dr anjani kumar jha,nomc,biratnagar,nepal

1. Approach to the patient with
Anemia
Dr. Anjani kumar Jha
1st year Resident
Internal medicine, NOMC

2. CONTENTS:
1) DEFINITIONS
2) HEMATOPOIESIS
3) CLASSIFICATION
4) APPROACH TO ANEMIA
5) CLINICAL PRESENTATION
6) INVESTIGATIONS
7) BRIEF INTRODUCTION TO SPECIFIC
TYPES
6/30/2020
APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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3. DEFINITIONS..
• Anemia is defined as a decrease in circulating red blood
cell mass; the usual criteria being hemoglobin<12 g/dl
or hematocrit<36% for nonpregnant women and
hgb<13 g/dl or hct <39% in men.
• The WHO defines anemia as a hemoglobin level
<130g/l(13g/dl) in men and <120g/l(12g/dl) in women.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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4. DEFINITIONS..
• From Greek meaning “without blood”
• Condition where capacity of blood to transport
oxygen to tissues is reduced(Decreased hemoglobin
,RBC count and hematocrit)
• Anemia is not a disease but a manifestation of
disease.
• Treatment depends on discovering underlying
cause.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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5. DEFINITIONS..
• Haematopoiesis is the process by which the formed
elements of blood are produced.
• The process is regulated through a series of steps
beginning with the hematopoietic stem cell.
• Stem cells are capable of producing red cells , all
classes of granulocytes, monocytes, platelets, and the
cells of the immune system.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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APPROACH TO PATIENT WITH ANEMIA PPT
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APPROACH TO PATIENT WITH ANEMIA PPT
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8. DEFINITIONS..
• Mean corpuscular volume(MCV): it is the average volume
of a single RBC and it is expressed in femtoliter.
• Mean corpuscular hemoglobin(MCH): it is the quantity or
amount of hemoglobin present in one RBC, expressed in
picogram.
• Mean corpuscular hemoglobin concentration(MCHC): it is
the concentration of hemoglobin in one RBC. This is the
most important absolute value in diagnosis of anemia.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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9. DEFINITIONS..
• Packed cell volume(PCV): it is the measure or
proportion of blood volume that is occupied by red
blood cells.
• Red cell distribution width(RDW): it is the coefficient
of variation in size distribution of red blood cells.
Increased value indicates anisocytosis. Normal is 11.5
to 14.5%.
• Poikilocytosis: abnormal shape of cells.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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APPROACH TO PATIENT WITH ANEMIA PPT
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12. Clinical presentation of anemia:
• Anemia is most often recognized by abnormal screening
laboratory tests.
• acute anemia is due to blood loss or hemolysis.
• If blood loss is mild i.e. if 10-15% then the issue is not
anemia but hypotension and decreased organ perfusion.
• If blood loss is >30% then the patient is unable to
compensate so pt prefers to remain supine and will show
postural hypotension and tachycardia.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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13. CONTD..
• If blood loss is >40%(about 2L in average sized adult)
then signs of hypovolemic shock including confusion
,dyspnea , diaphoresis, hypotension and tachycardia
appear.
• Intravascular hemolysis with release of free
hemoglobin may be associated with acute back pain,
free hgb in plasma and urine and renal failure.
• Chronic anemia: symptomatic when hgb<7g/dl.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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14. CONTD..
• Moderate chronic anemia presents with fatigue, loss of stamina,
breathlessness and tachycardia(particularly with physical exertion).
• The following history will aid in the evaluation and management of
anemia:
 Gastrointestinal hemorrhage
 Obstetric and menstrual history
 Comorbidities associated with anemia such as GI resection or
malabsorption, renal disease, rheumatologic disease, or other chronic
inflammatory conditions.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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15. CONTD..
 Comorbidities conditions that may be exacerbated by anemia, such
as cardiovascular disease.
 Family history of anemia
 Prescribed and over the counter medicines including herbal
supplements, alcohol consumption, diet , ethnic background, and
religious beliefs pertaining to blood transfusions.
 Symptoms suggestive of other cytopenias (such as bruising
thrombocytopenia) or infections(neutropenia).
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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16. Physical examination:
• Common S/S of anemia include pallor, tachycardia, hypotension,
dizziness, tinnitus, headache, loss of concentration, fatigue and
weakness ,forceful heartbeat , strong peripheral pulses and a systolic
flow murmur.
• Atrophic glossitis , angular cheilosis , koilonychia (spoon nails), and
brittle nails are more common in severe long standing anemia.
• Patient may also experience reduced exercise tolerance , dyspnea on
exertion , and heart failure.
• High output heart failure and shock may be seen in most severe
cases.6/30/2020
APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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17. APPROACH TO THE PATIENT:
• THE EVALAUTION OF THE PATIENT WITH ANEMIA REQUIRES A
CAREFUL HISTORY AND PHYSICAL EXAMINATION.
• Nutritional history related to drugs or alcohol intake and family history of anemia
should always be assessed.
• Certain geographic backgrounds and ethnic origins are associated with an increased
likelihood of and inherited disorder of hgb molecular or intermediary metabolism.
• G6pd deficiency and certain hemoglobinopathies are seen more commonly in
middle eastern or African origin including African Americans.
• Exposure to certain toxic agents or drugs.
• Symptoms related to other diseases such as bleeding , fatigue, malaise, fever,
weight loss, night sweats and other systemic symptoms.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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18. CONTD..
• Clues to the mechanisms of anemia may be provided on
physical examination by findings of blood in stool,
lymphadenopathy, splenomegaly , or petechiae.
• Splenomegaly and lymphadenopathy suggest an underlying
lymphoproliferative disease whereas petechiae suggest
platelet dysfunction.
• The skin and mucous membrane may be pale if the hgb is
<8-10g/dl.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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19. CONTD..
• This part of examination should focus on areas where
vessels are close to the surface such as mucous
membrane, nail beds, and palmar creases.
• If the palmar creases are lighter in color than the
surrounding skin when the hand is hyperextended, the
hgb level is usually <8g/dl.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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20. Laboratory tests in anemia diagnosis:
I. Complete blood count
A. Red cell count
1) Hemoglobin
2) Hematocrit
3) Reticulocyte count
B. Red blood cell indices
4) MCV
5) MCH
6) MCHC
7) RDW
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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21. CONTD..
C. White blood cell count
1) Cell differential
2) Nuclear segmentation of neutrophils
D. Platelet count
E. Cell morphology
1) Cell size
2) Hemoglobin content
3) Anisocytosis
4) Poikilocytosis
5) polychromasia
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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22. CONTD..
II. Iron supply studies
A. serum iron
B. TIBC
C. serum ferritin
III. Marrow examination
A. aspirate
A. M/E RATIO
B. CELL MORPHOLOGY
C. IRON STAIN
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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23. CONTD..
B. BIOPSY
A. Cellularity
B. Morphology
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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APPROACH TO PATIENT WITH ANEMIA PPT
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APPROACH TO PATIENT WITH ANEMIA PPT
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26. CLASSIFICATION OF ANEMIA:
• The functional classification of anemia has three major categories.
These are 1)marrow production defects(hypo proliferation), 2)red
cell maturation defects(ineffective erythropoiesis), and 3)decreased
red cell survival(blood loss/ hemolysis)
• A hypo proliferative anemia is typically seen with a low reticulocyte
production index together with little or no change in red cell
morphology( a normocytic, normochromic anemia).
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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27. CONTD..
• Maturation disorders typically have a slight to
moderately elevated reticulocyte production index that
is either macrocytic or microcytic red cell indices.
• Increased red cell destruction secondary to hemolysis
results in an increase in the reticulocyte production
index to at least three times the normal provided
sufficient iron is available.
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APPROACH TO PATIENT WITH ANEMIA PPT
BY DR. ANJANI KUMAR JHA
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APPROACH TO PATIENT WITH ANEMIA PPT
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32. THANK YOU!!!
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APPROACH TO PATIENT WITH ANEMIA PPT
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