Advanced Practice Education Associates
Hematology
Hematology
HEMATOLOGY
Anemias
Platelets
White Blood Cells (CBC interpretations)
Image Copyright AM-Medicine; Chronic myelogenous leukemia-
CML. http://am-medicine.com/2014/07/chronic-myelogenous-
leukemia-cml.html
OVERVIEW
Laboratory Background
Iron Deficiency Anemia
Anemia of Chronic Disease
Thalassemia
Vitamin B12 Deficiency
Autoimmune Thrombocytopenia Purpura (“Immune TP”)
CBC Interpretation
32 Copyright 2018 Advanced Practice Education Associates
Hematology
ANEMIA
How do you know whether someone has anemia?
Anemia
Reduction in one or more RBC measurements:
1. Hemoglobin
2. Hematocrit
3. RBC count
Is this patient anemic?
Patient Norms
RBC 4.0 4.2-4.9 million/microL
HGB 11.5 g/dL 12-15 g/dL
HCT 35.6% 37-51%
MCV 90 80-96
MCH 25.7 23.7-28.4
MCHC 33.4 31.3-35.7
RDW 14.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12
Should I memorize these lab values? Be able to recognize abnormal values
Patient Norms
RBC 4.0 4.2-4.9 million/microL
HGB 11.8 g/dL 12-15 g/dL
HCT 36.6% 37-51%
MCV 90 80-96
MCH 25.7 23.7-28.4
MCHC 33.4 31.3-35.7
RDW 14.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12
Additional Notes:
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Hematology
Rule 1: Anemia is Never Normal!
Always suspect that something is going on with your patient!
Why do people become anemic?
1. Blood loss (Most common reason in US and Canada)
Melena
Hematemesis
Trauma
2. Bone marrow not making enough RBCs:
Lack of nutrients: not enough Fe, folate, B12
Bone marrow disorders: aplastic anemia, myelodysplastic syndromes
Bone marrow suppression: chemo, others
Low levels of erythropoietin (Chronic renal failure)
Anemia of inflammation: malignancy, anemia of chronic disease
3. Increased destruction of RBCs:
Inherited disorders (Sickle cell anemia, thalassemias)
Malaria
Hemolytic anemia (G6PD deficiency)
Question
What’s the average lifespan of a normal RBC?
1. 3 days
2. 7 days
3. 28 days
4. 3 months
How do the following characteristics affect Hgb/Hct?
Characteristic Effect on H/H:
COPD
Chronic kidney disease
Hypertension
DM with A1C 13.8
Aspirin Use
Testosterone Use
Resident of Denver, CO
Age: 84 years old
Rule 2: Never presume that anemia in an older patient is due to aging!!!
Older patients
Tend to have lower H&H than younger counterparts
Up to 20% can have "idiopathic anemia of aging"
34 Copyright 2018 Advanced Practice Education Associates
Hematology
Every anemia in the world is characterized by:
1. RBC Size
2. RBC Color
1. RBC size: cytic = “cell”
Micro cytic = small cells
Normo cytic = normal-sized cells
Macro cytic = large cells
Microcytic Normocytic Macrocytic
<80 fl 80-96 fl >96 fl
A Day In Clinical Practice
Which laboratory test describes the size of a patient’s RBCs?
1. PLT
2. MCV
3. MCH
4. RDW
MCV (Mean Corpuscular Volume) = RBC size
If you had to calculate a patient’s MCV:
MCV = Hct/RBC count
Microcytic Normocytic Macrocytic
<80 fl 80-96 fl >96 fl
2. RBC color: Chromic = “Color” (hemoglobin content)
Hypo chromic = low in color
Normo chromic = normal color
Hyper chromic = too much color
Hypochromic Normochromic Hyperchromic
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Hematology
A Day In Clinical Practice
Which laboratory test describes the hemoglobin content of a patient’s RBCs?
1. PLT
2. MCV
3. MCH
4. RDW
MCH = RBC “color”
Mean Corpuscular Hemoglobin = wt of HGB in average RBC
Tells us about the hemoglobin content of a patient’s RBC
Hypochromic Normochromic Hyperchromic
The greater the Hgb content, the redder the cell
A Day In Clinical Practice
Is this patient anemic? ____________________________________________
What do the red cells look like? _____________________________________
Results Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 104 80-96
MCH 25.0 23.7-28.4
MCHC 34.4 31.3–35.7
RDW 18.6 12–17
PLT 265 150–375
MPV 7.1 6.5-12
Additional Notes:
36 Copyright 2018 Advanced Practice Education Associates
Hematology
The Basics: Red Cell Indices
Hgb: expressed in grams (11-15 mg/dL)
Hct: expressed in % (33-45)
MCV: indicates size of RBC
MCH: indicates hemoglobin content in cell
RDW: indicates degree of variation in RBC size (< 15% is normal)
<15% Normal >15% Abnormal
RDW (red cell distribution width): indicates degree of variation in RBC size
(<15% is normal)
The Rest of the Basics:
Serum iron: measure of iron in circulation
Serum ferritin: measure of iron in storage (ferritin is a protein that stores iron)
Reticulocyte count: indicates ability of bone marrow to produce RBCs
Peripheral smear: a visual description of the red blood cells
Should always be considered when a patient presents with anemia
Peripheral Smear Report – Example
Results Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 104 80-96
MCH 25.0 23.7-28.4
MCHC 34.4 31.3–35.7
RDW 18.6 12–17
PLT 265 150–375
MPV 7.1 6.5-12
Macrocytic, normochromic red cells present
The Rest of the Basics: Look at the palm of your hand
TIBC (transferrin): Total iron binding capacity – reciprocal relationship!
TIBC (Total Iron Binding Capacity)
Iron count is high - TIBC is low
Iron count is low - TIBC is high
Copyright 2018 Advanced Practice Education Associates 37
Hematology
MICROCYTIC ANEMIAS
Common Causes:
Iron deficiency anemia (IDA)
Thalassemia
Less Common Causes:
Anemia of chronic disease (< 20%)
Sideroblastic anemia
Lead toxicity
Image Copyright Medword Iron Deficiency Anemia.
http://www.medword.com/Gastro/ironDeficiency.html
Iron Deficiency Anemia (IDA)
Microcytic, hypochromic anemia
Most common reason is blood loss
Assessment Findings
Most people are asymptomatic (until 30/10)
Classic presentation: weakness, headache, irritability, fatigue, exercise
intolerance
Older adults may present with exacerbation of comorbids (angina, worsening
dementia)
Classic Iron Deficiency Anemia
Hgb ↓
Hct ↓
Serum Fe ↓
Serum ferritin ↓
MCV ↓
MCH ↓
TIBC ↑
RDW ↑ > 15%
A Day In Clinical Practice
A patient’s Hgb = 10.2g, Hct = 30.6%. Which findings are consistent with iron
deficiency anemia? (Norms: MCV: 80-100; MCH: 26-30)
1. MCV: 76; MCH: 28
2. MCV: 84; MCH: 26
3. MCV: 120; MCH: 30
4. MCV: 75; MCH: 25
Red Blood Cells
Average lifespan is about 100-120 days
New onset IDA: RDW >15% (mixture of normal sized RBCs with new
small RBCs)
Longstanding IDA: RDW <15% (all cells are small)
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Hematology
Management
Diet rich in foods containing iron
Organ meats (especially liver)
Red meat
Dried peas and beans
Dark, green, leafy vegetables
Whole grains
Replacement is 150-200 mg/d ELEMENTAL IRON when deficient
Replace for 4-6 months: oral replacement
If hemoglobin not increased after 1 month of iron replacement therapy
…TROUBLE!
Replacement Options:
Iron Source Mg Elemental Iron
Ferrous fumarate 325 mg 106 mg
Ferrous sulfate 325 mg 65 mg
Ferrous gluconate 325 mg 33 mg
A Day In Clinical Practice
A patient has recently developed IDA and is taking iron supplements. What is his
serum iron level likely to be?
1. Increased
2. Decreased
3. Unpredictable
4. There is no relationship
So, what’s the take-home point?
________________________________________________________________
What’s an exception to the take-home point?
________________________________________________________________
A Day In Clinical Practice
A 24-year-old woman was diagnosed with IDA 4 weeks ago. Her lab values are
below. How should the NP proceed?
Hgb g/dL Hct %
Normal = 12-15 g/dL Normal = 37-50%
4 weeks ago 11.5 34.5
Today 12.8 38.4
1. Stop iron supplementation since she is no longer anemic.
2. Order a TIBC today.
3. Consider iron supplementation for another 3-5 months.
4. Order a reticulocyte count today.
Copyright 2018 Advanced Practice Education Associates 39
Hematology
Which lab test would indicate that her iron supplementation could be
discontinued?
1. Peripheral smear
2. Serum iron level
3. Serum ferritin level
4. Reticulocyte count
RBC Timeline
Reticulocytosis: 3-10 days
Increased hemoglobin: 2-4 weeks
Replace iron stores: 4-6 months
How long does a patient usually have to take iron replacement?
________________________________________________________________
Health Promotion
Screen those at risk:
Pregnant women
Older adults
Alcohol abusers
NSAID users
Women with heavy menses
Vegetarians, vegans
Encourage adequate intake of iron in diet
THALASSEMIA
A group of hereditary disorders that affects the synthesis of hemoglobin
Characterized by microcytic, hypochromic anemia
Hallmark is insufficient synthesis of alpha or beta chains of hemoglobin (4
alpha chains, 2 beta chains)
Most common genetic disorder in the world
Thalassemia Characteristics
Microcytic/hypochromic red cells
Variation in size (anisocytosis) and shape (poikilocytosis) of RBCs
Possible nucleated RBCs
Uneven HGB distribution, producing “target cells”
A Day In Clinical Practice
Which lab test might be used to confirm a diagnosis of thalassemia?
1. Hemoglobin electrophoresis
2. Peripheral smear
3. Serum ferritin
4. Red cell smear
40 Copyright 2018 Advanced Practice Education Associates
Hematology
Health Promotion
Screen patient if positive family member(s)
Determine gene mutations/evaluate carrier status to advise about risk of
mutations for future pregnancies
Comparison of Thalassemia and Iron Deficiency Anemia
Thalassemia Fe Def Anemia
↓ Hct, Hgb ↓
↓↓ MCV, MCH ↓
Normal RDW ↑
Normal Serum Fe ↓
Normal TIBC ↑
Normal Serum ferritin ↓
ANEMIA OF CHRONIC DISEASE
(Anemia of chronic inflammation)
Mild to moderate normocytic, normochromic anemia associated with chronic
disease such as infections, inflammatory and/or malignant disease
If longstanding, may be microcytic, hypochromic — but not common
Red blood cell life span is shortened from the normal 100-120 days to 60-90
days.
A Day In Clinical Practice
A patient’s Hgb = 10.0g, Hct = 30.6%. Which findings are consistent with a
normocytic normochromic anemia? (Norms: MCV: 84-102; MCH: 29-35)
1. MCV: 90; MCH: 38
2. MCV: 84; MCH: 23
3. MCV: 93; MCH: 29
4. MCV: 83; MCH: 35
Management of ACD
Treatment aimed at control of underlying disease
Or, diagnosing the occult disease or illness
A Day In Clinical Practice
An 85-year-old patient presents with complaints of a burning
tongue. What is this termed?
1. Glossitis
2. Petechiae
3. Strawberry tongue
4. Kawasaki syndrome
Image Copyright Medicine World; Glossitis;
What often causes this? Symptoms and Treatment http://en.medicine-
worlds.com/stovr0_glossit.htm
________________________________________________________________
Copyright 2018 Advanced Practice Education Associates 41
Hematology
Common Macrocytic Anemias
B12 deficiency (Cobalamin, Cbl)
Folate deficiency
Vitamin Deficiencies
These are vitamin deficiencies!!!
B12 is an absorption problem, rarely a dietary deficiency
B12 deficiency and folate deficiency often co-exist!!!
Many patients have normal B12 level but are deficient in B12
B12 & Folate Deficiencies
Humans cannot make B12 or folate: must consume via food or supplement
Pernicious anemia is most common cause of B12 deficiency
B12 deficiency symptoms: diarrhea, dizziness, fatigue, muscle weakness,
loss of appetite, arrhythmias, SOB, sore tongue/mouth, confusion,
forgetfulness, paranoia
A Day In Clinical Practice
A 45-year-old patient has suspected B12 deficiency. What typical symptoms might
he exhibit?
1. Increased appetite
2. Abdominal pain
3. Burning in the hands or feet
4. Joint aches and lower extremity swelling
A Day In Clinical Practice
A 75-year-old patient has suspected B12 or folate deficiencies. What typical
symptoms might he exhibit?
1. Abdominal pain
2. Jaundice
3. Confusion, forgetfulness
4. Joint aches and lower extremity edema
B12 Deficiency - Characterized by neuro changes
Decreased Impaired Increased
Malabsorption
Intake Metabolism Needs
Alcoholics Sprue TMP-SMX Pregnancy
Strict vegetarians Ileitis Methotrexate Lactation
Diverticulosis Post-gastrectomy
Cancer
Hyperthyroidism
Other: Colchicine
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Hematology
Folate Deficiency - Not characterized by neuro changes like B12 deficiency
Decreased Impaired Increased
Malabsorption
Intake Metabolism Needs
Alcoholics Sprue TMP-SMX Pregnancy
Elderly Gastrectomy Methotrexate Lactation
Hyperthyroidism
Others
Vitamin Deficiencies
Many patients have normal B12 level but are deficient in B12
The Workup: B12, folate levels; if normal consider:
MMA Homocysteine Diagnosis
Normal Normal Unlikely B12 or folate deficiency
Normal Elevated Likely folate deficiency
Elevated Elevated B12 deficiency, maybe folate deficiency
Folate deficiency: homocysteine increased
B12 deficiency: homocysteine and MMA levels increased
Management
Vitamin B12 (cobalamin) IM (sub-q) administered every day for 1 week, then
weekly for 1 month, then monthly for life
Intranasal, oral forms B12 available
Folic acid given PO
Expected Course
Neurologic deficits of B12 deficiency usually reversible; improvement of
symptoms in 5-10 days
Reticulocyte count rapidly increases and peaks 7-10 days after treatment
initiated
Requires lifelong treatment with B12
Treat folate deficiency for 1-4 months or until hematologic recovery
A Day In Clinical Practice
A patient exhibits these lesions on his feet. What initial lab test
should the NP order?
1. Serum iron level
2. B12 and folate levels
3. PT/INR
4. CBC
Image Copyright Science Diseases Idiopathic
Thrombocytopenic Purpura
What finding on lab test would give you the dx? http://mdiaz1197.wixsite.com/sciencediseases/itp
________________________________________________________________
Copyright 2018 Advanced Practice Education Associates 43
Hematology
THROMBOCYTOPENIA
Decrease in platelet count
Rest of CBC is usually normal
Diagnostic Studies
Platelet count: <150,000
WBC: usually within normal limits
Thrombocytopenia Etiology
Recent infection (viral, bacterial)
Idiopathic
Drug-induced
SLE
Antiphospholipid syndrome
Leukemia
Others
Management
Referral to hematologist
Prednisone for 4-6 weeks; may need daily course for chronic ITP
Minimal activity to prevent injury or bruising (e.g., no contact sports)
Avoidance of aspirin
Neutrophils are the same as “Segs” = Polys
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Hematology
What is your interpretation of this CBC?
Patient Norms
WBC 7.9 4-15
RBC 4.38 4.2-4.9
HGB 11.0 (L) 12-15
HCT 33.0 (L) 37-51
MCV 70.4 (L) 73-85
MCH 21.2 (L) 23.7-28.4
MCHC 33.4 31.3-35.7
RDW 19.6 (H) 12-17
PLT 265 150-375
MPV 7.1 6.5-12
POLY% 46.5 (L) 55-75
LYMPHS% 43.1 (H) 30-40
MONO% 10.2 (H) 0-9 Differential
EOS% 0.1 0-6
BASO% 0.1 0-6
What is your interpretation of this CBC?
Patient Norms
WBC 15.9 (H) 4-11
RBC 4.01 (L) 4.5-5.60
HGB 11.4 (L) 13.7-17.3
HCT 34.8 (L) 37.5-51
MCV 107.7 (H) 83.4-96.0
MCH 28.1 27.8-32.5
MCHC 34.0 32.5-35.4
RDW 18 (H) 12-17
PLT 216 150-375
MPV 8.1 6.5-12
POLY% 81 (H) 55-75
LYMPHS% 2 (L) 30-40
MONO% 14.9 (H) 0-12
EOS% 0.1 0-6
Bands 2
Additional Notes:
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Hematology
What is your interpretation of this CBC?
Patient Norms
WBC 6.2 4-11
RBC 4.6 4.5-5.60
HGB 14.8 13.7-17.3
HCT 40.9 39.5-51
POLY% 90 (H) 55-75
LYMPHS% 8 (L) 30-40
EOS% 1 0-6
BASOS 1 0-6
Additional Notes:
46 Copyright 2018 Advanced Practice Education Associates
Hematology
CHECK YOUR KNOWLEDGE
Based on the following lab values, what diagnosis is likely?
Patient Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6 37-51
MCV 84 80.96
MCH 25.0 23.7-28.4
MCHC 31.4 31.3-35.7
RDW 18.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12
Serum Fe: LOW Serum ferritin: LOW TIBC: HIGH
________________________________________________________________
________________________________________________________________
________________________________________________________________
A 24-year-old woman was diagnosed with IDA 4 months ago. Her lab values are
below. How should the NP proceed?
Hgb g/dL Hct %
Normal = 12-15 g/dL Normal = 37-50%
At diagnosis 11.5 34.5
4 months on Fe 14.6 46.8
1. Stop iron supplementation since she is no longer anemic.
2. Order a TIBC today.
3. Consider iron supplementation for another 1-2 months.
4. Order a serum ferritin level today.
An 80-year-old woman who was diagnosed with IDA has taken 150 mg of ferrous
sulfate daily for the past 4 weeks. How should the NP proceed?
Hgb g/dL Hct %
Normal = 12-15 g/dL Normal = 37-50%
4 weeks ago 10 31
Today 10.2 31.8
1. Check B12 and folate level
2. Continue iron supplementation for one more month
3. Measure reticulocyte count
4. Measure serum ferritin
Copyright 2018 Advanced Practice Education Associates 47
Hematology
What diagnosis is most likely in this patient?
Patient Norms
RBC 3.9 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6 37-51
MCV 72 80.96
MCH 21.0 23.7-28.4
MCHC 26.4 31.3-35.7
RDW 14.6 12-17
Peripheral Smear: Anisocytosis, poikilocytosis
1. IDA-long standing
2. Thalassemia
3. Sideroblastic anemia
4. Leukemia
Which lab test might indicate iron deficiency anemia of long standing?
1. Increased reticulocyte count
2. Decreased serum iron
3. Normal serum ferritin
4. Normal RDW
Resources for Hematology
CareOnPoint, a mobile clinical reference tool developed by NPs; available by
subscription (provides contact hours):
http://www.apea.com/careonpoint/about-careonpoint
Clinical Guidelines in Primary Care; Amelie Hollier, DNP, FNP-BC, FAANP
(2016)
Clinician’s Guide to Laboratory Medicine; Samir P. Desai, MD (2009) … Dr.
Amelie calls it “The green lab book”
Additional Notes:
48 Copyright 2018 Advanced Practice Education Associates
