A Focused Approach to Anemia

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The physician managed this case reflexively rather than reflectively. Although the patient had severe anemia, her symptoms

were mild and she was hemodynamically stable. She had some shortness of breath on exertion but not at rest. She did not have orthostatic hypotension. She did have mild tachycardia, but even if her heart rate had been greater than 100 bpm, there would
have been no great cause for concern. The chest x-ray showed no signs of pleural effusion or cardiomegaly. Moreover, there was no occult blood in the stool or other evidence of active bleeding.

While the patient's symptoms had been present for only a month, the anemia almost certainly had begun to develop some time earlier. In other words, since she had lived with marked anemia for at least one to two months, there was no need to take drastic steps aimed at immediate correction. The order for an immediate transfusion almost certainly reflected a knee-jerk response by a physician looking at laboratory data instead of the patient. Immediate transfusion is indicated only if the patient's condition has deteriorated within the last couple of days, if clinical findings suggest a threat to life or a major organ system, or if the patient has severe symptoms, an underlying condition such as heart disease that increases risk if hypoxia occurs, or active bleeding. Examples of sufficiently severe signs and symptoms include angina, dyspnea at rest, pleural effusion, and dizziness or other signs of inadequate blood delivery to the brain. Orthostatic hypotension often contributes to the last category.

Many physicians believe that if the hemoglobin level is less than 8 gm/dL, it must be increased immediately, especially if it is extremely low and the patient is elderly (and therefore supposedly frail). That is not true, however. Patients in their 70s often tolerate hemoglobin levels as low as 3 or 4 gm/dL. The body has a variety of mechanisms to compensate, especially when the anemia develops gradually. Since compensation is better in some patients than others, management decisions should always be made on a case-by-case basis.

Physicians first should ask whether the anemia is an immediate threat to the patient, then whether it is possible to reverse the condition without transfusion. One can avoid a transfusion with this strategy. A serious omission in this case was the failure to examine the blood smear. This should be done immediately for any patient with severe anemia or pancytopenia. A smear examination might have saved this patient an unnecessary blood transfusion.

Another important omission was the failure to repeat the CBC in the hospital before transfusion. A blood count that shows severe anemia should always be repeated, for two reasons. First, to make sure that the first reading was correct. This is particularly important if the reading will be the basis for transfusion. Second, to provide some information about the course of the condition. For example, if this patient's hemoglobin level had fallen from 5.4 to 4.4 gm/dL during the hour or two that it took to travel from the office to the hospital, it would have suggested rapid progression. When symptoms are sufficiently worrisome to warrant a transfusion, start with one unit of blood. Give a second unit if the symptoms do not resolve. Only severe symptoms or active bleeding justify immediate administration of multiple units. In this case, the order for three units was another indication that the patient's physician was practicing medicine by numbers. Because each unit raises the hemoglobin level by about 1 gm/dL, the apparent objective was to raise the level to 8 gm/dL. It should be remembered, however, that each unit raises the risk of a transfusion reaction or disease transmission.

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There is pancytopenia and the indices of RBC are macrocytic so in this setting the first Q is megaloplastic or non megaloplastic? and the answer is easy by see hypersegmented neutrophil in peripheral blood film or bone marrow second Q is if megaloplastic what is the cause folate or B12 deficiency and what is the cause of that? if non megaloplastic we have to rule out autoimmune hemolytic anemia, mylodysplastic syndromes, hypothyroidism.


She has gradual onset of anemic symptoms Her CBC shows macrocytic [MCV.95fl],increased RDW .Platelets counts m/b reduced(<100,000/mm3).No h/o recent bleeding exclude IDA.Jaundice exclude haemolytic .Medication with methotrexate, exclude folic acid B12 deficiency.Alcoholism exclude folic acid def.Hospitalization exclude b12 def in gastric operation.Normal BUN exclude anemia of chronic disease. Dx is probably megaloblastic anemia due to combined f/a and B12 deficiency with underlying hypovitaminosis,antimetabolytes, copper deficiency with zinc excess.Bone marrow will show megaloblasts and hypersegmented neutrophils.


Diagnosis is must before blood transfusion in this case


megaloblastic anemia


mostly pernious anaemia

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