• CBC (Hb and Hct; consider checking Hb and Hct q 4 hrs if concerned about active bleeding)
  • Iron studies/profile (ferritin, TIBC, iron level)
    1. Tx iron deficiency anemia: Ferrous sulfate 325 mg PO tid and Vitamin C 500mg PO tid (helps with the absorption of the iron)
  • FOBT (determine if losing blood in stool)
  • Reticulocyte count (consider the need for Erythropoietin if kidney failure: Anemia of Chronic Disease)
  • Vitamin B12 (cobalamin) and folate level (macrocytic anemia)
  • May be secondary to poor nutritional intake.
  • May be secondary to kidney failure -> low erythropoietin -> low formation of new RBCs

Example A&P:

Acute on chronic anemia: Transfuse 1 U PRBC. Follow Hb/Hct closely overnight. Reassess need for additional transfusion. Order orthostatic vitals to be measured q shift. Initiate fall precautions. Place patient on telemetry.

***Order the following labs: iron level, TIBC, ferritin, folate level, Vitamin B12 level, haptoglobin, LDH, PT/INR, FIT/FOBT. Patient may also need a peripheral smear and/or bone marrow biopsy if prior labs do not lead to diagnosis.

  • Peripheral smear:
    1. Hypersegmented neutrophils.
      1. Macrocytic anemia: Vitamin B12 (cobalamin) and folate deficiency.
    2. Spherocytes: Order direct antiglobulin test (Coombs test) to differentiate between
      1. Autoimmune hemolytic anemia (AIHA): POSITIVE Coombs test.
      2. Hereditary spherocytosis: NEGATIVE Coombs test.
        1. Bilirubin gallstone formation appears in adult patients, requires cholecystectomy.
        2. Labs: Anemia, reticulocytosis, elevated MCHC, and increased
        3. Confirm diagnosis: Eosin-5-maleimide binding (flow cytometry) or acidified glycerol lysis tests.
        4. Treatment: RBC transfusion for symptomatic anemia, folic acid supplementation, and splenectomy for severe cases.

Bone marrow biopsy:

  • Performed to evaluate: Malignancy, pancytopenia, suspected MDS (myelodysplastic syndrome), bone marrow fibrosis.


  • Diagnose with hemoglobin electrophoresis (Ex: sickle cell anemia (HbF), beta thalassemia major).

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