Medicine 5th year, 5th & 6th lectures (Dr. Sabir)
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Medicine 5th year, 5th & 6th lectures (Dr. Sabir)

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The lecture has been given on Feb. 27th & Mar. 26th, 2011 by Dr. Sabir.

The lecture has been given on Feb. 27th & Mar. 26th, 2011 by Dr. Sabir.

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  • Limitations-1. Given that these ranges include 95% of the normal population, the 2.5% of normal subject with values which fall below the normal range will be arbitrarily depicted as being anemic 2. The normal range for HGB and HCT is so wide that, for example a male patient with a baseline HCT of 49% may lose up to 15% of his RBC mass through hemolysis or blood loss and still have a HCT within the normal range
  • CBC-red cell indices-size-micro,macro, normo, color(chromasia) WBC-leukopenia should alert to bone marrow suppression Differential-immature forms Retic count-high-indicates increased response to continued hemolysis or blood loss stable anemia w/ low retic is strong evidence for deficient production of RBCs (reduced marrow response) Smear-as above, nuceated RBCs hematologic dz(sickle, thal,hemolytic anemia), things missed by automated counters: schistocytes, RBC parasits, evidence for hemolysis
  • Primary Bone Marrow involvement Marrow dysfunction vs. Marrow infiltration
  • Note hypersegmented polys – B12 & folate deficiency
  • AKA: hemolytic anemias
  • Ferritin sen=90% spec=80%

Medicine 5th year, 5th & 6th lectures (Dr. Sabir) Medicine 5th year, 5th & 6th lectures (Dr. Sabir) Presentation Transcript

  • Approach to the Patient with ANEMIA Dr. SABIR
  • Definitions
    • Anemia-
      • HGB<13.5 g/dL (men) <12 (women)
      • HCT<41% (men) <36 (women)
  • Evaluation of the Patient
    • HISTORY
      • Is the patient bleeding?
        • Actively? In past?
      • Is there evidence of hemolysis?
      • Is the bone marrow suppressed?
      • Is the patient nutritionally deficient? Pica?
      • PMH including medication review, toxin exposure
  • Evaluation of the Patient (2)
    • SYMPTOMS of anemia:
    • Decreased oxygen delivery to tissues
      • Exertional dyspnea
      • Dyspnea at rest
      • Fatigue
      • Signs and symptoms of hyperdynamic state
        • Bounding pulses
        • Palpitations
      • Life threatening: heart failure, angina, myocardial infarction
    • Hypovolemia
      • Fatiguablitiy, postural dizziness, lethargy, hypotension, shock and death
  • Evaluation of the Patient (3)
    • PHYSICAL EXAM
    • • Stable or Unstable?
    • -ABCs
    • -Vitals
    • • Pallor
    • • Jaundice
    • -hemolysis
    • • Lymphadenopathy
    • • Hepatosplenomegally
    • • Bone Pain
    • • Petechiae
    • • Rectal bleeding? Occult blood
  • Not pale conjunctiva Pale conjunctiva
  •  
  • Laboratory Evaluation
    • Initial Testing
      • CBC w/ differential (includes RBC indices)
      • Reticulocyte count
      • Peripheral blood smear
  • Laboratory Evaluation (2)
    • Bleeding
      • Serial HCT or HGB
    • Iron Deficiency
      • Iron Studies
    • Hemolysis
      • Serum LDH, indirect bilirubin, haptoglobin, coombs, coagulation studies
    • Bone Marrow Examination
    • Others-directed by clinical indication
      • hemoglobin electrophoresis
      • B12/folate levels
  • Differential Diagnosis
    • Classification by Pathophysiology
      • Blood Loss
      • Decreased Production
      • Increased Destruction
    • Classification by Morphology
      • Normocytic
      • Microcytic
      • Macrocytic
  • Blood Loss
    • Acute
      • Traumatic
      • Variety of sources
        • Melena, hematemesis, menometrorrhagia
    • Chronic
      • Occult bleeding
        • Colonic polyp/carcinonma
  • Decreased Production
    • Infectious
    • Neoplastic
    • Endocrine
    • Nutritional Deficiency
    • Anemia of Chronic Disease
  • Decreased Production INFECTIOUS
    • Bacterial
      • Tuberculosis
      • MAI
    • Viral
      • HIV
      • Parvovirus
  • Decreased Production NEOPLASTIC
    • Leukemia
    • Lymphoma/Myeloma
    • Myeloproliferative Syndromes
    • Myelodysplasia
  • Decreased Production ENDOCRINE
    • Thyroid Dysfunction
      • Hypothyroidism
    • Erythropoietin Deficiency
      • Renal Failure
  • Decreased Production NUTRITIONAL DEFICIENCY
    • Iron
    • B12
    • Folate
  • Macrocytic Anemia
    • MCV > 100
    • Megaloblastic: Abnormalities in nucleic acid metabolism
      • B12, Folate
    • Non-megaloblastic: Abnormal RBC maturation
      • Myelodysplasia Alcohol, liver dz, hypothryroidism, chemotherapy/drugs
  • Microcytic Anemia
    • MCV <80
    • Reduced iron availability
    • Reduced heme synthesis
    • Reduced globin production
  • Microcytic Anemia REDUCED IRON AVAILABILTY
    • Iron Deficiency
      • Deficient Diet/Absorption
      • Increased Requirements
      • Blood Loss
      • Iron Sequestration
    • Anemia of Chronic Disease
      • Low serum iron, low TIBC, normal serum ferritin
      • MANY!!
        • Chronic infection, inflammation, cancer, liver disease
  • Microcytic Anemia REDUCED HEME SYNTHESIS
    • Lead poisoning
    • Acquired or congenital sideroblastic anemia
    • Characteristic smear finding: Basophilic stippling
  •  
  • Microcytic Anemia REDUCED GLOBIN PRODUCTION
    • Thalassemias
    • Smear Characteristics
      • Hypochromia
      • Microcytosis
      • Target Cells
      • Tear Drops
  • Differential Diagnosis-Revisited
    • Classification by Pathophysiology
      • Blood Loss
      • Decreased Production
      • Increased Destruction
  • INCREASED DESTRUCTION
    • Immune Mediated
    • Non-immune Mediated
  • Increased Destruction IMMUNE MEDIATED
    • Cold Agglutinin
      • Paroxysmal nocturnal hemoglobinuria
      • Post mycoplasmal hemolytic anemia
    • Warm Agglutinin
      • Drug induced
      • Autoimmune hemolytic anemia
      • Transfusion reaction
  • Increased Destruction NON-IMMUNE MEDIATED
    • Extra-corpuscular
      • Macro-circulatory
        • Hypersplenism
        • Extracorporeal circulation
      • Micro-circulatory
        • DIC
        • TTP
        • HUS
    • Intra-corpuscular
      • RBC Wall (membrane or enzyme defects)
      • Heme or globin abnormalities (HbS, C)
  • Reticulocyte count
    • Retic count = % immature RBC
    • Normal 0.5-1.5% (for non-anemic)
    • <1% Inadequate production
    • >=1% Increased production (? adequacy)
  •  
  • Reticulocyte Correction
    • %Retic count frequently overestimates
    • Retic count should be compared to non-anemic RBC count to assess adequacy of response
    • Corrected Retic count = %Retic X HCT/45
  • RBC morphology
    • 7-9  m with 1/3 central palor
    • Lifespan of 110-120 days
    • About the size of nucleus of normal lymphocyte
    • Poikilocytosis & Anisocytosis
  • Basophilic stippling
    • Precipitated RNA
    • lead or heavy metal poisoning
    • Alcohol abuse
    • Hemolytic anemia
  • Burr cells
    • Altered lipid in cell membrane
    • artifact
    • Uremia
    • Renal failure
    • gastric CA
    • transfused old blood
  • Elliptocytes/ovalocytes
    • Abnormal cytoskeletal proteins
    • Hereditary elliptocytosis
  • Howell Jolly body
    • Nuclear remnant - DNA
    • hemolytic anemia
    • absent or hypofunction spleen
  • Heinz body
  • Schistocyte/helmet cells
    • Fragmented (mechanical or phagocytosis)
    • DIC
    • TTP
    • HUS
    • Vasculitis
    • prosthetic heart valve
    • severe burns
  • Sickle cells
    • Molecular aggregation of Hgb-S
    • SS, SC, S-thal
    • rarely S-trait
  • NRBC
    • Common in newborn
    • severe degree of hemolysis
  • Spherocyte
    • Absent central palor
    • look smaller
    • Hereditary spherocytosis
    • immune hemolytic anemia
  • Stomatocyte
    • Mouth like
    • Membrane defect
    • Smear artifact
    • Hereditary stomatocytosis
    • Liver disease
  • Target cells
    • Increased redundancy of membrane
    • hemoglobinopathies
    • thalassemia
    • liver disease
  • Tear drop cells
    • Distorted drop shaped
    • Smear artifact
    • myelofibrosis
    • promyeloblastic leukemia
    • space occupying lesions of marrow
  • Microcytic anemia
    • Get Iron panel- S Fe, TIBC, ferritin