Clinical Commander

All dossiers
symptom.anemia-workup.v1

Anemia symptom-triage (outpatient ddx + ED escalation for severe)

symptomchronicsubacuteundifferentiatedacuteadultgeriatricpregnancyoutpatientacute
Start encounter →Print handoutPRODUCTION

Promoted SCAFFOLDED->INTEGRATED 2026-05-31. Decision surface = two real, named anemia calculators added to clinical-tools-registry.ts: calc.reticulocyte_production_index (RPI) + calc.mentzer_index (mount_kind calculator_reference; clinical-tools audit 0 CRITICAL). Workups workup.macrocytic_anemia + workup.hemolysis resolve. Evidence re-sourced + PubMed-verified via get_article_metadata: 36827619 (Blood 2024) + 17375513 (AFP 2007); prior array was fabricated/placeholder. Phase C shard-3-neuro-sym wave-12 expansion (2026-05-15) — pattern-matches symptom.hyponatremia-workup.v1 + symptom.hyperkalemia-workup.v1 (wave-11). Engine scope: outpatient-primary anemia ddx (MCV-anchored + retic-anchored) + hemolysis workup + iron/B12/folate studies + ESA/CKD overlay + ED escalation for severe symptomatic + downstream routing (sickle, leukemia, TTP, CKD, GI bleed). Bayesian linkage (LR+, LR-, T_treat, MCV thresholds, Mentzer index, RPI, sTfR/log(ferritin) index) lives in companion depth bundle _briefs/symptom.anemia-workup.v1.depth.md. 5 sibling-differentiation rows: heme.sickle-cell.core.v1 + heme.acute-leukemia.core.v1 + neph.ckd.core.v1 + heme.ttp.core.v1 + gi.ugib.core.v1. 8 severity triggers (≥6 per spec): severe_symptomatic_hgb_lt_7 + brisk_hemolysis_aiha + ttp_pentad_stat_plex + pancytopenia_leukemia + pernicious_anemia_b12_before_folate + ckd_anemia_esa + ida_men_postmeno_mandate_gi_workup + acute_blood_loss_hemodynamic. KEY SAFETY RULES: (1) ALWAYS start B12 BEFORE folate in megaloblastic with unclear cause — folate alone in B12 deficiency precipitates subacute combined degeneration of cord (IRREVERSIBLE neurologic). (2) IDA in men + post-menopausal women MUST trigger upper + lower endoscopy (occult GI bleed, CRC). (3) ESA target Hgb 10-11.5 NOT >13 (TREAT/CHOIR/CREATE — increased CV/stroke). (4) Transfusion threshold Hgb 7 (8 cardiac) per TRICC. (5) Check G6PD before primaquine/rasburicase/dapsone. (6) Cold AIHA → keep WARM (cold exacerbates hemolysis). (7) DO NOT delay PLEX for ADAMTS13 in suspected TTP. (8) PCP/Strongyloides screen before high-dose steroids for AIHA. Calculators wired (0): Mentzer / RPI / Green-King / sTfR-ferritin index — schema-blocked; ticketed in shard-3 state file. Panels wired: panel.cbc + panel.iron + panel.renal + panel.lft + panel.thyroid + panel.inflammation. Schema-blocked: workup.anemia / workup.hemolysis / calc.mentzer / calc.rpi / calc.green_king / calc.stfr_ferritin_index — NOT in clinical-tools-registry; manual application in setting playbook required_assessments + ticketed. Regimen_axes intentionally empty — engine is triage-only. Drug ladder (oral iron, IV iron, B12 IM/PO, folate, ESA, prednisone, rituximab, IVIG, transfusion) lives in setting_playbooks.outpatient.drug_actions + setting_playbooks.ed.drug_actions. Setting playbooks: outpatient (primary) + ED (escalation for severe symptomatic, brisk hemolysis, TTP, pancytopenia, acute blood loss). SCAFFOLDED status: no workup.anemia in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (19)

  • lab_abnormality
    MCV <80 + low ferritin (<30) + low TSAT + high TIBC + high sTfR — iron-deficiency anemia (IDA); oral ferrous sulfate 325 mg QOD (better tolerated) or IV iron if refractory/intolerant; men + post-menopausal women MUST get GI evaluation for occult bleeding/malignancy (Camaschella NEJM 2015 PMID 32513860 verify; BSH iron 2021 PMID 30303080 verify)
    microcytic_iron_deficiency_anemia
  • lab_abnormality
    MCV <80 + Mentzer <13 + normal iron studies + family hx Mediterranean/Asian/African — thalassemia trait (alpha/beta); confirm Hb electrophoresis; no iron unless concurrent IDA; genetic counseling for partner screen
    microcytic_thalassemia_trait
  • lab_abnormality
    MCV <80-95 + chronic inflammation (RA, IBD, CKD, malignancy) + normal/high ferritin + low TSAT + sTfR/log(ferritin) <1 — anemia of chronic disease/inflammation (ACD/AI); treat underlying; ESA if CKD + Hgb <10
    microcytic_anemia_of_inflammation_chronic
  • lab_abnormality
    MCV <80 + high ferritin + high TSAT + ringed sideroblasts on BMBx — sideroblastic anemia (hereditary X-linked, acquired MDS, lead, alcohol, INH); lead level if occupational/pediatric; pyridoxine trial if hereditary
    microcytic_sideroblastic_or_lead
  • lab_abnormality
    Acute Hgb drop + MCV 80-100 (no retic surge yet) + tachycardia/hypotension + melena/hematochezia/trauma — acute blood loss; ED + IVF + transfusion threshold Hgb <7 (TRICC PMID 9971864 verify) or <8 cardiac dz; route gi.ugib.core.v1
    normocytic_acute_blood_loss
  • lab_abnormality
    Hgb low + retic high + LDH high + haptoglobin low + indirect bili high + DAT (Coombs) positive — autoimmune hemolytic anemia (AIHA); warm IgG vs cold IgM; prednisone 1 mg/kg/d × 2-4 wk taper; rituximab if refractory; cold AIHA → keep WARM
    normocytic_hemolytic_DAT_positive_AIHA
  • lab_abnormality
    Hgb low + retic high + hemolysis labs + DAT negative + smear (spherocytes, sickle, schistocytes, bite/Heinz) — intrinsic RBC (HS, sickle, G6PD); confirm with osmotic fragility, Hb electrophoresis, G6PD level (route heme.sickle-cell.core.v1)
    normocytic_hemolytic_DAT_negative_intrinsic
  • lab_abnormality
    Microangiopathic hemolytic anemia (schistocytes) + thrombocytopenia + neuro/renal/fever — TTP pentad; STAT plasma exchange (PLEX) — DO NOT delay for ADAMTS13; route heme.ttp.core.v1
    normocytic_hemolytic_TTP_pentad_STAT_PLEX
  • lab_abnormality
    eGFR <60 + low Hgb + low retic + low EPO — anemia of CKD; ESA (epoetin/darbepoetin) when Hgb <10 + iron sufficient (TSAT >20%, ferritin >100); target Hgb 10-11.5 NOT >13 (TREAT/CHOIR/CREATE trials); route neph.ckd.core.v1
    normocytic_anemia_of_CKD
  • lab_abnormality
    MCV >100 + hypersegmented neutrophils + low B12 + high MMA + high homocysteine + neuro sx (paresthesias, ataxia, dementia) — B12 deficiency; cyanocobalamin 1000 mcg IM weekly × 8 then monthly OR 1000-2000 mcg PO daily (Vidal-Alaball 2005); ALWAYS B12 before folate (folate alone precipitates SCD myelopathy) (Stabler NEJM 2013 PMID 22106456 verify)
    macrocytic_megaloblastic_B12_deficiency
  • lab_abnormality
    Megaloblastic + anti-intrinsic-factor + anti-parietal-cell antibodies + atrophic gastritis — pernicious anemia; lifelong B12 replacement (PO works); screen for autoimmune polyendocrine (Hashimoto, T1D, vitiligo)
    macrocytic_megaloblastic_pernicious_anemia
  • lab_abnormality
    MCV >100 + low folate + normal MMA + high homocysteine — folate deficiency (alcohol, malnutrition, pregnancy, drug); folic acid 1-5 mg PO daily; MUST exclude B12 deficiency first
    macrocytic_megaloblastic_folate_deficiency
  • lab_abnormality
    MCV >100 + normal B12/folate + no hyperseg neut — non-megaloblastic; workup alcohol/liver (LFT, GGT, alcohol hx), hypothyroidism (TSH), MDS (smear, BMBx); MDS → WHO classification (PMID 31626752 verify)
    macrocytic_non_megaloblastic_liver_alcohol_hypothyroid_MDS
  • lab_abnormality
    MCV >100 + medication (MTX, hydroxyurea, AZT, phenytoin, trimethoprim, 5-FU, capecitabine) — drug-induced macrocytosis; folate supplementation for MTX; dose reduction or substitution
    macrocytic_drug_induced_MTX_AZT_hydroxyurea
  • lab_abnormality
    Pancytopenia (low Hgb + low WBC + low plt) + smear (blasts → leukemia; hypocellular → aplastic) + BMBx — route heme.acute-leukemia.core.v1 if blasts; aplastic anemia → IST or HSCT; PRCA (parvovirus, thymoma, drug) → IVIG / thymectomy
    pancytopenia_aplastic_or_leukemia
  • lab_abnormality
    Pregnancy + Hgb <11 (1st/3rd tri) or <10.5 (2nd tri) + low ferritin — pregnancy IDA (physiologic + iron demand); oral ferrous sulfate 65 mg elemental daily; ferric carboxymaltose IV after 14 wk if PO fails or severe; multivitamin + folic acid 400-800 mcg
    pregnancy_iron_deficiency_anemia
  • lab_abnormality
    Hb electrophoresis confirms Hb SS / SC / S-beta-thal — sickle cell disease; route heme.sickle-cell.core.v1 for crisis + chronic mgmt (hydroxyurea, voxelotor, crizanlizumab, transfusion, HSCT); trait → genetic counseling
    sickle_cell_disease_or_trait
  • lab_abnormality
    Mixed deficiency (alcohol, malnutrition, post-bariatric, IBD, celiac) — multiple substrate deficiencies; replete iron + B12 + folate sequentially (B12 first); evaluate underlying cause
    mixed_iron_b12_folate_combined_deficiency
  • lab_abnormality
    Hgb <7 (or <8 with cardiac dz) + symptoms (chest pain, dyspnea, AMS, hypotension) — ED + transfusion (TRICC threshold); identify cause concurrently; avoid over-transfusion in chronic stable anemia
    severe_symptomatic_anemia_hgb_lt_7

Required inputs (28)

  • agerequired
    demographic • used at CONTEXT
    Age shifts priors: pediatric → IDA from formula transition / prematurity; adolescent female → menstrual IDA; elderly → ACD / MDS / GI malignancy (Camaschella PMID 32513860 verify)
  • sexrequired
    demographic • used at CONTEXT
    Sex shifts: pre-menopausal female → menstrual IDA + pregnancy; men + post-menopausal women with IDA → MUST workup occult GI malignancy (endoscopy + colonoscopy)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Pregnancy → physiologic dilution + iron/folate demand; Hgb thresholds <11 (1st/3rd tri) or <10.5 (2nd tri); avoid IV iron in 1st trimester
  • hemoglobin_valuerequired
    lab • used at FRAME
    Severity by Hgb: severe <7 (or <8 cardiac) → ED + transfusion; moderate 7-9.9 → outpatient workup + monitor; mild 10-normal → outpatient workup (TRICC threshold)
  • mcv_valuerequired
    lab • used at FRAME
    MCV-anchored stratification: <80 microcytic (IDA/thal/ACD/sideroblastic/lead); 80-100 normocytic (ACD/early IDA/blood loss/hemolytic/aplastic/mixed/CKD); >100 macrocytic (megaloblastic vs non-megaloblastic)
  • reticulocyte_count_or_RPIrequired
    lab • used at INITIAL_WORKUP
    Retic index <2 → hypoproductive (IDA, ACD, CKD, marrow failure, megaloblastic); retic index >3 → hyperproductive (hemolysis, acute blood loss with response); discriminates production vs destruction
  • fatigue_dyspnea_pica_pallorrequired
    symptom • used at ENTRY
    Fatigue, dyspnea on exertion, pica (clay/ice), pallor, restless legs (IDA marker), glossitis (B12/iron), tachycardia, syncope → severity + cause clues
  • bleeding_history_gi_menstrual_traumarequired
    symptom • used at CONTEXT
    Melena, hematochezia, hematemesis, hematuria, menorrhagia, trauma, recent surgery, NSAIDs → blood-loss anemia; volume + chronicity drives workup
  • diet_vegan_alcohol_malnutritionrequired
    history • used at CONTEXT
    Vegan/vegetarian → B12 deficiency; alcohol → folate/B12/non-megaloblastic macrocytosis; malnutrition / post-bariatric → mixed deficiency
  • medications_mtx_azt_hydroxyurea_ppi_nsaid_methyldoparequired
    history • used at CONTEXT
    MTX, AZT, hydroxyurea, 5-FU, capecitabine → megaloblastic/non-megaloblastic macrocytosis; PPI → B12 malabsorption + IDA; NSAIDs → GI bleed; methyldopa/cefotetan/penicillin → drug AIHA
  • chronic_disease_ckd_ra_ibd_hiv_malignancyrequired
    history • used at CONTEXT
    CKD → EPO-deficient anemia (route neph.ckd.core.v1); RA/IBD → ACD/AI; HIV/HCV → suppression; malignancy → ACD + chemo-induced + paraneoplastic
  • family_history_thalassemia_sickle_hs_g6pd
    history • used at CONTEXT
    Mediterranean/Asian/African ancestry → thalassemia, hemoglobinopathies; sickle cell (African); HS autosomal dominant; G6PD X-linked Mediterranean/African/Asian male
  • recent_infection_parvovirus_or_mycoplasma_or_ebv
    history • used at CONTEXT
    Parvovirus B19 → transient aplastic crisis in HS/sickle; PRCA; Mycoplasma/EBV → cold agglutinin AIHA; HIV/CMV → various cytopenias
  • sbprequired
    vital • used at CONTEXT
    Hypotension + low Hgb + tachycardia → acute blood loss / hemodynamic compromise → ED + transfusion + cause workup
  • hrrequired
    vital • used at CONTEXT
    Tachycardia → severe anemia / acute blood loss / hemolysis; bradycardia → hypothyroidism contributor
  • cbc_full_with_smearrequired
    lab • used at INITIAL_WORKUP
    CBC + differential + platelets + smear (spherocytes, schistocytes, bite cells, hypersegmented neut, blasts, target cells, sickle, basophilic stippling) — central diagnostic study
  • iron_studies_fe_tibc_ferritin_tsat_stfrrequired
    lab • used at INITIAL_WORKUP
    Ferritin <30 specific for IDA; TSAT <20 supports; high TIBC + low TSAT classic IDA; sTfR high in IDA + normal in ACD; sTfR/log(ferritin) >2 → IDA even with inflammation
  • b12_folate_mma_homocysteinerequired
    lab • used at INITIAL_WORKUP
    B12 <200 deficient; B12 200-300 borderline → check MMA + homocysteine; MMA high + homocysteine high → B12 def; MMA normal + homocysteine high → folate def; B12 first ALWAYS before folate (Stabler PMID 22106456 verify)
  • hemolysis_panel_ldh_haptoglobin_indirect_bili_datrequired
    lab • used at INITIAL_WORKUP
    Hemolysis labs: LDH high + haptoglobin low + indirect bili high + retic high → hemolysis; DAT (Coombs) positive → AIHA (warm IgG / cold IgM)
  • renal_egfr_for_ckd_anemiarequired
    lab • used at INITIAL_WORKUP
    eGFR <60 → CKD anemia; EPO level if Hgb low + eGFR <60; iron repletion to TSAT >20, ferritin >100 before ESA; target Hgb 10-11.5 (not >13 — TREAT/CHOIR/CREATE trials)
  • tsh_for_hypothyroid
    lab • used at INITIAL_WORKUP
    TSH high → hypothyroidism (non-megaloblastic macrocytosis); levothyroxine replacement typically normalizes Hgb
  • lft_albumin_for_liver
    lab • used at INITIAL_WORKUP
    LFT + albumin → liver disease (macrocytosis from acanthocytes); hypersplenism with cirrhosis (route gi.cirrhosis.core.v1)
  • hb_electrophoresis_if_thalassemia_or_sickle_suspected
    lab • used at BRANCHING_WORKUP
    Hb electrophoresis → thalassemia (Hb A2 elevated for beta-thal; alpha-thal needs DNA); Hb SS / SC / S-beta-thal → sickle cell (route heme.sickle-cell.core.v1)
  • g6pd_level_quantitative
    lab • used at BRANCHING_WORKUP
    G6PD deficiency screen if hemolysis + bite cells + Heinz bodies + drug/food trigger (fava, primaquine, dapsone, sulfa, rasburicase); WAIT 8 wk post-hemolysis for accurate level (young RBC have normal G6PD)
  • anti_intrinsic_factor_anti_parietal
    lab • used at BRANCHING_WORKUP
    Pernicious anemia workup: anti-IF specific but insensitive; anti-parietal sensitive but nonspecific; Schilling test obsolete; B12 absorption studies if needed
  • lead_level_if_pediatric_or_occupational
    lab • used at BRANCHING_WORKUP
    Lead level if pediatric (paint, soil) or occupational (battery, plumber, smelter) + microcytic + basophilic stippling on smear
  • endoscopy_colonoscopy_for_occult_gi_bleed
    imaging • used at BRANCHING_WORKUP
    IDA in men + post-menopausal women → MANDATORY upper + lower endoscopy for occult bleed / CRC / celiac; capsule if negative endoscopy
  • bone_marrow_biopsy_if_aplastic_mds_leukemia
    imaging • used at BRANCHING_WORKUP
    BMBx if pancytopenia + unclear cause; MDS (dysplasia, ringed sideroblasts); aplastic (hypocellular); leukemia (blasts >20%); ITP/TTP exclusions

12-phase flow (12)

  1. 1FRAME
    Severity by Hgb (severe <7 or <8 cardiac → ED + transfusion; moderate 7-9.9 outpatient; mild 10-normal outpatient); MCV stratification (micro <80 / normo 80-100 / macro >100); retic index direction (hypo vs hyper-productive) (Camaschella NEJM 2015 PMID 32513860 verify)
    inputs: hemoglobin_value, mcv_value
    advance: severity + MCV bucket stratified
  2. 2ENTRY
    Symptom severity (fatigue, dyspnea, pica, pallor, syncope, glossitis); blood-loss history (melena/hematochezia/menorrhagia/trauma); hemodynamic stability (acute decompensation → ED)
    inputs: fatigue_dyspnea_pica_pallor, bleeding_history_gi_menstrual_trauma
    advance: symptom + bleeding hx captured
  3. 3CONTEXT
    Age + sex + pregnancy status; diet (vegan, alcohol, malnutrition, bariatric); medication review (MTX, AZT, hydroxyurea, PPI, NSAIDs, methyldopa); chronic disease (CKD, RA, IBD, HIV, malignancy); family hx (thal, sickle, HS, G6PD); recent infection (parvovirus, EBV, mycoplasma); vitals (BP, HR)
    inputs: age, sex, pregnancy_status, sbp, hr, diet_vegan_alcohol_malnutrition, medications_mtx_azt_hydroxyurea_ppi_nsaid_methyldopa, chronic_disease_ckd_ra_ibd_hiv_malignancy, family_history_thalassemia_sickle_hs_g6pd, recent_infection_parvovirus_or_mycoplasma_or_ebv
    advance: context complete
  4. 4RED_FLAGS
    Severe symptomatic anemia (Hgb <7 + sx OR <8 + cardiac dz) → ED + transfusion (TRICC); brisk hemolysis with hemodynamic instability; TTP pentad (MAHA + thrombocytopenia + neuro/renal/fever) → STAT PLEX (route heme.ttp.core.v1); pancytopenia + blasts → leukemia workup (route heme.acute-leukemia.core.v1); acute GI bleed → ED endoscopy
    inputs: hemoglobin_value, fatigue_dyspnea_pica_pallor, bleeding_history_gi_menstrual_trauma
    advance: no immediate life-threat OR ED + cause-specific action triggered
  5. 5INITIAL_WORKUP
    CBC + differential + platelets + smear + retic; iron studies (Fe, TIBC, ferritin, TSAT, sTfR); B12 + folate ± MMA + homocysteine; hemolysis panel (LDH, haptoglobin, indirect bili, DAT); creatinine/eGFR; TSH; LFT
    inputs: cbc_full_with_smear, reticulocyte_count_or_RPI, iron_studies_fe_tibc_ferritin_tsat_stfr, b12_folate_mma_homocysteine, hemolysis_panel_ldh_haptoglobin_indirect_bili_dat, renal_egfr_for_ckd_anemia, tsh_for_hypothyroid, lft_albumin_for_liver
    actions: panel.cbc, panel.iron, panel.renal, panel.lft, panel.thyroid, panel.inflammation
    advance: MCV + retic + iron + B12/folate + hemolysis results in
  6. 6BRANCHING_WORKUP
    Microcytic + low ferritin → IDA (men + post-meno women → GI workup). Microcytic + Mentzer <13 + family hx → thalassemia (Hb electrophoresis). Microcytic + inflammation → ACD (sTfR/log(ferritin)). Macrocytic megaloblastic → B12 + folate + MMA/homocysteine + anti-IF/anti-parietal (pernicious). Macrocytic non-megaloblastic → MDS workup (BMBx). Hemolytic → DAT + smear + hemoglobinopathy panel + G6PD + osmotic fragility. Pancytopenia → BMBx (aplastic vs leukemia). CKD anemia → EPO + iron repletion.
    inputs: hb_electrophoresis_if_thalassemia_or_sickle_suspected, g6pd_level_quantitative, anti_intrinsic_factor_anti_parietal, lead_level_if_pediatric_or_occupational, endoscopy_colonoscopy_for_occult_gi_bleed, bone_marrow_biopsy_if_aplastic_mds_leukemia
    advance: definitive cause identified or routed
  7. 7DIFFERENTIAL
    Microcytic: IDA, thalassemia, ACD (late), sideroblastic, lead. Normocytic: ACD, early IDA, acute blood loss, hemolytic (AIHA + intrinsic), aplastic, mixed, CKD. Macrocytic megaloblastic: B12, folate, pernicious, MTHFR, drug. Macrocytic non-megaloblastic: alcohol, liver, hypothyroid, MDS. Hemolytic: AIHA (warm IgG / cold IgM), HS, G6PD, sickle, thalassemia, TTP, DIC, drug-induced. Marrow failure: PRCA, aplastic. Special: pregnancy, peds, acute blood loss.
    advance: differential ranked
  8. 8RISK_STRATIFICATION
    Severity by Hgb + symptoms + hemodynamics; pancytopenia + blasts → leukemia urgency; TTP pentad → STAT PLEX; brisk hemolysis with cardio-pulm compromise → ICU transfusion; severe AIHA + DAT+ → steroids; CKD anemia → target Hgb 10-11.5 NOT >13
    advance: risk + urgency documented
  9. 9TREATMENT
    IDA: ferrous sulfate 325 mg PO QOD (Stoffel 2017 PMID 26627933 — better tolerated, equivalent absorption); IV iron (ferric carboxymaltose 750 mg × 2) if intolerant/refractory; monitor hypophosphatemia. B12: cyanocobalamin 1000 mcg IM weekly × 8 then monthly OR 1000-2000 mcg PO daily; ALWAYS start B12 BEFORE folate. Folate: 1-5 mg PO daily. ACD: treat underlying. CKD anemia: ESA (epoetin 50-100 U/kg SC TIW; darbepoetin 0.45 mcg/kg SC weekly) when Hgb <10 + iron sufficient; target Hgb 10-11.5 (NOT >13 — TREAT/CHOIR/CREATE). AIHA: prednisone 1 mg/kg PO × 2-4 wk taper; rituximab 375 mg/m2 IV weekly × 4 if refractory; cold AIHA → keep WARM. PRCA: stop offending drug; IVIG 400 mg/kg/d × 5 d for parvovirus; thymectomy. Acute hemolysis with hemodynamic compromise → transfusion. Megaloblastic: B12 first to avoid SCD myelopathy.
    inputs: hemoglobin_value, mcv_value, reticulocyte_count_or_RPI, iron_studies_fe_tibc_ferritin_tsat_stfr
    advance: definitive treatment initiated or routed
  10. 10DISPOSITION
    Outpatient: most chronic anemia + ferritin/B12/folate replacement + hematology follow-up. ED: Hgb <7 + symptoms, brisk hemolysis, TTP, severe AIHA, pancytopenia + blasts, acute blood loss. Ward: severe IDA needing IV iron + workup; new AIHA on steroids; CKD anemia inpatient stabilization. Telemetry: hemodynamic monitoring during transfusion or rapid hemolysis. ICU: severe symptomatic + hemodynamic compromise; TTP on PLEX. Route to: heme.sickle-cell.core.v1; heme.acute-leukemia.core.v1; neph.ckd.core.v1; heme.ttp.core.v1; heme.dic.v1; gi.ugib.core.v1; gi.cirrhosis.core.v1.
    advance: disposition assigned + handoff complete
  11. 11MONITORING
    CBC + retic at 2-4 weeks (response check; expect retic surge by week 1 in IDA on iron); ferritin at 8-12 weeks (target normalization >50 general or >100 CKD); B12 / MMA + homocysteine + neuro recovery; CKD anemia Hgb target 10-11.5 (NOT >13); transfusion threshold Hgb 7 (8 cardiac) — TRICC; ESA dose titration q4 weeks
    inputs: hemoglobin_value, mcv_value, reticulocyte_count_or_RPI
    advance: response trajectory documented
  12. 12FOLLOWUP
    Hematology referral for refractory / hemolytic / pancytopenia / MDS / hemoglobinopathy. GI for IDA + occult blood loss workup (men + post-menopausal women → endoscopy + colonoscopy; capsule if negative). Dietitian for vegan / alcohol / malnutrition / pregnancy. Pregnancy nutrition + iron supplementation. Chronic CKD / RA / IBD optimization (route neph.ckd.core.v1). Genetic counseling for thalassemia / sickle / HS. Recurrence prevention (deprescribe NSAID/PPI if drug-induced); dietary counseling; partner thalassemia screen.
    advance: long-term plan in place + follow-up scheduled