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CBC | Approach to Anemia

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This content provides a systematic, step-by-step approach to diagnosing red blood cell disorders, specifically anemia and polycythemia, by outlining the diagnostic tests and their interpretations following a Complete Blood Count (CBC).

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what's up ninja nerds in this video

today we're going to be talking about

red blood cell disorders that includes

anemia and polycythemia if you guys like

this video if it makes sense and you

enjoy it you know what to do hit that

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also you want some amazing notes

illustrations i highly suggest you check

them out go down the description box

below it'll take you to our website

where you guys can follow along with me

during this lecture now

this is going to be a little bit

different than our normal lectures where

we go into tons of detail about

pathophysiology and we go down this

rabbit hole kind of sometimes in this

video this is going to be a really like

very systematic approach a step-by-step

approach of whenever you order a cbc on

a patient you see that they have signs

of anemia or you say they have signs of

polycythemia what are the next tests

that i should order what would that test

tell me and then what we'll do is we'll

do some case studies to really make

sense of all of this it's going to be

quicker it's not going to be a ton of

explaining about things i just want us

to have a very systematic approach and

then we'll do repetition afterwards okay

so let's get right into it

however in order for us to understand

red blood cell disorders we have to have

a little quick tidbit on the life cycle

of the red blood cell if you want more

detail we do have a video where we cover

the whole life cycle and entire

destruction pathway of the red blood

cell in our physiology play let's go

check it out in hematology but for this

one we're going to keep it basic when we

talk about red blood cell production it

occurs where and the red bone marrow yep

that's right you got it now in the red

bone marrow we start off with a cell

called a myeloid stem cell now the

myeloid stem cell what happens is it can

become a red blood cell it can become a

platelet or it can become what's called

a neutrophil an eosinophil or a basophil

how does it know to go to become a red

cell did you just be like all right i

guess i'm going this way no it gets a

particular stimulus what are those

stimuli there's a lot of things to be

honest with you

what i want you to remember basically is

it receives hormonal

particular stimulus it receives a lot of

nutrients that are very essential for

making a red blood cell but you know

what unfortunately we take drugs or

prescribe drugs or there's certain

toxins that we're exposed to that can

actually inhibit red blood cell

production so remember not only can we

stimulate it we can also inhibit it

unfortunately and just remember the bone

marrow the actual cells inside of the

bone marrow have their own intrinsic

type of activity so here's what i want

you to remember

we need particular hormones to drive red

blood cell production what are those

hormones first thing thyroid you need

thyroid hormone so t3 t4

if you have anemia okay you're not

making enough red blood cells and

there's a drop in hemoglobin dropping

hematocrit maybe you have a low t3 t4

your kidneys your liver it actually

makes a hormone called erythropoietin

erythropoietin stimulates the actual red

bone marrow and drives red blood cell production

production

you need tons of nutrients from your git

you know what the three essential ones

are that you have to know one is iron

the other one is b12 and the other one

is foley also known as b9

these are essential in actually helping

you to make red blood cells then if

we're exposed to particular drugs

there's so many we'll talk about a few

big thing alcohol or you're exposed to

nasty toxins they can actually suppress

the bone marrow and inhibit the bone

marrow from being able to produce red

blood cells that's really important the

next thing that's also really important

for the production of red blood cells is

just the intrinsic bone marrow function

if somebody has some type of damage to

the red bone or they have a cancer they

have some type of destruction from like

chemo radiation or they have like a

cancer where their bone marrow cells

just suck and they aren't functioning

and making red blood cells that's a

problem so here's how i want you to

think about anemia anemia is the low

number of red blood cells therefore a

low hemoglobin and a low hematocrit

we'll write that down a little bit but

that's what i want you to remember for anemia

anemia

when a person has anemia they're not

making as many red blood cells right now

now

the way we can actually kind of really

dig down into the details of anemia is

anemia comes down to two different like

subtypes you're either not having enough

red blood cells hemoglobin and a good

hematocrit inside your bloodstream for

two reasons one

is your bone marrow socks or you're not

getting enough hormones nutrients or

you're exposed to a lot of drugs and toxins

toxins

and what happens is if any of those

things are present and your bone marrow

stops working or stops functioning

properly can it become go from a

myelinated stem cell to erythroblast to

reticulocyte to red blood cell no

you know it's really interesting at this

stage here right here if we zoom in on

it going from a reticulocyte site to a

red blood cell it's about one to two days

days

and so that's actually really important

because this cell here the reticulocyte

actually is a good indicator we can

actually test this to see how well the

bone marrow is actually functioning so

what i can do is i can check the

reticulocytes think about this

if we have low t3 low t4 low

erythropoietin low levels of these nutrients

nutrients

lots of these particular drugs and

toxins suppressing the bone marrow or

the bone marrow is destroyed it's

failing it has it's cancerous and it's

not working think about what will happen

to the production of reticulocytes will

it go down

yeah so if the reticulocytes go down

then subsequently these will go down but

we'll pick this up earlier so we can

check something called a reticulocyte

index and that stratifies my two

different types of anemia into a

decreased production due to this issue

or something else what is that something

else glad you asked

what if the bone marrow is working no

problem you got normal thyroid hormone

you got normal epo you got normal

nutrients you don't got no drugs no

toxins there's no problem with the bone

marrow it's working well and it's

producing red blood cells right but

but

the red blood cells get into the dang bloodstream

bloodstream

and unfortunately you lose it why

why

i don't know maybe because you end up

with a gi bleed maybe you bleed into

your retroperitoneum

maybe you end up bleeding into your

chest cavity maybe you're getting

frequent blood draws because you're in

the icu and or in the hospital and they

have to take and do blood draws every

single day and they're just taking and

draining your blood every day

or you just got some type of surgical

procedure that's ways that you're losing blood

blood

if you lose blood you lose red blood

cells what think about negative feedback

mechanisms man right

if we have low numbers of red blood

cells what do you think that'll do to

this myeloid stem cell

it'll say hey

we're low on red cells since you're

functioning well guess what i need you

to go ahead and start amping up

production and jack that up and make

more red blood cells more reticulocytes

and so their ticks will bump up

if the bone marrow is working

so that's important so one of the

reasons we could have anemia low

hemoglobin low hematomatic or lower

blood cells is because we're losing blood

blood

and again we'll talk about this for tick

index in just a second but we're already

kind of getting an idea that it should be

higher because why the red blood cells

are low if the bone marrow is working

all these things are good the bone

marrow should compensate and make more

red blood cells because you're losing them

them

if it's the other end of the spectrum

where you're not losing them you're just

chewing them to pieces they're getting

into the vasculature and they're getting

chewed up they can get up and chewed up

in two ways and we'll talk about it in

more detail for right now

they can get chewed up in the

vasculature there's many different

reasons why i can get you up in the

vasculature or it can get chewed up in

the spleen

when it happens in the vascular we call

that intravascular hemolysis

when it gets chewed up inside of these

things called splenic macrophages inside

of the spleen it's called extravascular

homolysis but either way what are we

doing we're chewing up the red blood

cells dropping the number of red blood

cells if the bone marrow is good these

things are present

what will happen the bone marrow should

compensate and say

got to make more red blood cells so what

do you think the ratic will happen it'll

go up for the reticulocytes

but you got to figure out why you're

hemolyzing and we'll go through and

figure out all the different causes for

that right

but that's the big thing so to put it

all together

comes down to two different types of

anemia anemia due to a decreased

production if it's a decreased

production what could be the issues it

could be decrease hormones

thyroid epo decrease nutrients

decrease b12 folate and iron it could be

due to lots of drugs and toxins exposure

think about alcohol is a big one

or it could be due to a decrease in the

intrinsic bone marrow function due to

cancer due to it being destroyed because

of a chemo radiation or something like

that if that's the case the bone marrow

is under producing therefore it's not

going to make a lot of reticulocytes the

reticulocytes will decrease

the reticulocyte index is a it's a

formula it's not worth remembering just

what happens is the reticulocyte index

is based upon your reticulocytes and

your hematocrit and something called a

maturation factor what i want you to remember

remember

is the reticulocyte index and under

production means that my bone marrow is

not working very well because of one of

these issues so will i have a lot of

reticulocytes no they're going to drop

so my reticulocyte index will drop

but we like to use a particular

percentage that i want you to remember

it'll actually drop to less than 2

and that's important

in the other end of the spectrum what if

it's due to an increased loss i'm

bleeding losing blood and then my

reticulocytes are having to be i'm

actually causing my bone marrow to

compensate if it's working all these

things are good then my bone marrow is

going to jack it up and produce tons of

red blood cells it's going to try to and

if that happens what would happen to the

reticulocyte index

it would go up

and so if the reticulocyte index

increases that would be more suggestive

of a loss or

a destruction problem if the bone

marrow's working and all these things

are good okay that's the caveat here and

we say technically it's when it's

greater than

two percent

all right my friends that will cover the

basic life cycle and i think it helps us

to stratify these two different types

because now we got to do is we got to

figure out anemia

how do we figure out the anemia that's

due to decreased production we got to

figure out all these issues and we're

going to talk about that now what kind

of tests and things that we go through

all the algorithmic steps then after

that we got to say okay how do i figure

out which type of issue it is here for

the actual destruction loss and we'll go

through all the systematic steps for

that and lots of case studies all right

here we go so we're going to talk about

these types of anemia specifically with

the decreased production issue now when

we talk about these one of the big

things that you want to think about here

so we know it's a decreased production

so we know it's a problem with hormones

nutrients drugs toxins or intrinsic bone marrow

marrow

dysfunction right that's what we have an

idea of so think about those things

under your differential but before we

even start kind of going down that

rabbit hole again quickly what is anemia

because now we're going to start talking

about that a little bit with anemia it

is a low

oxygen carrying capacity right and

usually the best way to define anemia is

whenever you have a decrease in your red

blood cell mass and specifically we say

there is a decrease in the hemoglobin

a decrease in the hematocrit

and technically in some situations in

most cases there is a decrease in the

number of red blood cells that doesn't

always hold true in every single type of

anemia i would say out of these three

these are going to be the most important

one but for the most part it's usually

all of those if they're low it's

suggestive of anemia okay so we have

anemia once we determine there's anemia

low hemoglobin low hematocrit low red

blood cells then we've got to say okay

is it due to an under production or an

increased destruction slash loss problem

how do i do that

in a perfect world you can check a

reticulocyte index so you order the

reticulocytes it's a separate order

when you order the reticulocytes you get

the number back you put it into that

reticulocyte index equation and you spit

out a percentage

we said if the reticulocyte index comes

back as less than two percent it's a

decreased production problem

yeah and if it comes back at greater

than two percent in a perfect world it's

an increase in destruction

like in hemolysis or it's a increase in

loss such as in bleeding and patients

who were talking about this problem

decrease in production in a perfect

world the reticulocyte index will be

less than two percent don't forget that

so order your ticks

boom stratify this now you have a person

who has some type of decreased

production problem and again this isn't

a perfect world that's not always the

case in true clinical situations

after you do that in the cbc there's

something called the mcv the mean

corpuscular volume

mean corpuscle volume just tells you the

size of the red blood cells and that

helps you to determine which type of

underproduction type of anemia we have

if the mcv normally normally it's 80 to

100 femtoliters and that's in like a

generalized number it can vary all the

time but that's a generalized number so

if the mcv is low less than 80

we call that a

micro acidic anemia okay so we'll put

here on the side a low mcv

if it's actually going to be normal

mcv so it's between 80 to 100 that is a

normal acidic anemia

and then if

it is a high mcv greater than 100

femtoleaders then this is a macrocytic

anemia and that would be the last one

that we talked about so now we have the

three types that we're suspicious of okay

okay

now we've got to say okay what kind of

tests what kind of things should i be

thinking about for a patient who has a

microcytic anemia differential don't

forget these i want you to keep

remembering these maybe you have to

repeat it a couple of times iron

deficiency anemia

anemia of chronic disease thalassemia

citroblastic anemia okay again iron

deficiency citroblastic anemia chronic

disease and thalassemia those are your differentials

differentials

how do i figure out which one it is

the first thing i think that's actually

somewhat beneficial okay is to just kind

of like write these three out here so

let's write these kind of general well

actually what i like to do is like to

check something called an rdw but we'll

get into all these things i'm going to

talk about in sequence

usually the way it's easily kind of

defined is you check a bunch of

different tests so here's what we're

going to do we're going to check a bunch

of different tests

the test that i will order for these patients

patients

is i will look at i'll check

their rdw

i will check their red blood cells

i will check what's called their mensers index

index

and then i will also look at what's

called a peripheral blood smear and then

i'll also take into consideration their

history but these are the basic things

that i'm going to test

all right once i check all of these

things i can kind of start going into my

different types here so now i'm going to

have iron deficiency anemia okay so iron

deficiency anemia that one being first

when i think about this one when i look

at the rdw

one of the big things is rdw tells me

like the variation in size of the red

blood cells and whenever somebody has

iron deficiency anemia they typically

have a high rdw so that's not the first

thing that i'll look at i get that from

my cbc as well so an iron deficiency

anemia one of the big things you'll see

a patient who has a high rdw

rdw

the red blood cells are typically low

okay so they have a low number of

red blood cells okay and obviously with

this patient having anemia

the next thing is i'll look at my

mincer's index all the mensers index is

if i write it up here all the

menstrual's index is is you're taking

the mcv divided by the red blood cell

number and that should give you kind of

that mensers index

and there's this is helpful in a

condition that we're going to talk about

a little bit called thalassemia

the menstrual's index and iron

deficiency anemia is somewhat helpful

and what i want you to just remember for

right now is the mincer's index is

greater than 13 i promise this will make

just sense in just a second but for

right now just remember that

the next thing i'll do is i'll check my

iron studies right so my iron studies

you get a bunch of different things from

the iron studies what are some of the

things that you get from iron studies

from the iron studies

you'll get a couple different

things you'll get what's called iron

obviously you'll get something called ferritin

ferritin

you'll get something called the tibc and

the last thing you'll get is something

called a transferrin saturation

saturation

out of all of these

this can get kind of complicated with

all these different types

of anemias and i feel like it can be way

too much to remember so you know what i

like to do i like to kind of make it a

little bit more simple and i only utilize

utilize

this one

and this one

i think all the other ones are kind of

like a little bit more complicated and

they just kind of like confuse me

sometimes and then i end up trying to

remember things and memorize and it

doesn't really work so the easy way to

look at these is look at the ferritin

and look at the transfer and saturation

that's what i kind of look at and that

usually can help me to differentiate

what i got here

so in iron studies what you want to look

at is ferritin ferritin is kind of like

your it tells you it's a protein that

binds to iron inside of our cells so it

kind of tells us about our iron reserves generally

generally

in a perfect world on your exams

the ferritin is usually low okay in a

perfect world that's not always the case

so remember that but in a perfect world

the ferritin

then the other thing is the transfer and

saturation you know how we actually get

transfer and saturation transfer and

saturation is an equation that utilizes

it takes iron and divides it by the tibc

okay divides it by the tibc generally

generally

the tibc in iron deficiency anemia patients

patients

is high

and then usually

iron is low

so if you look at this kind of like

number here i guess it should kind of

ding off a relatively obvious thing you

have a low numerator a high denominator

the overall percentage is going to be

low so you'll have a low percentage

percentage

so in these patients they'll have what's

called a low

transferrin saturation

and that's really the only time i think

this is actually the beneficial

component of the iron studies other than that

that

i don't really use the iron studies

other than that just for kind of like my

iron deficiency anemia i don't think

it's really helpful for that it may be a

little bit helpful in other kind of

diseases but not super great

so that's what i get from there

peripheral blood smear it's not super

helpful so i don't actually get a lot

from my peripheral blood smear on my

iron deficiency anemia all right boom

next one what do we say we have iron

deficiency anemia then what else did we

say we said anemia chronic disease so

anemia of chronic disease when i look at

this one i can look at the rdw the rdw

actually doesn't really help me it's

usually like relatively normal

so that's not a super beneficial thing

my red blood cells are usually low

my mincer index doesn't actually really

help me so i'm going to get rid of that

part one of the things i do think is

somewhat beneficial in a perfect world

for anemia chronic disease from the iron studies

studies

is that their actual ferritin levels

tend to be relatively high so that is

one thing i would actually take a look

at and the reason why and the most basic

concept is when someone has an anemia of

like a chronic disease it's usually an

inflammatory disease and the liver

the ferritin is actually an acute phase

reactant protein so it's released

whenever there's lots of inflammation

and an anemia of a chronic disease due

to inflammation it's going to cause the

liver to make a lot of ferrotin so

ferritin levels tend to be high the

transfer in saturation the tibc all that

stuff that can be variable so i don't

really want to get too much into that

just look at the ferritin but the big

thing is their history that's what

really cues you off in this one the labs

aren't super super helpful it's more

their history that leads you off to it

sometimes what you can do whenever

people are confused between this one and

this one

you can check like a soluble transfer

and receptor

sometimes that's helpful i don't

actually think it's usually necessary

and it's usually an expensive test i

wouldn't worry too much about that one

okay i think that's the big thing

peripheral blood smear also relatively unrevealing

unrevealing

big thing here i think that's key here

is looking at your history

that is like the huge component here

that you have to look at and usually

it's kind of like an exclusionary

component all right the next one here we

said is thalassemia so thalassemia

is a really interesting one so what i

would do is i check the rdw the rdw can

actually be somewhat high but it can

also be normal so

i don't really think it's super

beneficial in this condition to be

honest with you what i do think is

actually helpful here is you know what

classically the red blood cells tend to

be relatively normal so that's an

important component to remember the red

blood cells tend to be normal now this

is where that menser index actually

comes in handy

the menser index is really really good

for this one this one i want you to

remember for thalassemia especially in

these cases

is we said the menstrual index is the

mcv divided by the red blood cell

in thalassemia these patients mcvs are

super low

what i want you to remember i want to

put it down in just a second but their

mcv's are typically less than 70. so if

you see an mcv less than 70 and a mincer

index less than

13 percent

be potentially thinking about

thalassemia especially if they have history

history

okay so from there i want you to

remember that they'll have a super super

super low mcv

mcv

and their red blood cells are normal so

they'll have a super high a super low

den enumerator and therefore their

overall number will be really low so

their mincer index will put their menser index

index

is going to be less than 13

it's a really important thing to

remember there okay

next thing is my iron studies they're

usually not very helpful okay because

they can be like relatively normal so

they're not very helpful for the iron

studies i wouldn't worry about those too much

much

the peripheral blood smear can actually

be somewhat helpful

so for these patients the peripheral

blood smear may show something called basophilic

basophilic

stifling and that's not patho mnemonic

for thalassemia but it's something that

if you see in the clinical vignette

where you have a patient who has a very

very low menstrual index

they also have basophilic stipeling and

they have a history that's the key thing

look at their history i want to add that

on here plus

history i'm going to put ajax their

history that's another key component

that you need in their workup

and they have history so in other words

they have a positive family history

maybe their family history they have

like a person who has thalassemia or

they have like a mediterranean ancestry

they immigrated from somewhere look

about that in the clinical vignette

however the most important thing that we

did not add but i'm just going to add it

on usually as a specific diagnostic tool

if you see these things a really low mincers

mincers

high you know high rdw to a normal rdw

not very helpful

you see some basophilic stifling you

have history you're concerned for it

you can confirm

and get what's called a hemoglobin electrophoresis

electrophoresis

and this will usually cleanse your diagnosis

diagnosis

before actually having somebody who has

potentially a thalassemia okay

all right the last one here within these

is going to be citroblastic anemia

so citroblastic anemia is basically a

problem where

you don't have

you don't are able to use the iron that

you actually have because they're kind

of like stored with inside of your red

blood cells they're kind of just locked

within them

okay and this is usually due to

medications and drugs

all right this one is usually a genetic

defect of a globin chain so an alpha

chain or a beta chain this one's usually

due to a lot of inflammatory diseases

and this one's due to a deficiency in

iron right so it's pretty straightforward

straightforward

but in this situation with citroblastic

anemia when you check their rdw it tends

to be high so that may help you so you

can already see i would say the big ones

to remember is citroblastic iron

deficiency for the rdw not very helpful

for these two

next thing for the citroblastic is your

rbcs they are usually low

next thing is check your iron studies

are they going to be helpful not necessarily

necessarily

to be honest with you they don't really

give you a ton of information so i

wouldn't really look at those too much

to really kind of determine which one

these are

peripheral blood smear is where i think

it's going to be the key component in

helping you to determine this what i

would look at in the peripheral blood smear

smear

is you can get two types of things you

can sometimes see again just like you

saw over here with thalassemia

basophilic stifling that's why like not

it's not always like the case that oh

basophilic stifling is thalassemia no

you can see this in a bunch of other

diseases what i think is important

though for the basophilic stipeling is

one of the causes of citroblastic anemia

is lead poisoning and so if you see in

the case like a patient who's like a

little child and was like exposed to

paint or something like that check a

lead level

and see if that's elevated especially if

you see basophilic stipeling and signs

of citroblastic anemia but i think one

of the telltale signs and the giveaways

in your actual exam is they'll maybe

show you a blood smear i'm going to show

you guys some case examples but they'll

show you a blood smear and it'll show

something called citroblast and this is

basically these cells that have like

these like

bluish dots all within them and it's all

the iron that's just accumulated with

inside of the actual cell

and so that's one of the big things if

you see citroblasts sometimes they even

have what's called papanheimer bodies

don't worry about that i think

citroblast is the big thing

what you need to do though is if you see

citroblasts you need to get a bone

marrow biopsy to confirm that's the only

way that you can truly like confirm

citroblastic anemia is if you see the

citroblast on peripheral blood smear you

need the bone marrow biopsy to confirm

this is the way that i would go about

these types of conditions and again

history usually for the history here

for the history look at medications so

exposure to lead lots of alcohol use

certain medications that can trigger

this there's lots of medications for

citroblastic anemia but again these are

the things to think about here in your

differential all right we covered your

microstatics we'll do some case examples

in just a little bit to see if we can

test your knowledge let's move on to

normal acidic anemias

so for normal acidic anemia we said it

has to be within the 80 to 100

femtoleader so within the range we're

now within the range

of someone having 80 to 100 femtoliters

for their mcv so with normal acidic

anemia what is the differential here

okay it's a little odd but with these

patients what you actually want to do first

first

is sometimes in patients who have what's

called iron deficiency anemia you're

like wait zach you just said it was from

microcytic yes and patients who have

early iron deficiency anemia

they can actually have a normal acidic

anemia so what i do for these patients

for normal acidic anemia the first thing

i'll do is i will check an iron level i

will actually check iron studies

and the iron studies will be helpful

because what they'll help me to do is

see if i have an iron deficiency anemia

and i can still use all of these kind of

tools here

but i'll check my iron studies the next

thing i'll do is i'll check for a b12

level i'll check a folate level because

sometimes early

uh b12 deficiency and folate deficiency

can also cause a normal acidic anemia

you'll see here in a little bit that b12

and folate usually cause macrocytic

anemia but if it's early it can actually

cause this first just like iron

deficiency anemia normally causes a

microacidic but in the early stages of

iron deficiency it can cause a normal

acidic okay

i'll check these things

after i do the iron studies the b12 the folate

folate

the next thing i'll do is i'll check

potentially some other organs them to

see if they're a little jacked up so the

ones i'll look for is i'll check my

thyroid function because that was one of

the organs there so i'll check my tfts

i'll also look at liver function so i'll

and i'll also look at kidney function so

i can look at a bmp

okay and again look at their history

obviously if they have like a in stage

or chronic kidney disease that could be

potentially obvious okay

okay

and then we'll talk about something else

that's really important here in just a

second and these patients that also have

i've gone through these and i've looked

to see if they have any liver any kidney

disease any type of thyroid disease and

all of that's relatively normal the

other thing i can consider potentially

is is there any hemolysis

but we'll talk about that a little bit

more later in the actual increase in

destruction loss so you're probably like

wait zach i thought hemolysis that's

always going to be a retic index greater

than two percent you said that if it's

less than two percent it can't be

hemolysis that's not necessarily the

case and here's why it's a little caveat

in the in the boards it will be like

that it'll likely be heretic index

greater than two percent it's hemolysis

in the in an actual clinical situation

sometimes people can have an underlying

like bone marrow disorder where they're

not actually producing an adequate

number of red blood cells let's say they

have iron deficiency anemia

and then all of a sudden they develop a

hemolytic anemia on top of their

underlying iron deficiency anemia well

they're they're actually going to have

destruction of red blood cells that'll

try to tell the bone marrow to make more

red blood cells but guess what

the bone marrow is not working well

because they have iron deficiency anemia

and so the production of reticulocytes

will still be low and so that's why

sometimes you can still have hemolysis

in a normal acidic anemia i'm going to

put it in there but remember

we're going to talk about it more

in this actual increase in destruction

loss process so put hemolytic labs

you'll also order that as well

the last thing that you consider in

these patients is what's called a bone

marrow biopsy and again we'll talk about

that okay

so when you go through these these are

the things that you want to check okay

you check your iron studies if you check

your iron studies let's say and you

obviously have this super obvious let's

say that you check the iron studies and

you think that they have iron deficiency

anemia what would you look for you would

see that they would potentially have a

very low ferritin

ferritin

and they would have a low

transfer in saturation

that's a pretty obvious thing there okay

you know what else is really interesting

for the iron studies not only do they

help you to determine if you have iron

deficiency anemia okay so these can help

you with iron deficiency anemia they can

also say is there any anemia of chronic

disease you're probably like zach

you just said anemia chronic disease can

be a microacidic anemia it can but it

can also be a normal acidic anemia and

again it depends upon the history so you

got to look at the history do they have

ra do they have sle do they have a

malignancy do they have chronic kidney

disease check those things but if they

have anemia chronic disease what do i

tell you would happen with that ferritin

it's usually pretty high again that's

not always perfect but it can help you somewhat

somewhat

okay and again with these patients both

of them can have low iron

okay and their transfer and saturation

for anemia chronic disease it can also

vary a lot but again something to think

about then for the b12 and foley you

want to see if the b12 and folate is low

so if the b12 is low okay we got

b12 deficiency

if the folate is low which is also known

as b9 then it's we it's it's folate

deficiency but sometimes you can get a

little tweener

okay sometimes if it's not this one or

this one you get a weird situation where

low b12

b12

and folate where it's just that the end

up like the lower limit of normal if

that's the case what you order here is

you order something called a methylmalonyl

methylmalonyl

methylmalonic acid and you order

something called a homocysteine level

in these situations

if it's

borderline low you're not sure which one

it is if it's true b12 deficiency

the methyl malonic acid will be elevated

and the homocysteine will be elevated

if it's a b9 or folate deficiency

the methyl malonic acid will be normal

and their homocysteine levels will be

elevated okay so that's an important

thing to remember so we check our iron

studies we check our b12 and folate for

early iron deficiency anemia early b12

foley deficiency anemia also consider

anemia chronic disease but what i tell

you is really important here history my

friends that's the most important

component here

check your

tfts if you have low t3

low t4 what do you think it is

hypothyroidism oh man you're good

what if you have increasing lfts

increase asd increase alt increase um

other different like types of liver

enzymes maybe a drop in their albumin

and increase in their inr it could be

liver failure related that's important

if it's bmp do they have an increase in

their bun do they have an increase in

their creatinine

it could be ckd

so they may have chronic kidney disease

sometimes i don't suggest it but

sometimes the literal chair will say if

they have ckd

check like an epo level remember

erythropoietin was the driver for red

blood cell production if the kidneys are

failing can they make ippo

no so what would you think the epo

levels would be low

so sometimes you can do that sometimes

they suggest not necessarily doing that

hemolytic labs we're going to talk about

this more in destruction and loss you

still want to check them because you can

have this believe it or not

we're not going to go through it now i'm

going to put just c above we're going to

talk about that a little bit later

okay the next thing that you also want

to consider for these patients here

is would i ever get a bone marrow biopsy

why would i ever do a bone marrow biopsy

remember i told you that if it's a

problem it's a nutritional it's a

hormonal it's a drug or it's an

intrinsic bone marrow issue normal

acidic anemias

typically tend to be bone marrow issues

if you think about these ones usually if

it's an intrinsic bone marrow problem

it's likely normal acidic so here's what

would t like cue you up to say oh shoot

this could be an intrinsic bone marrow

problem i would consider a bone marrow

biopsy and this is where i'm i'm telling

you please listen here

if my reticulocyte index is like

super low like non-existent i'm talking

like 0.1 percent so it's less than two

but it's like almost zero

if that's the case like 0.1 percent

that's a concerning sign

another thing

is what if they also have what's called pan

pan

cytopenia you guys know what that is i

know you know what it is low red blood

cells low platelets and low whites like

white cells all the cell lines are dropped

dropped

if that's the case something is wrong

with the bone marrow if i am basically

making no red blood cells no

reticulocytes that's super concerning

for a bone marrow problem and if other

cells are being affected that's super

concerning for a bone marrow problem

biopsy the bone marrow and sometimes

what this can show you is three

particular types of conditions

one is called aplastic anemia

in this situation if you check their

bone marrow biopsy they're like they

like make no cells all their cell lines

are dropped and so what you would see is

we're going to just kind of look here low

low proliferative

proliferative

bone marrow biopsy you can check for

something called mds

myelodysplastic syndrome

in this situation they're producing lots

of blast cells that don't actually have

any room to allow for any red blood

cells platelets or white blood cells to

be produced and so they crowd out the

bone marrow but you're still having low

levels of all these cell lines and lower

ticks so again in aplastic lower ticks

and pancytopenia mds low vertex and pyoncytopenia

pyoncytopenia

but if you look at the difference here

they have a hyper proliferative bone

marrow filled with lots of blast cells

immature cells the last one is the most

rare one and weird one called pure red

celloplasia and this there is no

pancytopenia so here let's do this

none of that

only in the super obvious low

reticulocyte count you get a bone marrow

biopsy and you check and they have low erythroblasts

so their red cell line is the only one

that just pretty much stinks

if that's the case it could be

suggestive of pure red celloplasia

a lot of things to think about with this

one i promise i know it seems like a lot

but we're gonna do some practice

problems to make sense of it but these

are the things that i want you guys to

be thinking about when you're having a

patient who comes up with a normal

acidic anemia let's hit it home with

macrocytic all right macrocytic anemia

so we checked our mcv and it is greater

than 150 liters right so we have some

big big honking cells so high mcv

greater than 100 femtoleters okay

when we do this one we got to think

about our differentials for this one

all right so the way i think about the

differentials is again i think about the

test that i need to order it just helps

me to categorize it in my brain

so for macrocytic anemias i want to

check i would like to check first off a b

b 12

a folate level

then after i do that i like to look and

since i'm ordering labs i might as well

just add some other labs so i'll add in

some thyroid function tests

i'll add in some lfts

i'll look at their meds

and i'll also check a blood alcohol

concentration if they're not telling me

the truth about their alcohol history

after i do that

i also consider some other particular things

things

maybe like a peripheral blood smear also

can be somewhat helpful

lastly i usually don't actually like get

to this point where i think it's

absolutely necessary unless there's

something super super concerning but you

can sometimes consider

a bone marrow biopsy i would put plus or

minus there and kind of remember it's

easier to remember for normal acidic but

you can potentially have some bone

marrow problems with macroacidic anemia

all right but this is kind of like the

cut and dry way that i go about ordering

these tests

so first thing is i got the b12 and

folate why because b12 and folate

deficiency it's easiest to remember that

they're macroscience but don't forget

that they can cause early and their

early disease is normal studies just

like iron deficiency is microacidic in

the early diseases it can cause normal

acidic when i check the b12 and foley

this is going to be a reminder guys what

did i say you check the b12 level it's

low you're diagnostic

if it's you check the folia which is

also known as b line it's a b9 it's low

it's diagnostic

but if i have a patient who has

borderline it's just on that lower limit

of normal of their b9 their folate and

their b12 and i don't know which one it

is what can i do

you can obviously look at their history

but i can check

for the b12 deficiency

typically i look at the methyl myelinate

malonic acid and the homocysteine levels

and the same thing for b9 or folate

deficiency i look at the methyl malonic

acid and the homocysteine levels in a

perfect world

this for b12 is elevated for both of

them and for b9 the mma is normal

and the homocysteine is elevated okay

boom i figured that one out for the

thyroid function test i'm looking for a

low t3 and a low t4 for my lfts i'm

looking for increases in lfts and

remember this could have a patient who

has also a history look at their history

sometimes you don't even need these

tests you can actually look at their

history and they have diagnosis of our

hypothyroidism maybe they're not taking

their meds or they're not at a proper

dose they have a history of cirrhosis

right something of that nature and they

continue to do things that they're not

supposed to be doing worsening their disease

disease

look at their medications and so when

you look at their medications there are

so many different medications i think

sometimes on the boards they will

actually try to have you remember

certain ones and so the things i would

potentially consider here

is some of the meds like you're kind of

like the keem somewhat of the

chemotherapy things where they impair

dna synthesis or replication

methotrexate is definitely one of them

another one called

5-fluorouracil another one called hydroxy

hydroxy

urea is a big one

now you can utilize and a patient who

has um

a sickle cell anemia

other ones are any kind of like hiv

meds but more specifically like the

protease inhibitors like xydovidine

another one here would be like

antibiotics the specific antibiotics i

would remember here is what's called

trimethoprim sulfamethoxazole also known

as bactrum

another one is your anti-seizure meds

and so your anti-seizure meds like

phenytoin and

valproic acid are really big ones as well

well

here's the big mama though

if they have a history

that's positive for alcohol use heavy

alcohol use that could be also a very

important medication to be thinking

about as well

if maybe you're uncertain there's

questions that they're actually not

telling the truth you can look for an

elevated blood alcohol concentration to

verify that maybe they are a heavy

drinker and they just drank recently or

something of that nature okay

okay

these could be somewhat helpful in your

diagnosis now the peripheral blood smear

so what you can actually do is some of

the actual literature will actually say

you should order this first

to really determine how you're going to

test somebody which can somewhat be

helpful in stratifying you can remember

this i would say just in general

remember this one component of it from

the peripheral blood smear when you get

a peripheral blood smear you want to

determine if they have what's called

megaloblast so macros like megaloblastic

macrocyte acidic anemia or

non-megaloblastic macroacidic anemia and

so the way you do that is you get a

peripheral blood smear and you look to

see if they have what's called

megaloblast megaloblasts

so megaloblasts is basically you're

looking at the neutrophils

and when you look at the neutrophils

usually they have like a couple lobes

like three lobes generally

normally but in these patients who have

a macrocytic anemia which have

megaloblasts usually it's b12 foley

deficiency some types of medications or

alcohol they can impair the dna

synthesis in the maturation process and

they can cause like multiple lobes so if

they got greater than like five lobes we

sometimes call these hyper i'm going to

abbreviate hyper segmented neutrophils

that's megaloblastic and you should have

a high degree of suspicion for b12 foley

deficiency or some type of medication or

maybe even like alcoholism those would

be big things to think about and it

would make it easier what tests you can

kind of order and which ones maybe you

don't have to get right now

so that's one of the big things is is it

positive for megaloblast or is it non-megaloblast

and megaloblastic macrocytic anemia in

other words they do not have this above

issue there so in other words they don't

have greater than five lobed polymorph

nuclear leukocytes or neutrophils so

they don't have hyper segmented

neutrophils so in these situations they

are negative

for hypersegmented neutrophils more

likely suggesting like a thyroid issue a

liver issue or maybe some type of

underlying bone marrow problem

okay and sometimes even drugs and

medications as well

the bone marrow biopsy my friends i

would again i would caution to

potentially not always be right up front

with this one i think if you have a

patient who you see potentially like pancytopenia

pancytopenia

so you have any concerns and they have

pancytopenia low red cells low white

cells low platelets it might not be a

bad idea to potentially get a bone

marrow biopsy because this may tell you

if you have something called

myelodysplastic syndrome and with

myelodysplastic syndrome they would have

pancytopenia and again if you looked at

that bone marrow biopsy what did we say

would happened you'd have a high like a

high proliferative

type of bone marrow with tons of blast

crowding out the actual bone marrow and

not allowing for red cells and white

cells and platelets to be produced

adequately and so that could actually

also cause a macrocytic anemia sometimes

even say multiple myeloma but

i would kind of just keep it simple with

these and if you really have the extra

brain space maybe consider this one but

these are the things that i want you to

remember for your work up and how to

systematically approach your different

types of anemia is due to a decreased

production issue

so what we can do now is we can actually

take a look at a bunch of case studies

practice do some space repetition and

see if all of this stuff makes sense and

if you're able to solve some problems

and give you guys some confidence when

you see these cbc's and you have to

interpret it so let's get to it all

right so let's go through our case

studies guys and really put to practice

everything that we just talked about on

the board because it was a lot and i

want to make sure that you guys feel

comfortable with this all right so first

case this is going to put to practice

everything we talked about keep that

systematic approach ready 26 year old

female past medical history heavy

menstrual periods hemoglobin 9.6 she's

anemic we got to determine if it's a

decreased production or increased

destruction loss how do we do that we're

tick index for tick index is less than

two it's under production if it's

greater than two it's increase

destruction loss let's see what it is

it's less than two under production from

an under production point you have to

then check the mcv to see what kind of

acidic it is normal micro or macro we

checked the mcv

it's actually 75 that's less than normal

so it's a microacidic anemia if it's a

microcytic what's the differential iron

deficiency anemia thalassemia

citroblastic and anemia chronic disease

after we do that we check our rdw our

red blood cells and sometimes you can

calculate a menstrus index

boom rdw is high that's potentially

suggestive of iron deficiency anemia but

you can also see this in citroblastic

anemia red blood cells are low and the

menstrual index is 15. that kind of

tells me that it's unlikely thalassemia

since thalassemia is usually less than

13 percent okay next part is i check my

iron studies

ferritin is low whoa what did i say when

ferritin's low automatically have a high

degree of suspicion in a perfect world

that it's iron deficiency anemia and

then the transfer and saturation is also

low how do you calculate that you take

the iron divided by the tibc iron is low

usually iron deficiency anemia and tibc

is usually high so that's why you should

have a low transfer in saturation

very very likely that this is basically

an iron deficiency anemia and usually

the peripheral blood smear which is the

last test that we can get is usually

unrevealing it's not telling me very

much i think this is iron deficiency

with very strong confidence okay move on

to the next one

case two we got an 85 year old female

history of sle presents with hemoglobin

in 10.2 she's anemic check there were

tick index it's less than two under

production so now we got to check the

mcv mcv is 75 that tell me that it's a

microcytic it's one of those four what

do i do

again i gotta check my rdw my red blood

cells and sometimes my menstrual index i

check my rdw it's normal unlikely iron

deficiency anemia unlikely citroblastic

anemia could be

potentially what anemia chronic disease

or thalassemia red blood cells are low

usually they're normal in thalassemia

let's pretend that i put the mensers

index in here and this patient the

menstrual index is actually 16

let's just say so it's unlikely

thalassemia so we're kind of potentially

thinking this could be anemic chronic

disease plus what did i tell you to do

after this get your iron studies iron

studies ferritin's high what i tell you

was one disease i think is actually

relatively important to remember that

ferric kidney can be very very high

especially if there's a chronic disease

anemia chronic disease so ferritin is

pretty high and plus this person has a

medical disease that would actually put

them at risk of having a lot of

inflammation to cause that ferritin to

go up

okay next thing i could do is a

peripheral blood smear is it going to

help me with anemia chronic disease that

i have a high suspicion of no

so therefore i think that this is anemia

chronic disease because it fits well

with the presentation history and labs

okay next one three

three

past medical history of a guy who has tb

exposure got treated with isoniazid he's

got a hemoglobin 8.9 he's anemic what do

we do check her tick what's the retic

less than two under product under production

production

check the mcv if the mcv is there what

do we think this is a microacidic if

it's a microcytic it's one of those four

what do we always do rdw red blood cells mensers

mensers

and this person the rdw's high

potentially iron deficiency or

citroblastic red blood cells are low

let's just tell you that the menser is

again greater than 13 percent unlikely

thalassemia unlikely iron deficient i

mean it could be iron deficiency it

could be citroblastic anemia

we don't really have a strong

understanding if it's anemia chronic

disease just yet

what do we do iron studies they're normal

normal

that kind of tells me that it's not iron

deficiency anemia and it also tells me

that it's not likely that this person

has anemia of chronic disease

but again there's nothing like super

special about this what's the next thing

i need prefer blood smear

look at the birth bloods mirror guys

what do you see these things

oh those are your citroblasts this is a

slide that you definitely have to be

able to recognize if it's citroblast we

have to confirm with a bone marrow

biopsy but this would tell me that this

is citroblastic anemia and you guys are

on a roll all right here we go case

study four 34 year old

female mediterranean ancestry who has

been treated with iron supplementation

for a while and still has a hemoglobin

of 9.5 despite that

what do we do for tick index it's less

than two under production mcv

65 oh what i tell you to remember if

you've seen mcv less than 70 to have a

high degree suspicion for thalassemia

check the rdw check the red cells and

check the mensers rdw's normal it kind

of tells me that's unlikely iron

deficiency and citroblastic potentially

red blood cells are normal that also

made me think about thalassemia and the

mensers is less than 13 percent that

makes me think about thalassemia what do

i do iron studies

they're unrevealing again not very

helpful for the thalassemia patient

usually the relatively normal peripheral

blood smear what can we see

sometimes you can see basophilic

stipeling in these patients you guys see

like there's like these actual like

little blue dots around these like red

blood cells here some of them have some

basophilic stipeling and like in this

one here as well

and then this one here that would be

potentially something to think about

that you could see in a person who has

thalassemia but it's not pathodemonic

we definitely need to cert like

completely diagnose it we need history

they have a mediterranean history

that's possibility i would need a

hemoglobin electrophoresis i get it and

it's positive what's my diagnosis thalassemia

thalassemia

all right five

we have a 50 year old 54 year old female

past medical history seizures treated

with phosphoenotoin

and had a recent uti she was treated

with bactrim

which is trimethoprim sulfamethoxazole

and she comes in with a hemoglobin of

8.6 she's anemic all right what do we do

check the

retic it's less than two under

production we check the mcv determine if

it's micro normal or macro oh that's macro

macro

macro acidic what do we think

okay we always should check a b12 we

should check a folate we should look at

their meds look at their alcohol look at their

their

tsh look at their thyroid functions look

at their lfts and then if we're super

concerned we can also do a peripheral

blood smear lastly we can consider a

bone marrow biopsy we're going to do

these in order right all right so what

do we do check the b12 and folate first

they're normal kind of rules out that

they have b12 and foley deficiency will

be the other ones look at their

medications look at the alcohol look at

the thyroid functions the liver

functions let's do all that

tfts are normal lfts are normal blood

alcohol concentration is normal and they

have no history of alcoholism

okay what also i gotta look at look at

the meds

i look at the meds is there any one of

these meds that concern you

do you see anything

bactrim trimethoprem sulfur methoxazole

and then this is actually phosphoenotone

it's one of the actual brothers or

cousins you can say a phenotone so

there's a possibility that these two drugs

drugs

could have possibly done what

they could have actually caused this

anemia and then again we look to see the

actual peripheral blood smear sometimes

it can be helpful sometimes not again

you can get that peripheral blood smear

to see if you see any hyper-segmented

neutrophils suggestive of

megaloblastic anemia what did i say in

the perfect world megaloblastic anemia

suggest if it's present greater than

five polymorphonucleosites or white uh

neutrophils it's usually suggestive of

b12 or foley deficiency in a perfect

world but it's not actually present here

so it makes you think about all the

other causes like thyroid liver

medications alcohol stuff of that nature

so again likely medication related cause

for this patient's anemia a macrocytic type

type

all right here we go next one

case six

uh 75 year old male past medical history

cirrhosis secondary to non-alcoholic

fatty liver disease presents with

hemoglobin 10.1 he's anemic what do you

do check the retic

it's low under production what do i do

check mcv it's high macrocytic what do i

got to do b12 folate tfts lfts

medication alcohol peripheral blood smear

smear

foley b12 normal tft is normal oh

elevated lfts and they have a history of cirrhosis

cirrhosis

and there was no particular meds in

their actual history that was a

potential culprit and they don't drink

and there was no history of it their

blood alcohol concentration is normal

okay so i definitely have a likely

culprit here that being the cirrhosis we

should be consistent though what do we

say to check after this peripheral blood

smear we look at the peripheral blood

smear i didn't tell you guys this on the

white board but i'm gonna tell you now sometimes

sometimes

with liver disease you can actually get

these special types of like little like

pc kind of weird-looking cells here

called acanthocytes

so these are called a canthocytes and

you can kind of see these in patients

who have liver disease it's not

absolutely like oh you only see it in

this disease but it's somewhat

suggestive of it so that's something to

think about there and again they have no

hyper segmented neutrophils so that

would unlikely be a megaloblastic anemia

it's likely a non-megaloplastic

alright so it's likely a liver disease

related anemia all right great job seven

all right here we go

54 year old female past medical history

ckd4 presents with hemoglobin of 8.6

anemic what do you do check or tick it's

low under production what do you do

check mcv

it's low mcv is 85. sorry mcv is normal

i apologize 80 to 100 that's a normal

acidic anemia

you would also want to do what with

these again look at your red blood cells

they're low

what do we do for our normocytic anemias

what do they tell you to always check

could be early iron deficiency could be

early foley and b12 deficiency

then after that you also want to check

your kidney your liver and you also want

to check the thyroid function

and then after that you want to check

your hemolytic labs if you're absolutely

concerned for that but

in a perfect world we're probably not

going to do that right now because we're

going to keep it perfect is whenever

hemolysis is something i'm concerned

about when the tick is greater than 2.

so we're not going to check those

and then what do we say was last if we

have high concerns of it a bone marrow

biopsy possibly right

all right so let's go through here so

first thing that we should be checking is

again iron and b12 folate

so we check all of those things we check

the iron studies the ferritin is high

is ferritin usually high in iron

deficiency anemia in a perfect world no

it's usually low so the ferritin's high

that means that there's likely some type

of anemia of chronic disease here

what's this

ckd that's one of the diseases all right

transfer satch is normal folate b12

normal thyroid function functions normal

lft is normal no obvious meds in their

medical history

but they do have a history of chronic

kidney disease

that's interesting okay what else did i

check do i need to do any kind of like

bone marrow biopsy no the peripheral

blood smear doesn't really show me anything

anything

it's likely anemia of chronic disease

why because again ferritin's high

transference that's normal all the

folate b12 iron didn't suggest any iron

deficiency anemia no thyroid

abnormalities no lft abnormalities they

did have chronic kidney disease right

ckd was one of those

and ckd can actually be a chronic

disease that can actually cause anemia

chronic disease we actually called

anemia of chronic kidney disease and so

that's likely the problem here

okay if we got like a bmp we'd be able

to have evidence that they would have

been elevated potentially bu or

creatinine or some type of uh decrease

in their gfr all

right all right case study eight we got

a 75 year old male status post chemo

radiation for lung cancer presents with

pancytopenia what does that mean

low platelets low red cells low white

cells hemoglobin 7.3 they're anemic

what do i do check a retic retic is less

than two we actually get it and it's

zero point two percent it's barely there

oh that's interesting okay well whenever

we have a normal acidic anemia what do

we always have to check we got to make

sure it's not early

iron deficiency b12 foley deficiency

make sure there's no thyroid

abnormalities no liver abnormalities so

we got to go through all that stuff first

first

and well actually before we even do that

forgive me i went outside of my

systematic approach again once you have

a tick index less than two it's pretty

much very very bad what do we always do

again we under production checking mcv

normal acidic microcytic macrocytic in

this case it's normal acidic now we know

it's normal acidic

if it's normal acidic we have to confirm

that it's actually either early iron

deficiency b12 folate deficiency rule

out thyroid liver kidney disease and

then also potentially a bone marrow

problem so how do we do that let's check

those labs sequentially what are we

going to do

iron studies

normal folate b12 normal tft is the

thyroid function normal cmp which tells

me my liver function and my kidney

function normal

what i tell you was a concerning finding

my friends

if you see

pan cytopenia and a crazy low retic count

count

you got to be concerned about an

intrinsic bone marrow problem so what do

i really need to do here i probably need

to get a bone marrow biopsy and i get a

bone marrow biopsy i look at this and i

see a decreased cellular picture a low

proliferative picture filled with fat

tissue if it's decreased proliferative

area with a lot of fat tissue deposition

that is

aplastic anemia and usually aplastic

anemia is they have a high epo i don't

think that's really worth remembering

that's just an extra thing in case you

want to remember it

all right so let's move into this part

now so when we have somebody who has

increased destruction slash loss of

their red blood cells again we think

that they have anemia right so we're

kind of starting off that whole anemia

part they have a low hemoglobin they

have a low hematocrit they have a potential low number of red blood cells

potential low number of red blood cells we try to risk strata we try to kind of

we try to risk strata we try to kind of stratify which type they have

stratify which type they have so we check our reticulocyte index in a

so we check our reticulocyte index in a perfect world

perfect world the reticulocyte index would be greater

the reticulocyte index would be greater than

than two percent right so we know that in

two percent right so we know that in these patients they would have a

these patients they would have a reticulocyte index greater than two

reticulocyte index greater than two percent and the reason why we would say

percent and the reason why we would say in a perfect world is because we're

in a perfect world is because we're saying that the red bone marrow is

saying that the red bone marrow is blasting out red blood cells because

blasting out red blood cells because there is a drop in red blood cells

there is a drop in red blood cells because you're either losing them or

because you're either losing them or destroying them but in order to truly

destroying them but in order to truly have a retic index greater than two

have a retic index greater than two percent you got to have an actual

percent you got to have an actual functioning bone marrow so that's why i

functioning bone marrow so that's why i say in a perfect world in your clinical

say in a perfect world in your clinical vignettes your cases that you'll get on

vignettes your cases that you'll get on your boards it's gonna be perfect all

your boards it's gonna be perfect all right so you have a patient who has a

right so you have a patient who has a retic index greater than 2 so now you

retic index greater than 2 so now you know it's either an increase in

know it's either an increase in destruction or a loss how do i figure

destruction or a loss how do i figure out if it's a destruction issue and if

out if it's a destruction issue and if when i figure out it's a destruction

when i figure out it's a destruction issue how do i get to the actual

issue how do i get to the actual underlying problem here because again

underlying problem here because again you got to remember we are taking an

you got to remember we are taking an approach this is a diagnostic approach

approach this is a diagnostic approach to these we're going to have an

to these we're going to have an individual video microcytic macrocytic

individual video microcytic macrocytic normal acidic and hemolytic anemias

normal acidic and hemolytic anemias where we go into detail of all these

where we go into detail of all these things but i want to introduce you to it

things but i want to introduce you to it so you have an approach to these a basic

so you have an approach to these a basic understanding so it'll really help you

understanding so it'll really help you when we talk about these in detail

when we talk about these in detail so with hemolytic anemias let's start

so with hemolytic anemias let's start with that the destruction portion so

with that the destruction portion so when i talk about hemolytic anemias

when i talk about hemolytic anemias remember i told you that you could break

remember i told you that you could break down

down the actual red blood cell when you break

the actual red blood cell when you break it down you can break it down inside of

it down you can break it down inside of the vasculature intravascular or you can

the vasculature intravascular or you can break it down inside of this splenic

break it down inside of this splenic macrophages inside the spleen

macrophages inside the spleen extravascular

extravascular either way when you break down red blood

either way when you break down red blood cells inside of the red blood cells you

cells inside of the red blood cells you break down a very specific there's a lot

break down a very specific there's a lot of different things that can leak out of

of different things that can leak out of these red blood cells so say that i

these red blood cells so say that i break down these red blood cells when i

break down these red blood cells when i break them down i can release out a

break them down i can release out a couple different molecules that you have

couple different molecules that you have to check this is a part of those

to check this is a part of those hemolytic labs that i mentioned in the

hemolytic labs that i mentioned in the normal acidic anemia

normal acidic anemia first one that is usually released into

first one that is usually released into the bloodstream because it's released

the bloodstream because it's released from the red blood cell is ldh lactate

from the red blood cell is ldh lactate dehydrogenase that's usually elevated so

dehydrogenase that's usually elevated so it's an enzyme found inside the red

it's an enzyme found inside the red blood cell when you pop it open leaks

blood cell when you pop it open leaks out

out the other one

the other one that also can kind of leak out

that also can kind of leak out is

is bilirubin so you know um inside of the

bilirubin so you know um inside of the red blood cells you have hemoglobin

red blood cells you have hemoglobin hemoglobin has a protein component and

hemoglobin has a protein component and then it also has the heme component the

then it also has the heme component the heme component can get broken down into

heme component can get broken down into bilirubin what is really important

bilirubin what is really important though we're going to call it billy to

though we're going to call it billy to tell you it's bilirubin but you know

tell you it's bilirubin but you know there's two different types of bilirubin

there's two different types of bilirubin unconjugated also known as

unconjugated also known as indirect just so you know they can use

indirect just so you know they can use it two different ways indirect bilirubin

it two different ways indirect bilirubin i'll put in parentheses though

i'll put in parentheses though unconjugated bilirubin is another way of

unconjugated bilirubin is another way of explaining it

explaining it this will be elevated in these patients

this will be elevated in these patients so they may have some jaundice-like

so they may have some jaundice-like appearance and an increase in bilirubin

appearance and an increase in bilirubin it's more the unconjugated or indirect

it's more the unconjugated or indirect one

one okay

okay the next thing that you release out here

the next thing that you release out here is you also release out the hemoglobin

is you also release out the hemoglobin in general so whenever hemoglobin gets

in general so whenever hemoglobin gets released into the bloodstream we don't

released into the bloodstream we don't want it to be by itself it's a nasty

want it to be by itself it's a nasty little molecule and whenever you release

little molecule and whenever you release this hemoglobin just it's it's in a

this hemoglobin just it's it's in a vasculature on its own

vasculature on its own our beautiful liver says oh crap there's

our beautiful liver says oh crap there's lots of this hemoglobin out there guys i

lots of this hemoglobin out there guys i gotta fix this

gotta fix this and it makes a particular protein this

and it makes a particular protein this protein is called

protein is called haptoglobin so haptoglobe and imagine

haptoglobin so haptoglobe and imagine i'm gonna kind of draw him as like a

i'm gonna kind of draw him as like a little circle here and then imagine

little circle here and then imagine hemoglobin i'm going to draw him as this

hemoglobin i'm going to draw him as this circle here

circle here what happens is haptoglobin will not

what happens is haptoglobin will not allow hemoglobin to float around by

allow hemoglobin to float around by itself

itself and so hemoglobin

and so hemoglobin and haptoglobin will complex with one

and haptoglobin will complex with one another

another and bind to one another so that

and bind to one another so that haptoglobin can kind of bind the

haptoglobin can kind of bind the hemoglobin and prevent hemoglobin from

hemoglobin and prevent hemoglobin from causing all types of problems

causing all types of problems so there's the complex

so there's the complex now when the liver makes this

now when the liver makes this haptoglobin

haptoglobin and the haploglobins binding to the

and the haploglobins binding to the actual hemoglobin what happens to the

actual hemoglobin what happens to the free haptoglobin now now that it's

free haptoglobin now now that it's complex you're making a ton of this

complex you're making a ton of this a ton of these complexes what happens to

a ton of these complexes what happens to the free haptoglobin that drops because

the free haptoglobin that drops because you're complexing it with all this

you're complexing it with all this hemoglobin that's leaking out so you'll

hemoglobin that's leaking out so you'll have low

have low haptoglobin

haptoglobin the other thing is some of this

the other thing is some of this hemoglobin actually gets into the urine

hemoglobin actually gets into the urine it actually gets to your kidneys and

it actually gets to your kidneys and when it gets to your kidneys you can

when it gets to your kidneys you can actually pee out

actually pee out some of that hemoglobin

some of that hemoglobin into the urine and so the hemoglobin

into the urine and so the hemoglobin inside of your urine will also be

inside of your urine will also be elevated and so you'll have what's

elevated and so you'll have what's called an increase in the hemoglobin in

called an increase in the hemoglobin in the urine so many times we call this

the urine so many times we call this hemoglobinuria

hemoglobinuria hemoglobin neuria so one of the obvious

hemoglobin neuria so one of the obvious things that you can test for and a

things that you can test for and a patient who you're concerned you check

patient who you're concerned you check they have low hematocrit low hemoglobin

they have low hematocrit low hemoglobin lower red blood cells or tick index

lower red blood cells or tick index greater than two percent check your

greater than two percent check your hemolytic labs what are those labs

hemolytic labs what are those labs ldh

ldh indirect bilirubin

indirect bilirubin haptoglobin

haptoglobin and you can also order a ua and look for

and you can also order a ua and look for hemoglobin in the urine if you really

hemoglobin in the urine if you really want to boil this down to the most

want to boil this down to the most common two types

common two types it's going to be this one

it's going to be this one and this one these are going to be the

and this one these are going to be the biggest ones that you'll probably see in

biggest ones that you'll probably see in your clinical vignette so you'll check

your clinical vignette so you'll check an ldh and a haptoglobin and that will

an ldh and a haptoglobin and that will be the big thing for your hemolysis

be the big thing for your hemolysis if it comes back positive you have an

if it comes back positive you have an elevated ldh and a low haptoglobin you

elevated ldh and a low haptoglobin you can actually say with some relative

can actually say with some relative confidence there is hemolysis now

confidence there is hemolysis now technically if it's inside of the

technically if it's inside of the vasculature intravascular

vasculature intravascular it'll be crazy high

it'll be crazy high if it's inside of the splenic

if it's inside of the splenic macrophages it'll be high but not

macrophages it'll be high but not significantly so what you also want to

significantly so what you also want to consider sometimes is you want to take

consider sometimes is you want to take into consideration what's their spleen

into consideration what's their spleen looking like in some of these patients

looking like in some of these patients so maybe they do have some positive

so maybe they do have some positive hemolytic labs

hemolytic labs take a look at their spleen and

take a look at their spleen and sometimes what i like to just say is

sometimes what i like to just say is look to see if they have any splenic

look to see if they have any splenic diseases

diseases or any kind of liver disease

or any kind of liver disease and then you should consider a splenic

and then you should consider a splenic ultrasound because a splenic ultrasound

ultrasound because a splenic ultrasound may show you something called

may show you something called splenomegaly

splenomegaly and this is a pretty important thing

and this is a pretty important thing because splenomegaly may mean that the

because splenomegaly may mean that the spleen so sometimes you can have

spleen so sometimes you can have something called hyperspleenism where

something called hyperspleenism where the spleen just kind of like entraps and

the spleen just kind of like entraps and yanks red blood cells from your

yanks red blood cells from your bloodstream

bloodstream way faster and way more than it ever

way faster and way more than it ever should usually red blood cells get

should usually red blood cells get destroyed by your spleen whenever

destroyed by your spleen whenever they're old and defective but whenever

they're old and defective but whenever your spleen is just acting up and

your spleen is just acting up and there's many different reasons it can do

there's many different reasons it can do that we're not going to go down that

that we're not going to go down that rabbit hole in this video we'll do

rabbit hole in this video we'll do another one again on its own we'll talk

another one again on its own we'll talk about hemolytic anemias the spleen can

about hemolytic anemias the spleen can just chew through the red blood cells

just chew through the red blood cells and it can hyperfunction and yank them

and it can hyperfunction and yank them all out and it can get really big

all out and it can get really big because it's chewing through them so

because it's chewing through them so consider a splenic ultrasound when you

consider a splenic ultrasound when you have someone who has some big

have someone who has some big splenomegaly and think about that if

splenomegaly and think about that if they have underlying splenic disease or

they have underlying splenic disease or liver disease this will involve a lot

liver disease this will involve a lot heavier workup which we're not going to

heavier workup which we're not going to go into right now but that's something

go into right now but that's something to think about especially with the

to think about especially with the extravascular hemolysis

extravascular hemolysis okay so you think they have heme

okay so you think they have heme hemolysis check an ldh check a

hemolysis check an ldh check a haptoglobin you can also

haptoglobin you can also consider getting a splenic ultrasound to

consider getting a splenic ultrasound to look for any splenomegaly to rule out

look for any splenomegaly to rule out hyperspleenism got it

hyperspleenism got it okay

okay next thing i like to do after i've

next thing i like to do after i've confirmed so first thing is this this is

confirmed so first thing is this this is the first part first part is your

the first part first part is your hemolytic

labs that's the first part second part is is this

is is this autoimmune hemolysis

autoimmune hemolysis so that's the next thing i have to

so that's the next thing i have to determine so in order for me to do that

determine so in order for me to do that i have to do something called a direct

i have to do something called a direct antibody test sometimes we call this a

antibody test sometimes we call this a coombs test

coombs test and what i want to know is i want to

and what i want to know is i want to know if my coombs test is positive or

know if my coombs test is positive or negative

negative if the dat or the coombs is positive i

if the dat or the coombs is positive i have something called an autoimmune

have something called an autoimmune hemolytic anemia and again with these

hemolytic anemia and again with these there's many different types of issues

there's many different types of issues with these

with these so whenever we talk about autoimmune

so whenever we talk about autoimmune hemolytic anemia there's an endless

hemolytic anemia there's an endless number of causes we're not going to go

number of causes we're not going to go down that rabbit hole what i do want you

down that rabbit hole what i do want you to know is when you get these tests what

to know is when you get these tests what they tell you so let's say that you do a

they tell you so let's say that you do a dat or a coombs test what you want to

dat or a coombs test what you want to know is is it a warm first off you want

know is is it a warm first off you want to know if it's positive okay so if it's

to know if it's positive okay so if it's positive you have an autoimmune

positive you have an autoimmune hemolytic anemia but then you got to go

hemolytic anemia but then you got to go to the next step so if it's positive you

to the next step so if it's positive you have an autoimmune hemolytic anemia but

have an autoimmune hemolytic anemia but then you got to look at a little bit

then you got to look at a little bit more and determine if it's a cold

more and determine if it's a cold autoimmune hemolytic anemia or a warm

autoimmune hemolytic anemia or a warm autoimmune hemolytic anemia and the way

autoimmune hemolytic anemia and the way that you do that is by the way that

that you do that is by the way that they're positive on their dat or their

they're positive on their dat or their coombs test

coombs test in the warm autoimmune hemolytic anemia

in the warm autoimmune hemolytic anemia their igg is positive and their

their igg is positive and their complements

complements is positive

is positive and the cold autoimmune hemolytic anemia

and the cold autoimmune hemolytic anemia their igg

their igg is negative

is negative and their actual complements

and their actual complements are positive so that's something to

are positive so that's something to remember but either way they're both

remember but either way they're both autoimmune hemolytic anemias

autoimmune hemolytic anemias if you really just want to come down to

if you really just want to come down to the simplest point you check for

the simplest point you check for hemolytic labs it's positive you check a

hemolytic labs it's positive you check a dat it's positive if the dat's positive

dat it's positive if the dat's positive you do have autoimmune hemolytic anemia

you do have autoimmune hemolytic anemia if you want to figure out if it's hot or

if you want to figure out if it's hot or cold you just look at the patterns of

cold you just look at the patterns of their igg and their compliments if both

their igg and their compliments if both are positive it's warm if only the uh

are positive it's warm if only the uh igg is negative and the compliments are

igg is negative and the compliments are positive it's cold

positive it's cold and that can kind of differentiate like

and that can kind of differentiate like your two different types of autoimmune

your two different types of autoimmune hemolytic anemias

hemolytic anemias all right so first thing check your

all right so first thing check your hemolytic labs if they're positive good

hemolytic labs if they're positive good move on to the second part check for the

move on to the second part check for the dat if the dat's positive good it's

dat if the dat's positive good it's autoimmune look at the patterns is it

autoimmune look at the patterns is it warm or cold

warm or cold if the dat is negative

if the dat is negative okay

okay so then the third thing is

so then the third thing is if the dat

if the dat is actually potentially negative then

is actually potentially negative then you got to go down the rabbit hole of

you got to go down the rabbit hole of looking for another cause

looking for another cause of their hemolysis and so then that's

of their hemolysis and so then that's when you try to determine this is how i

when you try to determine this is how i look at it so if they're that's negative

look at it so if they're that's negative then i try to say okay

then i try to say okay they're hemolyzing now due to something

they're hemolyzing now due to something else that's not auto immune so then i

else that's not auto immune so then i try to think about reasons why someone

try to think about reasons why someone would actually get the red blood cells

would actually get the red blood cells hemolyzed is it something wrong with the

hemolyzed is it something wrong with the red blood cell intrinsic intrinsically

red blood cell intrinsic intrinsically or is there something else that's

or is there something else that's actually working against the red blood

actually working against the red blood cell extrinsically so some type of

cell extrinsically so some type of trauma is there some type of infection

trauma is there some type of infection is that what's going on outside the

is that what's going on outside the actual red blood cell that could be

actual red blood cell that could be affecting it that's the way i look at it

affecting it that's the way i look at it so with these it helps me to figure out

so with these it helps me to figure out my testing and what kind of things that

my testing and what kind of things that we should be thinking about so if my

we should be thinking about so if my dad's negative i think okay first let's

dad's negative i think okay first let's think about intrinsic hemolytic anemias

think about intrinsic hemolytic anemias so i think about the red blood cell is

so i think about the red blood cell is there something wrong with an enzyme

there something wrong with an enzyme inside of it if that's the problem the

inside of it if that's the problem the first disease i think about that you

first disease i think about that you guys would probably want to think about

guys would probably want to think about here is called g6 pdh deficiency so it's

here is called g6 pdh deficiency so it's called

called g6 pdh deficiency

g6 pdh deficiency in this disease you see this in younger

in this disease you see this in younger african-american children again in this

african-american children again in this one it's usually after they've had like

one it's usually after they've had like an infection they've been exposed to

an infection they've been exposed to some type of like fava bean like they

some type of like fava bean like they were eating fava beans stuff like that

were eating fava beans stuff like that but what you're looking at for these

but what you're looking at for these patients is you actually check this

patients is you actually check this enzyme and this enzyme level will

enzyme and this enzyme level will actually be low

actually be low you only want to check it though when

you only want to check it though when they're not hemolyzing so that's one of

they're not hemolyzing so that's one of the big things like little caveats in

the big things like little caveats in this is you only check for g6 pdh

this is you only check for g6 pdh deficiency when they're not actually in

deficiency when they're not actually in hemolytic crisis because whatever put

hemolytic crisis because whatever put them into it you have to wait a little

them into it you have to wait a little bit so they're a little bit healthier

bit so they're a little bit healthier and then you can check the enzyme but

and then you can check the enzyme but what actually may come up on the exam

what actually may come up on the exam is for these patients a lot when after

is for these patients a lot when after you get your dad i think the next two

you get your dad i think the next two big things to look at is your peripheral

big things to look at is your peripheral blood smear

blood smear and history that's the next thing so i

and history that's the next thing so i would do that so after the dat's

would do that so after the dat's negative the fourth step i would say is

negative the fourth step i would say is look at my peripheral blood smear and

look at my peripheral blood smear and look at my history

look at my history so for this peripheral blood smear what

so for this peripheral blood smear what i would actually see for these patients

i would actually see for these patients is i would see something called bite

is i would see something called bite cells and we'll show you what those look

cells and we'll show you what those look like

like and i could also see something called

and i could also see something called heinz bodies

heinz bodies so if i see these i have a concern of

so if i see these i have a concern of g6pdh deficiency if they're not in the

g6pdh deficiency if they're not in the hemolytic stage i can check their g6pdh

hemolytic stage i can check their g6pdh level and it'll be they'll actually have

level and it'll be they'll actually have a significant deficiency there

a significant deficiency there all right hemoglobinopathy

all right hemoglobinopathy so if they have um again

so if they have um again a history of some type of hemoglobin

a history of some type of hemoglobin problem they have a history of sickle

problem they have a history of sickle cell anemia a family history of sickle

cell anemia a family history of sickle cell anemia they've had a history of

cell anemia they've had a history of vasoclusive crises or they're having it

vasoclusive crises or they're having it right now in that kind of sense you can

right now in that kind of sense you can actually cons potentially assume it's a

actually cons potentially assume it's a hemoglobinopathy that's your history

hemoglobinopathy that's your history but if we wanted to get a peripheral

but if we wanted to get a peripheral blood smear what would the peripheral

blood smear what would the peripheral blood smear show if you had sickle cell

blood smear show if you had sickle cell anemia

anemia you would see sickle cells

you would see sickle cells and if you actually were potentially

and if you actually were potentially maybe this was their first vasoclusive

maybe this was their first vasoclusive event

event and you actually potentially got the

and you actually potentially got the peripheral blood smear and you saw that

peripheral blood smear and you saw that there was sickle cells you can actually

there was sickle cells you can actually confirm with a hemoglobin

confirm with a hemoglobin electrophoresis to show

electrophoresis to show sickle cell anemia

sickle cell anemia and obviously that'll show the

and obviously that'll show the hemoglobin f all right

hemoglobin f all right and in this case you'll actually see

and in this case you'll actually see like they'll have the sickle cell anemia

like they'll have the sickle cell anemia potentially so again that's your

potentially so again that's your hemoglobinopathy so i think is there an

hemoglobinopathy so i think is there an enzyme problem g6pdh is there a

enzyme problem g6pdh is there a hemoglobinopathy sickle cell anemia is a

hemoglobinopathy sickle cell anemia is a big one look for sickle cells look for

big one look for sickle cells look for the history any vaso occlusive events

the history any vaso occlusive events confirm with the hemoglobin

confirm with the hemoglobin electrophoresis

electrophoresis is there a membrane problem so with the

is there a membrane problem so with the membrane problems

membrane problems i think about two disorders here

i think about two disorders here one is called hereditary spherocytosis

one is called hereditary spherocytosis so with hereditary spherocytosis

so with hereditary spherocytosis usually these patients won't be super

usually these patients won't be super obvious they won't have a lot of like

obvious they won't have a lot of like symptoms or clinical features but again

symptoms or clinical features but again what's the next test peripheral blood

what's the next test peripheral blood smear and history nothing really special

smear and history nothing really special about their history

about their history but if you look at their peripheral

but if you look at their peripheral blood smear they will have spherocytes

blood smear they will have spherocytes so a lot of these like spherical shaped

so a lot of these like spherical shaped cells

cells what you'll do is is if you're concerned

what you'll do is is if you're concerned you can do something called an

you can do something called an osmotic fragility test

osmotic fragility test and if their osmotic fragility

and if their osmotic fragility test is positive you have a very high

test is positive you have a very high degree of suspicion for hereditary

degree of suspicion for hereditary spherocytosis okay

spherocytosis okay the next disease that you should be

the next disease that you should be thinking about here

thinking about here is actually called paroxysmal nocturnal

is actually called paroxysmal nocturnal hemoglobinuria

hemoglobinuria so in this disease it's actually odd

so in this disease it's actually odd because at night they actually kind of

because at night they actually kind of go through these hemolytic events

go through these hemolytic events and they have particular like mutations

and they have particular like mutations in very specific proteins in their cell

in very specific proteins in their cell membranes

membranes what you want to look at in their

what you want to look at in their history is they've had some type of

history is they've had some type of history of like

history of like clots like lots of actual venous clots

clots like lots of actual venous clots maybe they had like dvts and pes or bud

maybe they had like dvts and pes or bud chiari syndrome so look for like history

chiari syndrome so look for like history of like venus types of clots

of like venus types of clots especially like like bud chiari syndrome

especially like like bud chiari syndrome or something like that

or something like that then again look at your peripheral blood

then again look at your peripheral blood smear on the peripheral blood smear they

smear on the peripheral blood smear they will have spherocytes

will have spherocytes but one of the key things here

but one of the key things here is not only will they have a history of

is not only will they have a history of venous clots but they'll wake up they'll

venous clots but they'll wake up they'll actually in the morning they'll have

actually in the morning they'll have dark

dark urine

urine in the am

in the am okay so they'll wake up in the morning

okay so they'll wake up in the morning and they'll have dark urine in the am

and they'll have dark urine in the am they'll also potentially have history of

they'll also potentially have history of venous clots you get a peripheral blood

venous clots you get a peripheral blood smear it shows spherocytes if you have

smear it shows spherocytes if you have this high degree of suspicion with some

this high degree of suspicion with some of this history and spherocytes you

of this history and spherocytes you should consider

should consider sending off a very specific test called

sending off a very specific test called a flow cytometry so you can do something

a flow cytometry so you can do something called a flow

called a flow cytometry and if that is positive then

cytometry and if that is positive then it's very suggestive of peroxismal

it's very suggestive of peroxismal nocturnal hemoglobinuria

nocturnal hemoglobinuria all right so that's the way i would go

all right so that's the way i would go through that is it hemolysis ldh

through that is it hemolysis ldh haptoglobin that comes back positive is

haptoglobin that comes back positive is it autoimmune datums is that positive

it autoimmune datums is that positive okay autoimmune which one warm cold boom

okay autoimmune which one warm cold boom if it's negative okay is it an intrinsic

if it's negative okay is it an intrinsic problem get a peripheral blood smear and

problem get a peripheral blood smear and look at their history figure out if it's

look at their history figure out if it's an enzyme hemoglobinopathy or a membrane

an enzyme hemoglobinopathy or a membrane problem if you've gone through all of

problem if you've gone through all of these and you can't find it then move on

these and you can't find it then move on to your extrinsic problems

to your extrinsic problems all right

all right so for these bad boys

so for these bad boys you can think about something called

you can think about something called microangiopathic hemolytic anemia maha

microangiopathic hemolytic anemia maha and what this is is you're actually

and what this is is you're actually having a red blood cell problem but also

having a red blood cell problem but also look for low platelets so the other

look for low platelets so the other thing i would actually tell you to look

thing i would actually tell you to look at is what is their platelet count

at is what is their platelet count because if their platelet count is

because if their platelet count is dropping sometimes we call these like

dropping sometimes we call these like thrombotic microangiopathies

thrombotic microangiopathies this can actually be sometimes very

this can actually be sometimes very helpful so if you see a drop in their

helpful so if you see a drop in their platelets

platelets think about

think about microangiopathic hemolytic anemia the

microangiopathic hemolytic anemia the basic concept behind this

basic concept behind this is that you are actually having some

is that you are actually having some type of like

type of like small clots so the basic theory behind

small clots so the basic theory behind this is you have these vessels here and

this is you have these vessels here and they have like small clots here and as

they have like small clots here and as like your red blood cells

like your red blood cells and as the platelets are trying to kind

and as the platelets are trying to kind of like squeeze through like they're

of like squeeze through like they're getting kind of consumed up in these

getting kind of consumed up in these clots they're actually can get consumed

clots they're actually can get consumed or they can get ripped apart as they're

or they can get ripped apart as they're bumping up against these microthrombie

bumping up against these microthrombie the other thing is that sometimes if

the other thing is that sometimes if people have like heart valves those can

people have like heart valves those can actually kind of rip they can rip like a

actually kind of rip they can rip like a mechanical heart valve and you're

mechanical heart valve and you're pushing blood against it sometimes red

pushing blood against it sometimes red blood cells can get just get sheared

blood cells can get just get sheared apart on that as well

apart on that as well so i think one of the big things to look

so i think one of the big things to look for for maha

for for maha is there's a couple different disorders

is there's a couple different disorders first off look for the low platelets

first off look for the low platelets then you want to think about a couple

then you want to think about a couple different types of bajas the first ones

different types of bajas the first ones that you want to think about is dic

that you want to think about is dic then you want to think about something

then you want to think about something called ttp

called ttp think about hus

think about hus think about help syndrome

think about help syndrome and then lastly you want to think about

and then lastly you want to think about some type of mechanical

valve all right so dic has disseminated intravascular

so dic has disseminated intravascular coagulation and these patients all of

coagulation and these patients all of these they're kind of like having like

these they're kind of like having like somewhat of these low platelets

somewhat of these low platelets and low red blood cells because of these

and low red blood cells because of these multiple micro thrombi

multiple micro thrombi in dic some of the cueing kind of

in dic some of the cueing kind of features here is that usually the

features here is that usually the patient is like septic or critically ill

patient is like septic or critically ill and they have like elevated coagulation

and they have like elevated coagulation kind of problems so they have like an

kind of problems so they have like an elevated ptt a pt an inr they have like

elevated ptt a pt an inr they have like an increased d dimer

an increased d dimer they have like a low fibrinogen

they have like a low fibrinogen and they have like the low platelets

and they have like the low platelets and they're really sick and these

and they're really sick and these patients that would be kind of one of

patients that would be kind of one of the cueing factors for that one for ttp

the cueing factors for that one for ttp you would also have these patients who

you would also have these patients who have again low platelets

have again low platelets they would also have

they would also have acute renal failure

acute renal failure they would also have this actual drop in

they would also have this actual drop in red blood cells

red blood cells and they would have some type of like

and they would have some type of like fever

fever potentially

potentially and neuro

and neuro deficits

deficits so these are something to think about as

so these are something to think about as well and if you do have a high degree of

well and if you do have a high degree of suspicion for ttp sometimes you can

suspicion for ttp sometimes you can confirm that with the atom

confirm that with the atom uh

uh t13 testing and look to see if there's

t13 testing and look to see if there's some type of like deficiency there as

some type of like deficiency there as well

well hus usually hemolytic uremic syndrome

hus usually hemolytic uremic syndrome this is more common like your children

this is more common like your children your younger kind of children but

your younger kind of children but there's some type of like prior like gi

there's some type of like prior like gi infection

infection usually by like

usually by like what's called the sugar toxin

what's called the sugar toxin but these people will also have

but these people will also have low platelets

low platelets they'll have some type of acute renal

they'll have some type of acute renal failure and again you'll have evidence

failure and again you'll have evidence of anemia but probably some type of

of anemia but probably some type of underlying history of gi issues prior to

underlying history of gi issues prior to that so think about that and younger

that so think about that and younger children

children for help syndrome you obviously think

for help syndrome you obviously think about i have to think about like a

about i have to think about like a pregnant woman okay so think about a

pregnant woman okay so think about a pregnant woman that's one particular big

pregnant woman that's one particular big thing and then if you think about it

thing and then if you think about it help syndrome is hemolysis

help syndrome is hemolysis and then they're gonna have low

and then they're gonna have low platelets and elevated lft so they'll

platelets and elevated lft so they'll have low platelets

have low platelets and increase lfts and then again in a

and increase lfts and then again in a pregnant patient so that's another big

pregnant patient so that's another big thing to think about for these types of

thing to think about for these types of majors mechanical valve if they have

majors mechanical valve if they have like a mechanical aortic valve this can

like a mechanical aortic valve this can actually chew up

actually chew up their red blood cells so that's one

their red blood cells so that's one particular thing to think about now how

particular thing to think about now how do i i can obviously think that it's one

do i i can obviously think that it's one of these but how do i really kind of get

of these but how do i really kind of get down to business for these because you

down to business for these because you said zach check a peripheral blood smear

said zach check a peripheral blood smear and think about the history for these

and think about the history for these well for the peripheral blood smear for

well for the peripheral blood smear for these it's actually relatively helpful

these it's actually relatively helpful so the peripheral blood smear for all of

so the peripheral blood smear for all of your maha's

your maha's so we're going to put it right here the

so we're going to put it right here the peripheral blood smear will show

peripheral blood smear will show something called schistocytes

something called schistocytes and these are just like torn up red

and these are just like torn up red blood cells sometimes you can see these

blood cells sometimes you can see these things called helmet cells as well

things called helmet cells as well but i think this is the big big thing

but i think this is the big big thing here is the schistocytes so if you see a

here is the schistocytes so if you see a patient has schistocytes torn up ripped

patient has schistocytes torn up ripped up red blood cells

up red blood cells think about some type of maha

think about some type of maha and then look do they have low platelets

and then look do they have low platelets that also suggest a maha and then you

that also suggest a maha and then you can think about which one it is based

can think about which one it is based upon their history do they have a

upon their history do they have a history of any word like mechanical

history of any word like mechanical aortic valve

aortic valve do they have any of these findings of

do they have any of these findings of dic do they have any of these findings

dic do they have any of these findings of ttp do they have any of these

of ttp do they have any of these findings of hus do they have any of the

findings of hus do they have any of the findings of help syndrome and that will

findings of help syndrome and that will kind of lead you down that road of which

kind of lead you down that road of which type of problem it could be not too bad

type of problem it could be not too bad right

right all right

all right next one is infectious now infectious is

next one is infectious now infectious is a kind of a

a kind of a super super obvious one

super super obvious one with infectious ones you want to think

with infectious ones you want to think about a patient who is having a super

about a patient who is having a super high fever for all of these patients

high fever for all of these patients they're probably gonna have some type of

they're probably gonna have some type of high fever

high fever maybe like a rash of some kind

maybe like a rash of some kind and this is a really really important

and this is a really really important one okay for these ones

one okay for these ones you want to think about malaria

you want to think about malaria okay you want to think about malaria so

okay you want to think about malaria so in this situation obviously in their

in this situation obviously in their history they have some type of recent

history they have some type of recent travel to like africa or some some kind

travel to like africa or some some kind of area where there's a high possibility

of area where there's a high possibility of it's being exposed to malaria and

of it's being exposed to malaria and then they come back with a high fever

then they come back with a high fever they come back with fatigue they come

they come back with fatigue they come back with a lot of myalgias and things

back with a lot of myalgias and things of that nature

of that nature when you look at the peripheral blood

when you look at the peripheral blood smear

smear on these patients you'll be able to see

on these patients you'll be able to see the inclusions of the actual malaria

the inclusions of the actual malaria inside of them so you'll be able to see

inside of them so you'll be able to see the inclusions

the inclusions inside of the red blood cell they get

inside of the red blood cell they get inside of the actual red blood cell

inside of the actual red blood cell and so you'll be able to see that

and so you'll be able to see that on this one on their blood smear

on this one on their blood smear the other one you want to think about is

the other one you want to think about is something called babesiosis so it's

something called babesiosis so it's called babesiosis

called babesiosis so usually this is due to a tick bite so

so usually this is due to a tick bite so if you look in their history and they

if you look in their history and they have some type of tick bite they have

have some type of tick bite they have like a rash they have high fevers they

like a rash they have high fevers they were in an area like wisconsin or

were in an area like wisconsin or something like that then they could have

something like that then they could have been had a it could have been a

been had a it could have been a potential babesiosis so in this

potential babesiosis so in this situation their peripheral blood smear

situation their peripheral blood smear can actually show something that's very

can actually show something that's very patho-mnemonic called a maltese cross

patho-mnemonic called a maltese cross so look for this one

so look for this one as a big one for apobisiosis

as a big one for apobisiosis and the last one is called disseminated

and the last one is called disseminated c diff

c diff really really nasty stuff here if

really really nasty stuff here if someone gets a really really nasty

someone gets a really really nasty clostridium difficile infection

clostridium difficile infection so they have like just rip roaring

so they have like just rip roaring diarrhea just peeing out their bone hole

diarrhea just peeing out their bone hole and that kind of situation they look

and that kind of situation they look septic they're really sick high fevers

septic they're really sick high fevers lots of diarrhea then i would actually

lots of diarrhea then i would actually go ahead and again look at the

go ahead and again look at the peripheral blood smear test for c diff

peripheral blood smear test for c diff obviously and in this situation they

obviously and in this situation they have something called ghost

have something called ghost cells that pop up for c diff okay but

cells that pop up for c diff okay but test for c diff obviously you can check

test for c diff obviously you can check the peripheral blood smear look at their

the peripheral blood smear look at their history but again i think one of the key

history but again i think one of the key things that clues you to think about

things that clues you to think about fevers i mean think about the infectious

fevers i mean think about the infectious causes is very high fevers rashes some

causes is very high fevers rashes some type of recent travel into areas where

type of recent travel into areas where there's a high exposure or again

there's a high exposure or again potentially like with c diff lots and

potentially like with c diff lots and lots of diarrhea potentially

lots of diarrhea potentially all right so that's how i go about these

all right so that's how i go about these so

so real quick again you check for hemolytic

real quick again you check for hemolytic labs haptoglobin ldh if it's positive

labs haptoglobin ldh if it's positive check the dat if that's positive it's

check the dat if that's positive it's autoimmune if it's not then look at your

autoimmune if it's not then look at your again peripheral blood smearing history

again peripheral blood smearing history and figure out if it's intrinsic or

and figure out if it's intrinsic or extrinsic from there we've gone through

extrinsic from there we've gone through all of our oh and then lastly again if

all of our oh and then lastly again if you think that there could be some type

you think that there could be some type of hyperspleenism

of hyperspleenism check the spleen for splenomegaly by

check the spleen for splenomegaly by doing a splenic ultrasound all right now

doing a splenic ultrasound all right now that we've gone through these let's talk

that we've gone through these let's talk about the last part here that could be a

about the last part here that could be a part of these anemias though it's not

part of these anemias though it's not destruction it's a loss of blood let's

destruction it's a loss of blood let's talk about that all right so the last

talk about that all right so the last thing is we think it's blood loss how do

thing is we think it's blood loss how do i determine that so

i determine that so first thing i would actually do is i

first thing i would actually do is i would say okay

would say okay i know that it's again i have anemia low

i know that it's again i have anemia low hemoglobin low hematocrit low red blood

hemoglobin low hematocrit low red blood cells check my retic index greater than

cells check my retic index greater than two percent i know it's an increased

two percent i know it's an increased destruction or loss problem

destruction or loss problem how do i know that it's not actually a

how do i know that it's not actually a destruction problem what did i tell you

destruction problem what did i tell you to first check right away

to first check right away the first thing you check is for

the first thing you check is for hemolysis so if in these patients the

hemolysis so if in these patients the first thing you see is there is no

first thing you see is there is no evidence of hemolysis

evidence of hemolysis so in other words their ldh is normal

so in other words their ldh is normal their haptoglobin is normal you don't

their haptoglobin is normal you don't have to go down the direction of

have to go down the direction of checking a dat and then looking for any

checking a dat and then looking for any of these intrinsic and extrinsic

of these intrinsic and extrinsic hemolytic anemias you're done you

hemolytic anemias you're done you already know it's not hemolysis

already know it's not hemolysis i can move on and say that it's likely

i can move on and say that it's likely blood loss

blood loss plus here's the thing my friends

plus here's the thing my friends be intelligent if someone is losing

be intelligent if someone is losing blood

blood you can look at their actual physical

you can look at their actual physical exam so do they have any signs and

exam so do they have any signs and symptoms of bleeding

symptoms of bleeding do they look pale

do they look pale do they have power do they have dry

do they have power do they have dry mucous membranes decreased capillary

mucous membranes decreased capillary refill are they having hypotension

refill are they having hypotension tachycardia all evidence that they could

tachycardia all evidence that they could be losing blood

be losing blood and evidence of bleeding right in front

and evidence of bleeding right in front of you

of you you know look at those things but if if

you know look at those things but if if you kind of look at this systematically

you kind of look at this systematically they're negative for hemolysis and they

they're negative for hemolysis and they have some types of concerns for bleeding

have some types of concerns for bleeding they're on anticoagulants they just had

they're on anticoagulants they just had a recent procedure done think about

a recent procedure done think about those things and i think the first thing

those things and i think the first thing right away what you're probably going to

right away what you're probably going to experience a lot of the time in your

experience a lot of the time in your clinical world especially in the icu in

clinical world especially in the icu in the hospital is you're going to look and

the hospital is you're going to look and you're going to be like oh my gosh this

you're going to be like oh my gosh this patient is like anemic and they're going

patient is like anemic and they're going to look and it's because they'd be

to look and it's because they'd be getting blood draws every single day

getting blood draws every single day multiple blood draws every day and

multiple blood draws every day and that's why they're anemic so sometimes

that's why they're anemic so sometimes if you were to go down the rabbit hole

if you were to go down the rabbit hole of saying okay

of saying okay i see the patient's anemic i check their

i see the patient's anemic i check their hemolytic i check their writic it's

hemolytic i check their writic it's greater than two okay then i go ahead

greater than two okay then i go ahead and i do the next thing and i check to

and i do the next thing and i check to see what their

see what their uh i check their hemolytic labs their

uh i check their hemolytic labs their negative oh okay potentially from blood

negative oh okay potentially from blood draws so could it be from just frequent

draws so could it be from just frequent blood draws

blood draws that might be their reason especially if

that might be their reason especially if they have no obvious other source the

they have no obvious other source the other thing is was there any particular

other thing is was there any particular surgery

surgery so sometimes was there a recent surgical

so sometimes was there a recent surgical procedure that they lost blood

procedure that they lost blood the other thing i think where you lose

the other thing i think where you lose tons of blood is what we talked about is

tons of blood is what we talked about is the git you can lose tons and tons of

the git you can lose tons and tons of blood from the git so gi bleeds are sons

blood from the git so gi bleeds are sons of guns so look for any evidence of

of guns so look for any evidence of vomiting up of blood right hematemesis

vomiting up of blood right hematemesis look for any

look for any bright red blood prorectum or melano

bright red blood prorectum or melano dark stools and if you have potential

dark stools and if you have potential concerns of these

concerns of these then what you can do is you can actually

then what you can do is you can actually do something for the upper gi you can do

do something for the upper gi you can do like a in an egd

like a in an egd and that will be able to tell you if you

and that will be able to tell you if you have some type of like upper gi bleed

have some type of like upper gi bleed sometimes they can even do what's called

sometimes they can even do what's called a nasogastric tube and then they can

a nasogastric tube and then they can aspirate out some areas from the gastric

aspirate out some areas from the gastric tube and see if there's any blood in

tube and see if there's any blood in there after you levage it and then

there after you levage it and then aspirate some stuff back

aspirate some stuff back but i think the egd is probably going to

but i think the egd is probably going to be the best and if that's positive and

be the best and if that's positive and you find something within the esophagus

you find something within the esophagus or the stomach or proximal part of the

or the stomach or proximal part of the duodenum then you're done

duodenum then you're done if it's a lower gi bleed you maybe need

if it's a lower gi bleed you maybe need like a c scope so maybe you have to do

like a c scope so maybe you have to do like a colonoscopy and that's going to

like a colonoscopy and that's going to show you your lower gi bleed or maybe

show you your lower gi bleed or maybe you do a fecal occult blood test and you

you do a fecal occult blood test and you find that's positive when you test their

find that's positive when you test their stool you do like a digital rectal put

stool you do like a digital rectal put it on the little thing and it shows up

it on the little thing and it shows up positive for blood that could be a

positive for blood that could be a potential problem

potential problem so these are things to be thinking about

so these are things to be thinking about now

now the other thing that i would say is a

the other thing that i would say is a really big one that i've experienced a

really big one that i've experienced a lot of the times that can cause just

lot of the times that can cause just massive blood loss is what's called

massive blood loss is what's called retroperitoneal bleed so you know

retroperitoneal bleed so you know there's a little space behind your

there's a little space behind your peritoneum called the retroperitoneum

peritoneum called the retroperitoneum you can lose a lot of blood from it into

you can lose a lot of blood from it into these areas here especially if you have

these areas here especially if you have like any kind of aortic bleed you have a

like any kind of aortic bleed you have a small vessel bleed within the leg you're

small vessel bleed within the leg you're on anticoagulants so really be on high

on anticoagulants so really be on high alert for patients who have what's

alert for patients who have what's called a rp bleed and that's a big one

called a rp bleed and that's a big one and sometimes for this one we do

and sometimes for this one we do something called a cta

something called a cta of like the abdomen and the pelvis area

of like the abdomen and the pelvis area so you can do a cta of the abdomen and

so you can do a cta of the abdomen and pelvis to look for any kind of bleed in

pelvis to look for any kind of bleed in that areas you know what else sometimes

that areas you know what else sometimes if people kind of like hit like an

if people kind of like hit like an artery in their leg like they fracture a

artery in their leg like they fracture a bone or they get some type of procedure

bone or they get some type of procedure you can actually accumulate a lot of

you can actually accumulate a lot of blood within the leg too so take a look

blood within the leg too so take a look at their legs do they have any swollen

at their legs do they have any swollen legs or hematomas any visible things

legs or hematomas any visible things there that's also important too

there that's also important too but i think that really just gives you

but i think that really just gives you the basic idea my friends of how to

the basic idea my friends of how to approach anemia what i want us to do now

approach anemia what i want us to do now is put this to practice let's see if you

is put this to practice let's see if you remember this stuff so what we're going

remember this stuff so what we're going to do is we're going to do some case

to do is we're going to do some case studies and see if you can determine

studies and see if you can determine which type of problem it is with this

which type of problem it is with this increased destruction category case

increased destruction category case study nine

study nine okay here we go we have a 75 year old

okay here we go we have a 75 year old male status post mechanical thrombectomy

male status post mechanical thrombectomy they had a stroke and they had to go in

they had a stroke and they had to go in through like the femoral artery to go up

through like the femoral artery to go up and try to pull the clot out of one of

and try to pull the clot out of one of the vessels

the vessels comes back and then has later a

comes back and then has later a hemoglobin of 6.8 so he's anemic what do

hemoglobin of 6.8 so he's anemic what do we have to do

we have to do check the retic

check the retic where tick is seven percent it's greater

where tick is seven percent it's greater than two percent what does that mean

than two percent what does that mean it's not a decreased production problem

it's not a decreased production problem anymore my friends this is a what

anymore my friends this is a what it's either an increased destruction or

it's either an increased destruction or loss what do we have to do to make sure

loss what do we have to do to make sure what's either an increased destruction

what's either an increased destruction or a loss problem we gotta check for

or a loss problem we gotta check for hemolysis how do you check for hemolysis

hemolysis how do you check for hemolysis you gotta check your ldh you gotta check

you gotta check your ldh you gotta check your haptoglobin but you can also check

your haptoglobin but you can also check your indirect billy they're all normal

your indirect billy they're all normal if those are normal is there likely

if those are normal is there likely hemolysis

hemolysis no there's no hemolysis so what is it

no there's no hemolysis so what is it likely could be a bleed what do we have

likely could be a bleed what do we have to look for signs and symptoms of

to look for signs and symptoms of bleeding

bleeding so they just had a mechanical

so they just had a mechanical thrombectomy they have a big fat

thrombectomy they have a big fat hematoma on their hip

hematoma on their hip and they're hypotensive they're

and they're hypotensive they're tachycardic they look pale you send them

tachycardic they look pale you send them to get a ct abdomen pelvis because you

to get a ct abdomen pelvis because you think they have an rp bleed and there

think they have an rp bleed and there the arrow's pointing at it there's a

the arrow's pointing at it there's a bunch of blood sitting there after that

bunch of blood sitting there after that procedure

procedure you confirmed it now what do we know

you confirmed it now what do we know it's an rp bleed that caused their

it's an rp bleed that caused their anemia boom straightforward right

anemia boom straightforward right okay let's move on

okay let's move on case study 10.

case study 10. you get a 75 year old male past medical

you get a 75 year old male past medical history of cll chronic lymphocytic

history of cll chronic lymphocytic leukemia presents with the hemoglobin of

leukemia presents with the hemoglobin of 8.9 that's anemic what do we got to do

8.9 that's anemic what do we got to do check the retic

check the retic where tick is nine what does that mean

where tick is nine what does that mean it's not a decreased production it's an

it's not a decreased production it's an increased destruction or loss problem

increased destruction or loss problem how do i determine if it's an increased

how do i determine if it's an increased destruction or an increase in loss

destruction or an increase in loss hemolytic labs

hemolytic labs my ldh is high my haptoglobin is low my

my ldh is high my haptoglobin is low my indirect ability is high that's him

indirect ability is high that's him that's evidence of homolysis what do i

that's evidence of homolysis what do i check after hemolysis is present

check after hemolysis is present a dat why do i check a dat or a coombs

a dat why do i check a dat or a coombs test

test to see if it's

to see if it's autoimmune that's positive and it's and

autoimmune that's positive and it's and it's positive for igg and positive for

it's positive for igg and positive for compliments which one is that is that

compliments which one is that is that cold or warm

cold or warm that's warm if it's a warm autoimmune

that's warm if it's a warm autoimmune hemolytic anemia there's a bunch of

hemolytic anemia there's a bunch of different causes behind this but it's

different causes behind this but it's likely the cll that's probably the

likely the cll that's probably the culprit behind that okay we'll go again

culprit behind that okay we'll go again we'll go into more of the causes and all

we'll go into more of the causes and all the the details of that in individual

the the details of that in individual videos on these anemias but for right

videos on these anemias but for right now that's the basic concept all right

now that's the basic concept all right good job we're good we're moving along

good job we're good we're moving along guys

guys all right 75 year old male cough

all right 75 year old male cough shortness of breath green sputum

shortness of breath green sputum presents with a hemoglobin of 9.9 he's

presents with a hemoglobin of 9.9 he's anemic check the retic

anemic check the retic six percent is greater than two it's

six percent is greater than two it's either increased destruction or

either increased destruction or increased loss what do we do

increased loss what do we do hemolytic labs

hemolytic labs oh he's got hemolysis what do i do check

oh he's got hemolysis what do i do check a dat

a dat why do i check at that or combs to see

why do i check at that or combs to see if he's got autoimmune hemolysis

if he's got autoimmune hemolysis it's positive uh that their that

it's positive uh that their that actually combs is negative for igg but

actually combs is negative for igg but it's positive for complements in igm so

it's positive for complements in igm so he does have a positive dat but it's

he does have a positive dat but it's only positive for the again complements

only positive for the again complements what was that one that was a cold

what was that one that was a cold autoimmune hemolytic anemia and it's

autoimmune hemolytic anemia and it's likely secondary to mycoplasma pneumonia

likely secondary to mycoplasma pneumonia and again you can confirm that with a

and again you can confirm that with a pcr and again we'll go into more of the

pcr and again we'll go into more of the details of these in individual videos

details of these in individual videos but at least you got that it was a cold

but at least you got that it was a cold autoimmune hemolytic anemia all right

autoimmune hemolytic anemia all right 12.

12. 11 year old african-american male

11 year old african-american male treated for pneumonia with bactrim

treated for pneumonia with bactrim decided to eat some fava beans for lunch

decided to eat some fava beans for lunch presents with a hemoglobin a 10.2 he's

presents with a hemoglobin a 10.2 he's anemic what do i do check the retic

anemic what do i do check the retic it's four it's greater than two so it's

it's four it's greater than two so it's not a decreased production it's an

not a decreased production it's an increased destruction or loss what i do

increased destruction or loss what i do check pharmacist there's homolysis what

check pharmacist there's homolysis what do i do

do i do check a data to see if it's autoimmune

check a data to see if it's autoimmune that's negative it's not autoimmune what

that's negative it's not autoimmune what do i have to do now

do i have to do now look at the peripheral blood smear and

look at the peripheral blood smear and take into consideration his history

take into consideration his history what's suggestive in his history

what's suggestive in his history he's african-american he's young

he's african-american he's young and then there was some type of

and then there was some type of oxidative stress he was exposed to an

oxidative stress he was exposed to an infection with pneumonia he was exposed

infection with pneumonia he was exposed to baction which is antibiotic that can

to baction which is antibiotic that can cause oxidative stress and fava beans

cause oxidative stress and fava beans which can kind of cause some problems

which can kind of cause some problems all right let's look at what's next

all right let's look at what's next thing prefer blood smear what i tell you

thing prefer blood smear what i tell you was the big big words to think about

was the big big words to think about bite cells and heinz bodies

bite cells and heinz bodies g6pdh deficiency what do you actually

g6pdh deficiency what do you actually want to check for g6pdh deficiency the

want to check for g6pdh deficiency the enzyme levels but do you check it while

enzyme levels but do you check it while they're hemolyzing no you have to check

they're hemolyzing no you have to check it when they're not hemolyzing so check

it when they're not hemolyzing so check it again to see if they're when they're

it again to see if they're when they're not in a hemolytic state to see if it's

not in a hemolytic state to see if it's low what's my likely diagnosis g6pdh

low what's my likely diagnosis g6pdh deficiency oh man we're going

deficiency oh man we're going all right next one 12 year old

all right next one 12 year old african-american male presents with

african-american male presents with chest pain uh he's also got painful and

chest pain uh he's also got painful and pale extremities with hematuria uh

pale extremities with hematuria uh hemoglobin 7.2 he's anemic what do i do

hemoglobin 7.2 he's anemic what do i do checker tick

checker tick oh 7.5 it's greater than two so there's

oh 7.5 it's greater than two so there's not likely a decreased production it's

not likely a decreased production it's an increased destruction loss how do i

an increased destruction loss how do i know which one it is check my hemolysis

know which one it is check my hemolysis labs

labs oh he's hemolyzing is it autoimmune

oh he's hemolyzing is it autoimmune nope it's likely some type of intrinsic

nope it's likely some type of intrinsic or acquired problem how do i know look

or acquired problem how do i know look at the history and peripheral blood

at the history and peripheral blood smear history he's young he's

smear history he's young he's african-american he's got chest pain

african-american he's got chest pain painful pale extremities and hematuria

painful pale extremities and hematuria huh

huh could it be like a sickle cell kind of

could it be like a sickle cell kind of crisis like a vasoclusive crisis it

crisis like a vasoclusive crisis it could be how do i kind of add on to that

could be how do i kind of add on to that peripheral blood smear what does it look

peripheral blood smear what does it look like

like sickle cells

sickle cells what do i likely have sickle cell anemia

what do i likely have sickle cell anemia how do i confirm it hemoglobin

how do i confirm it hemoglobin electrophoresis it's positive what's my

electrophoresis it's positive what's my diagnosis

diagnosis sickle cell anemia

sickle cell anemia 44 year old female with past medical

44 year old female with past medical history bud kiari has dark urine in the

history bud kiari has dark urine in the morning prince of the hemoglobin 10.5

morning prince of the hemoglobin 10.5 anemia what do we do checker tick

anemia what do we do checker tick it's 2.5 it's high it's greater than two

it's 2.5 it's high it's greater than two percent is it hemolysis or is it a

percent is it hemolysis or is it a destruction what i got to do look at my

destruction what i got to do look at my hemolytic labs there's hemolysis

hemolytic labs there's hemolysis is it autoimmune check a dat it's

is it autoimmune check a dat it's negative

negative look at my peripheral blood smear and

look at my peripheral blood smear and consider my history

consider my history my history they have bud chiari syndrome

my history they have bud chiari syndrome that's a venus clot within the hepatic

that's a venus clot within the hepatic veins and they have dark urine in the

veins and they have dark urine in the morning i can look at my peripheral

morning i can look at my peripheral blood smear sometimes it'll show

blood smear sometimes it'll show spherocytes but sometimes it's

spherocytes but sometimes it's unrevealing oh it's unrevealing

unrevealing oh it's unrevealing i have a suspicion of what

i have a suspicion of what peroxism of nocturnal hemoglobin area

peroxism of nocturnal hemoglobin area what do i have to use to confirm

what do i have to use to confirm flow cytometry it's positive what do i

flow cytometry it's positive what do i have

have proximal nocturnal hemoglobin area

proximal nocturnal hemoglobin area all right next one 22 year old male with

all right next one 22 year old male with no past medical history that's pertinent

no past medical history that's pertinent for anything presents to the office with

for anything presents to the office with the hemoglobin 9.5

the hemoglobin 9.5 okay nothing special but he's anemic

okay nothing special but he's anemic what do i do check her tick it's 5.5

what do i do check her tick it's 5.5 increase destruction slash loss how do i

increase destruction slash loss how do i know hemolytic labs they're elevated is

know hemolytic labs they're elevated is it autoimmune that's negative not

it autoimmune that's negative not autoimmune

autoimmune what do i think i do prefer blood to me

what do i think i do prefer blood to me in history history doesn't really

in history history doesn't really suggest anything what is this peripheral

suggest anything what is this peripheral blood smear show

blood smear show oh boy these are spherocytes

oh boy these are spherocytes if they're spherocytes what do i

if they're spherocytes what do i obviously want to consider especially

obviously want to consider especially with no person with a very significant

with no person with a very significant past medical issue you know venous clots

past medical issue you know venous clots no kind of urinary dark urine in the

no kind of urinary dark urine in the morning hereditary spherocytosis with

morning hereditary spherocytosis with hereditary spherocytosis what do i

hereditary spherocytosis what do i actually have to check osmotic fragility

actually have to check osmotic fragility test

test if i check an osmotic fragility test

if i check an osmotic fragility test it's positive what do i have hereditary

it's positive what do i have hereditary spherocytosis

spherocytosis all right next one

all right next one 32 year old female no past medical

32 year old female no past medical history presents to the office after a

history presents to the office after a trip to africa with high fevers and

trip to africa with high fevers and fatigue hemoglobin of 8.5 all right they

fatigue hemoglobin of 8.5 all right they got anemia check their tick it's

got anemia check their tick it's elevated is it increased destruction or

elevated is it increased destruction or loss how do i know check my hemolytic

loss how do i know check my hemolytic labs they're elevated is it autoimmune

labs they're elevated is it autoimmune check a dat it's negative it's not

check a dat it's negative it's not autoimmune

autoimmune then what do i got to do

then what do i got to do look at my history and consider my

look at my history and consider my prayer for blood smear history what i

prayer for blood smear history what i what do i see here high fevers

what do i see here high fevers and fatigue trip to africa hmm that's

and fatigue trip to africa hmm that's interesting look at my peripheral blood

interesting look at my peripheral blood smear

smear i see inclusions

i see inclusions inside of these and they don't look like

inside of these and they don't look like a like a cross like a like a maltese

a like a cross like a like a maltese cross

cross and i have a trip to africa with high

and i have a trip to africa with high fevers and fatigue

fevers and fatigue i think it's uh malaria this is classic

i think it's uh malaria this is classic plasmodium falciparum so

plasmodium falciparum so i got malaria

i got malaria all right next one

all right next one 29 year old female no past medical issue

29 year old female no past medical issue presents to the office after a hiking

presents to the office after a hiking trip to wisconsin

trip to wisconsin came back with a rash high fevers and

came back with a rash high fevers and fatigue hemoglobin 9.5 she's anemic

fatigue hemoglobin 9.5 she's anemic check the retic

check the retic it's elevated if it's elevated i know

it's elevated if it's elevated i know that it's increased distraction or loss

that it's increased distraction or loss how do i know if it's which one

how do i know if it's which one hemolytic labs they're elevated is it

hemolytic labs they're elevated is it autoimmune that's coupons negative

autoimmune that's coupons negative therefore i have to look at my

therefore i have to look at my peripheral blood smearing history

peripheral blood smearing history history

history well i got high fevers i got fatigue i

well i got high fevers i got fatigue i got a rash and i got a trip to wisconsin

got a rash and i got a trip to wisconsin where there's potentially ticks

where there's potentially ticks what do i got to do get a peripheral

what do i got to do get a peripheral blood smear look for a maltese cross

blood smear look for a maltese cross look at that maltese cross what's that

look at that maltese cross what's that patho demonic for vabesiosis

the 65 year old female who's acutely ill has sepsis hemoglobin 6.5

has sepsis hemoglobin 6.5 has low platelets or thrombocytopenia

has low platelets or thrombocytopenia you also have other labs like a high ptt

you also have other labs like a high ptt a pti and r a d dimer and then they also

a pti and r a d dimer and then they also have a low fibrinogen again what do i

have a low fibrinogen again what do i always have to check their anemic

always have to check their anemic checkered tick or it takes 10.1

checkered tick or it takes 10.1 there's an increased destruction or loss

there's an increased destruction or loss how do i know which one hemolytic labs

how do i know which one hemolytic labs they're elevated is it autoimmune check

they're elevated is it autoimmune check a dat it's negative

a dat it's negative look at their peripheral blood smearing

look at their peripheral blood smearing history history suggests that they are

history history suggests that they are very ill they have low platelets and

very ill they have low platelets and they have a very significant kind of

they have a very significant kind of coagulopathy here let's check their

coagulopathy here let's check their peripheral blood smear

peripheral blood smear they have shistocytes and helmet cells

they have shistocytes and helmet cells that's suggestive of a

that's suggestive of a maha a microangiopathic hemolytic anemia

maha a microangiopathic hemolytic anemia do they have a mechanical valve no

do they have a mechanical valve no do they have any kind of recent kind of

do they have any kind of recent kind of like diarrhea along with acute renal

like diarrhea along with acute renal failure no do are they pregnant no

failure no do are they pregnant no um is there any kind of like

um is there any kind of like coagulopathies present yeah look at all

coagulopathies present yeah look at all that that's this is likely dic it's

that that's this is likely dic it's unlikely ttp it's unlikely hus it's

unlikely ttp it's unlikely hus it's unlikely help and they don't have a

unlikely help and they don't have a mechanical heart valve that's mentioned

mechanical heart valve that's mentioned here so it's likely dic

here so it's likely dic so it's a maha likely secondary to dic

so it's a maha likely secondary to dic all right

all right 65 year old female past medical history

65 year old female past medical history of non-hodgkin's lymphoma presents with

of non-hodgkin's lymphoma presents with abdominal fullness and hemoglobin of 7.7

abdominal fullness and hemoglobin of 7.7 all right what do we do

all right what do we do check our tick

check our tick 8.1

8.1 increase destruction slash loss which

increase destruction slash loss which one checkimolytic labs

one checkimolytic labs the hemolytic labs are high but they're

the hemolytic labs are high but they're borderline high so they're not crazy

borderline high so they're not crazy high remember what i told you

high remember what i told you if you have somebody who's hemolyzing

if you have somebody who's hemolyzing they have evidence of hemolysis but it's

they have evidence of hemolysis but it's just barely elevated and they have this

just barely elevated and they have this abdominal fullness

abdominal fullness now what do i tell you to potentially

now what do i tell you to potentially consider

consider think about the spleen right

think about the spleen right maybe but we know we're in the hemolytic

maybe but we know we're in the hemolytic area all right so we can continue to

area all right so we can continue to move forward it's just it's barely

move forward it's just it's barely elevated all right what do we always got

elevated all right what do we always got to do make sure it's not autoimmune

to do make sure it's not autoimmune check a dat that's negative

check a dat that's negative look at the history and consider your

look at the history and consider your peripheral blood smear if you need one

peripheral blood smear if you need one in their history they have non-hodgkin's

in their history they have non-hodgkin's lymphoma that likes to involve lymphatic

lymphoma that likes to involve lymphatic tissue one of those lymphatic tissues

tissue one of those lymphatic tissues potentially could be these spleen

potentially could be these spleen lymph nodes all that kind of stuff like

lymph nodes all that kind of stuff like that right

that right all right so if i have borderline

all right so if i have borderline hemolytic labs that's negative

hemolytic labs that's negative and again they don't have like any

and again they don't have like any history to suggest an intrinsic problem

history to suggest an intrinsic problem like g6pdh or sickle cell or any kind of

like g6pdh or sickle cell or any kind of like membrane problem

like membrane problem i don't have any like low platelets or

i don't have any like low platelets or anything concerning for maha i don't

anything concerning for maha i don't have any high fevers what did i tell you

have any high fevers what did i tell you was something to think about

was something to think about consider checking that spleen maybe a

consider checking that spleen maybe a splenic ultrasound wouldn't be a bad

splenic ultrasound wouldn't be a bad idea but either way we should check a

idea but either way we should check a peripheral blood smear right and check

peripheral blood smear right and check their history prefer blood sphere is

their history prefer blood sphere is unrevealing what i tell you to think

unrevealing what i tell you to think about at that point in time splenic

about at that point in time splenic ultrasound you do a splenic and liver

ultrasound you do a splenic and liver ultrasound you find splenomegaly you

ultrasound you find splenomegaly you think that they have hyperspleenism all

think that they have hyperspleenism all right so guys that covers

right so guys that covers all of these anemia case studies i

all of these anemia case studies i really hope that this helped i hope it

really hope that this helped i hope it made sense i know it was a ton of

made sense i know it was a ton of information but my goal at the end of

information but my goal at the end of this is that you guys would understand

this is that you guys would understand this stuff and you would be able to take

this stuff and you would be able to take any question and dissect it with a very

any question and dissect it with a very straightforward systematic approach to

straightforward systematic approach to get down to the bare nitty gritty of

get down to the bare nitty gritty of what is the problem and then what we'll

what is the problem and then what we'll do is

do is over some time as we're going to go over

over some time as we're going to go over every single type of anemia we have a

every single type of anemia we have a video on micro acidic macrocytic normal

video on micro acidic macrocytic normal acidic hemolytic and so on and so forth

acidic hemolytic and so on and so forth where we'll go into these in more detail

where we'll go into these in more detail but ninjas thank you guys for being so

but ninjas thank you guys for being so awesome i love you i thank you and as

awesome i love you i thank you and as always until next time

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YouTube Transcript:CBC | Approach to Anemia

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CBC | Approach to Anemia