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The definition of anemia. The hemoglobin is low but that’s not really the true definition of anemia in that there is a reduction in red blood cell mass but there is also a corresponding decrease in the oxygen carrying capacity. Because some patients can be completely B12 deficient.
Neurologic examination, that I forgot to mention, is again B12 and folate deficiency. If you are severe enough to have an anemia as a direct result of B12 and folate, you can also worrying about having a neuropathy at the same time. So we have our history and we have our physical examination and then we have what should be enough along with what we need is our CBC. And the CBC should contain hemoglobin, hematocrit, it should have a red blood cell indices, it should have a reticulocyte count. It will also have our white blood cell count and our white blood cell differential. It will have our platelet count and we’ll have our peripheral smear. And again, we will know relative to symptoms, hemoglobin, hematocrit, we’ll look at our indices to see if this is microcytic or macrocytic and whether it is hypochromic, hyperchromic or normochromic. We’ll see if they are producing red blood cells, we’ll see if the white blood cell is either high relative to infection or low, another sign of production. We will have our differential in looking if there’s a huge left shift or are there blasts present or is it a mononucleosis or is there basophils which might be an allergic reaction or we’ll have within there, our platelet count, again, is it high.
Then we’ll look at our peripheral smear and on there we’re going to see our white blood cells, we might see in the neutrophils, multiple segments, which is a sign of B12 and folate deficiency, we’re going to see if there are blasts, we’re going to see if there are red blood cell fragments all over the place. And rare if we were in a country outside the United States, we might even see malaria.
For your patients who have a macrocytic anemia, again, looking at the peripheral smear you will see hypersegmented neutrophils. Generally, a neutrophil should only have about four lobes. You will see five and that is not unusual but when you see six, seven, even eight lobed, you should be thinking in your mind, "This is B12 deficiency" and you measure B12-folate level, B12 is low and you should be starting the work up for pernicious anemia because remember B12, there’s a weird reason if your B12 levels are low.
The other thing is if you see folate is low, you’re thinking about folate deficiency, again, this is more explicable because we don’t have as long of stores as we do of B12 and again this may be a malnutrition problem, a dietary problem and you start them on some folic acid.
Remember that when you are treating these, it may take several weeks to see improvement because the time from a stem cell to a mature erythrocyte is approximately 14 days so don’t expect any sudden changes relative to when you supplement with folate and B12 and iron. Give the patient some time. You should start seeing some increased reticulocyte counts pretty soon, within about a week or so but again you should see gradual improvement relative to the degree of anemia.