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In evaluating a patient with anemia, it is critical to determine if the patient is clinically stable or unstable. Red blood cell transfusions may be necessary in patients with symptomatic anemia (that is, those with angina, hypotension, shortness of breath, palpitations, syncope, or pre-syncope). The hemoglobin value alone does not determine if a patient requires a blood transfusion. Anemia is usually due to one of three processes: Bleeding Bone marrow production problems, or Hemolysis, which is excessive red cell breakdown. Hospitalized or complex patients may have multifactorial anemia, with a combination of the above processes. Anemia can also be classified by red cell size: Microcytic anemia can be due to thalassemia, iron deficiency, or anemia of chronic disease. Macrocytic anemia can be caused by B12/folate deficiency, alcohol use, chronic liver disease, drugs (such as methotrexate), reticulocytosis, aplastic anemia, myelodysplastic syndrome, or hypothyroidism. Normocytic anemia