CBC & Pheripheral Blood Smear

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CBC & Peripheral Blood Smear - Comprehensive Medical Test Information Guide

Section 1: Why is it done?
- Test Overview: The Complete Blood Count (CBC) and Peripheral Blood Smear is a comprehensive hematological assessment that evaluates the cellular components of blood. The CBC measures quantitative parameters (cell counts), while the peripheral blood smear provides qualitative microscopic analysis of blood cell morphology and characteristics.
- Primary Indications for Testing:
  - Evaluation of symptoms such as fatigue, weakness, unexplained fever, or infections
  - Diagnosis and monitoring of blood disorders (anemia, leukemia, thrombocytopenia)
  - Assessment of immune system function and infection status
  - Routine screening during physical examinations and pre-operative evaluations
  - Monitoring effects of medications or chemotherapy
  - Investigation of unexplained bleeding or bruising
  - Follow-up of previously diagnosed hematological conditions
- Typical Timing and Circumstances:
  - Ordered as part of routine annual physical examinations
  - Emergency department evaluation for acute presentations
  - Pre-surgical and pre-operative baseline assessment
  - Periodic monitoring during active treatment or chronic disease management
  - When CBC results show abnormalities requiring morphological clarification
Section 2: Normal Range
- White Blood Cell (WBC) Count:
  - Normal Range: 4.5 - 11.0 × 10³/µL (or 4,500 - 11,000 cells/µL)
  - Low (Leukopenia): < 4.5 × 10³/µL
  - High (Leukocytosis): > 11.0 × 10³/µL
- Red Blood Cell (RBC) Count:
  - Male: 4.7 - 6.1 × 10⁶/µL
  - Female: 4.2 - 5.4 × 10⁶/µL
  - Low (Anemia): Below normal range for sex
  - High (Polycythemia): Above normal range for sex
- Hemoglobin (Hgb):
  - Male: 13.5 - 17.5 g/dL
  - Female: 12.0 - 15.5 g/dL
  - Low (Anemia): Below normal range for sex
  - High (Polycythemia): Above normal range for sex
- Hematocrit (Hct):
  - Male: 40.7 - 50.3%
  - Female: 36.1 - 44.3%
  - Low: Indicates anemia or hemodilution
  - High: Indicates polycythemia or hemoconcentration
- Platelet Count:
  - Normal Range: 150 - 400 × 10³/µL (or 150,000 - 400,000/µL)
  - Low (Thrombocytopenia): < 150 × 10³/µL
  - High (Thrombocytosis): > 400 × 10³/µL
- Mean Corpuscular Volume (MCV):
  - Normal Range: 80 - 100 fL (femtoliters)
  - Low (Microcytic): < 80 fL - suggests iron deficiency or thalassemia
  - High (Macrocytic): > 100 fL - suggests B12 or folate deficiency
- White Blood Cell Differential:
  - Neutrophils: 50 - 70% (or 2.5 - 7.5 × 10³/µL)
  - Lymphocytes: 20 - 40% (or 1.0 - 4.8 × 10³/µL)
  - Monocytes: 2 - 8% (or 0.2 - 0.8 × 10³/µL)
  - Eosinophils: 1 - 4% (or 0.05 - 0.5 × 10³/µL)
  - Basophils: 0 - 1% (or 0.0 - 0.1 × 10³/µL)
- Peripheral Blood Smear Interpretation:
  - Normal: Uniform RBC morphology, appropriate WBC types in expected proportions, platelet adequacy
  - Abnormal: Presence of immature cells, abnormal cell morphology, toxic granulations, or evidence of hematological disease
Section 3: Interpretation
- Interpreting Elevated WBC (Leukocytosis):
  - Mild elevation (11-15 × 10³/µL): May indicate infection, stress, or inflammation
  - Moderate elevation (15-30 × 10³/µL): Suggests serious infection, leukemia, or hematologic malignancy
  - Marked elevation (>30 × 10³/µL): Highly suggestive of leukemia, especially if immature cells present on smear
  - Look for left shift (increased immature neutrophils) indicating acute infection
  - Toxic granulations and Döhle bodies on smear indicate severe infection
- Interpreting Decreased WBC (Leukopenia):
  - Mild reduction (3.5-4.5 × 10³/µL): May be normal variant or mild infection
  - Moderate reduction (2.0-3.5 × 10³/µL): Suggests bone marrow suppression, medication side effects, or immune destruction
  - Severe reduction (<2.0 × 10³/µL): Indicates serious bone marrow failure, HIV/AIDS, or severe chemotherapy effects
  - Increased infection risk, especially with count <1.0 × 10³/µL
- Interpreting Anemia (Low RBC, Hemoglobin, and Hematocrit):
  - Microcytic Anemia (MCV < 80 fL): Suggests iron deficiency, thalassemia, or chronic disease; smear shows small RBCs
  - Normocytic Anemia (MCV 80-100 fL): Suggests hemolytic anemia, acute bleeding, or bone marrow disorder
  - Macrocytic Anemia (MCV > 100 fL): Suggests vitamin B12 or folate deficiency; smear shows large RBCs
  - Peripheral smear findings help differentiate cause: target cells, spherocytes, fragmented cells, or hypersegmented neutrophils
- Interpreting Platelet Abnormalities:
  - Mild thrombocytopenia (100-150 × 10³/µL): Usually asymptomatic, may observe
  - Moderate thrombocytopenia (50-100 × 10³/µL): Increased bruising or bleeding risk
  - Severe thrombocytopenia (<50 × 10³/µL): Significant bleeding risk; may require transfusion
  - Causes include bone marrow suppression, immune destruction (ITP), DIC, or sequestration
  - Thrombocytosis may indicate reactive process or myeloproliferative disorder
- Key Peripheral Blood Smear Findings:
  - Blasts (immature WBCs): Abnormal in peripheral blood, suggests leukemia
  - Schistocytes: Fragmented RBCs indicating hemolytic anemia or DIC
  - Spherocytes: Small, dense RBCs seen in hereditary spherocytosis or autoimmune hemolytic anemia
  - Target cells: Seen in liver disease, thalassemia, or iron deficiency
  - Auer rods: Abnormal inclusions in myeloblasts indicating acute myeloid leukemia (AML)
  - Toxic granulations and Döhle bodies: Indicate severe bacterial infection
  - Hypersegmented neutrophils: Associated with B12 or folate deficiency
- Factors Affecting Test Results:
  - Medications: Chemotherapy, antibiotics, antithyroid drugs, immunosuppressants
  - Physiologic stress: Exercise, emotional stress, or smoking can elevate WBC
  - Altitude: High altitude increases RBC production
  - Pregnancy: Expected physiologic changes including mild anemia
  - Recent transfusion: Affects RBC parameters immediately
  - Time of day: Diurnal variation in WBC counts (higher in afternoon/evening)
Section 4: Associated Organs
- Primary Organ Systems:
  - Hematopoietic System (Bone Marrow): Primary site of blood cell production; abnormalities in CBC often reflect bone marrow dysfunction
  - Lymphoid System: Includes spleen, lymph nodes, and thymus; produces lymphocytes and monocytes
  - Vascular System: Blood circulates through vessels; abnormal cells may aggregate causing complications
- Associated Diseases and Conditions - Leukemias:
  - Acute Lymphoblastic Leukemia (ALL): Marked leukocytosis with blasts on smear, often in children
  - Acute Myeloid Leukemia (AML): Blasts with myeloid characteristics, may have Auer rods
  - Chronic Myeloid Leukemia (CML): Massive leukocytosis with left shift, often basophilia and eosinophilia
  - Chronic Lymphocytic Leukemia (CLL): Absolute lymphocytosis with small, mature-appearing lymphocytes
- Associated Diseases - Lymphomas:
  - Hodgkin Lymphoma: May see Reed-Sternberg cells on smear; anemia and leukopenia common
  - Non-Hodgkin Lymphoma: Various morphologic patterns depending on subtype
- Associated Diseases - Myeloproliferative Neoplasms:
  - Polycythemia Vera: Elevated RBC count, hemoglobin, hematocrit; absolute polycythemia
  - Essential Thrombocythemia: Marked thrombocytosis with abnormal megakaryocytes
  - Primary Myelofibrosis: Leukocytosis, anemia, immature precursor cells (leukoerythroblastic picture)
- Associated Diseases - Anemias:
  - Iron Deficiency Anemia: Microcytic, hypochromic RBCs; low MCV and MCH
  - Vitamin B12 Deficiency: Macrocytic RBCs with hypersegmented neutrophils
  - Folate Deficiency: Macrocytic anemia similar to B12 deficiency
  - Hemolytic Anemia: Schistocytes, spherocytes, polychromasia; reticulocytosis
  - Thalassemia: Microcytic, target cells, nucleated RBCs
  - Aplastic Anemia: Pancytopenia (reduction in all three cell lines)
- Associated Diseases - Infections:
  - Bacterial Infections: Leukocytosis with left shift, toxic granulations
  - Viral Infections: May show normal WBC or lymphocytosis; atypical lymphocytes present
  - HIV/AIDS: Progressive leukopenia, lymphopenia, eventual pancytopenia
- Associated Diseases - Other Conditions:
  - Disseminated Intravascular Coagulation (DIC): Schistocytes, thrombocytopenia, prolonged PT/aPTT
  - Hemolytic Uremic Syndrome (HUS): Microangiopathic hemolytic anemia with schistocytes
  - Systemic Lupus Erythematosus (SLE): May show cytopenias, LE cells on smear (historical)
  - Liver Disease: Pancytopenia due to bone marrow suppression or platelet sequestration
  - Kidney Disease: Anemia due to erythropoietin deficiency
- Potential Complications of Abnormal Results:
  - Severe Anemia: Fatigue, dyspnea, syncope, cardiac complications, organ hypoxia
  - Severe Thrombocytopenia: Spontaneous bleeding, intracranial hemorrhage, gastrointestinal bleeding
  - Severe Leukopenia: Life-threatening infections, sepsis, septic shock
  - Leukostasis: WBC aggregation in microvasculature causing stroke, MI, or pulmonary hemorrhage
  - Thrombotic Events: Polycythemia increases blood viscosity, increasing thrombosis risk
Section 5: Follow-up Tests
- Follow-up Tests for Anemia:
  - Serum Iron Studies: Iron, ferritin, TIBC, transferrin saturation (assess for iron deficiency)
  - Vitamin B12 and Folate Levels: Check for megaloblastic anemia causes
  - Reticulocyte Count: Assess bone marrow response to anemia
  - Peripheral Blood Smear Review: Detailed morphologic analysis if not already done
  - Direct Antiglobulin Test (DAT/Coombs): Assess for hemolytic anemia
  - Bone Marrow Biopsy and Aspiration: If aplastic anemia or marrow infiltration suspected
  - Hemoglobin Electrophoresis: Assess for hemoglobinopathies like thalassemia or sickle cell disease
- Follow-up Tests for Abnormal WBC:
  - Flow Cytometry: Characterize abnormal lymphocytes or blasts; essential for leukemia diagnosis
  - Cytochemical Staining: Myeloperoxidase, PAS, Sudan black to classify leukemias
  - Cytogenetics: Chromosomal analysis for chromosomal abnormalities associated with leukemias
  - Molecular Studies: PCR for BCR-ABL fusion (CML), FLT3-ITD (AML), immunoglobulin/T-cell gene rearrangements
  - Bone Marrow Biopsy: Determine cellularity, fibrosis, and more detailed morphology
  - Immunophenotyping: Detailed immune analysis, particularly for lymphoid malignancies
- Follow-up Tests for Platelet Abnormalities:
  - Coagulation Profile (PT, aPTT, INR): Assess coagulation function if bleeding risk
  - Fibrinogen Level: Check for DIC if thrombocytopenia with coagulopathy present
  - D-Dimer: Elevated in DIC and thrombotic conditions
  - Antiplatelet Antibody Testing: For immune thrombocytopenia (ITP) diagnosis
  - Bone Marrow Biopsy: If thrombocytopenia is unexplained or severe
- Associated Tests by Suspected Diagnosis:
  - For Infectious Processes: Blood cultures, urinalysis, chest X-ray, viral serology (EBV, CMV), HIV testing
  - For Suspected Leukemia: Bone marrow biopsy, flow cytometry, cytogenetics, molecular studies, LDH, uric acid
  - For Suspected Lymphoma: Imaging (CT/PET), lymph node biopsy, EBV serology, flow cytometry
  - For Pancytopenia: Bone marrow biopsy, hepatitis serology, autoimmune studies, vitamin levels
- Monitoring Frequency for Ongoing Conditions:
  - Acute Leukemia on Chemotherapy: CBC daily or every few days during treatment; weekly during remission maintenance
  - Chronic Anemia: CBC every 4-12 weeks depending on cause and treatment
  - CML on Tyrosine Kinase Inhibitor: CBC initially every 2 weeks, then monthly, then every 3-6 months
  - Immunosuppressive Therapy: CBC weekly initially, then monthly for monitoring cytopenias
  - Post-Chemotherapy Follow-up: Periodic CBC depending on residual effects and ongoing therapy, typically every 3-6 months
Section 6: Fasting Required?
- Fasting Requirement: NO - Fasting is NOT required for CBC and Peripheral Blood Smear
- Rationale:
  - CBC measures blood cell counts, which are not affected by fasting state
  - Peripheral blood smear examines cell morphology, also independent of nutritional status
  - Can be performed at any time of day with food or fluid intake
- Patient Preparation Requirements:
  - Arm Selection: Avoid arm with recent intravenous lines or hematoma; avoid arm with lymph node dissection if history present
  - Positioning: Patient should be seated comfortably for at least 5 minutes before venipuncture to allow blood distribution to stabilize
  - Timing Considerations: Diurnal variation exists in WBC counts (higher in afternoon/evening); standardize time if serial comparisons needed
  - Stress Avoidance: Emotional or physical stress can elevate WBC; allow 10-15 minutes rest after stressful activity if possible
- Medications to Avoid or Notify Provider:
  - NO specific medications need to be discontinued for CBC
  - However, inform healthcare provider of medications that may affect blood cell counts:
    - Corticosteroids (increase WBC)
    - Chemotherapy agents (suppress all cell lines)
    - Antibiotics (can cause cytopenias)
    - Antithyroid medications (can decrease WBC)
    - Anticonvulsants (may affect counts)
    - Anticoagulants like warfarin (monitor platelet trends)
- Specimen Collection Requirements:
  - Specimen Type: Whole blood collected in EDTA (ethylenediaminetetraacetic acid) tube (purple/lavender top tube)
  - Collection Method: Routine venipuncture with minimal trauma to avoid hemolysis or white cell damage
  - Volume: Typically 3-5 mL depending on laboratory requirements
  - Mixing: Invert tube gently 8-10 times after collection to ensure proper mixing with anticoagulant
  - Temperature: Keep at room temperature (do not refrigerate) until analysis
  - Timing: Process sample within 24 hours of collection for optimal results
- Special Instructions:
  - No special preparation required for routine CBC
  - May eat and drink normally before the test
  - Continue taking all regular medications unless specifically instructed otherwise by provider
  - If test is ordered as part of a panel with other tests requiring fasting, follow fasting requirements for the most restrictive test
  - Inform phlebotomist of recent transfusions, recent infections, or current treatments that may affect results

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