Anemia Flashcards
Definition of anemia
Men - < 13. Women - < 12. Pregnancy women - < 11
What does CBC measure
Decreased Hct and Hgb
What does MCV measure
Mean corpuscular volume - measures size of RBC. Normal 80-100
What does MCHC measure
Mean corpuscular hemoglobin concentration - measure how fully the RBC volume is filled with hemoglobin. Normal - 31-36
What does serum ferritin measure
Body’s major iron storage protein and correlates with total body iron stores. Normal 16-300 for men and 4-161 for women. Decreased with iron deficiency anemia
What is TIBC
Total iron binding capacity - Capacity to bind iron calculated from transferrin levels. Normal 250-460. Increased with iron deficiency anemia
What is a reticulocyte count
Immature RBC that are associated with RBC production. Normal 33-137. Decreased in iron deficiency anemia and anemia of chronic disease
Serum iron levels
Plasma iron concentration. Normal 50-175. Decreased in iron deficiency anemia
Types of microcytic anemias
MCV < 80. Iron deficiency anemia and thalassemia
Types of normocytic anemias
MCV 80-100. Anemia of chronic disease. Sickle cell. Acute blood loss. Early iron deficiency anemia
Types of macrocytic anemias
MCV > 100. Vitamin B12 deficiency - pernicious anemia is most common form. Folate deficiency.
Most common causes of microcytic anemias
Men and post-menopausal women from chronic GI blood loss, menstruating women, and children from nutritional deficiencies. May be asymptomatic.
Common symptoms of microcytic anemias
Fatigue, weakness, dyspnea with exertion, and lightheadedness.
Medicine history of microcytic anemias
History of PICA. Medications including antacids, H2 blockers, PPIs, chronic NSAID use, chronic ASA use, use of zinc or manganese supplements.
History of pt with microcytic anemia
History of inflammatory bowel disease or gastric surgery. Family hx of bleeding disorders or colon cancer. Hx of smoking or alcohol intake.
Physical assessment of pt with microcytic anemia
Cannot be reliably diagnosed by clinical presentation. Abnormal physical findings usually found only with severe, chronic anemia. Pallor and poor cap refill, pale conjunctiva, angular stomatitis, atrophic glossitis, tachycardia, spoon-shaped nails, pale palmar creases, brittle nails, cold hands and feet.
Differentials of microcytic anemia
Thalassemia. Lead poisoning. Anemia of chronic disease
Diagnostics with microcytic anemia
Low H&H, low MCV & MCHC, low serum ferritin (most specific and one of first indices to change), high TIBC, low serum iron
Treatment of microcytic anemia
Identify and treat cause. Increase dietary iron. Oral iron supplement. Typical dosing 50-100 mg TID. Normal Hgb usually achieved in 2 months unless continued blood loss. Continue iron therapy for 6 months in severe deficiency. Recheck retic count in approximately 2 wks.
Education of microcytic anemia
Keep out of reach of children. GI upset. Take 2 hr apart from meals, antacids, calcium supplements, fluroquinolones, penicillins, tetracycline, thyroid meds. Increased absorption with vitamin C
Thalassemia
Hereditary. Characterized by reduction in synthesis of Hgb chains. Most common in Asian, African, and Mediterranean descents. If 2 of 4 alpha genes affected - alpha thalassemia minor. If homozygous for defective B chain - B thalassemia intermedia or major. Intermedia or major are move severe and diagnosed within first few yrs of life.
Milder forms of thalassemia and iron deficiency anemia
Must differentiate because treatment with iron in thalassemia can result in iron overload and lead to life limiting organ damage. Minor thalassemia pt will not respond to iron therapy and will have normal iron studies.
History, physical, and management of thalassemia
Most often found by accident. Physical unremarkable. Management - none other than education. Offer genetic counseling.
Vitamin B12 deficiency
Macrocytic anemia - Pernicious anemia most often found in older people secondary malabsorption from lack of gastric intrinsic factor. Also with chronic alcoholism, H. Pylori infection, long-term use of antacids, H2 receptor antagonists, or PPIs, long use of metformin. Dietary deficiency is rare.
Symptoms of vitamin b12 anemia
Irritability, mild memory impairment or dementia, depression, psychosis, personality change, sensory deficits or parasthesias, ataxia, jaundice. Polyneuropathy - onset of hands is sudden.
History of vitamin B12 anemia
Long-term use of acid reducing meds and metformin. Gastric surgery, Chron’s, Whipple, or celiac disease, frequent UTIs, hypofertility, vegetarian, chronic ETOH.
Physical of vitamin B12 anemia
Jaundice. Smooth, shiny beefy red tongue. Polyneuropathies, ataxis, Babinski, congnitive imparement, atrophy of vaginal mucosa may occur.
Diagnostics of vitamin B12 anemia
MCV significantly elevated, but can be normal. Serum B12 level 1 of elevated serum methylmalonic acid or elevated homocystein level. Absence of renal failure, folate deficiency, or vitamin B6 deficiency. Retic count is low. Folate is normal.
Management of B12 anemia
B12 supplement - 1000-2000 mcg/daily. IM - 100-1000 MCG daily or every other day for 1-2 wks, then 100-1000 every 1-3 months. Intranasal as 1 spray once weekly after normal parameters. Treat underlying factors such as alcohol use. Repeat serum B12, homocystein, and methylmalonic acid levels in 2-3 months after starting treatment.
Folate deficiency
Most common cause is inadequate dietary intake. Phenytoin and sulfa drugs may interfere with absorption. Elevated requirements during pregnancy. Recommend 0.4 mg/day to prevent neural tube defects.
Predominant symptoms of folate deficiency
Fatigue, anorexia, gastritis, low-grade fever, dyspnea, palpitations, mild jaundice. Weakness, lightheadedness, and pallor may be seen.
Physical assessment of folate deficiency
Pallor or hyperpigmentation, glossitis, or mild icterus
Diagnostics of folate deficiency
Serum folate < 7, RBC < 305, normal methylmalonic acid with elevated homocysteine indicates likely folic acid deficiency.
Management of folate deficiency
Ensure adequate folate intake. Folic acid 1 mg daily - will replenish in 3 wks. Reduce ETOH intake. CBC 10-14 days after starting treatment should show increased Hgb and decreased MCV. Full response within 8 wks.
Normocytic anemia
Mild or moderate anemia caused by chronic systemic disease. Common cause chronic infection or inflammation from autoimmune diseases, cancer, liver disease, or renal failure.
Symptoms of normocytic anemia
Most are asymptomatic, fatigue, weakness, dyspnea with exertion. History of inflammatory conditions or chronic kidney disease. Likely no specific physical findings. May see pallow
Diagnostics of normocytic anemia
Hgb 8-9.5. MCV 81-99. Low reticulocyte count. Low serum iron concentration, low or normal transferrin, low transferrin saturation, normal or increased serum ferritin
Management of normocytic anemia
Mild may not need treatment. Control underlying condition. Should be managed by provider who is managing underlying disease.
Neck pain and paresthesias - cervical radiculopathy
Compression of cervical nerve roots. Caused by age related changes, injury, herniated disks, muscle spasms. Most commonly affects C6&C7.
Clinical exam of neck pain and paresthesias - cervical radiculopathy
Elevate ROM, Spurling’s maneuver. Palpate for tenderness, muscle spasm, lymphadenopathy. Assess sensory and motor function, DTRs. Treatment - refer if nerve involvement.
Neck pain - strain or sprain
“Whiplash” usually C7 ligament is torn. Full neck x-ray post trauma. If no broken bones - soft c-collar, ice for 24 hrs then alternate, NSAIDS.
Low back pain
80% of adults affected and most common disability.
Clinical exam of low back pain
Inspect, palpate, straight leg raise, ROM, sensory, motor function, DTRs, abdominal exam
Diagnostics of low back pain
None on first visit. If more than 6 wks conservative Rx, then x-ray. If radiculopathy present, refer and let neurologist decide on MRI
Management of low back pain
Usually self-limited - 90% resolve 1-6 wks. Tylenol, NSAIDS, muscle relaxants. Activity as tolerated (no longer than 2 days), walk.
Shoulder pain
Common conditions - diagnosed with history, exam, and plain x-ray
Rotator cuff tear symptoms
Lateral deltoid pain and weakness, “reached overhead and felt something give in shoulder”, “empty can” test.
Treatment of rotator cuff syndrome
Resting, NSAIDS, refer if no better in 6 wks
Management of elbow pain
Rest, ice, NSAIDS, splinting, physical therapy
Management of carpal tunnel syndrome
Neutral wrist position splint - at night, NSAIDS, reduce fluid retention, referral if no improvement
Management of hip pain
DJD - tylenol, NSAIDS, capsaicin. Bursitis - avoid aggravating activities, moist heat, ROM, NSAIDS.
Knee pain - Meniscus tear
Positive McMurry sign. If no mechanical problem - RICE, crutches. Traumatic - refer
Criteria for diagnosis of fibromyalgia
Pain in axial skeleton and all 4 quadrants for 3 or more months. Excessive tenderness of 4 kg of point pressure in 11 of 18 specific tendon sites.
Intertrigo
Inflammation of skin folds caused by friction between skin surfaces. Macerated areas are susceptible to bacterial and fungal infection. Co-morbidities such as diabetes may worsen infection. Treat with antifungal powder and keep dry.
Treatment of mild acne
Topical meds only - Retin-A, Differin, Azelex. Improvement in 6-8 wks.
Treatment of inflammatory acne
Topical agents - single or combined - e-mycin, clincamycin, benzoyl peroxide
Treatment of moderate and severe acne
Moderate - oral antibiotics, oral contraceptives. Severe - Accutaine - referral to dermatologist.
Treatment of rosacea
Mild soaps or cleaners. Exfoliating agents should be avoided. Use mild moisturizers daily. Sunscreen is strongly recommended. Avoid triggers - physical, food, emotional, temperature, dairy, citrus, hot or alcoholic beverages, cosmetics
ABCDEs of skin cancer
Asymmetry. Borders are irregular. Color change or variation. Diameter larger than pencil eraser. Elevation from a flat lesion to a raised one.
