ringed sideroblasts
Bone marrow aspiration and biopsy

Anemia of chronic disease

Iron studies
❑ Normal or Increased serum ferritin
❑ Decreased serum iron
❑ Decreased transferrin
❑ Normal or low-normal percent saturation of transferrin
❑ Increased cytokines (e.g., IL-6, interferon-gamma)
❑ Increased acute phase reactants (e.g., fibrinogen, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP))
Rheumatologic assays or Serological tests (e.g., anti-nuclear antibody, rheumatoid factor, anti-CCP, anti-dsDNA)

Vitamin B12 deficiency

❑ Decreased serum B12 levels
❑ Increased serum homocysteine levels
❑ Increased serum methylmalonic acid levels
Anti-IF antibodies
Anti-parietal cell antibodies
Peripheral blood smear
❑ Multisegmented neutrophils

Folate deficiency

❑ Decreased serum folate levels
❑ Decreased RBC folate levels
❑ Increased homocysteine levels
❑ Normal methylmalonic acid levels
Peripheral blood smear
❑ Multisegmented neutrophils

Liver disease
Liver function tests

Total protein
ALP (alkaline phosphatase), ALT (alanine transaminase), AST (aspartate aminotransferase), and GGT (gamma-glutamyl transpeptidase)
LDH (lactate dehydrogenase)
Prothrombin time


❑ Low serum T3,T4 levels
❑ Low or elevated serum TSH levels

Hemolytic anemia

❑ Elevated total bilirubin
❑ Elevated LDH
Direct antiglobulin test (DAT) (Coomb's test)
Indirect antiglobulin test (indirect Coombs' test)
Osmotic fragility test
❑ Urine hemosiderin
❑ Urine hemoglobin
Peripheral blood smear
Target cells
Bite cells
Sickle shaped RBC

Hemorrhages or Bleeding

Complete blood count
Bleeding time
Prothrombin time (PT) and the activated partial thromboplastin time (aPTT)
Coagulation factors
❑ Serum fibrinogen
❑ Serum D-dimer


CBC with differentials
Blood smear for malaria
Blood culture and sensitivity
Gram stain
Urine culture and sensitivity

Aplastic anemia

Bone marrow biopsy
Hypocellular bone marrow with increased adipose tissue and decreased hematopoietic cells in the marrow space
❑ Normal maturation of all cell lines


Bone marrow biopsy
Complete blood count
Leucocytosis or Leucopenia
❑ Absolute basophilia and eosinophilia
Neutrophilia or Neutropenia
Low or elevated leukocyte alkaline phosphatase


Anemia Treatment

Abbreviations and Formula

MCV = mean cell volume RDW = Red blood cell distribution width TIBC = total iron binding capacity HEENT = head, eyes, ears, nose, and throat CNS = central nervous system WBC = white blood cells GI = gastrointestinal SLE = systemic lupus erythematosus EBV = epstein-barr virus HIV = human immunodeficiency virus IL-6 = interleukin 6 T3 = triiodothyronine T4 = thyroxine TSH = thyroid stimulating hormone LDH = lactate dehydrogenase DMSA = dimercaptosuccinic acid




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