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Hey. There. Its liz roar from real world.
Np and youre watching np np practice. Made simple. The weekly videos to help save you time frustration.
And do we learn faster. So you can take the best care of your patients. So today.
Im gonna be talking about anemia. Im actually going to be covering a case study with a lab result interpretation that youve probably seen before and havent really known what to do with so i hope. Its really helpful and important note is that it even is a really big topic so im really only covering a small portion of it if youre interested in learning.
More if you want to feel more confident with your cbc interpretation. And lab interpretation. In general definitely come join me for the lab.
Interpretation crash course for new nurse practitioners. The first editions gonna be launching the november with a limited number of spots and then the full thing is going to be happening in mid january um. So definitely head over to real world n pecan slash labs to join in but with that without further ado.
Im gonna share my screen with you so lets jump right into the anemia case study. So this is lisa. Shes 46 year old 46 years old female shes a new patient.
Establishing care at the clinic and again this is not her real name or her photo. So shes got no concerns today. Shes here just to establish care.
Shes switching clinics meeting. You for the first time. She was told that she had anemia in the past.
Shes not sure what treatment. Shes done she may have had iron. She cant really remember.
But she said that she was told. It was fine um. Shes a nonsmoker does not drink alcohol or use other drugs.
Shes a single mom no sexual partners and then she said that she had sti testing recently and hasnt had any partner since then and everything. She said was normal so path medical history you know question of anemia otherwise. She says.
Shes been pretty healthy family history of hypertension and her mom has some mild high blood pressure. No past surgical history. No medications her blood pressure heart rate.
Bmi are all normal as well as her oxygen. And her temperature so making it pretty easy for us today so plan. Im gonna be talking about labs today im gonna touch on the other components of ballistic here at the end like the other case studies so for labs.
Im gonna keep it really conservative break so shes 46 years old she is a three of a question of anemia so im gonna check his cbc shes asymptomatic luckily but i do want to kind of investigate that just to make sure its all right im doing a basic metabolic panel. We could have a whole discussion about you know testing and and all that and over testing and under testing and all that stuff in terms of lab tests so i added that on for my own reassurance purposes. I dont necessarily have a very good clinical reason aside from just kind of getting some baseline information.
But other than that im just trying to im trying to work in my own practice on ordering less blood tests. Then more theres a pretty standard one that everybody gets which is a cbc a cmp a tsh lipids anyone see all that stuff. But because she does really have any risk factors.
I mean. Shes 46 years old no girly family history of hyperlipidemia or mi or anything like that i i guess i could have added a lipid profile and maybe well discuss that more when she comes back for her physical also im gonna look at her previous labs. But anyway thats a longer discussion but pretty much im just looking at the cbc and the bmp today.
So here. Our results are bmp was to call it totally normal. So this is a really common lab pattern that i see so her matic rate.
If youre listening to this instead of watching him a decreased 33 for the reference range for this lab is 35 to 45 hemoglobin. Is 11 and the normal range is. 115 to 155.
Mch mch c. Are both normal. The mcv is 77.
So slightly below the normal of 80 to 100 or of this lab is 80 to 90 for platelets are normal red blood cells are. 55 the normal range upper limit being 51. Her rtw is normal thirteen point nine and then her white blood cells are also normal so really the main abnormalities here are the low hematocrit hemoglobin and mcv and high red blood cells.
So i see this lab. All the time i wonder if youve seen this lab pattern as well so im gonna jump into anemia. Im gonna its a really big topic but im gonna really focus on this kind of like case.
Study and tie in some other things as well so low hematocrit hemoglobin and rbc question mark. Because anemia typically you think of being low hematocrit. A mcglynn and low red blood cells.
But weve got some high red blood cells. So i you can i wonder if you can guess kind of whats going on. But i want to do a brief overview the cbc components um.
So white blood cells. If you saw the wbc lecture. Thats all about the leukocytes the number of leukocytes hematocrit and hemoglobin hematocrit is the concentration of your plasma of the red blood cell kind of components in proportion to the rest of the plasma.
The human bullivant is the protein that carries oxygen and the note about that is that the lab will thats an accurately measured component in terms of the cbc is the hemoglobin is directly measured where some of the other components are calculated. So if youre looking for something thats kind of reliable. The human globin.
Its kind of the one to look at red blood cells is the number of cells and so typically youd expect that the number of cells would correlate with the human occur concentration. But doesnt always thats in this case. Mcv is the mean corpuscular volume.
So thats the red blood cell cell size thats really important um rdw is the red blood cell distribution width. And what that means is that when you have blood existing currently in your bloodstream our red blood cells turnover about every 120 days correct so the ones that currently exist compared to the ones that are being produced there is a size differential so instead of them all being normal. There be theyre abnormal or theyre smaller or larger than what currently exists so when you have something like some types of anemia for example iron deficiency anemia youre going to as your iron stores drop youre going to get smaller and smaller cells being released and so your rdw is going to increase because of that so platelets repair injury to a vascular epithelium.
Theyre important for blood clotting. Im not gonna be talking about that in this lecture and mchc and mch just a really quick note about that so its the average hemoglobin per red blood cell.
And its just not very useful of a measure. So im sure youve learned about it in school and you know the hypo microcytic hypochromic cells. That commonly come with any deficiency anemia.
Youll have that kind of abnormality. Honestly hematologist are not really even looking at that its really not that relevant and if you see something that just has nchs or mch abnormal and everything else is normal dont worry about it because that kind of fluke happens quite frequently. I think so if i have steps to an anemia workup in general so number one is do they have symptoms and thats pretty much for any lab that were talking about or any lab that youre looking at is your first question should really be do they have symptoms right and hello is it knowing your thresholds of whats important in terms of emergent versus outpatient workup.
Number three. I want you to reflexively look at when you have low hemoglobin to reflexively look at the mcv. The mean corpuscular vaughn the size of the cells.
Which you probably learned in school. Again maybe thats just a review. But and then the other thing to think about is plus or minus the smear.
So if you listen to the white blood cell or watch the white blood cell video. I really talked about the smear. Quite a bit and how important that is when youre interpreting a cbc so go back and watch that if you havent watched that already but thats a really important depending on kind of how you go with anemia number four is looking at the trend over time.
Thats definitely like a kind of a mistake that i see of new grads looking at lab. Interpretation is that theyre not really comparing to the previous one. So you might get a hemoglobin of eight which sounds really scary.
But if you look at the last blood test that was done three months ago. The hemoglobin was also eight so looking at that trend is really important and number five is called morbidities so im really not going to be talking about anemia of chronic disease today. But thats something to think about thats really important when youre.
When youre interpreting any kind of anemia. Putting the clinical picture together. Its not really just about the numbers.
And the shapes and all that stuff you really have to look at the big clinical picture. So this is a kind of anemia workup. Pretty briefly.
So the the normal range for him at accrete for women is thirty seven to forty seven. The hemoglobin is twelve to sixteen approximately for me for men. Its forty medic rate is 42 to 50 percent and humid low in about fourteen to eighteen and the upper limit of eighteen you know for certain conditions.
Were not talking about high kinetic right today. But if youre thinking about high home attic rat. It may or may not be eighteen.
It might actually be a little bit lower sixteen if youre talking about certain conditions. They are investigating. But side note on that but were talking about amia today.
So hemoglobin of 12 for women hemoglobin of 14 for men. So if you have a hemoglobin of less than seven and or theyre symptomatic like they have hypotension or tachycardic obvious signs of bleeding obviously those people are gonna need to go to the er right because thats thats really concerning. But if its above 7.
I mean that round seven if theyre asymptomatic as well or any obvious signs of bleeding definitely send them if its eight or something like that but if its if its above seven. And its under that 12 to 14 for men women and men. The first thing youre going to look at is the mcv like i kind of said that should really be reflexive for you so if its a less than 80 youre thinking about microcytic anemia.
So those are small cells. Which has a different differential than normocytic. Which is eighty to a hundred versus greater than 100 is gonna be your macrocytic and depending on where youre mcb is gonna bring you down different paths right maybe.
Thats a review for you. But just its a good way to conceptualize it and so it loops. I didnt animate this slide.
Very well but testing for anemia that you can think about for microcytic anemia. You can consider doing some iron studies. So thats ferritin t ibc and serum iron or the main iron studies that are recommended and a reticulocyte count so reticulocytes are the kind of early red blood cells.
And then ill give you an idea of whether or not the bone marrow is responding to the anemia and able to produce more red blood cells or not and that will give you kind of clues about where to go in your investigation. Whether its higher. Its low you also want to consider adding a differential or a smear peripheral smear for abnormal looking cells.
And then if you have those thatll kind of give you further clues about what type of microcytic anemia. Were talking about and so i should have this should have come up first. But microcytic anemia again is less than eighty of an mcd iron deficiency is your number one reason just.
Globally but also in the us. Number. 2 is a mimi of chronic disease and chronic inflammation.
So those are people who have like rheumatoid arthritis or even like diabetes or heart problems like they can kind of have this chronic inflammation affiliated with that disease state. Which kind of causes impaired and it causes an anemia. Its kind of lets it get into.
But just knowing that thats an option and your differentials for this patient and hemoglobinopathies are pretty common and im going to talk about that on the next slide in just a sec and then the other thing to kind of consider less common myelodysplastic syndromes like aplastic anemia or other kind of hematology oncology. Ideologies or something i really consider so if you and and thats why you would add on a smear right because you know does the clinical picture make sense. Does it seem like its one of those top three or does it not and then you look at the peripheral smear theres abnormal cells.
Theres other components of your cdc that are abnormal the white cells. The platelets things like that thatll kind of cue you to think about like okay. Like this is not just a garden variety microcytic anemia.
This is because of like a larger you know human illogic oncological. A so hemoglobinopathies there are many types right so. But the most common lab.
Excuse me so spoiler alert. The most common lab pattern that i see is a microcytic anemia with high red blood cells. And a low reticulocyte count.
And this is kind of affiliated with alpha or beta thalassemia minor. So this is kind of what this patient has spoiler alert. But theres major and theres minor alpha and beta thalassemia so major these people you would know if they had nature right because these people are transfusion dependent pretty much for life and youre probably not going to be diagnosing.
These incidentally on your cbc right especially 46 year old woman. So this is unlikely to be a major thalassemia minor is whether its alpha or beta. I tend to be asymptomatic so either they have a you know theres two theres four different kinds of alphas.
I mean sidenote. Theres four different kinds of alphas and two different kinds of betas alpha. One theres no symptoms at all alpha 2.
Theres you know this mild microcytic anemia with high red blood cells. 3.
Is that more major transfusion dependent in 4. Is the hydrops fetalis cause and those those patients dont survive. Those are those are you know in utero dont survive so um and then for beta.
Theres only 2. Theres minor and theres major so just fun facts about that. But yeah so either theyll have no symptoms at all or theyll have that like trait.
Which is the mild macrocytic anemia microcytic anemia with a high red blood cell. So um in terms of other hemoglobinopathies. Theres other kinds right.
Theres sickle. So theres like other things like that but typically and you can check a smear and theyll have abnormal looking cells. But again like if you have a 46 year old female.
This is unlikely going to be the first time that youre going to diagnose a musical right because when theyre a kid. This is this is a lifelong illness right this is not gonna be the first time diagnosis. But if youre really not sure check us mir.
Just make sure that theres nothing else abnormal going on considering iron studies for this kind of pattern and then these are likely going to be normal. I mean. Theres a chance that you had could have concomitant um.
You know iron deficiency and hemoglobinopathies. But most likely most likely theyre going to be normal and another test that you can do is a hemoglobin electrophoresis. The main reason to do this is because youre trying to get diagnostic clarity right its gonna give you some results that its a.
Im not gonna get into the interpretation. I really dont order this very often. But its gonna give you different types of chemo blub and its gonna give you a heme and globin a hemoglobin a1.
A2 hemoglobin f. Hemoglobin easy things like that the main reason to order that is so that you can get diagnostic clarity. And then for people who have prenatal considerations right so if you are a trait carrier you might want to consider if youre if youre seeking pregnancy as a female or you know a partner you want to think about genetic genetic testing and recommending that for them.
Im not gonna be doing that in primary care right and then dont treat them with iron. I think thats one of the main mistakes that i see is that like you see a microcytic anemia. You think okay.
Its iron deficiency throw some iron at them. But these visions can actually get overloaded. So you just want to be careful and if you happen to find iron overload on your on your labs.
Then you can like can refer them to mythology for treatment for that and then hakeem referral. If its still unclear if youre very uncomfortable send them right if its more if its more significant than like the minor lab that ive shown you something to think about or if its kind of like a progressive and it seems like its not kind of stable chronic right so whats next for lisa so for her most likely this is normal right. Its probably an alpha or beta thalassemia minor her hemoglobin is greater than seven.
Shes asymptomatic. Its were gonna be requesting records from the previous pcp. Its a likely long standing versus.
A new and developing problem because she again was told that she was anemia of some kind and thats normal. Shes not taking any iron for things like that so for any abnormal cbc. Any sign of anemia aside from people who are under 7 or symptomatic.
I mean they need everyone needs to be rechecked right. I mean. Thats just a consent guideline for general practice right because.
No lab is perfect. And who knows right so thats like the general recommendation for most providers has to recheck it but like for the people who are 7 or under or symptomatic. They need to go to the er and they will recheck it there for them right anybody else recheck in about one to two weeks.
Considering iron studies and reticulocyte count to verify it and then also considering adding on a peripheral smear to a to assess like theres any abnormal cells. And then also again assessing to see if theres any signs of iron overload like has this person been treated with multiple courses of iron because they were worried that you know they thought it was an iron deficiency and didnt really think that through things like that so and i havent discovered that myself and in primary care. But if i did discover that iron overload situation.
I would have them see hematology or at least consult with them to get recommendations of what to do next and then again discussing contraceptive implications for this patient was 46. Shes a single mom she has no sexual partners. She has no intentions of you know having other children right now shes using abstinence for her contraceptive method.
But thinking about like if she were to get pregnant genetic counseling considerations there so going back to lisa shes 46 again not her real name or photo. So i rechecked her hematocrit and hemoglobin in a few weeks again its not urgent shes not symptomatic. I requested her records her previous pcp and im considering doing iron studies versus a reticulocyte count.
Im gonna have a feeling this is long standing. So im not really that worried about it. Shes probably had the iron studies done with her previous pcp.
So im just gonna kind of wait for those records to come through and ive advised her of the alarm signs and symptoms right so is this a new and me mia thats developing and it was just a fluke that the rbcs were high is you know does she have any fatigue signs of bleeding. Things like that what are those alarm signs that i want to advise her of to come back with in the meantime and then im just gonna have her come back for a physical exam. Just because thats kind of like my flow of care for patients who are establishing care.
I get their previous records and then they i recommend physicals once per year just because its important to touch base with that make sure theres nothing else thats going on with them kind of jumping on preventative healthcare and again considering to a lipid doing a lipid profile. Because shes over the age of 45 which i didnt do at the first visit. But we can have a discussion about that and thats according to uspstf screening guidelines and the other things i think about are just screenings and vaccinations right for somebody comes into established care.
So when was her last pap is shes considering doing mammograms because shes over the age of 45 and that depends on if youre looking at uspstf guidelines are you looking at acs criteria. Is it flu season right at the day of this recording. This is definitely in the middle of flu season are starting at flu season rather tetanus every 10 years hepatitis these series versus like do we do a screening lab test for her to see if she has any antibodies antibodies are antigen things like that yeah.
And then just waiting for those records. And thats it did you like this video. If so hit like and subscribe and share with your mp friends so together.
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