HEMATOLOGY Last edited: 8/25/2022

2. CBC APPROACH TO ANEMIA Medical Editor: Mina Ragy

I. RED BLOOD CELLS (RBCS) III. ↓ PRODUCTION OF IV. ↑ DESTRUCTION / LOSS OF RBC’S (RI > 2%) V. BLOOD LOSS
A. STIMULI FOR CREATING RBCS RBC’S (RI < 2%) HEMOLYTIC ANEMIA (DESTRUCTION OF RBCS) CAUSES
B. RETICULOCYTE INDEX MICROCYTIC ANEMIAS AUTOIMMUNE HEMOLYSIS VI. APPENDEX
INTRODUCTION NORMOCYTIC ANEMIAS INTRINSIC HEMOLYTIC ANEMIA VII. REVIEW QUESTIONS
II. ANEMIA MACROCYTIC ANEMIAS MICROANGIOPATHIC HEMOLYTIC ANEMIA (MAHA) VIII. REFRENCES
A. CAUSES OF ANEMIA INFECTIOUS
B. CLASSIFICATION OF ANEMIA
C. CLASSIFICATION OF ANEMIA

I. RED BLOOD Cells (RBCs)

Red blood cells are also known as erythrocytes and Red Blood Corpuscles
Red blood cell production occurs in the red bone marrow
They start as Myeloid Stem Cell
o Progenitor for red blood cells, platelets, and granulocytes
(e.g. neutrophil, basophil, eosinophil)
o Receives stimuli which direct it to form red blood cells

What are those Stimuli? Remember

01:54 Erythropoiesis (RBC Development)
A. Stimuli for Creating RBCs
o Myeloid Stem Cell
Erythropoiesis refers to the process of red blood cell
production
There are different factors which influence production:
o Hormones – stimulates production
o Nutrients – stimulates production
o Drug/Toxins – inhibits production 05:07
o Intrinsic Bone Marrow Function
B. Reticulocyte Index Introduction
o Reticulocytes are immature/developing red blood cells
o It takes 1-2 days for a reticulocyte to develop into an RBC
 If we have low Erythropoiesis

 If Loss or destruction of RBCs

1. Hormones and Erythropoiesis is compensating

a) Thyroid Hormones (T3 and T4)

b) Erythropoietin
o Produced by the liver and kidney
o Stimulates the bone marrow to produce RBCs

2. Nutrients
We need a ton of nutrients to make RBCs
Some of the essentials are:
a) Iron
b) Vitamin B12 / Cobalamin
c) Vitamin B9 / Folate
3. Drugs/Toxins
o Suppress RBC production in the bone marrow
o Example: Alcohol FIGURE 1 RETICULOCYTE INDEX IN EXAMPLE CASES OF ANEMIA

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 11:05
II. Anemia
Anemia refers to a decreased red blood cell mass, manifested Anemia can be due to either:
as: o External stimuli
o Decrease in Hemoglobin (Hgb) o Poor bone marrow function
o Decrease in Hematocrit (Hct) o Bleeding / Increased blood loss
o Decrease in RBCs o Increased destruction of RBCs

01:54
A. Causes of Anemia
To determine the cause of anemia, a comprehensive history and laboratory tests
(e.g., complete blood count, iron studies, peripheral blood smear, etc.) are needed.

1. External Stimuli 3. Poor Bone Marrow Function

There are different stimuli/factors which influence red blood cell When there is active bleeding or increased blood loss, the RBC
mass count may decrease
o Hormones Since bone marrow function is normal, the decreased RBC
o Nutrients count triggers a compensatory mechanism which increases
o Drugs/Toxins erythropoiesis and subsequently increases the reticulocyte
Reticulocyte index is low (less than 2%) index
Examples:
o GI bleed
o Frequent blood withdrawals (e.g. in the ICU)
o Surgery
Reticulocyte index will increase
as a compensatory mechanism

2. Bone marrow function is affected when: 4. Poor Bone Marrow Function

o Exposure to chemoradiation destroys the structure of the RBCs may be destroyed or lysed within the vasculature or the
bone marrow spleen
o There is a neoplasm/cancer of the bone marrow o Intravascular Hemolysis – destroyed within the vasculature
Reticulocyte index is low (less than 2%) o Extravascular Hemolysis – destroyed within the splenic
macrophages of the spleen
Reticulocyte index will increase as a compensatory
mechanism

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 01:54 14:34
B. Classification of Anemia C. Classification of Anemia
Anemia may be classified based on the reticulocyte index Diagnostic tests are often necessary – on top of a
The reticulocyte index (RI) is a good indicator of bone marrow comprehensive history and physical examination – to
function determine the cause of anemia
o RI <2 % - decreased RBC production (due to decreased The following are the most common diagnostic tests ordered for
stimuli or bone marrow dysfunction) anemia:
o RI >2% - increased destruction or loss of RBC; bone
marrow is functioning 1. RDW
This diagnostic parameter is ordered separately from the o measures the variation in size of RBCs
complete blood count (CBC)
o The reticulocyte count shown in the diagnostic results is 2. RBC count
NOT the reticulocyte index, This value should be inputted in 3. Menser’s Index (MI)
a reticulocyte index calculator
o Computed as MVC / RBC

4. Iron Studies
RI >2%

o Fe++
o Ferritin
increased decreased RBC
destruction or loss production protein which binds to irons inside the cells; reflects iron
of RBC; reserves
o Total Iron Binding Capacity (TIBC)
(due to decreased
o Transferrin Saturation %
bone marrow is stimuli or bone
functioning marrow o Computed as Fe/TIBC
RI <2 %

dysfunction)
5. Peripheral Blood Smear (PBS)

FIGURE 2 HEMATOLOGY TESTS AND IRON PROFILE EXAMPLE

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 11:05
III. ↓ Production of RBC’s (RI < 2%)
Disorders with a reticulocyte index < 2% may be further classified based on the RBC morphology
The mean corpuscular volume (MCV) determines the size of the red blood cells
o Normal Value: 80 – 100 femtoliters (fl)
The types of anemia based on MCV value are:
o Microcytic Anemia: < 80 fl
o Normocytic Anemia: 80 – 100 fl
o Macrocytic Anemia: > 100

Microcytic Anemias
MCV: < 80 fl Diagnostic Tests
Differentials o RDW
o Iron Deficiency Anemia o RBC
o Anemia of Chronic Disease o MI
o Thalassemia o Iron Studies
o Sideroblastic Anemia o Peripheral Blood Smear (PBS)

1. Iron Deficiency Anemia 3. Thalassemia

↑ RDW ↔ or ↑ RDW
↓ RBC ↔ RBC
MI > 13% MI < 13%
↓ Ferritin o ↓↓↓ MCV / RBC
↓ Transferrin Sat % Iron studies are not helpful
PBS is not helpful PBS: may show basophilic stippling
o Correlate with history findings (e.g. family history of
2. Anemia of Chronic Disease thalassemia, Mediterranean ancestry)
History is the most important factor; look for symptoms and signs Hemoglobin Electrophoresis
of chronic disease o Will clinch the diagnosis of thalassemia
↔ RDW
↓ RBC 4. Sideroblastic Anemia
MI is not helpful
History: Look for exposure to lead, alcohol use, medication use
↑↑ Ferritin
Causes: lead poisoning, toxins
o Ferritin is an acute phase reactant; it may be elevated when
↑ RDW
there is an active inflammatory process such as in chronic
diseases ↓ RBCs
Iron studies are not helpful
Transferrin Sat % is variable PBS
o Shows basophilic stippling
 Check lead (Pb) levels
o Shows sideroblasts
 Get a bone marrow biopsy to confirm

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Normocytic Anemias
MCV: 80-100 fl Diagnostics
Differentials o Iron Studies
o Early Iron Deficiency Anemia o B12 Levels
o Early B12 deficiency o Folate Levels
o Early Folate deficiency o Thyroid Function Tests
o Thyroid Disease o Liver Function Tests
o Liver Disease o BMP (kidney function)
o Kidney Disease o Hemolytic Labs
o Hemolysis o Bone Marrow Biopsy

1. Early Iron Deficiency Anemia 6. Chronic Kidney Disease

↓ Ferritin / ↑ BUN
↓ Transferrin Sat % ↑ Creatinine
↓ Erythropoietin (EPO)
2. Anemia of Chronic Disease o The kidney fails to produce EPO
↑↑ Ferritin
7. Intrinsic Bone Marrow Problem
3. B12 and Folate Deficiency ↓↓↓ Reticulocyte Index (0.1%)
↓ B12 levels Pancytopenia
↓ Folate levels o ↓ RBC
If the levels are borderline, measure the methylmalonic acid o ↓ WBC
(MMA) and homocysteine (HC) levels o ↓ Platelets
o B12 Deficiency = ↑ MMA, ↑ HC
o Folate Deficiency = ↔ MMA, ↑ HC Bone Marrow Biopsy
4. Hypothyroidism o Aplastic Anemia
 low proliferative bone marrow biopsy
↓ T3, T4
o Myelodysplastic Syndrome (MDS)
5. Liver Failure  hyperproliferative bone marrow due to overproduction of
blast cells
↑ AST, ALT (liver enzymes) o Pure Red Cell Aplasia (PRCA)
↓ Albumin  low erythroblasts
↑ INR  no pancytopenia because only the red blood cell line is
affected

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 26:47
Macrocytic Anemias
MCV: > 100 fl Diagnostics
Differentials o B12 / Folate levels
o B12 Deficiency o Thyroid Function Tests
o Folate Deficiency o Liver Function Tests
o Hypothyroidism o Look at medication use
o Drug-induced o Blood Alcohol Concentration
o Alcohol Abuse o Peripheral Blood Smear
o Myelodysplastic Disorder (MDS) o Bone Marrow Biopsy

1. B12 and Folate Deficiency 4. Drug-induced 💊💊

↓ B12 levels Drugs which can cause macrocytic anemia include:
↓ Folate levels o Chemotherapeutic agents
If the levels are borderline, measure the methylmalonic acid  Methotrexate
(MMA) and homocysteine (HC) levels  Fluorouracil (5FU)
o B12 Deficiency = ↑ MMA, ↑ HC  Hydroxyurea
o Folate Deficiency = ↔ MMA, ↑ HC o HIV Medications
Peripheral Blood Smear: megaloblastic anemia  Zidovudine
o Shows megaloblasts (neutrophils with >5 lobes/segments) o Antibiotics
 Trimethoprim Sulfamethoxazole (TMP-SMX)
2. Hypothyroidism o Anti-seizure Medications
History: hypothyroid symptoms  Phenytoin
↓ T3, T4  Valproic Acid
Peripheral Blood Smear: megaloblastic anemia
3. Liver Failure o Shows megaloblasts (neutrophils with >5 lobes/segments)
History: cirrhosis, alcohol abuse
5. Alcohol 🍷🍷
↑ AST, ALT (liver enzymes)
↓ Albumin History: heavy alcohol use
↑ INR ↑ Blood alcohol concentration
Peripheral Blood Smear: megaloblastic anemia
o Shows megaloblasts (neutrophils with >5 lobes/segments)

6. Myelodysplastic Disorder
Peripheral Blood Smear: non-megaloblastic anemia
o No megaloblasts / hyper-segmented neutrophils
o Suggestive of a thyroid, liver, or bone marrow issue
Bone Marrow Biopsy
o Consider in patients with pancytopenia
o Shows hyperproliferative bone marrow

Case Studies 45:40

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IV. ↑ Destruction / Loss of RBC’s (RI > 2%)
We have somebody who has increased destruction or loss of their red blood cells
o We think that they have anemia
 Low hemoglobin
 Low hematocrit
 Potential low number of red blood cell
In a perfect world, the reticulocyte index > 2%
o Assuming that the red bone marrow is producing red blood cells to compensate
for the drop in red blood cells caused by destruction or loss
o We need an actual functioning bone marrow to see an elevated RI

1:01:18
Hemolytic Anemia (Destruction of RBCs)
1. Classification
3. Splenic ultrasound
We can break them down
Consider getting splenic ultrasound looking at the spleen
o Inside the vasculature (intravascular)
o Especially in extravascular hemolysis
o Inside splenic macrophages inside spleen (extravascular)
Look for any splenomegaly to rule out hypersplenism
2. Hemolytic labs o Look to see if they have any splenic disease or liver disease
Splenic ultrasound may show splenomegaly
When we break down red blood cells There are different
o Sometimes we might have hypersplenism
molecules that leak out from red blood cells we must check
 Entraps red blood cells from bloodstream way faster
these Part of hemolytic labs
 Usually old and defective red blood cells gets destroyed
a) Lactate dehydrogenase (LDH)  But the spleen can just go hyperfunction and destroys
the normal red blood cells
o Usually, the first one that is released into bloodstream
b) Bilirubin
Remember
Hemoglobin is composed of Heme and a protein (-globin)
Heme breaks down into bilirubin
there are 2 types of bilirubin
Indirect/unconjugated bilirubin
 More increased in hemolytic anemia
 So, they may have some jaundice-like appearance
Direct/conjugated bilirubin

c) Hemoglobin FIGURE 3 US SHOWING SPLENOMEGALY

Whenever hemoglobin gets released into the bloodstream
o Liver makes a particular protein → haptoglobin

o Some hemoglobin gets into kidneys

 Pee out hemoglobin into the urine

Haptoglobin
Hemolysis Hemoglobinemia
Hemoglobinuria

Important labs to remember in clinical vignette

Hemolytic lab
o LDH
o Haptoglobin
If it comes back positive, We can say with some relative
confidence → there is hemolysis
 Intravascular → the elevation is really high
 Extravascular (inside splenic macrophage)

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Autoimmune Hemolysis
1. Direct antibody test/DAT (Coombs test)
Positive result → autoimmune hemolytic anemia
o Warm AIHA
 Positive IgG
 Positive complement
o Cold AIHA
 Negative IgG
 Positive complement

2. Simplest point
Check for hemolytic lab → positive
Check for direct antibody test → positive
o Hence, we have autoimmune hemolytic anemia
Figure out warm or cold AIHA
o Look at the pattern of IgG and complement

Negative result
Looking for another cause of hemolysis
They’re hemolyzing due to something else that’s not
autoimmune
o Something wrong against red blood cell intrinsically or
extrinsically (outside red blood cell)
 E.g., trauma, infection

1:09:33
Intrinsic hemolytic anemia
1. Enzyme Defect
3. Membrane defect
G6PDH deficiency
Hereditary spherocytosis
o Can be seen in younger African American children
o Won’t have a lot of symptoms or clinical features
o Clinical workup
o Clinical workup
 Low G6PDH enzyme level
 Peripheral blood smear
• We only want to check it when
they’re not in hemolytic crisis • Spherocytes
 Peripheral blood smear  Osmotic fragility test
• Positive → very high degree of suspicion for hereditary
• Bite cells
spherocytosis
• Heinz body
 History Paroxysmal nocturnal hemoglobinuria
• Usually, they’ve had infection o At night they go through these hemolytic events
• Exposed to some kind of fava beans o Mutation in very specific proteins in their red blood cell
membrane
2. Hemoglobinopathy o Clinical workup
Sickle cell anemia  History of venous clots
o Clinical workup • Deep venous thrombosis
 They have history of sickle cell anemia (DVT)
 Family history of sickle cell anemia • Pulmonary embolism (PE)
• Budd-Chiari syndrome
 History of vaso-occlusive
 Peripheral blood smear
crisis
• Spherocytes
 Peripheral blood smear o Key thing
• We’ll see sickle cells
 History of venous clots
o If this is potentially their first vaso-occlusive event and with
 Wake up in the morning, they have dark urine in the a.m.
peripheral blood smear we see sickle cells
o High degree of suspicion with this history and spherocytes →
 We can confirm with hemoglobin electrophoresis to
consider flow cytometry
show sickle cell anemia
 Positive → suggestive of paroxysmal nocturnal
• The result will show HbF
hemoglobinuria

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1:15:40
Microangiopathic Hemolytic Anemia (MAHA)
Red blood cells problem and also look for low platelet count Basic concept behind this
o Low platelets count due to thrombotic microangiopathies
There are small clots in the vessels
As the red blood cells and platelets are trying to squeeze
through
o They get ripped apart as they’re bumping against these
microthrombi
Sometimes people that have mechanical heart valve
o The red blood cells can just get sheared apart
o Look for low platelet

1. Disseminated intravascular coagulation (DIC) 4. HELLP syndrome

Cue features Pregnant woman
o Septic or critically ill HELLP syndrome include
o Elevated coagulation problem o Hemolysis
 Increased PT o Low platelet
 Increased aPTT o Elevated LFT
 Increased INR
 Increased D-dimer 5. Mechanical valve
• Low fibrinogen Mechanical aortic valve
• Low platelet o Chew up their red blood cells
2. Thrombotic Thrombocytopenic Purpura (TTP) 6. Peripheral blood smear
Cue features Schistocytes
o Low platelet o Torn up red blood cells
o Acute renal failure o Think about MAHA
o Drop in red blood cells  And look do they have low platelets that also suggests
o Fever potentially MAHA
o Neuro deficits  And think which one it is based upon their history
High degree suspicion of TTP Helmet cells
o Confirm with ADAMTS13 testing

More common in younger children

Prior GI infection
o Usually by sugar toxin
Low platelets
Acute renal failure
Evidence of anemia
o Probably some type of underlying history of GI issues

FIGURE 4 PERIPHERAL BLOOD SMEAR IN PATIENT WITH THROMBOTIC THROMBOCYTOPENIC

PURPURA. TYPICAL SCHISTOCYTES ARE ANNOTATED (FRAGMENTED AND HELMET CELLS).

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 1:15:40
Infectious
Super obvious → think about a patient who is having a super high fever
o Maybe there’s kind of rash
o Also, some kind of recent travel into areas where there’s high exposure

1. Malaria 3. Disseminated C. diff

History of recent travel to Africa or some Really nasty Clostridium difficile infection
kind of area where there’s high possibility Clinical workup
of it’s being exposed to malaria o Physical examination
o And come back with myalgia  They look septic
Peripheral blood smear  High fever
o Inclusion of malaria inside red blood cells o Lots of diarrhea
o Check for C. diff
o Peripheral blood smear
 Ghost cells
o Also, some kind of recent travel into areas where there’s high
exposure of C. diff

2. Babesiosis
History of tick bite
o They have rash, high fever
o They were in area like Wisconsin or
some kind of area where there’s high
possibility of getting babesiosis FIGURE 5 GHOST CELLS
Peripheral blood smear
o Pathognomic → Maltese cross

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V. BLOOD LOSS
Remember the first thing we do
Anemia
o Low hemoglobin
o Low hematocrit
o Low red blood cells
Check reticulocyte index > 2%
o Increased destruction or loss problem
How do we know it’s not actually a destruction problem?
o No evidence of hemolysis
 Normal LDH
 Normal haptoglobin
 Doesn’t need to check for direct antibody test (DAT)
• Because we know it’s not hemolysis

1:15:40
Causes
Be intelligent!
If someone is losing blood, look at their actual physical exams
o Do they have signs or symptoms of bleeding?
 Do they look pale?
 Do they have power?
 Do they have dry mucous membrane?
 Decreased capillary refill?
 Are they having hypotension, tachycardia?

1. Anticoagulants 9. Look out for bright red blood per rectum or dark stools
2. Recent surgery procedure done Upper GI bleed
3. Frequent blood draws every single day o We can do EGD
Probably will be experience a lot in the clinical world especially o Also, we can do nasogastric tube
in the ICU • Aspirate out some areas from
gastric tube and see if there’s
Especially if they don’t have no obvious other source
any blood in there after we
lavage it and then aspirate
4. Recent surgery procedure some stuff back
5. GI bleeds
6. Hemoptysis FIGURE 6 UPPER GI ENDOSCOPY (EGD)

Vomiting up the bloods

Lower GI bleed
o C scope (colonoscopy)
o Fecal occult blood test
7. Retroperitoneal bleed
 Positive → test their stool
Remember retroperitoneum is a little space behind peritoneum  Do a digital rectal
Due to • Positive for blood → potential
o Aortic bleed problem
o Small vessel bleed within the lag
o On anticoagulants
Do CTA of the abdomen and pelvis area
FIGURE 7 COLONOSCOPY
o Look for any kind of bleed in the area

8. Blood accumulation within the leg

Due to
o Hit artery in the leg
o Fracture a bone
o Undergo some type of procedure
Look for swollen legs or hematomas
Case Studies 1:29:14

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 VI. Appendex
M R R Peripheral
Differential Mentzer’s
RI C D B Iron Studies Blood Additional Information
Diagnosis Index
V W C Smear

Iron deficiency ↑ ↓ > 13% ↓ Ferritin

anemia ↓ Transferrin Sat %

↔ ↓ ↑↑ Ferritin Ferritin is an acute phase reactant; it may be

Anemia of elevated when there is an active
chronic disease inflammatory process such as in chronic
diseases
Microcytic

< 80 fl

↔ ↔ < 13% Basophilic Correlate with history findings (e.g., family

/ stippling history of thalassemia, Mediterranean
Thalassemia ancestry)
↑ Hemoglobin Electrophoresis

↑ ↓ Basophilic History: Look for exposure to lead, alcohol

stippling use, medication use
Sideroblastic Causes: lead poisoning, toxins
anemia Sideroblasts Check lead (Pb) levels
Get bone marrow biopsy to confirm

Early iron
↓ Ferritin
deficiency
↓ Transferrin Sat %
anemia

chronic disease ↑↑ Ferritin

↓ B12 levels
↓ Folate levels
B12 and folate If the levels are borderline, measure the methylmalonic acid (MMA) and homocysteine (HC) levels
Normocytic

deficiency o B12 Deficiency = ↑ MMA, ↑ HC

< 80 fl

o Folate Deficiency = ↔ MMA, ↑ HC

Hypothyroidism ↓ T3, T4

↑ AST, ALT (liver enzymes)

Liver failure ↓ Albumin
↑ INR

↑ BUN
Chronic kidney ↑ Creatinine
disease ↓ Erythropoietin (EPO)
The kidney fails to produce EPO

↓ B12 levels
↓ Folate levels
B12 and folate If the levels are borderline, measure the methylmalonic acid (MMA) and homocysteine (HC) levels
deficiency o B12 Deficiency = ↑ MMA, ↑ HC
Folate Deficiency = ↔ MMA, ↑ HC

Hypothyroidism ↓ T3, T4

↑ AST, ALT (liver enzymes)

Liver failure ↓ Albumin
Macrocytic

↑ INR
> 100 fL

Drug-induced Peripheral Blood Smear: megaloblastic anemia

Shows megaloblasts (neutrophils with >5 lobes/segments)
Alcohol

Peripheral Blood Smear: non-megaloblastic anemia

o No megaloblasts / hyper-segmented neutrophils
o Suggestive of a thyroid, liver, or bone marrow issue
Myelodysplastic
Bone Marrow Biopsy
disorder
o Consider in patients with pancytopenia
o Shows hyperproliferative bone marrow

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 VII. Review Questions VIII. Refrences
1) Which of the following parameters reflects bone marrow ● Harrison, T. R., & Kasper, D. L. (2015). Harrison's principles of Internal
Medicine. McGraw-Hill Medical Publ. Division.
function?
a) Mean Corpuscular Volume
b) Reticulocyte Index
c) Total Iron Binding Capacity
d) INR
2) If the reticulocyte index is 0.9%, which of the following is the
LEAST LIKELY differential?
a) B12 Deficiency
b) Myelodysplastic Syndrome
c) G6PD Deficiency
d) Hypothyroidism
3) A 31-year-old female patient’s CBC results showed the
following:
Hgb 10.3 g/dL
Hct 30.3 %
MCV 121
a) Iron Deficiency
b) Folate Deficiency
c) Gastrointestinal bleeding
d) Thalassemia
4) Which of the following is CORRECTLY paired?
a) MCV < 80 : Normocytic Anemia
b) MI < 13% : Iron Deficiency Anemia
c) ↔ MMA, ↑ HC : Folate Deficiency Anemia
d) RI < 0.8% : Hemolytic Anemia
5) Reticulocyte index > 2% in anemia cases indicates
a) Functional bone marrow → compensates for blood loss
b) Aplastic anemia → unable to compensate for blood loss
c) Anemia caused by nutrient deficiencies
d) Anemia induced by drugs with bone marrow suppression
effect
6) What clinical result that is always present and unique to
microangiopathic hemolytic anemia?
a) High platelet count
b) Low platelet count
c) Warm AIHA
d) Cold AIHA
7) Osmotic fragility test is commonly used to diagnose which
type of anemia?
a) Hereditary spherocytosis
b) Paroxysmal nocturnal hemoglobinuria
c) Thalassemia
d) G6PDH deficiency

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