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HEME > Evaluation of Anemia > Flashcards

Evaluation of Anemia Flashcards

1
Q

What sorts of signs on a physical exam indicate severity of anemia?

A

tachycardia, tachypnea, orthostatic hypotension

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2
Q

What sorts of signs on a physical exam point to possible causes of anemia?

A

Pallor
Facial structure (maybe an indicator of thalassemia if you have “chipmunk facies)
Oral mucosa (glossitis, look for ulcers on sides of lips, red beefy tongue or atrophied glossy one)
Hands (shortened fingers, brittle nails, spooning nails etc)
Hepatosplenomegaly (often seen as a distended abdomen)
Lymphadenopathy
Telangiectasia

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3
Q

what’s a key sign on physical exam of CML?

A

Cachexia plus hepatosplenomegaly comes with chronic myeloprolif. disorders like CML

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4
Q

how can hereditary hemorragic telangictasia lead to anemia?

A

You have a bunch of venous and arterial malformations, so these people have leaky vessels in the GI tract… chronically losing blood in GI tract–>ANEMIAAA

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5
Q

Recall, two signs of iron deficiency?

A

Glossy tongue and spooning of nails

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6
Q

What’s the most important lab indicator for iron deficiency

A

FERRITIN LEVELS (they will be dizzown)

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7
Q

Normal Hemoglobin Levels

A

14-18 in men, 12-16 in women

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8
Q

Normal Hematocrit Levels

A

37-42 in women, 42-52 in men

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9
Q

Normal WBC Count

A

4,800-10,800

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10
Q

Normal RBC Count

A

4700-6100 in men, 4200-5400 in women

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11
Q

Normal Reticulocyte Percentage

A

0.5-2.5%

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12
Q

What disease do you see sickle shaped cells in?

A

Sickle Cell Disease DUH

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13
Q

What disease do you see target cells in?

A

both types of Thalassemias

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14
Q

What disease do you see Schistocytes (fragmented cells) in?

A

microangioplastic diseases (3 of them…TTP, DIC, Hemolytic Uric Syndrome)

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15
Q

What disease do you see Blister Cells in? Also wtf are blister cells?

A

seen in G6PD Deficiency,
they’re a bubble like thing, with a stained rim, protruding out of red cells

you will also see bite cells in G6PD deficiency

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16
Q

What disease do you see Tear Drop Cells, aka dacrocytes in?

A

infiltrative disease of the bone marrow (Example being fibrosis)

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17
Q

What disease do you see Microspherocytes in?

A

autoimmune hemolytic anemias, tranfusion rxns, or hereditary spherocytosis

these have fragile cell membranes, so they burst bc of osmotic pressure

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18
Q

When do you see howel jolly bodies?

A

Spleen removed, or sickle cell autosplenectomy, because they are little remnant pieces of DNA, which would otherwise be removed if your spleen was functioning

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19
Q

How can you tell the difference between howel jolly bodies and heinz bodies?

A

first of all, they are different things. Howel Jolly bodies are dna remnants, whereas heinz bodies are precipitated pieces of hemoglobin.

also heinz bodies are only visible in microscopy if they are stained with supervital new methlyene blue stain. NOT visible on normal H+E stains

Howel Jolly stain blue because they are nucleic acid stuff

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20
Q

If you see trophozoites in a red blood cell, what is on your differential diagnosis?

A

malaria

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21
Q

Hypersegmented neutrophil (5-6 or more nuclear lobes) is an indication of what?

A

megaloblastic anemia

22
Q

Bisegmented neutrophil (hyposegmented) is indicative of what?

A

sign of myelodysplasia and Pelgett Huet anomaly (a congenital defect)

bisegmented neutrophil is NOT a band…there is a clear thin bridge between the two lobes to indicate segmentation

23
Q

Chronic Lymphocytic Leukemia…microscopic indications?

A

most of your cells will be lymphocytes
you will see smudge cells, which are essentially red blood cells that were so fragile that they broke apart in the slide prep of the blood smear

24
Q

What is the best way to check for inadequate bone marrow production in anemia?

A

a reticulocyte count. if you have an anemic patient, their reticulocyte count should be elevated to compensate for the loss of RBC’s

25
Q

Normal Reticulocyte Absolute Count

A

25-125 x 10^9 cells.

26
Q

Calculation used for Corrected Reticulocyte Percentage

A

reported reticulocyte percentage x (hematocrite/45)

27
Q

True or False: you have an anemia with an elevated reticulocyte count, so the problem is bone marrow production

A

FALSE, that means your bone marrow is cranking out excess reticulocytes as expected in anemia

28
Q

If you have anemia with an elevated reticulocyte count, what should be the next potential?

A

maybe acute GI blood loss?

29
Q

To confirm Hemolysis, what lab values would be elevated? what lab values would be low?

A

elevated: LDH, Bilirubin, Plasma Free Hemoglobin (in intravascular hemolysis),
decreased: haptoglobin levels (which binds to free hemoglobin)

30
Q

If you suspect someone has hemolyzed, but all of the typical lab values (LDH, Bilirubin, Plasma Hemoglobin, Haptoglobin) are normal, what’s the next molecule you would check for?

A

Well so first, the values may be normal because the hemolysis occurred like a week ago. In that instance, check:

Urine Hemosiderin (in intravascular hemolysis) you release hemoglobin, it filters to glomeruli, to renal tubules, taken up by renal tubules, so if you collect a urine specifimin, and you stain the renal tubules with prushin blue stain, youll be staining the hemosiderin

31
Q

Intravascular Hemolysis vs Extravascular Hemolysis?

A

intravascular hemolysis is generally mediated lyses of the RBC, whereas extravascular hemolysis involves phagocytosis by RES system (reticuloendothelial system…or macrophages)

32
Q

How does a Direct Coombs test work?

A

Well, the point is that you are checking if a certain blood sample has specific antibodies (usually autoimmune ones) or complement molecule.

So you have a blood sample, and you add an anti-human-antibody to the sample.

POSITIVE TEST: the anti-human-antibody WILL bind to the autoimmune antibodies or complement molecule you are testing for, causing agglutination

NEGATIVE TEST: since there aren’t actually any autoimmune antibodies stuck to the red blood cells, the anti-human-antibody WILL NOT bind to anything. no agglutination

33
Q

Direct Coombs test for Warm Autoimmune Hemolytic Anemia will be positive for what?

A

Antibody and complement

34
Q

Direct Coombs test for Cold Autoimmune Hemolytic Anemia will be positive for what?

A

complement

35
Q

Indications for a bone marrow exam?

A
  1. Multiple cell lines affected
  2. Unexplained anemia with a low reticulocyte count (bc that means the reticulocytes count isnt responding as expected)=unresolved hyporegenerative anemia
  3. abnormal cells in peripheral blood (most often malignant)
36
Q

What is hyporegeneratiave anemia?

A

anemia with Unresponsive reticulocyte count

37
Q

What are the four categories for types of anemia?

A
  1. Decreased prod
  2. Increased destruction
  3. Blood loss (usually figured out by history)
  4. Sequestration (almost always history and physical) the large spleen that soaks up your blood. –you have excessive pooling of blood in the spleen
38
Q

In increased destruction of RBCs is your reticulocyte count up or down?

A

up (as expected)

39
Q

In decreased bone marrow production of RBCs is your reticulocyte up or down?

A

down or normal (baddddd)

40
Q

if a direct coomb’s test is positive for complement on a differential for increased destruction, what’s the next step to check the dx?

A

Is the direct coomb’s test for antibody positive in warm temperature? if it is…warm autoimmune hemolytic anemia

if it’s not…cold autoimmnune hemolytic anemia

41
Q

if your direct coomb’s test is negative for a increased destruction of RBC situation, what’s next?

A

do a peripheral blood smear and see if schistocytes are present

42
Q

if you do a peripheral blood smear and schistocytes are present, what types of hemolytic diseases are you thinking of?

A

microangioplastic diseases
prosthetic heart valves
hypertension caused by a malignancy

43
Q

if you do a peripheral blood smear and you DON’T see schistoctyes, what cells would you see that would indicate thalassemia?

A

target cells

44
Q

how do you distinguish between alpha and beta thalassemia with tests?

A

check hemoglobin levels for HbA2 and HbF with hemoglobin electrophoresis…elevated values of these=beta thal

45
Q

Bite cells and/or blister cells on a blood smear would indicate what cause of RBC destruction?

A

GP6D Deficiency. you will also see heinz bodies if you stain the slide with a special stain…bite cells occur when the spleen’s macrophages eat out the heinz bodies

blister cells look like these bubble spheres pushing out of the RBC

46
Q

If you determine that the RBC destruction is NOT due an autoimmune disease, NOT due to microangioplastic disease, and NOT due to congenital diseases..what’s left?

A

acquired diseases
1. a mutational disease like Paroxymal Nocturnal Hemoglobinuria (do flow cytometry for PGI..the anchoring protein…Strom calls it PIG idk why)

  1. Infection (malaria maybe???)
  2. Lead poisoning (not really sure how this causes hemolysis but whatever it’s in his notes)
47
Q

Big picture…8 possible causes for decreased production of RBC’s and subsequent anemia

A 
Nutritional (B12 and folate)
Infectious (HIV, TB)
Inflammation (chronic rheum arthritis)
Endocrine (hypopituitary, hypothyroid)
Metabolic (renal insuff...means not enough EPO prod)
Toxins (drugs and alcohol)
Bone Marrow Failure
Infiltration (fibrosis, tumor)
48
Q

If you have a macrocytic anemia, what’s the first differential to make?

A

is my retic count low (look for b12 def/folate def next)

or is my retic count high (look for hemolysis or acute blood loss)

49
Q

if you have macrocytic anemia with a low reticulocyte count, but your b12 levels and folate are normal, what do you look for next?

A

if your b12 and folate levels are normal, than it’s NOT a megaloblastic anemia. next step:

look for other causes for macrocytic anemia besides megaloblastic anemia!
-alcohol levels to check for alcoholism, TSH (thyroid stim hormone) to check for hypothyroidism

50
Q

if you have microcytic anemia, what’s the first differential to make?

A

are my ferritin levels high or low

elevated ferritin–>iron deficiency

51
Q

if you have a microcytic anemia with low or normal ferritin levels, what’s the next differential?

A

check your hemoglobin via hemoglobin electrophoresis…you gotta rule out beta thal

if your hemoglobin comes out normal, you gotta rule out alpha thal by checking RBC Count.

Alpha thalassemia (in the US at least) comes with a NORMAL or HIGH rbc count…because it’s probably alpha thal type 2 if the person is african american

52
Q

if you have a microcytic anemia, low or normal ferritin levels, normal hemoglobin levels, BUT LOW RBC COUNT…

A

yea…go do a whole anemic workup, because now you’re back to trying to figure out if the low RBC count is from increased RBC destruction or decreased production

HEME (4 decks)

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