What is the initial evaluation for a healthy 35-year-old African American male with mild anemia (Hemoglobin (Hgb) of 11.6 g/dL, Hematocrit (Hct) of 35.7%, and Mean Corpuscular Volume (MCV) of 88 fL)?

From the Guidelines

For a healthy 35-year-old African American male with incidental mild anemia (Hgb 11.6, Hct 35.7, MCV 88), the initial evaluation should include a complete blood count with differential, reticulocyte count, iron studies (ferritin, iron, TIBC, transferrin saturation), vitamin B12 and folate levels, and a comprehensive metabolic panel, as this approach is supported by the most recent and highest quality study 1.

Initial Evaluation

The patient's mild normocytic anemia, indicated by an MCV of 88 fL, suggests that the initial evaluation should focus on identifying underlying causes such as iron deficiency, vitamin B12 or folate deficiency, or other conditions like hemoglobinopathies, which are more common in African Americans 1.

Key Considerations

• A thorough history and physical examination are essential to identify potential sources of blood loss, such as gastrointestinal bleeding, and to assess for signs of chronic disease or renal insufficiency.
• Inflammatory conditions should also be considered, as they can contribute to anemia.
• The reticulocyte count is a crucial test to distinguish between production problems (e.g., iron deficiency, bone marrow failure) and destruction or loss of red blood cells (e.g., hemolysis, bleeding) 1.

Diagnostic Approach

The diagnostic approach should involve:

• Complete blood count with differential to assess for other cell line abnormalities.
• Reticulocyte count to evaluate bone marrow response.
• Iron studies (ferritin, iron, TIBC, transferrin saturation) to assess for iron deficiency.
• Vitamin B12 and folate levels to evaluate for deficiencies.
• Comprehensive metabolic panel to assess for renal function and other potential underlying conditions.

Next Steps

If initial testing is inconclusive and anemia persists or worsens, referral to hematology may be appropriate for further evaluation and management. This systematic approach helps identify the cause of anemia while avoiding unnecessary treatments before establishing a diagnosis 1.

From the Research

Initial Evaluation for Anemia

The initial evaluation for a healthy 35-year-old African American male with mild anemia (Hemoglobin (Hgb) of 11.6 g/dL, Hematocrit (Hct) of 35.7%, and Mean Corpuscular Volume (MCV) of 88 fL) consists of:

• A thorough history and physical examination
• A complete blood cell count (CBC) to provide important clues to the classification and cause of anemia 2
• Supplemental tests may include a peripheral blood smear; reticulocyte count; iron panel (ie, ferritin and iron levels, total iron-binding capacity, transferrin saturation); and levels of vitamin B12, folate, lactate dehydrogenase, haptoglobin, and bilirubin 2

Classification of Anemia

The classification of anemia can be determined by the mean corpuscular volume (MCV) and red cell distribution width, along with a peripheral smear examination 3

• A normal serum iron level excludes iron deficiency anemia and indicates other causes for microcytic anemia 3
• A low serum iron level and total iron-binding capacity are often due to chronic disease, and measurement of serum ferritin or a bone marrow stain for hemosiderin will be necessary to diagnose iron deficiency 3

Diagnostic Tests

Diagnostic tests for iron deficiency anemia include:

• Serum iron studies (i.e. serum iron, Total iron binding capacity (TIBC) and serum ferritin) to confirm the diagnosis 4
• Bone marrow examination, which is the most sensitive test for diagnosing iron deficiency in hospitalized patients 5
• Serum ferritin, which is clearly the only useful serum test for diagnosing iron deficiency in hospitalized patients, but is limited by a low sensitivity 5