Anemia and Bleeding

Question 1

What History or questions with anemia

Answer 1

• Duration of symptoms?- Chronic vs acute
• Episodic?- Drug or illness driven?
• Associated symptoms?
• Jaundice/dark urine= hyperbili=hemolysis
• Medications
• Iron source in diet?
• Family Hx- early gallstones, food intolerance, etc.

Question 2

Review of symptoms in anemia

Answer 2

• Feeding?
• Bruising/bleeding
• Rashes
• Joint/Bone pain
• Fevers
• Other symptoms: viral syndromes in past couple weeks

Question 3

PE in anemia pt

Answer 3

• CV: Tachycardia, murmur, CHF (feeding problems)
• Lungs: Crackles, wheezes
• Liver/spleen enlargement
• Ascites/edema
• Pallor (palmar creases-lighter color)

Question 4

Lab eval in anemia

Answer 4

• Basic workup: CBC, Peripheral smear, retic count. Bilirubin, DAT (Coombs Test), UA
• Focused workup: Depends on Hx/PE. Includes iron studies, osmotic fragility, Hgb electrophoresis, G-6PD
• Retic: gauge RBC production rate
• RDW: Gauge homogeneity of RBC population.

Question 5

Cell size normocytic, retic increased. Likely Dx?

Answer 5

1) Blood loss
2) Hemolysis
3) AIHA

Question 6

Cell size normocytic, decreased retic. Likely Dx

Answer 6

-Anemia of chronic disease

Question 7

Cell size macro, increased retic. Likely DX?

Answer 7

• Blood loss

- Hemolysis

Question 8

Cell size Macro, retic decreased. Likely Dx?

Answer 8

• Folate/B12 def.
• Drug induced
• Marrow failure
• AIHA

Question 9

Cell size micro, retic decrease. Likely Dx?

Answer 9

• Iron def.

- AIHA

Question 10

Cell size micro, retic increased. Likely dx?

Answer 10

• Thalassemia

- AIHA

Question 11

Iron deficiency anemia would look like what under microscope?

Answer 11

-Microcytic, hypochromic aregenerative anemia.

Question 12

Leading cause of anemia in Children? And leading cause of MR and LD in children?

Answer 12

Iron deficiency

Question 13

Pathophys of Iron deficiency? (3)

Answer 13

1) Inadequate dietary intake
2) Excessive consumption (growth spurt)
3) Excessive loss (GI blood loss, menses, pulm bleeding, excessive sports in children/teens)

Question 14

Treatment of Iron deficiency

Answer 14

• Find site of blood loss.
• Iron replacement- Ferrous sulfate 3-6 mg Elemental Iron/Kg/day TID- Retic increase in 3-5 days, Hgb increases 0.25 grams/dl per week, treat 4-6 months. Replace BM stores and stores elsewhere.
• Patients with Chron’s or other problems that dont respond to Ferrous sulfate can be given IV iron

Question 15

What is this: Clinical syndrome where there is just about enough iron to make a normal Hgb, but no reserve. Common in teen girls (diet restriction, menstrual loss, exercise). What can this cause in pregnancy?

Answer 15

Non Anemia (latent) iron deficiency
-Iron deficient babies- neurologic problems, lasting behavioral and intellectual defects.

Question 16

The most common form of anemia in adults. Second most common in childhood. Seen with common infection. Stimulation of inflammatory processes.

Answer 16

Anemia of Chronic Dosorders

Question 17

What does Anemia of Chronic disorders look like under mcroscope

Answer 17

Normocytic/Normochromic anemia

Question 18

Anemia of Chronic disorders lab features

Answer 18

• Transferrin low
• Serum iron low
• Serum transferrin receptor low
• TIBC low

Question 19

Bleeding disorders come from three sources. Match number with letter:

1) Vascular phase
2) Platelet Phase
3) Humoral phase

A) Thrombocytopenia, VWD
B) Ehlers-Danlos Syndrome
C) Hemophilia, DIC

Answer 19

1-B
2-A
3-C

Question 20

Each phase has a pattern of bleeding:

1) Humoral:
2) Vasc/Platelet

Answer 20

1) Bleeding into soft-tissue/joints

2) Muco-cutaneous bleeding

Question 21

Bruises age and change color. How old is a…

1) Red (swollen tender)
2) Blue
3) Green
4) Yellow
5) Brown
6) Clear

Answer 21

1) 0-2 days
2) 2-5 days
3) 5-7 days
4) 7-10 days
5) 10-14 days
6) 2-4 weeks

Question 22

Nosebleed Lab Eval

Answer 22

Evaluate the phases of coagulation:

• Platelet phase:
  1) CBC with platelet count
  2) Platelet fxn tests
  3) bleeding time (also vascular phase)
• Humoral Phase:
  1) prothrombin time
  2) Partial thromboplastin time

Question 23

PTT normally 34-36 sec. What about a kid with PTT of 38. WHat is DDX? and what is work-up

Answer 23

DDX:

• Lab error
• Vit K def (Antibiotic, diet)
• Mild hemophilia or VWD
• Normal variation
• Inhibitor

Work-up:
-If recent diet or AB concerns, give vit K for 2 weeks and repeat. If still abnormal, do a mixing study.

Question 24

After a mixing study if you have a:
1) Corrected PTT
2) Uncorrected PTT
What do yo look for

Answer 24

1) Factor levels: VWF

2) Inhibitor search: Lupus anticoagulant panel, anticardiolipin IgG and IgM, anti B2 microglobulin

Question 25

1) Classical or Hemophilia A is deficiency of factor ____.

2) Hemophilia B, or christmas disease is deficiency of Factor ____.

Answer 25

1) VIII

2) IX

Question 26

How to treat hemophilia

Answer 26

-Give factor
~FACTOR VIII: 50 units/kg IV as bolus then 4 units/kg/hr IV continuous infusion startings ASAP after bolus
~FACTOR IX: 100 units/kg IV as bolus then 5 units/kg/hr IV continuous infusion
* In emergencies, give factor BEFORE you image patient.

Question 27

Deficiency of normal VWF fxn due to either deficiency or mutation of the protein. WHat are common subtypes?

Answer 27

Type 1: deficiency
Type 2: mutation
type 3: No detectable factor

Question 28

T/F: VWF is estrogen dependent

Answer 28

True- important to get menstrual hx. Also bleeding after child birth

Question 29

Von Willebrand Disease prolongs PTT due to deficiency of VIII which is stabilized by VWF. Treatment with:

1) Agent to increase VWF
2) Factor concentrates
3) Antifibrinolytics

Answer 29

1) DDAVP (Stimate)
2) Humate P and Alphanate SD
3) Amicar

Question 30

What is Immune Thrombocytopenic Purpura

Answer 30

Immune attack on platelets.

• Opsonization rather than lysis
• -In pre-pubertal kids, usually post viral infection by a couple of weeks.
• If platelets drop low enough, small bleeding sites (petechiae) form
• Acute <1 yr

Question 31

Treatment of Immune Thrombocytopenic Purpura

Answer 31

1) Observation
2) IVIG
3) Prednisone
Second line: WInRho SD, Rituxan, Splenectomy