Dr. Pence - Anemia Clinical Diagnosis And Management Flashcards
Anemia : is what and can happen due to what
Low RBC mass
- TH : low
- ERP : low (chronic kidney disease)
- Testosterone : lower
- Fe+3 : low
- VIT B12 : low
- Folate : low
Anemia Sx
- fatigue
-Dyspnea - pre-syncopal sx
- pale conjunctiva
- Pale skin
- lines on nails
(Can be sleep deprivation)
In the cross that Dr. Pence has what is in leach space (X)
TOP : Hgb
BOTTOM : Hct
LEFT : WBCs
RIGHT : Plt
Hct normal
Hgb normal
Reticulocyte count Index
Hct : 37%-54%
Hgb : 12-16 F, 14-18M
R county Index : > 2 means BM is responding to an anemia
Normocytic MCV
78-98fL
RDW is what and normal range
Variation in size of RBC
12%-15%
High variation is more in anemia (esp, in Fe+3 deficiency)
LDH
Lactate Dehydrogenase
= high inside blood and tissue
= high level if tissue damage or hemolysis
Indirect (unconjugated bilirubin)
Breakdown product of RBC
High is hemolysis
Haptoglobin
Plasma protein binding to free hemoglobin
= LOW if there is hemolysis
Iron Studies what it means :
Ferritin
Transferrin
Total Iron Binding Capacity
Ferritin : Fe storage , best way to measure amount of iron in blood
Transferrin : iron transporting protein (high during anemia = TIBC) = to confirm Fe+3 deficiency anemia
= low in Anemia of chronic disease
When can Ferritin be high
- high Fe*
- inflammation *
- autoimmune *
- infection *
Anemia + low reticulocyte count
What do I do now
Check MCV
Anemia and Reticulocyte count is high
What do I do now
Reason through if it is blood loss or consumption issue
- LDH, Haptoglobin, Bilirubin = hemolysis
- find bleed
EX of high reticulocyte count anemia
- chronic bleeding
-
EX of low MCV anemia
- Fe+3 deficiency (IDA)
- Thalassemia
- SC
- Sideroblastic
EX of normal MVC anemia
- renal disease
- BLOOD LOSS
- ANEMIA or CHRONIC DISEASE (ACD)
EX of anemia with high MCV
- Folate deficiency (megaloblastic)
- B12 deficiency (megaloblastic)
- Hypothyroidism
- EtOH
- MDS (macrocytic only)
CASE 1 : male 68yo, 3mo of easy fatigabilty, dyspnea on exertion Fingernails tear, looks skinnier, drinking pain used on car , nails are curled and lines PE : pale and conjunctiva pallor bilaterally, inflammation on corner of mouth - low Hgb - low Hct - normal WBCs and Plt - low reticular count -MCV LOW - high RDW - low ferritin, and high Transferrin - Transferrin saturation % = LOW = what is it and what do you do
= Fe+3 deficiency (IDA)
due to the high transferrin = high Total Iron Binding Capacity
Low T sat = stored/capacity
= find out reason, change in bowel habits, blood in stool, vomit blood, diet….
Male 68yo with IDA has blood in stool what do you do
Colonoscopy and colon cancer
35yo male fatigued started 60month before Wrist hand and knee swollen bilaterally = morning stiffness Takes NSAIDS don’t help - low Hct - low Hgb - normal WBC and Plt -low reticulocytes - MCV NORMAL - RDW : N - Fe+3 LOW - Ferritin HGIH - Transferrin Low - Trasnferrin Sat LOW
Anemia of Chronic Disease (ACD) (malignancy, infection, autoimmune like RA)
How does inflammation increases Ferritin
Inflammation :
- Decreased absorption of Fe
- Decreases EPT production
- Increases HEPCIDIN : increases Ferritin and lowers Transferrin/Ferroportin
How to TX ACD
- TREAT cause of the anemia
(Don’t give Fe+3 supplements without knowing cause of problem)
** if there is CKD or malignancy = give Erythrocytes Stimulating Factor (ESF) , can give thrombosis however improves anemia
Blood transfusion should be given to
Only for rotations
Hgb less then 7 or 8 if pt has acute coronary syndrome or problems
35yo males epigastric pain 3months ago onset, 3 episodes of coffee ground emesis (past 24hrs), OTC antacids help, NSADS taken regularly for various injuries, ABD distention - Tachy, hypotension, cool extremities = not good HYPOVOEMIC SHOCK - pallor - VERY low hgb (6) -low Hct - normal WBC, plt - retic count normal, RI low MCV : normal
UGIB and in hemorrhagic shock
- normal retic count - since it’s acute bleeding
- RI is usually high in acute bleeding so its low here because : BM has not been able to start making more
Normocytic anemia + normal reticulocyte count when there is hypovolemic shock is now
Hemorrhagic shock
Uncompensated blood loss —> BM has not had time to compensate
What can happen from anemia from acute blood loss
Renal failure
MI
Hypovolemia
TX hemorrhagic shock
- Apply pressure and compression when you can
- Give blood and fluid (2 IVs), O- blood
- Surgery and suture up the bleed
If someone is visibly bleeding and there Hgb is normal what do you do
Give them blood and fluids still
who makes Anti-D AB
Someone who is Rh-
What to do if mom is Rh- and fetus is Rh+
Give Rhogam to mom (it is a drug antibody against the Anti-D AB)
4yo AA right leg pain in hip, trauma moved states to higher elevation
- SOB when playing,
- FH of blood in urine, and anemia
- tachy, and HTN, 91% O2 sat
- crackles in left base lung
- LUQ tenderness and fullness
- low Hgb and low hct
- WBC and plt low
- MCV low
- RDW HIGH
- Retic count is low , RI low
He has SC
And osteonectrosis in hip femoral hip
Usually a SC crisis has a high Retic count however it can be low also
= give opioids
= transfusions to reduce HgS less then 30 (high alloimmunization + FE iron overload)
3 common presenting sx of SC
- Microvascular occlusion
- Tissue damage
- Chronic Hemolysis
- Stroke
- Thrombosis
- Acute Chest Syndrome : fat thrombus from the necrosis of a bone (pulmonary infiltrate on CXR, hypoxemia, SOB, fever) pneumonia **
- Kidney/spleen problems
Acute Chest Syndrome how to TX
= give pneumonia medication (in case)
=transfusion and O2 given
Kidney problems in SC
- Polyuria (can’t concentrate urine)
- Hematuria (even SC trait can have it)
- Vasocclusion of small vessels
Osteomyelitis is what
Fever and hip pain (infection in the dead bone)
Spleen problems in SC
Hypovolemia
Splenomegaly
Autosplenectomy (splenic infarcts)
No spleen casuals what common things
Encapsulated infections
Dots in the RBCs
How to TX SC crisis
- Start O2 and exercises (blow in from a tube as much as you can to expand the lung)-center spirometer
- Control pain : opioids, NSAIDS, Tylenol (to help breathing, oxygenation, hostle behavior)
- Check in on them often (like after 4hrs)
What can cause SC crisis
Cold weather and high elevation
Hydroxyurea
Upregulate HgF
Downregulate HgS
= for SC patients
= can cause FE overload
Exchange transfusion in SC
Take out there old blood put in new blood
- prevents iron overload
Stem cell transplant in SC
Only for under 16yo
Can be curative
With 10% mortality rate
25yo female with 1 week fatigue, weakness, dizziness, red spots all over the shoulder where she has her purse , gingival bleeding, - she had a UTI and was TX with ABs - pale and tired, conjunctival pallor, petechiae - low Hct - low Hgb - low WBCs - Low plt - MVC HIGH - Retic count low, RI low - normal RDW - BM only fat -
Panocytopenia **
Aplastic Anemia
What can cause AA
Drugs
Virus
Radiation/benzene
Fanconi anemia
AA TX
Transfusion support and Growth factor support
= if nothing then stem cell transplant (young respond to this more
B12 foods
Dairy, cheese, fish, meats, fortified food
Deficiency happens over years
Other name for B12
Cobalamin
B12 deficiency can happen from
Diet Gastrectomy Crohn’s disease Gastric bypass Pernicious anemia
B12 deficiency confirmed by
HGIH Methylmalonci acid and Homocysteine
Low B12 vitamins
Folate Deficiency confirmed how
High homocysteine only
Other name for Folate
VIT B9, folic acid
Takes some months
Folate deficiency can happen from
Diet Crohns celiac Pregnancy Mx like Methotrexate (SLE,RA)
Folate in absorption is where
Jujunnium and lillium
Low MCV
Normal RDW
ACD
Normal MCV
Normal RDW
ACD
HIGH MCV
Normal RDW
Chemo, Anti-viral medication, alcohol in excess,
APLASTIC ANEMIA
Low MCV
HIGH RDW
IDA
