Check reticulocyte count 2. Addison's disease consider AOCD chronic renal failure liver disease aplastic anemia 3. Macrocytic anemias are classified as megaloblastic or non-megaloblastic. The first step in the evaluation of a macrocytic anemia is to examine the smear for hypersegmented neutrophils. The majority of megaloblastic anemias are due to cobalamin deficiency, or to ethanol-related folate deficiency.
Physical exam can reveal glossitis and decreased vibratory and position sense.
Approximately 50 percent of patients with pernicious anemia have antibodies to intrinsic factor, and in advanced cases, pancytopenia can be seen. Sprue is another common cause of cobalamin deficiency. When ordering lab tests to evaluate a macrocytic anemia, remember that in the presence of severe anemia, there is a compensatory marrow response, resulting in increased RBC production and premature reticulocyte release. If none are present, proceed to step 7. If there has been a recent folate meal or recent supplementation with oral folate and the folate is normal, check RBC folate levels.