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Approach to patient with Pallor
Learning objectives
1. To understand the importance of proper history and
clinical examination in the workup of a patient presenting
with pallor in various age groups.
2. Causes and classification of Anemia
3. Interpretation of Lab. Investigations for diagnostic
purposes.
4. understanding of ordering specific investigations for
confirmation and finding out the cause of Anemia.
5. To describe the management plan of anemia in various
conditions and to ensure proper replacement therapy.
Pallor
• Pale color of the skin and mucous membrane
due to deficiency of hemoglobin. (hemoglobin
in carried in the RBCs)
There are many causes of pallor :
Anemia : Most common
Heart disease
Sleep deprivation
Shock : septic , Anaphylactic, Cardiogenic,
Neurogenic or hypovolemic
Pallor is also seen in case of
Endocrine defect :
1.long standing diabetes leading to keratin deposition
in the skin
2. Hypothyroidism with or without anemia
3.Hypopituitarism leading to decrease in the melanin
stimulatory hormone
Pallor is seen in : * Palm creases * Conjunctiva.
* And mucous membranes
Pallor in mucus membrane of lower
eye lid and conjunctive
Angular cheilitis (AC) is inflammation
of one or both corners of the mouth.
Angular chelosis & Glossitis
Koilonychia in Iron def.
Iron Deficiency Anemia - koilonychia
Case Presentation
• HISTORY: A 60- year- old male presented with marked
pallor, easy fatigability and breathlessness on exertion.
On questioning he revealed that he is taking pain killers
for his joint pains for the last 3 years. He mentioned
about passing dark colored stools off and on.
• On examination, he was markedly pale, tachycardia and
having spoon shaped deformity of nails.
• Blood examination: Hemoglobin 7 g/dl
• MCV: 68 fl, MCHC:
• Raised Iron binding capacity with serum Ferritin 12ug/l
(Normal range 60 or above ug/l)
Anemia is defined by
• Reduction in Hg Concentration,
•Hct Concentration or
• RBC count according to the age & sex of the
individual
13
Considerations by Age, Sex, and Other
Factors 1 of 2
• Newborns less than one week old have hemoglobin
of 14-22 g/dl.
• By six months , hemoglobin levels are11 and 14 g/dl.
• 1 year and 15 years hemoglobin is 11-15 g/dl.
• Normal adult hemoglobin depends on gender:
– ♀ 12-16 g/dl
– ♂ 14-18 g/dl
• In geriatric age group, men and women have same
hemoglobin range: 12-16 g/dl.
Symptoms
• Exertional dyspnea and Dyspnea at Exertion
• Headaches
• Fatigue
• Bounding pulses and Roaring in the Ears
• Palpitations
• PICA is an eating disorder typically defined as the persistent ingestion of nonnutritive substances
for at least 1 month at an age for which this behavior is developmentally inappropriate.
Etiology of anemia
• Iron deficiency 25%
• Anemia of inflammation 25%
• Hemoglobinopathy 25%
• Hemolytic anemia/marrow failure 15%
• Myelodysplasia 10%
First Step in Evaluation
Clinical PresentationClinical Presentation
17
Approach
• Detailed History
• Review of Systems
• Physical Exam
• Laboratory Evaluation
– Prior documentation of CBC’s
– CBC with RETICULOCYTE COUNT
– Review peripheral blood smear
18
History
Family historyFamily history
Spherocytosis
Sickle cell
anemia
Thalassemia
DietDiet
Vegetarian
Drugs/Toxins
Infection
Alcohol AbuseAlcohol Abuse
Folate
deficiency
Liver disease
MalabsorptionMalabsorption
B12
Folate
Iron
Exposure
Lead
Chemotherapy
Peptic UlcerPeptic Ulcer
DiseaseDisease
DiverticulitisDiverticulitis
Colonic PolypsColonic Polyps
GI MalignancyGI Malignancy
colorectal
esophageal
Recent SurgeryRecent Surgery
TravelTravel
Symptoms
Weakness
Fatigue
Dizziness
Headache
Chest pain
SOB / DOE
Palpitations
Cold intolerance
Dysphagia
Jaundice
Hematemesis
Diarrhea
Constipation
Melena
Hematuria
Menorrhagia
Pica (clay, dirt,
chalk, ice)
Hematoma
Physical Exam
21
Physical Exam
Ophtho exam
Flame hemorrhage
Papilledema
Exudates
Pallor
Blue sclera
Angular Cheilitis
Iron Deficiency
GlossitisGlossitis
B12 / Folate / Iron
Tachycardia
Jaundice
Liver Disease
Hemolysis
Guiaic positive (gFOBT)
Splenomegaly
Malignancy
Infection
Liver disease
Chronic Hemolysis
Adenopathy
SkinSkin
Pallor
Ulcerations
Scars
Thin/Brittle, Spoon-
shaped nails
Edema
Neurologic
Headache, fatigue
Lack of concentration
Syncope
Paresthesias
Ataxia
Dementia
Essential laboratory tests in the evaluation
of anemia
• Hemoglobin – amount of lysed pigment in a volume
of blood
• Mean corpuscular volume – size of red blood cells
• Red cell distribution width – measure of variation of
cell size
• Red blood cell count – absolute number of red
blood cells per volume
• Platelet count
• White blood cell count
• Peripheral blood smear
Diagnostic approach to anemia
1. Review prior CBCs
2. Take comprehensive history and physical
3. Classify anemia by MCV
– Microcytic (MCV <80 fL)
– Normocytic (MCV 80-100 fL)
– Macrocytic (MCV >100 fL)
• Mild macrocytosis MCV 100-110 fL
• Marked macrocytosis MCV >110 fL
1. Reticulocyte Count (classification of proliferation)
2. Order appropriate additional tests
Case 1
• 52 year old male construction worker with
presenting complaint of fatigue for 2 months. He
now reports getting dyspnea when climbing stairs or
carrying heavy loads at work. He says, “I never go to
doctors.”
• Physical exam unremarkable
• ROS occasional crampy abdominal pain
Case 1
• Hgb 10.2 gm/dl, MCV 68 fL, Platelets
450,000/dL
• How do you classify the anemia?
Case 1
• Serum Iron is low
• Fecal occult blood test is positive
Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.
Features of iron deficiency anemia
• Clinical
– Symptoms of anemia
– Evidence of blood loss
– Pica (very specific)
• Laboratory
– Microcytic anemia (occasionally normocytic)
– Elevated RDW
– Elevated platelet count
– Low serum iron, ferritin and elevated TIBC
28
Fe Deficiency Anemia
29
Iron Deficiency – Etiologies
• History –History – GI (blood loss, diarrhea/constipation),GI (blood loss, diarrhea/constipation),
menses, coagulopathy, urine color (menses, coagulopathy, urine color (cokecoke-colored-colored
[bilirubin] OR[bilirubin] OR redred [hematuria, hemoglobinuria])[hematuria, hemoglobinuria])
• Guaiac stoolsGuaiac stools
– Office DRE
– Hemocult cards as outpatient
• Colonoscopy / EGDColonoscopy / EGD
• PT / APTT, UAPT / APTT, UA
Case 2
• 48-year-old white man is referred for pallor and
unexplained tierdness. He is an executive in a
software company and reports fatigue and dyspnea
during brisk walk
• Physical examination: He is a normal, healthy-looking
man, perhaps pale, with a clean tongue. The results
of his chest, abdomen, and neurologic exams are all
normal.
Case 2
• Hemoglobin 9.2 gm/dl
• Mean corpuscular volume (MCV) 112 fL
• White blood cells 3,400/ul normal differential
• Platelets 89,000/ul
Case 2 laboratory results
• B12 level 100 pg/mL, folate >20 ng/mL
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply.
Schrier, S. ASH Image Bank 2001;2001:100231
Case 3
• 45 year old African-American female presents with fatigue for
6 months. She now only works 6 hours a day at her
secretarial job and is now dyspneic climbing 2 flights of stairs
at home.
• PMH: Hypertension, depression, G6P6
• PSH: C-section x 2, breast biopsy – benign
• FH: Father – multiple myeloma, Mother – DM2 on
hemodialysis, 2 younger siblings are well
• SH: No tobacco or alcohol
• ROS: Joint pains for about 6 months, intermittent chest pain
worse with deep breathing
• Medications: Lisinopril, aspirin, venlafaxine
Case 3
• Hemoglobin 8.0 gm/dL
• MCV 81 fL
• WBC 3,200/uL
• Platelets 450,000/uL
Management of iron deficiency
• Rule out blood loss, reason for negative iron
balance
– Gastrointestinal
– Genitourinary
– Poor iron absorption
– Pregnancy
Oral iron supplementation
• Goal: 150-200 mg elemental iron daily
• Administration
– DO NOT give with food
– Give 2 hrs from antacids
– May give with ascorbic acid 250 mg
• Gastrointestinal intolerance (~20%)
– Decrease daily elemental iron dose
• Switch from sulfate to gluconate or elixir
– Give with food (will decrease absorption)
Reticulocytes
Interpreting reticulocyte counts
• Reticulocytes are erythrocytes new to peripheral
circulation
• Need to correct for degree of anemia
– Reticulocyte index = Retic % x [Pt Hct/NlHct]
– Absolute reticulocyte count = Retic % x RBC number
• Appropriate reticulocytosis
– Reticulocyte index >2%
– Absolute reticuocyte count >100,000/mcl
Anemia in the elderly
10-30% of elderly are anemic
• Consequences
– Decreased physical performance
– Increased mortality in CHF patients
– EPO improved LV function in elderly CKD patients
treated with EPO
• About 30% have “unexplained anemia”
Guralnik J Hematology: ASH Education Book 2005

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Approach to a pationt with pallor

  • 1. Approach to patient with Pallor
  • 2. Learning objectives 1. To understand the importance of proper history and clinical examination in the workup of a patient presenting with pallor in various age groups. 2. Causes and classification of Anemia 3. Interpretation of Lab. Investigations for diagnostic purposes. 4. understanding of ordering specific investigations for confirmation and finding out the cause of Anemia. 5. To describe the management plan of anemia in various conditions and to ensure proper replacement therapy.
  • 3. Pallor • Pale color of the skin and mucous membrane due to deficiency of hemoglobin. (hemoglobin in carried in the RBCs) There are many causes of pallor : Anemia : Most common Heart disease Sleep deprivation Shock : septic , Anaphylactic, Cardiogenic, Neurogenic or hypovolemic
  • 4. Pallor is also seen in case of Endocrine defect : 1.long standing diabetes leading to keratin deposition in the skin 2. Hypothyroidism with or without anemia 3.Hypopituitarism leading to decrease in the melanin stimulatory hormone Pallor is seen in : * Palm creases * Conjunctiva. * And mucous membranes
  • 5. Pallor in mucus membrane of lower eye lid and conjunctive
  • 6. Angular cheilitis (AC) is inflammation of one or both corners of the mouth.
  • 7. Angular chelosis & Glossitis
  • 9. Iron Deficiency Anemia - koilonychia
  • 10. Case Presentation • HISTORY: A 60- year- old male presented with marked pallor, easy fatigability and breathlessness on exertion. On questioning he revealed that he is taking pain killers for his joint pains for the last 3 years. He mentioned about passing dark colored stools off and on. • On examination, he was markedly pale, tachycardia and having spoon shaped deformity of nails. • Blood examination: Hemoglobin 7 g/dl • MCV: 68 fl, MCHC: • Raised Iron binding capacity with serum Ferritin 12ug/l (Normal range 60 or above ug/l)
  • 11.
  • 12. Anemia is defined by • Reduction in Hg Concentration, •Hct Concentration or • RBC count according to the age & sex of the individual
  • 13. 13 Considerations by Age, Sex, and Other Factors 1 of 2 • Newborns less than one week old have hemoglobin of 14-22 g/dl. • By six months , hemoglobin levels are11 and 14 g/dl. • 1 year and 15 years hemoglobin is 11-15 g/dl. • Normal adult hemoglobin depends on gender: – ♀ 12-16 g/dl – ♂ 14-18 g/dl • In geriatric age group, men and women have same hemoglobin range: 12-16 g/dl.
  • 14. Symptoms • Exertional dyspnea and Dyspnea at Exertion • Headaches • Fatigue • Bounding pulses and Roaring in the Ears • Palpitations • PICA is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for at least 1 month at an age for which this behavior is developmentally inappropriate.
  • 15. Etiology of anemia • Iron deficiency 25% • Anemia of inflammation 25% • Hemoglobinopathy 25% • Hemolytic anemia/marrow failure 15% • Myelodysplasia 10%
  • 16. First Step in Evaluation Clinical PresentationClinical Presentation
  • 17. 17 Approach • Detailed History • Review of Systems • Physical Exam • Laboratory Evaluation – Prior documentation of CBC’s – CBC with RETICULOCYTE COUNT – Review peripheral blood smear
  • 18. 18 History Family historyFamily history Spherocytosis Sickle cell anemia Thalassemia DietDiet Vegetarian Drugs/Toxins Infection Alcohol AbuseAlcohol Abuse Folate deficiency Liver disease MalabsorptionMalabsorption B12 Folate Iron Exposure Lead Chemotherapy Peptic UlcerPeptic Ulcer DiseaseDisease DiverticulitisDiverticulitis Colonic PolypsColonic Polyps GI MalignancyGI Malignancy colorectal esophageal Recent SurgeryRecent Surgery TravelTravel
  • 19. Symptoms Weakness Fatigue Dizziness Headache Chest pain SOB / DOE Palpitations Cold intolerance Dysphagia Jaundice Hematemesis Diarrhea Constipation Melena Hematuria Menorrhagia Pica (clay, dirt, chalk, ice) Hematoma
  • 21. 21 Physical Exam Ophtho exam Flame hemorrhage Papilledema Exudates Pallor Blue sclera Angular Cheilitis Iron Deficiency GlossitisGlossitis B12 / Folate / Iron Tachycardia Jaundice Liver Disease Hemolysis Guiaic positive (gFOBT) Splenomegaly Malignancy Infection Liver disease Chronic Hemolysis Adenopathy SkinSkin Pallor Ulcerations Scars Thin/Brittle, Spoon- shaped nails Edema Neurologic Headache, fatigue Lack of concentration Syncope Paresthesias Ataxia Dementia
  • 22. Essential laboratory tests in the evaluation of anemia • Hemoglobin – amount of lysed pigment in a volume of blood • Mean corpuscular volume – size of red blood cells • Red cell distribution width – measure of variation of cell size • Red blood cell count – absolute number of red blood cells per volume • Platelet count • White blood cell count • Peripheral blood smear
  • 23. Diagnostic approach to anemia 1. Review prior CBCs 2. Take comprehensive history and physical 3. Classify anemia by MCV – Microcytic (MCV <80 fL) – Normocytic (MCV 80-100 fL) – Macrocytic (MCV >100 fL) • Mild macrocytosis MCV 100-110 fL • Marked macrocytosis MCV >110 fL 1. Reticulocyte Count (classification of proliferation) 2. Order appropriate additional tests
  • 24. Case 1 • 52 year old male construction worker with presenting complaint of fatigue for 2 months. He now reports getting dyspnea when climbing stairs or carrying heavy loads at work. He says, “I never go to doctors.” • Physical exam unremarkable • ROS occasional crampy abdominal pain
  • 25. Case 1 • Hgb 10.2 gm/dl, MCV 68 fL, Platelets 450,000/dL • How do you classify the anemia?
  • 26. Case 1 • Serum Iron is low • Fecal occult blood test is positive Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.
  • 27. Features of iron deficiency anemia • Clinical – Symptoms of anemia – Evidence of blood loss – Pica (very specific) • Laboratory – Microcytic anemia (occasionally normocytic) – Elevated RDW – Elevated platelet count – Low serum iron, ferritin and elevated TIBC
  • 29. 29 Iron Deficiency – Etiologies • History –History – GI (blood loss, diarrhea/constipation),GI (blood loss, diarrhea/constipation), menses, coagulopathy, urine color (menses, coagulopathy, urine color (cokecoke-colored-colored [bilirubin] OR[bilirubin] OR redred [hematuria, hemoglobinuria])[hematuria, hemoglobinuria]) • Guaiac stoolsGuaiac stools – Office DRE – Hemocult cards as outpatient • Colonoscopy / EGDColonoscopy / EGD • PT / APTT, UAPT / APTT, UA
  • 30. Case 2 • 48-year-old white man is referred for pallor and unexplained tierdness. He is an executive in a software company and reports fatigue and dyspnea during brisk walk • Physical examination: He is a normal, healthy-looking man, perhaps pale, with a clean tongue. The results of his chest, abdomen, and neurologic exams are all normal.
  • 31. Case 2 • Hemoglobin 9.2 gm/dl • Mean corpuscular volume (MCV) 112 fL • White blood cells 3,400/ul normal differential • Platelets 89,000/ul
  • 32. Case 2 laboratory results • B12 level 100 pg/mL, folate >20 ng/mL Copyright ©2001 American Society of Hematology. Copyright restrictions may apply. Schrier, S. ASH Image Bank 2001;2001:100231
  • 33. Case 3 • 45 year old African-American female presents with fatigue for 6 months. She now only works 6 hours a day at her secretarial job and is now dyspneic climbing 2 flights of stairs at home. • PMH: Hypertension, depression, G6P6 • PSH: C-section x 2, breast biopsy – benign • FH: Father – multiple myeloma, Mother – DM2 on hemodialysis, 2 younger siblings are well • SH: No tobacco or alcohol • ROS: Joint pains for about 6 months, intermittent chest pain worse with deep breathing • Medications: Lisinopril, aspirin, venlafaxine
  • 34. Case 3 • Hemoglobin 8.0 gm/dL • MCV 81 fL • WBC 3,200/uL • Platelets 450,000/uL
  • 35. Management of iron deficiency • Rule out blood loss, reason for negative iron balance – Gastrointestinal – Genitourinary – Poor iron absorption – Pregnancy
  • 36. Oral iron supplementation • Goal: 150-200 mg elemental iron daily • Administration – DO NOT give with food – Give 2 hrs from antacids – May give with ascorbic acid 250 mg • Gastrointestinal intolerance (~20%) – Decrease daily elemental iron dose • Switch from sulfate to gluconate or elixir – Give with food (will decrease absorption)
  • 38. Interpreting reticulocyte counts • Reticulocytes are erythrocytes new to peripheral circulation • Need to correct for degree of anemia – Reticulocyte index = Retic % x [Pt Hct/NlHct] – Absolute reticulocyte count = Retic % x RBC number • Appropriate reticulocytosis – Reticulocyte index >2% – Absolute reticuocyte count >100,000/mcl
  • 39. Anemia in the elderly 10-30% of elderly are anemic • Consequences – Decreased physical performance – Increased mortality in CHF patients – EPO improved LV function in elderly CKD patients treated with EPO • About 30% have “unexplained anemia” Guralnik J Hematology: ASH Education Book 2005

Editor's Notes

  1. Hemoglobin is a MEASURED value, and thus is more reproducible in contrast to the hematocrit which is caluclated a subject to other variations such as plasma volume.