Interpretation of CBC and Newer Parameters

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Interpretation of CBC and Newer Parameters

16 Sep, 2 PM

[Music] and i'm glad you are here today and uh guide us on this really interesting and very basic topic uh which we all need to understand as a physician so interpretation of cbc and newer parameters uh dr mahadeva uh he's a consultant physician practicing it in the path he has over 35 years of teaching experience and so he's a amazing teacher and has joined us today so i'll stop this uh before i hand it over to you sir uh i i just done few polls and that will give you basic idea of what we are going to learn today and uh let's see how whatever things you know right now and uh concert is done with all the parameters uh some previous parameters order parameters and some new uh that things will be really beneficial for you to understand as a physician so uh let's run to that poll and we'll start so should i start with the polls yeah please go ahead good evening everyone so here goes your host so there are some uh cbc values hp rbc uh rdw and mcb so looking at these values what do you think is the most likely type of anemia [Music] again you see the final reasons uh most of them have answered iron deficiency anemia we'll not discuss right now we'll really see all the food and later on during the course of the day and i we can again project and then decide is that all right yeah yeah sure i'm running the second poll which has different values and some same options actually let's see how you all respond again there's a cpc report again four values for important values and what is the most likely type of okay okay so here goes the last hole in this would quickly we have a timer also at the bottom okay so we have the results with us and uh i'll hand it over to sir now uh let him explain and we'll go through that poll again and then we'll discuss the answers we will discuss during the no we don't want to discuss right now because we don't want to jump to the conclusions of the different types of you know straight away without having a background so maybe we will discuss during the course of the discussion but right now yeah yeah good evening and welcome everyone and i'm very happy to see such a large number of gathering at an odd hours and it's a great pleasure at netflix for all of us to have discussion of this kind of topics and as i can see when i scroll through the number of participants and their different specialities i can say that there is going to be something for everyone everyone something to know and something to get bored also right if that doesn't belong to your speciality but hang on and at least remember that these newer parameters that we are going to discuss is going to be the order of the day and virtually every person will come up with this kind of sophisticated reports and at least we need to know how to interpret these reports even if you don't know the nitty gritty of how that comes at least we should know what they indicate and the basics of this so let's the very first idea before that disclaimer i am neither a hematologist nor a pathologist i am a practicing consultant physician so my talk will be more of clinical based and not much of the statistics or much of the figures and datas i am going to talk about abc of cbc and not a to z of cbs he should expect everything that we are going to discuss about every aspect of complete blood count that's not possible in a limited time and it's not required for most of the uh people who are attending this so make sure that what we are going to discuss is more of a curtain raiser or a very primer of the complete interpretation of complete plot counts and most of the slides and the material that we have taken are from the websites or the friends who have taken their topics earlier and i am grateful to all of them and nothing belongs to me so what i am going to discuss is the in two part talk first is the conventional parameters which we routinely order and which are available at any corner of india but the newer parameters are specifically available with the laboratories which are sophisticated and which have got the automatic now when we say cbc when we write cbc cbc will be different to different people so make sure that if you want these informations you better write everything rather than just write cbc because there is a habit of writing complete blood count and people will come out only the reports of hemoglobin wbc count and the platelets and nothing more that's not what we want when we say cbc when we say cbc we want the rbc indices also so it's better to mention what we mean by cbc rather than what the pathologies interpret as our order of cbc so that when we want cbc we would write we would like to have at least hemoglobin the red blood cell counts the rbc indices routinely we do hematocrate mean corpuscle volume mean corpuscular hemoglobin methyl hemoglobin concentration and newly added or red cell distribution width then we see we want the total count as well as the differential count and the platelet counts this is what we want for cbc we also want esr in all our patients and we also want the good peripheral smear that's very very important so this is what we mean by conventional parameters and we will be discussing each and every aspect of this cpc then the newer parameters that is part two of my talk here we are going to discuss about the neutrophil lymphocyte ratio i'm sure most of the people know because of the coping pandemic that this has come to highlight but the real newer parameters are one which are given by the automated hematology analyzers and they are really giving the wealth the decision immature granulocytes nucleated rbcs red cell fragments the immature reticulocyte fractions immature platelet fraction or mean platelet volume so same thing that we look for in cbc the rbcs wbcs and platelets are further added informations over and above the information that we get in the cbc this informations will be added to and without any extra cost so that's why they are very very important i have purposefully pushed the slides in the initial so that you get prime to these different terminologies some of you might have heard for the first time but this will help to remember and interpret in the time to come so first and foremost the hemoglobin obviously this is something that basically want to have for each and every patient when we ask for cbc we know hemoglobin and all these values which are given as normal may differ from textbook or from the pathology or from the risk and the community so make sure what i have given is generally acceptable the values and there may be little variations which is not to be discussed further males usually 13.5 to 17 grams hemoglobin and females 12 to 15 grams and the who definition of anemia is less than 12 gram anybody who has hemoglobin of less than 12 gram is labeled as anemia as far as the who definition is concerned when do we get high hemoglobin see if somebody's hemoglobin comes to 16 or 17 definitely it's high but we need to know where and every parameter whether it is hemoglobin or tcdc or anything we have to correlate with the patient's history and it's always to be interpreted in clinical context that's why i said being a clinician i know the parameters can be abnormal right because of the pre-analytical errors that means there may be faulty collections or there may be the diluents or the anti-colons are not added correctly so never ever interpret one single reading without having a look at the patients or the patient's history and when in doubt better to repeat rather than act upon an abnormal reading that's very very important so polycythemia when the hemoglobin concentration is more than 17 gram percentage it's polycythemia it could be a because of the genetic deficience defect and that will talk later but very importantly whenever somebody's hemoglobin is very high in the context of having a fever joint pain headache severe back egg and all and we are suspecting dengue then it assumes very important thing chemo concentration is the reason for high hemoglobin nobody's hemoglobin will rise from 13 to 14 to 15 a matter of two three days time without having been transmitted blood so it's very important that if the person's hemoglobin on day one of the fever say suppose is 12 and the next day is 13 and the next day after that is 14 surely you are dealing with something like dehydration or dehu in dehydration also the same things happen because of hemoconcentration so any abnormal reading need to be serially checked and then only we can save and it's very very important parameter anybody having a dengue and proven dengue and the hemo concentration occurs by more than 20 persons there are very high chances that they'll go into complications like dengue shock syndrome or dengue hemorrhagic fear and we should be alert and patient should be instructed to take as much fluid as you can take if there is a question of vomiting or not taking orally that patient need to be hospitalized for that purpose so that's about the high hemoglobin polycythemia in the we need to investigate in more detail there can be secondary polycythemia also that because the hemoglobin may go up right in other conditions the next is normal if somebody's hemoglobin is normal right maybe he's in good health but i put a question mark why if the patient has suppose emphysema or chronic bronchitis that seemingly normal hemoglobin is not normal what we expect in the patient with emphysema is secondary polycythemia or higher hemoglobin because of the hypoxia so a hemoglobin of 13 in a patient with emphysema longstanding chronic bronchitis may not be normal that's why we have just put mark and we have to see the overall patient's outcome then if the hemoglobin on day one is this it could be because of some blood loss which is over or occult or there may be hemolysis it's very important to remember the broad causes of low hemoglobin it could be blood loss it could be hemolysis it could be chronic anemia or patient might be having some coexisting chronic or congenital conditions like thalassemia that's inherited hemoglobinopathy so it's very important that hemoglobin is very important parameter to begin with but always remember the if the patient has previous reports it's worthwhile to check and somebody's hemoglobin has been persistently nine or ten either he has some chronic anemia like iron fist anemia or maybe he has thalassemia we'll be further discussing later it's important to remember that hemoglobin by what we do by the conventional methods like sahali's method or cyan hemoglobin methods there can be falsely high hemoglobin also if the patient has hypertriglycemia a psn has hemolysis or cool regulatory disease or autoimmune hemolytic anemias the hemoglobin may go up in spite of patients actual hemoglobin being low right so it's remember that hemoglobin can be falsely elevated also next is rbc cow the red blood cell counts in males is four to six uh millions per cubic millimeter and females is three point five to five rbc count again like hemoglobin obviously will be increased in polycythemia or secondary polycythemia right like the chronic bronchitis emphysema we said or maybe a congenital heart disease and again like hemoglobin it can be hemoconcentration or it can be seriously increased when the patient has increased wbc count it will be decreased in anemia and spurious decrease in cold gluten is that we discuss with hemoglobin so practically hemoglobin and rbc can't go almost parallely except one of our questions was there in the poll also right when the rbc count does not decrease in proportion to the low in the hemoglobin think of thalassemia trait or thylacine minor so very important and will be discussing further about this also but remember this part whenever you see hemoglobin also see the rbc count and try to correlate whether the fallen hemoglobin and fall in rbc count match or they deviate wbc count is very important again routinely order we ask for total count as well as the differential count the total count is normally range from 4 000 to 10 000 per cubic kilometer and whenever there is increase in the count we call it leukocytosis and when there is leukocytosis what we need to concentrate in the differential count and see whether the leukocytes is with abnormal cells like glucamic cells then the pathology would have mentioned whether it's an acute myelocytic leukemia or acute lymphocytic leukemia or even chronic myelocytic leukemia where the counts will be high very high maybe 50 000 1 lakh and also there will be abnormal cells on the peripheral smear examinations on in the report but if the patient has leukocytes without abnormal heads or may be very few abnormal cells then we say it's usually because of the bacterial viral or parasitic infections so here we need to see the differential count and if there is neutrophilia that the absolute neutrophil count is more than eight thousand then it's usually pneumonia urine attack infections sepsis inflammations vascularities and also whenever the neutrophil leukocyte was there in an elderly patients with having some vague joint pain right i would also keep in mind adult muscle steel disease aosd so all these rare conditions also we have to keep in mind because there is no specific diagnostic criteria for such diseases like steels disease we have to rely on the history and some of the parameters like this and maybe we had seven ferritin in that case then if there is lymphocytosis mind you i have not given the complete list of neutrophilic leukocytes just giving the few representative conditions that can reach the increased neutrophil counts lymphocytosis when the absolute lymphocytosis count is more than four thousand it's usually because of the infectious mononucleosis tuberculosis mums even in dengue we might find lymphocytosis what is important is we have to discuss with the pathologist for whether there is activated lymphocytes right that's very very important in conditions like dengue monocytosis we don't routinely look for it but whenever there is more than 10 percent of the monocytes are present and the absolute count is more than 500 then we think of conditions like malaria but remember the conditions like after post monsoon we have leptospirosis then brucella is always then the differential diagnosis of all un diagnosed fevers then ricket cell infections they are not very uncommon right we have started seeing this crop typhus and many castle fevers and so is leptospirosis so we keep in mind leptospirosis brucella particularly when the patient sphere is not a routine one and there is monocytosis and when there is eosinophilia obviously we'll think of something like parasitic infections or allergic disease or we have to check the patient's drug history many drugs produce the eosinophilia and they can also produce fevers any patients as fewer and having been taking certain drugs like phenytoin suppose then we have to correlate with this the lycopedia the other side of the wbc count when the count is low obviously we always think of the viral fevers there are so many viral fevers these days we dengue chikungunya even kobe there can be lymphopenia or the normal count with low lymphocytes lymphopenia rather than leukopenia but we also keep in mind at least in the first week there may be the entry fever when the counts may be normal or on the lower side right and again drug induced many drugs and chemotherapeutic agents will produce leukopenia then reactive lymphocytes i just discussed that in some conditions like infectious mononucleosis dengue or mums will have activity lymphocytes and we should discuss with the pathologies about any abnormal report it's just they are on call away it's better that we discuss because they may not know the clinical background and it's very very important for tinon that we take the initiative to discuss with the pathologist or when we write in the requisition form we make a mention that this is what we suspect then they will better look at the slides again if there is any doubt so it's very important right next is platelet count the normal platelet counts is anything from 1.5 to 4x but we define thrombocytopenia when the platelets counts are less than one lakh per cubic millimeter liquid counts again are very important and now we give lot of importance to the platelet counts and here lies the automated hematology analysis they give far more information than the conventional parameters but nonetheless very important we see thrombocyte opinion so many conditions but these days we are most important in the two conditions that is the dengue as well as chikungunya as well as malaria malaria especially the vivex malaria we have seen so many patients with thrombocytopenia all thrombocytopenia or lower platelet counts do not need hospitalizations do not need platelet transmissions dengue fever especially we give platelet transmission only if the patient is bleeding or the platelet counts are below 20 000 or patient as pre-existing conditions or patients elderly otherwise you don't need to give the platelets platelet thrombocytopenia is more of a surrogate marker for dengue rather than the diagnostic feature of dengue the diagnostic figure is the test is either dengue ns1 antigen or you go for the rtpcr for the we have now got the rtpcr for dengue and chikungunya also and we see so many positive patients these days so most viral fevers can have thermocytopenia but keep in mind malaria and there can be mixed infections this scissor particularly we can have mixed infections so keep an eye open and look the peripheral smear more closely for any parasites that we might see or and immune thermocytonic purpura is always a differential diagnosis any thermocytopenia persist actually look for the patient's previous reports if the patient's count has been something around sixty thousand seventy thousand eighty thousands little accounts it could very well be the itp and because the patient has no bleeding tendencies and somebody has not pointed it he may go undiagnosed but it's important to diagnose and keep a watch on the patients having a low platelet counts then some of the even in india some of the regional abnormality about the platelets there are northern sides northern india especially bengal and assam and all they have sometimes the low platelet counts without any problem they are called the heritage macro thermocytopenia that the platelets are large in size and that's also to keep in mind whenever the patient comes we keep in mind where he's coming from even if we are practicing the western side if the patient happens to belong to the eastern india we keep this in mind that there may have a thrombocytopenia without any clinical features and we have to interpret accordingly drug induce we know that so many drugs especially drugs like heparin we know linasoli can cause if a person takes it for more than continuous two weeks then line isolate can also cause chemotherapeutic agents obviously will cause thrombocytopenia ttp is a very serious conditions and we have to keep in mind especially when the patient is sick or patient has neurological symptoms and the peripheral smear is very peculiar for the thrombocytopenic parker the chronic lower disease the other day we talked about that because the thrombocotin is produced in the liver as well as bone marrow can be also one of the cause for the one of the feature of chronic liver disease hyperspinalism alcohol can also cause thrombocytopenia uh platelet counts on the higher side if the platelet counts are more than 4.5 lakhs we call it thrombocytosis and it could be because of the genetic mutations because of the chapter or the other genes or it that is called an essential thrombocytosis but more often it is because of the acute blood loss whenever there is an acute blood loss the bone marrow responds in all fragments and will get the high platelets also low hemoglobin obvious blood loss and low high platelets don't worry about the platelets part concentrate more on the hemoglobin and the cause of blood loss that's very important but it's a frequently seen high wbcc lately and patients point more towards the because it is highlighted by the pathologist so they will comment uh more about worry about the high platelets not to be worried about patients who undergo splenictomy obviously we expect the thrombocytosis then very we have seen many obstetricians are in this audience and remember for in any patients who are pregnant persons who are pregnant and their hemocytopenia has to be always at the back of the mind and he llp is no longer a benign conditions and also considers a variant of the preeclampsia or preeclampsia with complications is when we already discuss about this even at the time of liver function test interpretations very important conditions generally occurring in the second half of the pregnancy right milo proliferative disorders can initially to begin with thrombocytosis and then there is going to be thrombocytopenia and one cytokine esr yeah erythrocyte sedimentation rate yeah rucha any questions sure yeah uh if there is no thrombocytopenia see thrombocytopenia is a marker right and most of the time there is no bleeding right and you don't need to attend to that we have just to have a watchful observation for that reasons and you have to see in what what's clinical context that thrombocytopenia is low it could be low because as i said because of the just a patient happens to belong to a particular area and that he is born with a big platelets he's born with a big platelets and that big plate says form a calm clump and the platelet counts may be lower side but actually the platelets are not pathological they are active and you don't need in fact you will be surprised to know that i had a patient of chronic itp right where we subjected her to bone marrow aspiration with a zero platelet so patients don't bleed necessary patients don't bleed unless there are some other issues so it's important that you just don't uh give only platelet counts as long as there is no bleeding tendency but if the patient is on drugs like nsaids or if the patient is an elderly or we have to keep patients complaining of headache i will be worried about the internal bleeding so not that we disregard it but lately alone is to be interpreted with the other features i hope that's uh satisfy the answers or if there are any questions they can ask some questions uh so there is one more uh so what are the investigations uh see the itp is an immune thrombocytopenic parpeera that means we have to demonstrate that these platelets are destroyed peripherally how can we so say that the diagnosis of itb comes only by showing the bone marrow aspiration and showing that the bone marrow is normally functioning or producing enough number of megakaryocytes it is the peripheral destructions but generally we don't go for it but that is how the diagnosis can come only from the bone marrow aspiration showing increased megakaryocyte but this is where the newer parameters would help you that i'll be discussing when we discuss the newer parameters that we can definitely say that this is thrombocytopenias because of the peripheral destructions right so esr again erythrocyte sedimentation rate also called sad rate by the our uh western counterparts this at three side segment translator is not interpreted correctly or most often for the simple reason is the values that are given by the pathology laboratories most often are far less than the values which we encounter in the clinical practice the reason being these values are not that these values are abnormal but these values represent to the young people most often while the esr keeps on increasing with the age also so the good rule of thumb is that always try to reduce the see the age of the patient and divide by 2 that is the maximum esr as a normal variation for that if the person is 50 years then 25 would be a maximum upper limit and that is why because most of the patients would always complain that my esr is very is there anything wrong with my blood basically we know what is esr ecsr is an attribute sedimentation trait so what we do in a specific tube the western green methods the anti-governed blood is allowed to stand right and we measure after one hour how much rbc's have settled or how much is the plasma right so that is what we do it's a very sensitive marker but not a specific marker it just indicates that probably the person has some kind of inflammations or tissue damage some injury also the esr will rise uh infections any infection which is bacterial oil is going to rise so it's a very sensitive marker but it's very important to use it as a serial for the response to treatment or a prognosis and it's also important conditions like collagen disease where we see really measure after starting a specific treatment and see whether ears are forms esr is affected by many parameters like in the patient has acute phase reactants like fibrinogen alpha and encryption heptoglobin or even crp crp is a phase reactance here can affect the esr only thing is crp is much robust than the esr but very expensive almost three times the cost of esr and crp rises fast and disappears fast compared to esr so esr is something we have to keep in mind and in the next slide i'll show that esr is important but important mainly when we see the extremes of esr right and esr the laboratory has to wait for one hour or sometimes two hours i feel to understand now whether the two hours except the little increase in the sensitivity or specificity of the second hour most of time one hour suffice but the near automated machines cannot even give the esr values in 20 minutes which are comparable to esr values of one hour that we have started seeing we have sent the blood and within half an hour patient comes with the yes our report we are worried how come it comes but this is the reason esr is very important when the values are very high when the esr is more than 100 it's a red flag we have to search for the cause it's not normal so maybe patient has chronic infections like disseminated tuberculosis or malignancy with metastasis or patient has many any of the collagen diseases like hypersensitive vasculitis or giant cell arteritis for which probably there is no other laboratory test we don't go for the temporary biopsy often we just see the clinical feature headache you are right maybe some visual disturbances and very high esr right every reason after rolling out the other collision disease we might give just this trial of redness alone and within day or two we'll know whether we are on the track polymyalgia rheumatic cause and cell arteries they are all practically same different part of the body is involved called just microglobulin or hyperfibrium these are the conditions when the esr is extremely raised we don't need to discuss the much higher part of it very low esr like the what we mean by very low issue is less than five millimeter right if we have diagnosed few conditions when the patients have come with joint pain and very low esr generally we expect very high sr or at least normally sr but when we see they take the history and we see it's probably an acute humanity crisis and esr is low very low in conditions like sickle cell anemia polycythemia patients with congestive heart failure hypovolemia or hypoprotein so it's worthwhile remembering and just have a look if the patient's esr is very low could this be one of these conditions maybe it's a blind sort but sometimes we are rewarded by just looking at some abnormal parameters like this now coming to the peripheral blood sphere peripheral blood smear is very very very important and we need a good pathologist friend to help us in coming out with many important diagnoses by correctly interpreting the peripheral sphere the important part starts with the collection of the blood and preparation of the good peripheral smear and good straining it's very important and send it to a pathologist who is well ours with the microscopic and has patience and time and passion to read the peripheral sphere it's very important because peripheral smear is a i i would say it's as important in a patient's right fever or any unknown conditions fever or say acute illnesses as is ecg for a patient with chest pain i would give too much importance to peripheral smear and we have so many diseases which can be diagnosed but peripherals near us strongly suspected so this is the peripheral smear you can zoom out and see write the different parts you can see that this particular peripheral smear the picture is taken from the up to date and we are grateful very useful medical information sites and we often use it here we have seen that the wbc's one wbcc that's a small lymphocyte and the we know that small lymphocyte has practically very little cytoplasm it's mainly the nucleus and all the rbcs have to be compared as far as the size of the rbcs are concerned we talk of microcytic macrocytic normocytic but how do we do without getting the herbicide disease the pathologists look at the smear and say that this is microcytic this particular one is a normal peripheral smear because most of the rbcs are rounded and they are just the size of almost the size of the nuclear nucleus of the small lymphocyte this herbicide you can see as also showing the hemoglobinization except a small one third part of the rbc is pain most of it's a condensed hemoglobin so this is a normal peripheral smear keep this slide should be in your hard disk and then you can you can always compare with the subsequent slides and you know so this is what is normochromic normocytic rbc right so what we do as i said well prepared well peripheral smear is very very important and what we see in a peripheral smear is the size of the rbcs any various in the science is called anisocytosis it can be microcytic macrocytic or dimorphic then shape of the rbcs are called oe kilocytosis it can be different shape like the spherocytes or ovalocytes ah there can be different shape abnormal shapes within the smear because of the liver or kidney diseases and we also look for the parasites it's mainly the malaria collagen we hardly see at least in the peripheral smear more often in the bone marrow but once in a while we might pick up with heavy paracetamia even in the so what is important is we look at the rbcs right and we see so here see the normal smear is on the left corner and as we said the lymphocyte is our the comparator right and you can see that in the right corner there is one lymphocyte i mean for polymorphs which is hyper segmented and the most of the rbc's are also much bigger than this right and there is also some hypochromia so it's a macrocytic rbc as against that the left lower corner you can see they are all pale there is hardly any hemoglobin its central pallor is much expanded a very thin dream of hemoglobin and they are all small so this is microcytic herbicides the other one is the macrocytic and the last one the right lower corner as you can see there are many cells which are small and there are many cells which are sickle shape right so this is a sickle cell anemia these are just the representative and we have to discuss with the pathologists but what is important the role of pathologists come in situations like this when the patient is critically ill patient is anemic patient might be bleeding patient mic and neurological symptoms and we want to know whether we are dealing with some kind of thrombotic microangiopathy or thrombotic thrombocytopera here the peripheral smear is very important if you find the abnormal rbcs the abnormal shape of the rbcs right the abnormal shapes like the rbcs might be speculated having some spikes or rbc might look like the helmet cells as you can see they are just look like the helmet or they might find that the rbcs are microspherocytes spherocytes are the one where there is no central disappearance of the central panel if the hemoglobin is condensed fully that the whole rbc is rounded and full of hemoglobinization that is called spherocytes these are the spherocytes which have lost their capability to deform right we know the rbcs are about seven to eight milli micron and they traverse through a capillary which is smaller than that how that is because they are dumbbell shaping they can just pass through these small capitals by changing their shape they will dumbbell shape and they can pass but spherocytes can't do that because they are rigid and that is why they get trapped in the spleen and they produce the hemolytic anemia and that is where we just remove the spleen that the patient is called so that is here it is perocytosis but we are coming back to the peripheral smear or the spherocytes these pyrocytes are i mean the cystocytes the cystocytes are the abnormal fragmented cells and they are different shape and a good pathologist can point to this there may also be clumping of the rbc showing the role of formations again an evidence of hemolysis so patients having bic or patient disseminated interstellar coagulations or patient asymptotic thrombotic thermos and bacteria pathologies give a big help and we can then further take up with the hematologist or show certain investigations and diagnose and treat faster very importantly we also look for the rbc diocese we look for the pack cell volume or also called hematocrit then we look for the mean corpuscular volume mean corpuscular hemoglobin main copper hemoglobin concentrations and rdwr red cell distribution with hematopoietis routinely ask for what is hematocrit is the volume of red blood cells that occupy right the volume of volume occupied by the red blood cells in a given volume so in males the paxil volume or hematocrit is around 45 females it's 38 to 40 and a very simple rule of three that is when you want hematocrit just multiply hemoglobin by 3 that's usually plus minus 3 is a rule of three for the hematocrit and for hemoglobin rbc multiplied by three point three plus minus one point five is this this is very very important first especially when the hematocrit hematocrit and hemoglobin do not match right patients who is dehydrated or hydrated hemoglobin hematocrit and hemoglobin will not match that's where it is useful but remember this is useful only when the rbc is normal with abnormal rbcs this rule doesn't apply so it's just for the convenience but otherwise what we need to see is the detailed analysis of the parameters the main corpuscular volume is the hematocrit upon the rbcs which is something around 78 to 100 femtoliters them total risk 10 is to minus 15 and again the values may differ from laboratory laboratory generally it is 78 to 100 or some levels mentioned or 80 to upper limit of 95 or 99 so that's just a range the anything less than 78 or 76 is called microcytic anything more than 100 or 95 is macrocytic and depending on that anemia can be classified as microscientific normocytic or microscientific the mean corpuscular hemoglobin is the amount of hemoglobin in an individual rbc right so it's generally measured in picogram that is 10 raised to minus 12 27 to 32 anything less than 27 is microcytic or mean corpuscular hemoglobin concentration is measured in grams per deciliter and its decrease again in microscopic like the iron deficiency anemia but it is in green not only in macrocytic but also in heavier spherocytosis so when the patient's mchc is very high right then we have to look again for the peripheral smear and see whether we are dealing with simple macrocytic or something like spherocytosis next is rdw red cell distribution green we did talk about the red cell sizes in the peripheral smear what we called n isocytosis same thing but it is electronically measured and this is done in the automatic uh analyzers that they give the distribution volume of the rbcs so within the rbc populations some may be young some may be old some are the normal young or the adult so here if the patient has some kind of anemia then the rbc size will differ right but if the patient has only one condition like thalassemia the rdw remains same so it's very important and we'll see the importance in the next slides that rdw is a very important simple parameter of giving some idea about whether we are dealing with the iron deficiency anemia or the thalassemia so this is this slide which gives the comparative values of the different commonly look uh types of anemia the normal values of rbc count as we said anything from four to six cubic millions and the normal mcv is around 78 200 and the normal rdw rate cell distribution weight is anything from 12 to 50. if the patient has iron his anemia there is decrease in the rbc mass or the rbc count as well as the mcb both are reduced but the mcb is not reduced so much right but the rdw is always higher so iron deficiency anemia low rbc low mcb and high rdw as against the d thalassemia the rbc count is nearly normal in most of the conditions it's neon and all we are talking about this metric thalassemia measure is a different conditions right we are talking about rate of telescope minor where the rbc count is generally not affected unless there is a coast 16 iron deficiency so thalassemia the rbc count whenever the patient's hemoglobin is low but the rbc count is almost normal think keep in mind the possibility of thalassemia minor and try to rule out by the screening methods right and here the rdw is not different because most of the cells are almost of the same size so the red cell distribution with size is not different while b12 and iron deficiency because of the deficiency the cells which are recently produced may be larger size in b12 or smaller in the iron deficiency anemia and the older cells are all the normal size so the rdw is different in deficiencies and they are always on the higher side right [Music] and whenever it comes to the rbs indices there is one index called menser index this is a very simple mathematical formula where you just see the mcb and divide by rbc count if the ncb divided by rbc count is less than 13 it suggests thalassemia and when it is more than 13 it suggests ironification many of the pathological reports would indicate menstrual index remember value of 13 the very pointer is that in thalassemia you will have more smaller rbcs with a nearly normal hemoglobin while in iron fish anemia the rbcs are small but the hemoglobin is also less so the index is always higher than 13. [Music] say this is one type of reports that we see routinely here first see the hemoglobin what is hemoglobin hemoglobin is 13 the rbc count is 4.39 almost normal we say 4 to 6 is normal now look at the mcv mcb is 92.9 so again falls in the normal range now look at the rdw is 13.6 so here lies the patient's report where the hemoglobin is normal rbc count is normal the mcv is normal and ideal so it's a normal report absolutely normal as against that see this report here the patient's hemoglobin is 9.3 definitely low but what is the rbc count is 5 normal almost normal and mcb is markedly decreased 64.7 but the rdw is high so what do you think this probably patient has not only thalassemia he also has co-existing iron deficient this much we can get right from this much report itself we need to confirm with the other studies like the we can go for the hba2 estimation for thalismus screening or we can go for the signum ferritin ceramide and all right but always correlate the hemoglobin rbc count idw and mcb all together and you will get the picture immediately right the last one here the patience him globin is 9.5 hemoglobin is 9.5 mcbs 8 and 3.28 ibc with [Music] so what's this [Music] so this particular hemogram the mcb is 99 the hemoglobin is 12 and we count right polymer maybe this is an early part the megaloplastic animal so what i was talking was that reticulocyte count is not totally order but it has to be order and i wouldn't give a single tablet of iron or b complex without having the reticulocyte count because one tablet can also change the picture and reticulocyte count we know the reticulocytes are the the precursors of the rbs our reticulocytes are there are one kind of sensitivity but reticulocytes contain a large quantity of rna and dna and that need to be strained with the specific strains right strain or the supravital brilliant crystal strains then we can get the reticular pattern that's why they are called reticulocytes very important whenever the reticulocyte count is reduced in a patient with anemia either it is a substantive significance or non-chronic h either hemorrhage hemolysis or humility whenever there is increase in the radical side count it's either hemorrhage hemolysis or patient has been receiving hematite and that's why the deficient bone marrow is now getting the substance producing more rbcs and the reticulocytes right so very important always go for uh increase for the reticulocyte counts and always see a patient of anemia don't treat patients without theoretical side counts that's all about the conventional parameters and now we have got the same parameters in a new form the nlr is the neutral is in the center a single but again let me tell you the nlr is just the ratio of how much is the neutrophil lymphocytes and it's considered a very important parameter the nlr is nothing but the neutrophils to lymphocyte ratio and it can increase in bacterial infections which we see more often but in the kovidian infections in this pandemic initial part when we did not have much of the parameters or when the facilities of rtpc was not there or they probably went for this and there were initial studies which saw that whenever the see an initial part when we we did not have much of the details unfortunately available we used to see that the nlr ratio of less than three is the good prognosis and and whenever the nsr ratio is higher in the patient is in icu it carries a bad prognosis but very important to remember that if the patient has received steroids it will change the whole game because there is all anyway going to be neutrophilic illegal cytosis so nlrsu not really very very important what is important is the next round bear with me that's that's major part is over now we'll have only 10 or 15 minutes for the newer laboratory parameters all these parameters may not be available in every part of the country and these parameters are possible only when the laboratories use the automated hematology analysis which the cost runs in lags so only the bigger laboratories would keep it but it's very important they give a lot of informations here the because it's just electronic instruments and no technical error or man-made error is likely it gives large number of cells it counts in a short period of time manually it is not possible to count innumerable cells right we get a quicker results we eliminate human errors we have many more parameters which can predict the faster response of our treatment or the prognosis part that we discuss when we say thank you better parameters are coming and the electronic para all these instruments have the inbuilt software where we can have the program and we can put that if this report is abnormal give me a flag so there are flags generated which can indicate the abnormal results that abnormalism can be artifact it can be really abnormal results you need to check it with the conventional parameters there so it's not that the conversion parameters are out they are never going to be out we need to counter check with the conventional parameters always right so what are these newer parameters the all the reports would come like this these are all the histograms and the scatter programs right uh they were basically on the principles of electronic impedance and optical scatter so the all the cells are lined uh kept in the electronic analyzers and here they just pass the light through a very small apparition all the cells are in line and depending on the degree of the size of the cells right and the different strainings are also done they can come out with the different types of scatter programs and wealth of influence we can get the individual lymphos will come to that later so what do we look for we look for the newer parameters like immature granulocytes we'll talk about it there is one slide for each immature granulocytes nucleated rbcs ratio of microcytic to hyperchromic rbcs the fragmented rbc what we saw in the peripheral smear as cystocytes then immature reticulocyte fragments something equivalent to what we look for the reticulocytes in the peripheral smear with the specific stains here it comes in built then immature platelet fraction and mean platelet volume mean platelet form right so all these there are parameters for wbc series the rbc series and the platelet series we'll take one by one a very small part of its blood pressure this immature granulocytes are the nothing but the fraction of the neutrophils which are earlier premature that means whenever there is an infection there is a large number of wbcs are produced and they will come which we may not be able to see in the peripheral smear but here we can see the immature uh granulocytes as a special different kinds of scatterogram as i if you need to just zoom it and see that relative positions of the different cells on this kind of diagrams right if you want to see further you can see here that the monocytes in the center atypical lymphocytes on the top in immature gramulocytes on the right side and the lower downs are the eosinophils then also there are nucleated rbc so everything is there in one slide and depending on that we can just and that is also given in the figures this is all given in the histograms catalog grams as well as in the figures whenever the immature garner sides it predicts the infections and sepsis almost on the same day or the next day rather than we have to wait for the serial counts to go up or the blood culture and all for the sepsis here we have informations and increasing the immature granulocytes on a daily basis can give you the picture that something is not valid so nucleated rbcs or the nrbc is another important parameters which we cannot see in the conventional what is nucleated rbcs are as i said the rbc's when they come to the peripheral blood they are without they lose their nucleus right so as long as they are in the bone marrow they have nucleus and what we used to call it normoblast is nothing nucleated orbits are nothing but the normal blast right so these are the erythroid precursors and they lose the nucleus and they come to the peripheral sphere they will increase much before the reticulocytes increase so nrbc uh we don't have to ask for these newer parameters come straight away by the newer metal analyzers so they will rise same like the reticular sides as we said no reticulocytes increase in all edge hemolysis hemorrhage or hypoxia state or person's hematurial treatment so saying the nrbc can also give the pictures and here it's given in one of the patients that from day one today one month one month they have seen that the nucleated rbc's have reduced uh gradually and that means the patient is improving so it gives the prognostic marker in ico patients if we follow up the nrbc on the regular basis we can get the informations i am not going to talk in the details because it's not required all that we need to understand this is a primer right just like the fragmented rbc or cystocyte that is in the peripheral smear that need a good pathologist and experienced pathologist to talk look for this be confident about the here they straight away it comes as a lower panel compared to the rbcs on the upper panel the frc are on the lower panel and that gives the idea that something is not wrong the normal upper limit of the fragmented rbcs or the cystocytes which can be in any form whether it is a helmet cells or the grenade cells or a speculated cells all these are cystocytes and normally they are less than one percent if they are high there is a very high chance that patient is dealing with some kind of micro thrombotic microscope hemangiopathy or ttp or dic the ratio of microcytic to hyperchromic rbcs that we just discussed the iron deficiency and thalassemia it's very important if the ratio is lower side it is iron deficiency if the microcytosis is more than the hypochromia it is thalassemia and it can easily be seen at the just a glance that iron deficiency mia there is going to be less hypo more hypochromia and less microcytosis compared to thalassemia which is more microcytic the erratic count we have already talked about but we need a specific strain in the conventional parameters here it comes inbuilt and they kill not only the reticulocyte count they give the hemoglobin content of the reticulocyte count hemoglobin content of the reticular reticulocyte so the first thing that affects in electrophoresis is the precursors and the cells which are still in the bone marrow so if you can pick up the hemoglobin content of the electrical sites we can almost we can say we are we can almost forecast or the weather so what is going to happen so or when we start the treatment the first thing to occur is the change in the reticulocytes and the change in the hemoglobin of the reticulocyte so this is the importance of this kind of newer parameters that they can pick up or they make us two or three or four days ahead of the conventional parameters and whenever the reticulocyte count is uh showing a value of less than 27 picograms it suggests anemia immature radicalized fragments just like the image of platelet infection that will come the immaturity fractions give a different picture than the irreticulocytes you can see here the immature eclipse are different than the normal reticulocytes and the picture see immature reticulus fractions are very important because they are just the first part of it they contains more rna and this will give the picture that the patient is suffering from withdrawal or iron deficiency or patient is if you start erythropoietin treatment the response will come immediately in increasing the irf so these are the parameters which help us if the suppose the patient is given chemotherapy for the cancers we know whether there is an effect it's on the bone marrow so basically all these parameters are important to understand the response of the treatment very important the last is the platelet parameters the the most important is immature platelet fractions the platelets we now we get lot of importance to the platelets especially when there is a dengue as in pandemic and perennially we can see the eye not pandemic but the it's a perennial present throughout the year we have patients of dengue and there there is the patients they know a lot of the platelet council there is too much of pressure of giving the platelets and we are tempted but we know platelets are very live products we don't we should not give it unless it is indicated because there are lots of complications with the platelets platelets don't come from one donor it's always from multiple donors so we are subjecting the patient to lots of multiple donors which can carry lots of infections in all right so platelet parameters like immature platelet fractions the immature platelet attractions are the blood cells which are released in response to the thrombocytopenia whenever there is thrombocytopenia the image of platelet traction count will rise and that will give the idea about whether the platelet counts are destroyed peripherally then the ipf will go up but if there is a bone marrow failure then temperature platelet fractions would not rise so not only it gives the idea about the etiology of the thrombocytopenia if the patient said normal thrombosis platelet count and ia we have increased that's probably we are dealing with some myofibrosis so these are all the way we can judge about the because of the ipf we can know about the cause of platelet disorders it's very important but most important to me the help of ipf is in the dendue patients when the thrombocytopenia is there but the image immature platelet fraction is more than 10 percent if it is there we can say that this patient is on the path of recovery and in the matter of next 48 hours the electrons will return to normal or start showing recovery so there is no need of giving the platelet transmissions because the bone marrow is doing the job so there is no needing so this is where these newer parameters help and the last is the main platelet volume just like the ipf is also very important and here as i said see some of the uh patients in the central part of the india they are born with large platelets right so it's very important if the main platelet volume is high right with thrombocytopenia we know that it is an itp right rather than some bone marrow pathology but it can be high in milo probability disorders also but there really the platelet counts would be normal the low mpv is suggest you of aplastic anemia or a rare heritage disorder so the all the whole the point is what we see in the conventional parameters can be report or can be seen ahead of the time by using the newer parameters there is lot of things that need to be discussed it's not that these newer parameters are without the false positive and false sensitive reports they are right we need to have the interpretation with careful interpretations and whenever in doubt we have to correlate with the conventional parameters also right very very important so i just say that the conventional parameters are widely available very useful and they are obviously the required in most of the patients in acute as well as chronic illnesses and everybody is well conversant with it whatever discipline you belong to but newer parameters are very important and they give lot of informations and they definitely reduces the human errors more accuracy and practically hardly any cost is involved if you have to go for the other parameters are separately the patient has to increase the cost but all investigation need to be correlated with the patient's history physical findings and they need to be repeated one single value may not justify the starting the treatment it's very very important that we look at the cbc more carefully and whenever required you ask for the patient's previous reports somebody having a thrombocytopenia for a long time we are dealing with itp and not dengue even if he has come with fever right so like this you always interpret all the reports right keeping patients in the mind and always have look for the previous reports also i stop here right and ready for any questions that are remaining on the second part thank you for beautifully explaining this abc of cbc uh really loved it and stopped presenting it it still remains abc and not a200 there are so many things to talk but not for everyone i am sure i have taught enough and bored also enough to many of the people so yeah any questions or so yeah there are so many questions actually and if you or any one of you wants to uh ask yeah somebody has asked the question of when to go for ipf right so that means the i ipf is an image of platelet fractions if you do the see now most of the if the patient is in the hospital will go for the cbc daily ideally the patients are admitted in a dengue in a critical period when the platelets are required to be done daily and we look for the ipf on daily basis right because it's a automated humidizer that is always available with hospitalized patients right so if we need to go for it on a daily basis the point is when the patient's thrombocytopenia or the platelet counts are falling or on the day the patient's fear has gone the next 48 hours are very very crucial because this is the time when the patient is likely to go into the complications like the hemorrhagic complications or the dengue shock syndrome there it is very very important if the platelet counts are low but the ipf is more than 10 percent we need not just give the platelets out of panic or out of desperations or because the patients are demanding other relatives are demanding we just convince them that wait there is all our parameters in dengue we know that the dengue is always right there are some warning signs now it's never that the patient will suddenly go to patient may have abdominal pain vomiting or high potency and all they will give the idea that the higher some complications are coming right in post dengue infection uh so can patients have chronic thrombocytopenia no no thank you is just an absolutely average time-bound illnesses and the platelet recovery the platelet count itself beginning of the uh convulsants period so i i don't think that the itp uh thank you can get converted into itp maybe that any infection can just unmask and previously existing itp but thank you itself would not lead to i think okay so dr yook i guess that answers this question as well uh what you have asked uh then uh so uh how do we uh differentiate between uh which is actually the most accurate marker i did not get it cbc dr himanshu can you please elaborate your question i'll ask that again [Music] so i guess the rest of the questions actually you have covered uh i know one of the questions that asks is in details of mpv this was in relation to what i said earlier that some of the people particularly when we see a patients coming from the assam or bengal they are born with the large platelets they are called macro thrombocytopenia if their mpv is more than 13 the normal value is 7 to 12 but if they are not drilling their platelet counts are low but we don't need to really get panic and we just observe them as long as their platelets are functional and we don't have to worry but if they are bleeding tendencies see sometimes the large platelets they do not do their functions of the plugging because they are not as efficient as the regular platelets in that case we need to treat like the thrombocytopenia but otherwise in most of the patients it is not required to we need to do anything it's just 10 variations they are born with and most of them don't need any treatment for that okay there is one interesting question by dr so uh right that is uh something that i think is a little definitely it's there is one in million but it's a real definitely that see basically the vaccines can induce the antibody productions so vaccine any other just like any other virus or the proteins can produce the so it's a vaccine induce the platelet antibodies and that will produce thrombocytopenia it's definitely when it occurs it's very very important and i think this has led to a lot of mobility and even some deaths also see whenever the patient is given this it occurs usually in the first few days and more often with the first blows and whenever the patient has been given the vaccines and here it has produced headache or some dizziness or all this we need to have high alert and we should be looking for these different more detailed investigations but it's a reality and that is why some people believe that this would be good but there is no point in giving prophylactic antiplatelets or neural oral anticoagulants trucks because that kind of details are not available okay uh sir what is the uh what is rdwsd and rdwcv which is more accurate i i really look for it but i am honestly not aware of the second part of it uh so generally we go for the red cell distribution width as is given in the percentage the normal one spin 13 to 15 but i am not really very sure about this maybe you need to deal with the pathologies because uh they would be able to understand that part clearly i do not know somebody has asked about can is an opinion occur in thai food fear very good questions and yes yes whenever the patient is high grade fever we look for the differential count and we look for the use of india patients with very high grade fever right and if the username of count is zero is considered as one of the uh surrogate marker for anti-fever and remember we always go at least if the patient tripod is a typical illness where the patient is usually a very high grade fever and no localizing findings in the sense that there is no running nose or no urine disturbance or cough or cold or something so very high grade fever on third fourth day or fifth day only we ask for the sonograph but eosinophilia is definitely one of the important surrogate marker for typhoids we are agreeing and sonography to me is a better investigation than the vidal test result is so many people go for vidal taste in the first week it's never positive in the first week the antibodies need time to develop so it's usually come the second week and there are a lot of false positive in the dal i would go for the sonography my good sonologist can pick up the ulcers or edema or the terminal ilium where the typhoidal cells or may be mesenteric lymph nodes or maybe hepatocellular megalith yeah somebody has mentioned about the sdw and cd1 yeah i was i'm not aware of it honestly i'm not aware of it can thank you present with hemorrhage with coagulation generally the dengue presence with the thrombocytopenia and bleeding tend this is only i don't think that it's present with unless it can lead to bic and as a bic can occur with any infections and then we can have both in the phase of the consumption of the clotting factors we have what on one side there is thrombosis on the other side there is bleeding it's very very tricky and difficult to treat such kind of patients but yeah that's the only way if you produce dic yes it can so we have two raised hands as well so i'll just yeah sure yeah sure sure [Music] yeah my queries regarding the thrombocytosis one of the causes you had mentioned help syndrome yes i can remember the classical teachings that help syndrome look like that [Music] uh yeah clearly i need to check yeah i am sure it says the very economy is the hemolysis with elevated so if it is there it's probably yeah if it is mentioned then it said definitely need to be corrected i'll check it and definitely it's not there absolutely it's a low platelet always always look at this okay thank you they're good to point out and thank you and good that's at this others don't go with that impression that you can get thrombocytes also there no thank you thank you thank you which parameters of cbd is increased you mean rheumatoid arthritis yeah generally see the rhomatositis initially there may be monocytosis is like any other collagen diseases but important one is esr and crp only so we go for esr and crp only as a serial measurement whenever the end there will be anemia if the patient is an acute uh in inflammatory stage right then definitely there will be anemia there will be esr and crp will be raised uh it doesn't affect much of this unless the patient is on treatment then we need to go for the cbs and serially but otherwise or say for rheumatoid arthritis what we need is an anemia and isr understood so and uh this question has come up like three times about this so uh patients with low platelet count for years and there are no clinical symptoms so does that person need to be evaluated what could be the cause see always if there are low platelets we have as i said the most important is either they are born with the low platelets or there is abnormal platelets large side platelets or there is chronic itp if it's a chronic itp see we may not treat if there is no bleeding but we have to keep in mind and we have to see really follow because once in a while we might need to give steroids the point is if you can make out that this thrombocytopenia is a part of itp we can increase it particularly if the patients are female and their menorah or such issues or they have to undergo surgeries then definitely we have to bring the platelet counts to the acceptable limits for any surgery but otherwise looking at they don't need any treatment but if it is many times the patients are given steroids just because they are thrombocytopenia and it may be just as i said the macro thermocytopenia because the large size of the platelets they don't need steroids in fact it might harm so we need to find out the cause we need to get the details of whether the patient is receiving specific drugs which can produce sombocytopenia and whether there is a it's a beginning of some kind of myeloproliferative disease right so definitely all low platelet counts low hemoglobin have to be investigated no question about it right so uh there could be a there will not be a situation where there is this low platelet count other parameters will also go down right if uh there can be low platelet counts because of the just as i said they are born with the large platelets with lower number right that is possible that is called yeah that is called harry's some syndrome i don't remember exactly but that's what is what we find in the northern india and could this be associated with hyperbaria so that's one last on this uh chain hyper bilirubin if the patient has chronic liver disease right then we know there can be thrombocytopenia and there is involved in the liver so definitely or there may be the biliary cirrhosis and all they are all the diseases where there will be there may be thrombocytopenia so it need to be investigated right and bilirubinia can be anemia right and some g6p definitely something so point is that we need to investigate any abnormal report we should not take it on the face value right in from cbc how do we differentiate between uh bacterial and viral as well as parasitic infection so there are three right see it's just the we cannot say swear and say that this is this but in complete in the cbc if there's a bacterial infections the wbc count will be very high and it's mainly predominantly polymorphs polymorphs right and if you do crp crp also is very high in bacterial infections as against that in viral infections the wbc count is normal right initially there will be neutrophilia but the wbc count is never very high right and even even if it is high most of the time then the second part in seconds invest second round it will be the lymphocytosis viral infections and esr or crp is never very high in the viral infections in parasitic infections usually the wbc count total count remains normal but it's the eusenophilia that may be high but again it's not sacrosanct and just by the cbc report you cannot say this person has to have bacteria this has to have viral or parasite yeah [Music] we have said that nlr is just indicative of what is the neutrophil to lymphocytes what is important is is there a lymphopenia or there is a neutrophilia see that is what so when we see the total count if the total count is normal and there is a marked degree of lymphopenia definitely indicates the patient's immune system is attacked and that is very critical whether it is kovid or dengue any other condition so very low lymphopinea is more important so whenever the nlr is more because of the lymphoma rather than the absolute lymphocyte count is less or the lymphoma lymphocyte count is three four five rather than the normally we get 20 or 30 right so if the lymphopenia is there that's far more dangerous right so there is one question where uh uh there are a lot of different opinions uh on the uh cbc changes in covet patients so just that one if you can address see i would say simply there are few issues in the covid infections right the issues are one is there can be secondary bacterial infection one and second part is use of steroids they will change the picture completely otherwise in kovid per se probably what we expect is the covalent fluoride or patented the severe cytokine storms and what we expect for the lymphopenia right and but if there is a patient the secondary infection bacterial infections the counts neutrophils will go up and the total count will also go up and your crp will just double in the next 48 hours like that we also have if there's cytokines storm will have il6 will rise so we need to go for all these parameters and if the patient is on steroids it will change the picture it will all will come down steroids will produce the low uh it will increase the lymphocytes i mean the neutrophils but the lymphocytes are not affected and the crp and also falls will be low because of the steroids yeah okay so i hope uh all of these questions that you have addressed right now um uh i can see many more coming up but in the interest of time i would request you all to put all your queries uh on support id and we will try and get back to you on that uh to support at the right netflix dot app is the email id and you can mail us all the queries that you have many uh doctors have asked if this session will be made available or uh will we get the ppt so uh ppt uh will not be mailed you separately uh you can watch the session again uh you can go to replay section of the app uh after 48 hours and you will see the recording of the session and you can watch the entire session again so uh this is how yeah just a minute some doctor has asked the question if menser index is 14 but serum iron is normal what does it suggest so i would not say that menser index is again the only thing that we decide whether facing is iron deficiency and serum ion alone is also again not important we have to go for the oral picture and if the menser index is 14 that does not mean it patient has to have iron deficiency it can still be thalassemia right it can still be thalassemia we have to go for the further test to decide but i would go for the serum iron ferritin sibc right and decide whether there is iron deficiency anemia or existing okay so shreya i hope this answers uh beautifully your question so with this i guess we can end the session here and hope to see you again really soon with some interesting sessions


Interpretation of CBC forms the base of diagnosis for many procedures and if we overlook some hidden hack, we might prescribe next level diagnostic procedure which could be unnecessary at times. Let's brush up on those basics and learn some important new concepts with Dr. Mahadev Desai.


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