Practice Rational testing

Investigating suspected anaemia

BMJ 2009; 338 doi: (Published 22 May 2009) Cite this as: BMJ 2009;338:b1644
  1. James Uprichard, clinical lecturer in haematology,
  2. Barbara J Bain, professor of diagnostic haematology and honorary consultant haematologist
  1. 1Department of Haematology, St Mary’s Hospital and Hammersmith Hospital Campuses of Imperial College Faculty of Medicine, London W2 1NY
  1. Correspondence to: B J Bain b.bain{at}

    Often a blood count only is not sufficient for prompt diagnosis of suspected anaemia. This article details the additional tests that should be performed

    The patient

    A 70 year old retired barber presented to his general practitioner with breathlessness on walking. A history of gradual onset of fatigue, lethargy, and exertional dyspnoea was elicited. The patient was a non-smoker who had previously been well, took no medications or supplements, and shared a bottle of wine with his wife at weekends. He was not a vegetarian and took a good mixed diet. Physical examination showed pallor of the conjunctiva and nail beds and mild oedema of the ankles. There was no hepatosplenomegaly nor were there any signs of iron deficiency (such as glossitis, angular cheilosis, or koilonychia). Anaemia was suspected. An initial full blood count confirmed this suspicion: haemoglobin concentration was 76 g/l (normal range 133-167 g/l), mean cell volume was 110 fl (82-98 fl), white cell count was 4.7×109/l (3.7-9.5×109/l), neutrophil count was 1.4×109/l (1.7-6.1×109/l), and platelet count was 182×109/l (145-350×109/l). Serum creatinine was 98 μmol/l (60-125 μmol/l) and serum ferritin was 875 ng/ml (20-200 ng/ml).

    What is the next investigation?

    First, the cause of the macrocytic anaemia should be established, because many of the causes are treatable. The possibility of renal insufficiency or iron deficiency would not be relevant to a case of macrocytic anaemia, but exclusion of these common and important causes of anaemia …

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