3. what diagnose can be possible and what means to diagnose?

Diagnostic Assesment on Anaemia

Reduced Hb, no specific cause implied (and not a diagnosis, so dont be complacent): male
<13.5g/dL, female <11.5g/dL. Often associated with non-specific symptoms such as fatigue,
poor concentration, shortness of breath and dizziness. Older patients may experience palpitations
and exacerbation of angina, congestive cardiac failure or claudication.

Signs
Pallor of conjunctivae and skin creases, nail pallor and koilonychias (spoon-shaped nails, rare
finding in severe chronic iron deficiency), angular cheilitis and glossitis. Difficult to gauge
anaemia from skin signs alone.

Causes
Two common approaches to assess anaemia.
1. Red cell dynamics
Increasing of RBC loss/breakdown, e.g. haemolysis (congenital or acquired) or bleeding.
Decreasing of red cell production, e.g. vitamin/mineral deficiency, marrow
suppression/infiltration, myelodysplasia, haemoglobin disorders (e.g. thalassaemia), chronic
disease, renal failure.
2. Red cell indices
Microcytic/hypochromic

decreased of MCV & MCHC

E.g. Fe deficiency, thalassaemia,
anaemia of chronic disease

Macrocytic

increased of MCV
Reticulocytosis (polychromasia on blood film), B12/folate
deficiency, chronic liver disease, hypothyroidism, alcohol,
myelodysplasia

Normocytic, normochromic

normal MCV & MCHC

Anaemia of chronic disease (e.g. chronic infection,
inflammatory disease or malignancy), acute blood loss,
renal failure, myeloma

Investigations
FBC and film
Assessment of RBC indices helps direct investigation as above.
Microcytic
Check iron stores (ferritin or soluble transferrin receptor assay). Note: ferritin is high in acute
inflammation and may be misleading. Iron/TIBC no longer used for assessment of iron
deficiency.

Consider thalassaemia screening if not iron deficient.

If iron deficient assess dietary history (vegetarians) and look for risk factors for blood loss
and increased demands.
Premenopausal womenassess menstrual losses.
Pregnancy/infants/adolescence consider physiological (increase requirements).
All others: look for source of blood loss. GI tract is most common source. Consider OGD
and/or colonoscopy guided by symptoms and barium studies.

Macrocytic
Reticulocyte count.
Serum B12 and red cell folate levels.
If folate deficient: assess dietary history and physiological requirements.
If B12 deficient: rarely dietary cause alone, usually an associated pathology. Pernicious
anaemia is the most common cause: check parietal cell antibodies (90% patients with PAare
+ve, but seen in other causes of gastric atrophy, especially in older individuals) and/or
intrinsic factor antibodies (+ve in only 50% with PA but specific). Consider ileal disease and
malabsorption.
LFTs.
Thyroid function.
Normocytic
Blood film.
ESR.
Renal function.
Consider myeloma screen in older adults (Igs, protein electrophoresis, urine BJP. Skeletal
survey of value if paraprotein or BJP).
Autoimmune screen to exclude connective tissue disease.
Haemolysis screen
FBC, MCV (4 due to reticulocytosis).
Blood film (spherocytes, polychromasia, bite cells and red cell fragmentation).
Reticulocyte count.
Bilirubin and serum LDH.
Haptoglobins (absent in haemolysis).
DAT (old term is direct Coombs test).
Consider
Congenital haemolytic anaemias: membrane defects, enzyme deficiencies (e.g. G6PD,
pyruvate kinase).
DIC/microangiopathic haemolysisDIC screen.

Normal range in CBC (complete blood cell)

Possible diagnose based on scenario

Megaloblastik Anemia
Megaloblastik anemia is an anemia characterized by existence of megaloblast cell in bone
marrow. Megaloblast cell is erythrocyte precursor with massive cell morphology with
existence of cytoplasm dan core maturations gap. It caused by disturbance of DNA
formation in core of eritroblast which cause by deficiency of B12 and folic acid
- Clinicals sign
1. Glosittis
2. Changes in mucosa cell
3. Gastrointestinal disturbance
4. Fever
5. Pallor
6. Weakness
7. Decreased of appetite
8. Nausea and vomiting

Laboratory finding
1. Decrease of hemoglobin (3-4 gr/dl)
2. oval macrocyte finding with poikilositosis and anisositosis. Increase of MCV
110-125 fl. Normal reticulocyte
3. Often associated with leucopenia and hypersegmentation of neutrophil
4. Often associated with trompositopenia
5. In bone marrow examination, found:
Eritroid hyperplasia with megaloblast cell, giant metamyelocye
6. Decrease of B12 and folic acid. B12<100 pg/ml, folic <3ng/ml.

Poikilositosis

Anisositosis

Hemolytic Anemia
Hemolytic anemia is an anemia that caused by hemolytic process. Hemolytic process is
erythrocyte breakage before its time (average live is 120 days). It can be differentiate into
two causes which are intrakospuler and ekstrakospuler disturbance.
- Clinicals sign
1. Pallor
2. Weakness
3. Hepatomegaly and spleenomegaly
4. Icterus
5. Hiperbilirubinemia

Laboratory Finding
1. Decreased of hematocrit, hemoglobin, and erythrocyte
2. MCH & MCV normal
3. High reticuloyte
4. Positive for Coomb test in AIHA
5. Abnormality in blood cell

Macrocytic red cell

Spherocyte
Refrences :
- Profan, Drew. Oxford Handbook of clinical and laboratory inverstigation. 2002
- Atlas Hematology
- Guide to lab & diagnostic test. 2005