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Fundamentals 3- Heme > Clinical Evaluation of Anemia > Flashcards

Clinical Evaluation of Anemia Flashcards

1
Q

What is the definition of anemia?

How is it measured?

A

It is a decrease in circulating RBC mass measured by Hb or Hct (percentage of blood made up by RBC).
Hct = 3x Hb

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2
Q

What are the 5 ways the body tries to compensate for anemia?

A
  1. Increase erythropoietin, RBC production
  2. Increase 2,3 DPG to release O2 to tissue easier
  3. shunt blood from periphery to central organs
  4. Increase CO
  5. Increase pulmonary respirations
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3
Q

A patient is considered to be anemic if the Hb concentration is more than _____________ below the mean for their age and sex.

A

2 SD

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4
Q

What are the three basic causes of anemia?

A
  1. Decreased RBC production
  2. Increased RBC destruction/consumption
  3. Blood loss
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5
Q

Symptoms of anemia can vary depending on what three patient factors?

A
  1. age
  2. CO/respiratory function
  3. onset of anemia
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6
Q

Rapid onset of anemia from acutre bleeding is __________________ symptomatic than chronic anemia and any given Hb. Why?

A

Acute is more symptomatic because chronic allows time for compensatory mechanisms

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7
Q

Why might a person with anemia present with:

  1. pallor
  2. fatigue and weakness
  3. palpations, chest pain
  4. shortness of breath
  5. Bone abnormalities
A
  1. shunting of blood
  2. tissue hypoxia due to decreased O2 delivery
  3. Increased CO
  4. Increased respirations
  5. Increased marrow to compensate
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8
Q

What six questions asked in the history will help narrow down what the cause of the anemia is ?

A
  1. Food intake
  2. Alcohol
  3. Duration of the anemia
  4. Blood loss
  5. family history
  6. medications
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9
Q

What three symptoms and signs would you look for in suspected Fe deficient anemia?

A
  1. angular cheilosis- dermatitis at mouth corners
  2. Koilonychia - spoon shaped nails
  3. Pica - aggressive ice eating, soil eating, etc
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10
Q

What secondary symptom would you notice with a B12 deficient anemia?

A

Neurological changes due to subacute degeneration of the cord

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11
Q

What 4 symptoms and signs would you look for in suspected hemolytic anemia?

A
  1. Jaundice due to increased serum UCB
  2. Dark urine due to bilirubinuria
  3. Pigmented gallstones
  4. skeletal changes-tall skull, high cheekbones
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12
Q

What signs and symptoms can tell you that the anemia may be due to :

  1. cancer
  2. infection
  3. Renal failure
A
  1. weight loss, pain, a mass
  2. fever, sweats, cough, UTI symptoms
  3. Nausea, fluid retention
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13
Q

What are the three potential causes of decreased RBC production?

A
  1. ineffective erythropoiesis/ maturation defects
  2. Marrow failure (due to chemo/radiation etc)
  3. Anemia of chronic disease
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14
Q

What is the normal level of reticulocytes in the peripheral blood?
What happens with decreased red cell production anemia?
What happens with blood loss or hemolytic anemia?

A

0.5-1.5% of the peripheral blood is reticulocytes
In decreased RBC production anemia, reticulocyte counts decrease.
In hemolytic or blood loss anemia, the reticulocyte count increases

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15
Q

What is the most common source of bleeding that causes anemia (specifically in older people)?
What are the 3 ways this can present?

A

Bleeding of the GI tract in men and post-menopausal women.

  1. Hematemesis- vomiting blood
  2. Melena- high GI bleed (stomach, duodenum) that comes out black bc its older
  3. Hematochezia- low GI bleed because its fresh blood so colon/rectum
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16
Q

What are the things you need to assess on a patient suspected of anemia secondary to blood loss?

A
  1. Check acute bleeding with tilt test and orthostatic BP and pulse tests.
  2. Check on-going bleeding with stool guaiac, gastric lavage, urinanalysis
  3. Check “other” bleeding like bruises, petichiae
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17
Q

What is the tilt test?

A

A test to check for acute blood loss.
You take the patients BP and pulse lying down and standing up.
If the BP drops and pulse goes up when they stand, it is a positive tilt test showing acute blood loss

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18
Q

What is the time frame for hemodilution after an acute bleed?
What does this mean for CBCs and smears?

A

24 hours
Within the first 24 hours of the bleed, the blood will be normocytic and normochromic and Hb levels will be normal (because they are a percentage of blood and whole blood was lost).

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19
Q

What would you see on CBC for early chronic blood loss? Late chronic blood loss?

A

Early:
Normocytic and normochromic with elevated reticulocytes
Late:
microcytic and hypochromic with reduced reticulocytes due to acquired Fe deficiency

20
Q

What condition is determined by the presence of :

  1. Howell-Jolly bodies
  2. Pappenheimer bodies
  3. Heinz bodies
A
  1. Asplenia
  2. Asplenia
  3. clumped Hb in oxidized states (G6PD deficiency)
21
Q

If you see a microcytic anemia with low reticulocyte count, is the anemia likely due to blood loss, RBC destruction or impaired RBC production?
What are the possible underlying causes?

A

Low reticulocytes imply it is a problem with RBC production.

  1. Fe deficiency
  2. ACD (Fe stored away)- cancer/inflammation
  3. Thalassemia, Hemoglobinopathy (would have target cells, low RDW and REALLY small cells)
  4. Sideroblastic anemia (REALLY uncommon)
22
Q

What test would allow you to differentiate between Fe deficiency and ACD?

A

In ACD, ferritin will be high, as will hepcidin

In Fe deficiency, ferritin will be low

23
Q

How do you diagnose a thalassemia?

A sideroblastic anemia?

A

Thalassemia-
Run Hb electrophoresis. If decreased HbA, and increased HbA2 and HbF this suggests B thalassemia
Sideroblastic anemia-
Bone biopsy to reveal # of sideroblasts in marrow

24
Q

Describe what you would see in Fe deficient anemia in terms of:

  1. serum Fe
  2. Total Fe Binding capacity
  3. % saturation
  4. Ferritin
A
  1. decrease
  2. increase
  3. decrease
  4. decrease
25
Q

Describe what you would see in ACD for:

  1. serum Fe
  2. TIBC
  3. % saturation
  4. Ferritin
A
  1. decrease
  2. decrease
  3. — or decrease
  4. increase
26
Q

What would you see in thalassemia for:

  1. serum Fe
  2. TIBC
  3. % saturation
  4. Ferritin
A

all normal

27
Q

What would you see in sideroblastic anemia for:

  1. serum Fe
  2. TIBC
  3. % saturation
  4. Ferritin
A
  1. slight increase
  2. normal
  3. normal or high
  4. normal or high
28
Q

What percent of Fe is normally bound to transferrin?

A

about 1/3

29
Q

Iron deficiency is NEVER a ______________. It is a _____________ so you need to look for the underlying cause.

A

Never a diagnosis, and always a symptom of an underlying cause

30
Q

How much iron is in one mL of RBCs?

What are the implications of this fact?

A

1mgFe/mL RBC.
We usually take in 1-2mg Fe a day and excrete 1-2mg Fe a day. Fe is very tightly regulated.
The implication is that even a modest bleed can cause iron deficiency especially in pre-menopausal women

31
Q

If a man is vomiting blood, but is not showing a positive tilt, what information does this give us?

A

The process is chronic.

Acute blood loss shows a positive tilt

32
Q

If blood smear shows a macrolytic anemia and there is a history of alcoholism, what might you suspect the issue to be?

A

A folate deficiency. The ‘empty calories’ of alcohol are replacing leafy greens, etc the person needs.

33
Q

What are two situations where you would see decreased WBC and platelet count in a megaloblastic state?

A
  1. B12/folate deficiency because they are needed for the DNA of the other cell types too
  2. suppressed marrow and splenomegaly due to cirrhosis that can sequester cells and decrease peripheral count
34
Q

What are 7 common causes of increased RBC size?

A
  1. folate/B12 deficiency
  2. liver disease (membrane changes)
  3. alcohol (membrane changes)
  4. Bleeding - reticulocytosis
  5. Myelodysplasia- abnormal marrow stem cells
  6. Drugs
35
Q

If a smear show hypersegmented neutrophils and macro-ovalocytes, what does this suggest?

A

Megaloblastic anemia (B12 or folate deficiency)

MDS would have hyposegmented neutrophils

36
Q

For normal MCV anemias, what must be assessed in addition to Hb and Hct?

A

Platelet and WBC numbers

37
Q

If reticulocytes are low for an anemia, what 3 things must be evaluated?
If reticulocytes are high, what must you evaluate?

A 
Low:
1. Fe status
2. Epo level
3. Renal function (bc it makes epo)
High:
1. occult bleeding
2. hemolysis
38
Q

A child comes in with acute normocytic anemia with no increase in reticulocytosis.
WBC is extremely elevated with “unknown granulocytes”.
What is the likely problem?

A

Because of the low reticulocyte count, we can say that something is probably wrong in the marrow.
The extremely elevated WBC count of “unknown cell” suggest blastic cells (high N/C ratio, immature nuclei)

ALL

39
Q

Jaundice + anemia =

A

hemolysis

40
Q

If a smear shows blister or bite cells, what is the likely underlying problem?
Why do these bite cells form?

A

G6PD deficiency excacerbated by an oxidative stressor.

Hb clumps up and forms Heinz body inclusions which the spleen attempts to remove causing the bite cell

41
Q

How is G6PD deficiency genetically transmitted?
Who would we typically see this mutation in?
What would exacerbate a G6PD deficiency anemia?

A

X-linked
AA males and mediterraneans eating fava beans

Exacerbated by oxidative drugs (sulfa, dapsone, antimalarials), infections (viral or bacterial)

42
Q

Most intrinsic defects are ______ while most extrinsic defects are _________. In both types of hemolysis, the red cells are predominantly destroyed ___________________.

A

intrinsic= inherited
extrinsic = acquired
Both hemolyze RBC extravascularly (a more mild response than intravascular) especially in the spleen

43
Q

What are the three signs of intravascular hemolysis?

A
  1. hemoglobinemia- free Hb in plasma with reduced haptoglobulin levels
  2. hemoglobinuria- pee out excess Hb
  3. Hemosiderinuria- hemosiderin builds in renal tubule cells and when they slough it comes out in urine
44
Q 
You did a CBC and the MCV is low. 
What would you suspect if the smear showed:
1. Target cells 
2. Oval/pencil cells 
3. poikilocytosis and no Fe deficiency
A
  1. thalassemia or hemoglobinopathy (electrophoresis)
  2. Fe deficiency or ACD (Fe parameters)
  3. sideroblastic anemia (do marrow biopsy)
45
Q

You did a CBC and the MCV is normal. Smear is normal.

What is your next move if anemia is still suspected?

A

Reticulocyte count

  1. Low- check renal function, Fe parameters for ACD
  2. High- check occult bleeding and hemolysis
46
Q

You did a CBC and saw MCV. WBC, platelet and/or smear is abnormal. What do you suspect?

A
  1. Check HIV Ab, antinuclear antibody

2. Consider testing bone marrow for neoplasm

47
Q

You did a CBC and MCV was high. Reticulocyte count was low. What do you suspect if the smear shows :

  1. hyper-segmented neutrophils with oval macrocytes
  2. Target cells
  3. abnormal weird shapes
A
  1. B12/folate
  2. liver disease
  3. MDS

Fundamentals 3- Heme (19 decks)

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