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1. APPROACH TO ANEMIA
PRESENTERS; TOHA YASIN, NAKACWA
JOAN, ONYAIT TEDDY,

2. OBJECTIVES
• To define anemia
• Classification
• Approach to a patient with anemia
• Investigation
• Treatment
• Complication
• prevention

3. ANEMIA
Definition:
• This is defined as a reduction in the hemoglobin
concentration of the blood below normal range
for age and sex.
• According to WHO criteria, anemia is defined as
blood hemoglobin (Hb) concentration < 130 g/L
(<13 g/dL) or hematocrit (Hct) < 39% in adult
males;
• Hb < 120 g/L (<12 g/dL) or Hct < 37% in adult
females.

4. CLASSIFICATION OF ANEMIA
• Functional
• Clinical
• Quantitative
• Morphological

5. Functional classification
• Due to decreased red cell production;
 Defective hemoglobin synthesis;
 Iron deficiency
 Vitamin B12 deficiency
 Folate deficiency
Sideroblastic anemia
thalassemias
 Impaired bone marrow or stem cell function
• Increased red cell destruction; in Sickle cell anemia and
hemolytic anemias.
• Combination of the two sometimes called ineffective
erythropoiesis as in the case of B-thalassemias

6. Clinical Classification of anemia.
• According to the cause;
 blood loss
Iron deficiency
Vitamin B12 deficiency
Folate deficiency
Hemolysis
Aplastic anemia
Anemia of chronic disease(e.g kidney failure)
Enzyme deficiencies.

7. Quantitative classification of anemia
• Red cell count; a measure of how many red
blood cells an individual has. In males 4.7 to
6.1 million cell/mcL and in females 4.2 to 5.4
million cells/mcL.
• A low red cell count indicates iron deficiency
anemia, vitamin B6, B12 or folate deficiency
anemias, internal bleeding, kidney disease and
malnutrition; And a high red cell count can be
due to smoking, congenital heart disease,
dehydration from severe diarrhea, hypoxia,
pulmonary fibrosis.

8. Quantitative classification continued;
• Parameters involved in red cell count include;
• Hemoglobin analysis is based on
spectrophotometric absorbance readings of
cyanmethemoglobin .
• Normal HB; in males 14.0 – 17.5 (mean 15.7)
g/dL. In females 12.3 – 15.3 (mean 13.8) g/dL.
• A <-2SD of the mean is an indicator of anemia.
In pregnant women <11g/dL is considered
anemia.
• Note; Hemoglobin is reduced in anemia and
increased in polycythemia.

9. Quantitative classification continued;
• Hematocrit/packed cell volume; proportion of
total blood volume composed of red blood cells.
Determined by centrifugation.
• Normal range adult males 42% - 4-52%.
• Normal range adult non pregnant females 38% -
46%.
• Normal range pregnant women 30% - 34% lower
limit and 46% upper limit.
• Note; on basis of hemoglobin and hematocrit
anemia can be classified as mild, moderate and
severe.

10. Morphological classification
• Microcytic Hypochromic;
 Iron deficiency anemia
 Anemia of chronic inflammation e.g SLE,
Rheumatoid arthritis.
 Sideroblastic anemia
 Thalassemias.
 Lead poisoning
• Normocytic Normochromic.
 Acute blood loss
 Expanded plasma volume
 Aplastic anemia
 Chronic renal disease.

11.  Hemolytic anemias
 Endocrine disorders
 Anemia in AIDS
 Chronic inflammation
• Macrocytic Normochromic
 Folate deficiency
 Vitamin B12 deficiency

12. CLASSIFICATION

13. Clinical Features
SYMPTOMS
 Due to precarious state
of oxygen delivery to
tissues;
 Dyspnea on exertion
 Easy fatigability
 Fainting
 Light headedness
 Tinnitus
 Headache
 Due to hyper dynamic
state of circulatory
 Palpitations
 Roaring in ears
 Pre-existing cardiac
pathologies that can be
worsened by anemia
include;
 Angina pectoris
 Intermittent claudication
 Night muscle cramps

14. CLINICAL FEATURES CONTINUED
• SIGNS:
Pallor
Tachycardia
Ejection murmur
Gallop rhythm
• If anemia is rapidly developing like in
hemorrhage;
 syncope on rising from bed
Orthostatic hypotension
Orthostatic tachycardia.

15. Approach to a patient with anemia
• History taking:
• Ask about jaundice, cholelithiasis ( abdominal pain in
the upper or upper middle abdomen, fever, nausea,
jaundice and itchy skin).
• Fever for infections e.g malaria and HIV, neoplasms,
collagen vascular disease.
• Blood loss; stool – color and if the is blood, seek history
of GI complaints suggestive of gastritis (nausea,
vomiting, abdominal pain, burning or gnawing feeling
in the stomach between meals or at night, hiccups),
peptic ulcers (a gnawing or burning in the middle or
upper stomach between meals, heart burn, bloating,
nausea or vomiting). If a woman ask about
pregnancies, abortions and menstrual loss.

16. Approach continued;
• Abnormal urine color that is, is it tea colored
urine as in kidney failure, red urine in march
hemoglobin or bright red as in paroxysmal
nocturnal hemoglobinuria and the if the urine
color is associated with physical activity or the
time of day.
• Cold intolerance; as in the case of
hypothyroidism, systemic lupus erythematous,
paroxysmal cold hemoglobinuria.

17. Approach continued;
• Prior medical treatment;
• Drugs such chloramphenicol, sulfonamides,
chloroquine, NSAIDs indomethacin, diclofenac,
naproxen, piroxicam, anti-cancer drugs e.g
methotrexate, carboplatin, tetracyclines and and
quinolones (chelate iron and prevent absorption).
• History of previous blood examination, obtaining
those record, rejection as a blood donor and
prior prescription of hematinics.

18. Approach to anemia
• Diet; food the patient eats, avoids, quantity
estimate.
• Eating substances such as clay.
• Family history of abnormal hemoglobin
diseases, bleeding disorders.
• House hold exposures to potentially noxious
agents.
• Occupation; works in a chemical or pesticide
factory

19. Approach continued;
• Nutritional deficiency; 1) Iron deficiency;
pagophagia (frequently chew or suck ice),
dysphagia(due to esophageal web with
chronic iron deficiency), fatigue and cramps in
the calf while climbing stairs. 2) Vitamin B12;
early graying of hair, burning sensation is the
tongue, loss of proprioception (stumble in the
dark), paresthesias. 3) Folate; sore tongue,
cheilosis, and symptoms associated with
steatorrhea.

20. Approach to anemia
• Physical exam;
• General exam:
Pallor
Icterus
Petechiae
Purpura
Ulcerations
Palmar erythema
Coarseness of hair
Puffiness of face

21. Physical exam continued;
Thinning of lateral aspects of eye brows.
Nail defects.
An unusual prominent venous pattern on the
abdominal wall.
Facial puffiness.
Lymphadenopathy (infections and
malignancies)
Edema; bilateral (cardiac, renal and hepatic
disease) unilateral lymphatic obstruction due
to a malignancy.

22. Physical exam continued;
• Systemic exam;
• Per Abdomen; hepatomegaly and
splenomegaly. Do not only check for presence
or absence but also for size, tenderness,
firmness, presence or absence of nodules.
• NOTE; Chronic disorders – firm, non-tender
and non- nodular; Carcinoma – hard and
nodular; Infection (acute) – softer and tender.

23. Physical exam continued;
• Do a rectal/pelvic exam because the cause of
anemia could be due to a tumor or infection
of these organs.
• Cardiac enlargement may provide evidence of
duration and severity of the anemia. NOTE;
murmurs maybe evidence of bacterial
infective endocarditis which could be the
cause of anemia.

24. investigation
 Complete blood count.
 Peripheral blood smear
 Fe, TIBC, Folate, VitB12 levels. V
 Anti-globulin test.
 LFTS/RFTS
 Enzyme deficiencies.
 Clotting studies – PT, PTT
 Bone marrow test.
 Osmotic fragility (hereditary spherocytosis and
thalassemias)
 Hams/acid hemolysin test. (paroxysmal nocturnal
hemoglobinuria)

25. Treatment of anemia
• Establish severity and diagnosis
• Transfusion – indications –
– Severe anemia - if Hb < 4 or 5 gm (15%) in presence of
acute malaria or sickle cell crisis
– Impending or over cardiac failure
– Severe blood loss
• Iron therapy – 6 mg/kg/day of elemental iron for
minimum of 1 month
• Folate - <5 yrs – 2.5 mg/day
- >5 yrs – 5 mg/day
• Antihelminthics – mebendazole for parasites
every 3 – 6 months

26. Complication

27. Prevention of anemia
• Increase dietary intake – introduce source of
iron (fish, meats, beans..) after 6 months
• Prevent infections – immunize, encourage
longer breastfeeding
• Prompt treatment of malaria
• Routine deworming <5 years every 3-6
months

28. Conclusion
• Remember anemia is not a diagnosis , always
find out what is causing it before instituting
treatment.
• Its treatable once the underlying cause is
identified
• Long standing or severe lack of oxygen can
damage the brain, heart and other organs