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
• Thalassemia
• Anemia of Chronic Disease
• Vitamin B12 Deficiency
• Autoimmune Thrombocytopenia Purpura (“Immune TP”)
• CBC Interpretation

24 Copyright 2020 Advanced Practice Education Associates

 Hematology

ANEMIA
• Reduction in one or more RBC measurements:
1. RBC count
2. Hemoglobin
3. Hematocrit

Is this patient anemic? _________________________________________________________

Patient Norms
RBC 4.3 4.2-4.9 million/microL
HGB 11.5 g/dL 12-15 g/dL
HCT 37.2% 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

Rule 1: Anemia is never normal!

Always suspect that something is going on with your patient!

Rule 2: Normal lab values don't mean things are normal!

How do the following characteristics affect Hgb/Hct?

Characteristic Effect on H/H:
Normal, , 
1. Dehydration
2. Chronic kidney disease
3. DM with A1C 11.3
4. Anabolic steroid use
5. Pregnancy
6. Age: 88 years old

A Day In Clinical Practice

Patient has Stage 3 COPD. See labs below.
1. Anemia present? ____________________________________________________________
2. Normal (Yes or No)? _________________________________________________________
3. Why? _____________________________________________________________________
Results Norms
RBC 4.3 4.2-4.9 million/microL
HGB 12.4 g/dL 12-15 g/dL
HCT 37.2% 37-51%
Additional Notes:

Copyright 2020 Advanced Practice Education Associates 25

Hematology

Every anemia in the world is characterized by:

1. RBC Size
2. RBC Color

Diagnosis of Anemias
RBC size (MCV): cytic = “cell”
Red Cell Size Term
Small cells (<80) Micro cytic
Normal sized cells (80-100) Normo cytic
Large cells (>100) Macro cytic

Microcytic Normocytic Macrocytic

<80 fl 80-96 fl >96 fl

RBC color (MCH): chromic = “color”

Red Cell Color Term
Low in color (pale) Hypo chromic
Normal color Normo chromic
Excess color Hyper chromic

Hypochromic Normochromic Hyperchromic

Every Anemia … in the world is characterized by size and color of RBCs.

Examples:
Red Cell Size (MCV) Red Cell Color (MCH) Type of Anemia
Small Pale Microcytic, hypochromic
Normal Normal Normocytic, normochromic
Big Normal Macrocytic, normochromic

A Day In Clinical Practice

Is this patient anemic? __________________________________________________________
What do the red cells look like? ___________________________________________________
Patient Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 86.5 80-96
MCH 26.4 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

26 Copyright 2020 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 (how uniform in size are RBCs)

• RDW (red cell distribution width): indicates degree of variation in RBC size (<15% is
normal)

Question
Which plate has a Normal RDW? _________________________________________________
Plate #1 Plate #2

Image Copyright © Copyright 2008-2018 • Christy Image Copyright © 2018 MACHEESMO,

Jordan - Southern Plate® • All Rights Reserved ALL RIGHTS RESERVED
https://www.southernplate.com/melt-in-your- https://www.macheesmo.com/30-minute-
mouth-doughnuts-made-at-home-foolproof-and- donut-holes/
great-for-beginners/
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 Image Copyright © 2018 Published in Multimedia
Tools and Applications 2018. Allen Institute for AI.
 Should always be considered when a patient presents https://www.semanticscholar.org/paper/Development-
of-a-robust-algorithm-for-detection-of-Hegde-
with anemia Prasad/1cc5c06528524e6de48409a7007bb3e1c9a3d
40a

Rule 3: If the peripheral smear description of RBCs doesn’t match the MCV, MCH values,
consider that 2 anemias are present at same time.

Peripheral Smear Report – Example

Patient Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 90 80-96
MCH 25 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
Microcytic, hypochromic red cells present

Copyright 2020 Advanced Practice Education Associates 27

Hematology

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)

Image Copyright ChickTech.com Image Copyright Cambridge Connection Newsletter

http://chicktech.com/food-hack-how-to- https://cambridgeps.ocdsb.ca/UserFiles/Servers/Server_216786/
know-if-an-egg-is-fresh/ File/News/2018-2019/September%202018%20Newsletter.pdf

Egg count is high Egg count is low

Capacity is low Capacity is high
Iron count is high Iron count is low
TIBC is low TIBC is high

The Basics need Mastery!

RBC Indices Other Important Labs
Hemoglobin Serum Fe
Hematocrit Serum Ferritin
MCV Reticulocyte count
MCH TIBC
RDW Peripheral smear
Know what they are and why they are important!

MICROCYTIC ANEMIAS
Common Causes:
• Iron deficiency anemia (IDA)
• Thalassemia

Less Common Causes:

• Anemia of chronic disease (<20%)
• Sideroblastic anemia
• Lead toxicity

Iron Deficiency Anemia (IDA)

• What: Microcytic, hypochromic anemia
Image Copyright Medword Iron Deficiency Anemia.
http://www.medword.com/Gastro/ironDeficiency.html
• Why: Blood loss
• Where: GI, Gyn

IDA Clinical Presentation

• Most people are asymptomatic (until 30/10)
• Young/middle adults: weakness, headache, irritability,
fatigue, exercise intolerance
• Older adults: may present with exacerbation of
comorbids (angina, worsening dementia)
Image Copyright Sept 11 2019 Medline Plus.
(Copyright 1997-2019, A.D.A.M., Inc.)
https://medlineplus.gov/ency/imagepages/2008.htm

28 Copyright 2020 Advanced Practice Education Associates

 Hematology

Quiz: Classic IDA Lab Presentation

Lab Index ↓ or ↑
Serum Fe
Serum ferritin
MCV (microcytic)
MCH (hypochromic)
TIBC
RDW

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: Usually 4-6 months

Iron Source Mg Elemental Iron
Ferrous fumarate 325 mg 106 mg
Ferrous sulfate 325 mg 65 mg
Ferrous gluconate 325 mg 33 mg
Extended-release forms ($$) Varies (150 mg)

A Day In Clinical Practice

A 35-year-old woman tried to donate blood but was unable due to a “low blood count.” Which lab
tests should the NP order today to evaluate this patient?
1. Hgb
2. CBC
3. CBC, peripheral smear
4. CBC, Fe studies
Her CBC results are below. What should be ordered to evaluate this anemia?
Patient Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 72 80-96
MCH 21.6 23.7-28.4
RDW 18.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12
1. Repeat CBC
2. Serum iron, serum ferritin, TIBC
3. Lead level
4. Screen for thalassemia

Copyright 2020 Advanced Practice Education Associates 29

Hematology

A Day In Clinical Practice

A 35-year-old woman was diagnosed today with IDA. The NP has prescribed once daily ferrous
sulfate to treat her. What labs should be ordered when she returns in 4 weeks for a clinic follow-
up?
1. CBC
2. CBC, serum iron
3. CBC, serum ferritin
4. CBC, serum ferritin, RDW

A Day In Clinical Practice

Adolescent female patient complains of fatigue.
Next step? ___________________________________________________________________
Patient Norms
RBC 3.5 4.2-4.9
HGB 9.5 g/dL 12-15 g/dL
HCT 28.6% 37-51%
MCV 72 80-96
MCH 21.6 23.7-28.4
RDW 18.6 12-17
PLT 265 150-375
MPV 7.1 6.5-12

Is she iron deficient? (see table above)

_____________________________________________________________________________
• Normal serum Fe level
• Normal serum ferritin level
• Normal TIBC

What is the diagnosis? (see table above)

_____________________________________________________________________________

• Peripheral Smear:
 Microcytic, hypochromic red cells present
 Poikilocytosis, anisocytosis, target cells present

THALASSEMIA
Thalassemia Characteristics
• Microcytic/hypochromic red cells
• Variation in size (anisocytosis) and shape (poikilocytosis) of RBCs
• Possible nucleated RBCs
• Uneven Hgb distribution, producing “target cells”

Thalassemia
• What: Microcytic, hypochromic
• Why: Inherited
• Types: alpha, beta, others
• Diagnostic test: Hgb electrophoresis
• Treatment: Consider reproductive counseling

30 Copyright 2020 Advanced Practice Education Associates

 Hematology

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)
• What: Normocytic, normochromic anemia; microcytic, hypochromic (not common)
• Associated with: Chronic disease, infection, inflammation, and/or malignancy
• Why: Red blood cell life span is shortened from the normal 100-120 days to 60-90 days
• Treatment: better control of underlying chronic disease, treatment of malignancy

A Day In Clinical Practice

A patient has been diagnosed with anemia of chronic disease. What might be part of the reason
for this diagnosis? Select all that apply.
1. Colorectal cancer
2. Iron deficiency anemia
3. Poorly controlled lupus
4. Metastatic breast cancer
5. Severe ulcerative colitis

COMMON MACROCYTIC ANEMIAS

• B12 deficiency (Cobalamin, Cbl)
• Folate deficiency

Classic B12/Folate Deficiency

• What: Macrocytic anemia
• Presentation: Asymptomatic patient, unexplained neuro symptoms, weakness, cognitive
changes, “burning tongue”
• Who: Older adults, alcoholics, malnourished, bariatric surgery patients, strict vegans
• Why: Poor absorption thru GI tract
• Treatment: B12 and/or folate supplementation

Vitamin Deficiencies
• These are vitamin deficiencies!!!
 B12 is an absorption problem, rarely a dietary deficiency
 B12 deficiency and folate deficiency often coexist!!!

A Day In Clinical Practice

A malnourished 85-year-old patient is in your exam room today. What symptoms might reflect a
B12/folate deficiency? Select all that apply.
1. Abdominal pain
2. Jaundice
3. Confusion
4. Forgetfulness
5. Anorexia
6. Petechia

Copyright 2020 Advanced Practice Education Associates 31

Hematology

A Day In Clinical Practice

A 45-year-old patient has suspected B12 deficiency. What symptoms might reflect a B12
deficiency?
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

An 85-year-old patient presents with complaints of intermittent burning lips and tongue. She is
asymptomatic at the time of exam and has a normal-appearing tongue. What action by the NP
will elicit the most beneficial diagnostic information?
1. Extensive gum and tooth assessment
2. B12, folate levels
3. Assessment of her anterior cervical nodes
4. CBC

B12 deficiency may be characterized by neuro changes

Decreased Intake Malabsorption Impaired Metabolism Increased Needs
Alcoholics Sprue TMP-SMX Pregnancy
Strict vegetarians Ileitis Methotrexate Lactation
Diverticulosis Post-gastrectomy
Cancer
Hyperthyroidism
Other: Colchicine

Folate deficiency not usually characterized by neuro changes like B12 deficiency
Decreased Intake Malabsorption Impaired Metabolism Increased Needs
Alcoholics Sprue TMP-SMX Pregnancy
Older adults Gastrectomy Methotrexate Lactation
Hyperthyroidism
Others

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
Additional Notes:

32 Copyright 2020 Advanced Practice Education Associates

 Hematology

A Day In Clinical Practice

A patient complains of a “rash” on the top of both feet that became
noticeable a few days ago. See below.
1. What diagnosis should the NP suspect?
______________________________________________________
2. Does the rash itch?
______________________________________________________
3. Is this usually present bilaterally? Image Copyright Science Diseases
Idiopathic Thrombocytopenic Purpura
______________________________________________________ http://mdiaz1197.wixsite.com/sciencedisea
ses/itp
4. What test should be ordered initially?
______________________________________________________

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

A Day In Clinical Practice

A patient has been diagnosed with thrombocytopenia. If this is secondary to poorly controlled
lupus, what lab tests might be expected to be abnormal? Select all that apply.
1. INR
2. PT/PTT
3. Hgb/Hct
4. Platelet count

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

Leukocytes
• Neutrophils are the same as “Segs”
= Polys

Copyright 2020 Advanced Practice Education Associates 33

Hematology

What is your interpretation of this CBC?

_____________________________________________________________________________
Patient Norms
WBC 15.9 (H) 4-11
RBC 4.08 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 29.4 (L) 31.3-35.7
RDW 19.6 (H) 12-17
PLT 315 150-375
MPV 7.1 6.5-12
POLY% 81 (H) 55-75
LYMPHS% 2 (L) 30-40
MONO% 14.9 (H) 0-12
EOS% 0.1 0-6

What is your interpretation of this CBC?

_____________________________________________________________________________
Patient Norms
WBC 3.9 4-15
RBC 4.01 (L) 4.5-5.60
HGB 11.4 (L) 13.7-17.3
HCT 34.8 (L) 37-51
MCV 103.7 (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 316 150-375
MPV 8.1 6.5-12
POLY% 46.5 (L) 55-75
LYMPHS% 43.1 (H) 30-40
MONO% 10.2 (H) 0-9
EOS% 0.1 0-6 Differential
BASO% 0.1 0-6
Anemia? ______________________________________________________________________
What lab next? _________________________________________________________________
Additional Notes:

34 Copyright 2020 Advanced Practice Education Associates

 Hematology

What is your interpretation of this CBC?

_____________________________________________________________________________
Patient Norms
WBC 2.9 (L) 4-11
RBC 4.08 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 115 (L) 150-375
MPV 7.1 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
Peripheral Smear: Myelocytes, metamyelocytes, and promyelocytes are visualized.

Exam Checklist:
• Anemia of chronic disease ✓ Know clinical presentation (subj, obj
• IDA findings)
• Thalassemia ✓ Know how to diagnose
• G6PD deficiency ✓ What’s in diff dx?
• B12, folate deficiency ✓ Pharm, nonpharm mgt
• Thrombocytopenia ✓ Follow-up labs
✓ Follow-up care

Additional Notes:

Copyright 2020 Advanced Practice Education Associates 35

Hematology

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
• Hollier, A. (2018). Clinical Guidelines in Primary Care, 3rd ed. Lafayette, LA: APEA.
• Clinician’s Guide to Laboratory Medicine; Samir P. Desai, MD (2009). Amelie calls it “the
green lab book”
• To view this lecture again, visit the APEA CE Library and purchase the Fundamentals of
Hematology on video: https://www.apea.com/ce-library
Additional Notes:

36 Copyright 2020 Advanced Practice Education Associates