GIM Question 32 Instructor

A routine CBC of a patient on your ward comes back showing Hgb 90, MCV 86. Your patient has been complaining of new onset fatigue for the past two days.

  1. What classification of anemia is this?
    This patient is presenting with normocytic anemia. Specific labwork that can help with the diagnosis includes:

    • CBC – Hgb, MCV (80-100 fL normocytic), RDW (if high, suspect a mixed picture)
    • Reticulocyte count (should be elevated in an acute bleed or hemolytic process)
    • Fe studies
    • B12 levels
  2. What is your differential diagnosis?
    The differential diagnosis for normocytic anemia is extensive, but can be thought of as arising from increased loss, increased destruction, increased sequestration, and/or decreased production.
    The differential therefore includes:

    • Acute blood loss (increased loss)
    • Hemolytic anemia (increased destruction)
      • Hereditary – hemoglobinopathies, disorders of RBC membrane, RBC enzyme deficiencies
      • Acquired – mechanical hemolysis, autoimmune, paroxysmal nocturnal hemoglobinuria
    • Hypersplenism (increased sequestration)
    • Primary bone marrow dysfunction (decreased production)
      • Bone marrow invasion (leukemia)
      • Aplastic anemia
      • Myeloproliferative disorder
      • Red blood cell aplasia
    • Secondary causes of decreased production
      • Chronic kidney disease
      • Hypothyroidism
      • Hypopituitarism
      • Hypoadrenalism
      • Anemia of chronic disease/inflammation
    • Overhydration (dilutional)
  3. Which of these diagnoses are you most worried about at this time?
    An acute bleed must be ruled out in a patient with new onset normocytic anemia.

Brill JR and Baumgardner DJ. Normocytic Anemia. Am Fam Physician. 2000, 62:2255-2263.

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