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Anemia!

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ali ramaeker

on 15 June 2016

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Transcript of Anemia!


leading cause
of anemia
most common-
GI BLEED, PUD
OR MALNUTRITION
must rule out Gi bleed
Others: nsaids heavy periods, pregnancy
chronic blood loss
not diet
Siderblast
Anemia of chronic disease
what: herditary underproduction of

alpha and beta leading to RB hemolysis
alpha:
SE asia, china,
Middle east
gene deletion
beta:
mediterranean
Alpha major: barts hgb,
heniz body/target cell/tear drop
1 nml gne; pallor, hepatospelnomeglay, anemia, frontal sull/mxilla overgrowth
side effects: still birth
hydrops fetalis (hcg barts)
they have no response to iron therapy. genetic.
tx: peripheral smear (heniz body/tear drop) inc RBC. low mcv.
tx: only if severel transufions and iron chelating agests.
b-Major: cooley anemia
problems at 4-6mo old: swtich from Hgb F to adlts Hgb A.
basophillic stripping
sxs:
severe anemia,
growth retardation, abnormal facial
structurs, bone deformtities,
janudice, splneomelgaly. ftt.
osteopenia. sob. cardiac failure by age 30
Dx:
hemoglobin electrophoresis.
labs: hypocrhomic microcytic red cells, anisocytolis and poikilocytois (shape)
Normal: fe, tibc, rdw. increaed ferritin.
microcytic target cell
DO NOT GIVE IRON!!!!
tx:
transufsions, allogenc bone marrow transplant, splenectomy and folic acid
+ chelation: only if have the disease, not a carrier.
genetic testing. prenatal diagnosis
Fe Deficinecy:
b12 deficient
what:
lack of i
nstrinsic factor
to absorb b12 at the
terminal ilium

cause:

chrons,

poor diet,

gastrectomy,
ppi, metform, no intrinsic factor,
vegans (meat contains b12),
pancreatic infusfficieny
features:
sore tongue, glossitis, smooth tongue, cheilosis, pale icterus, vague GI pains
neuropahty
-
stocking/glove
loss of fine touch. vibration. dementia. ataxia. clumsiness. AMS
psinal cord: d/c: vibratory sensory ; weakness; ataxia babinskis/increase DTRs
incontinece
impotence
dx
schilling test- perncious anemia- low b12
macroovalcytes.
anioscytosis.
hypersemented neuts.
poikilcytosis
low b12. low retic <2.
high MMA + homocysteine.
low hepatoglobulin
anti-intrinsice and anti-parietal cells
tx:
IM b12. watch for high k
folate
what:
low folate levels due to poor dietary intake
+ (takes place in jejunem)
preggers
diet/etho abuse/anorexia
inadequate intake of fruits/veggies
hemolysis or hemorrage
folic acid antagonists: bactrium. pehytoin. sulfasalazine
sxs:
incontinence
NO NEUROPATHY
sore tongue (glossitis)
vague Gi complaints/diarrhea
dx:
low folate. elevated homocysteine
howell jowell bodies, hypersegmented neuts, macro ovalocytes
Treat:
folic acid.
avoid etho.
Thrombocytopenia
what: low plateletes
cause:
impaired production- folate, b12, marrow damage from leukemia
destrction: HIT, ITP, HIV, SLE, DIC, TTP, HELLP
labs: PT, aPTT:, PFA: normal Low platlet count.
Von Willie: heparin/ptt pathway/intrinsic
what:
decrease in
factor VIII antigen.

sticking/aggregation
and
adhison of plateles
for clotting
AD disorder
features: cutaneous bleeding, epistaxis, easy brusing, menorrhagia, petchiae/purpura, tooth extration excessive bleeding from scratches/cuts
.
d
x: prolonged BT.
aPTT: increased/prolonged Extrinsic
decreased Factor V111.
ristocetin co-factor is down
tx:
demospression and factor 8
. avoid nsaids/asa.
Hemophila A:
xlinked recessiv
e = males. factor V111 deficient
excessive
coagulopahty time
features;
hemarthorsis, intracrnial bleeding, intramuscular hematoms.
hematuria. melena.
dx:
proloned PTT
and
low factor VII
I C
normal PT, PFA, firbinogen, plalets
tx: infusion of VIII. desmopresin could elevate factor VIII
Microcytic
Macrocytic
bleeding disorders
Anemia!
Other Blood Disorders
Anemia:

What RBC transport hgb
hgb = oxygen carrying capacity of the cell
- oxygen, coarbon dioxide, carbon minoxide, nitric oxide
low hemoglobin - degraded into indirect hemoglobin --> liver--> gallbladder
high indriect: hemolysis of filbert
low hematocrit
the percent of RBC to total bloodvolume
low RBC - mature reticulocyes that are made in the bone marrow from epo (released from kidency) that tranport hemolgobin.
retics tell if the bone marrow is working
>2: hemolysis - bone marrow is working
<2: bone marrow is not working/lack of epo or nutrients
polycytghemia: elevatedhemoglobin, RBC, hematocrit
sxs:
tachycardia. SOB. fatigue. hypotension. arrythmias. smooth tongue (b12/folate, fe). diarrhea. restless legs. brittle nails. GI. pallor. lethargy. faintness. exertional dypsnea.
crhonic: hyerkinetic ciruculation: large pulse volume. tachy
smooth tongue: nutritional deficienes: iron, folate, vit b12
prolonged bleeding, epistaxis, gum bleeding, ehavy menses, easy brusisin- vWD

PE:
jaundice. GI bleed (melana)/rectal bleed. dark urine. pica.
jaundic is seen more with indirect bill
indirect hyperbili:
inc destruction of RBC exceeds liver capacity to conjugate bilirubin from destroyed RBC (cilders, heaptitis)
direct: dark urine
- enhanced urine excretion =
hemolysis
dx markers:

LDH (increase w/ destroyed RBC-aka: hemolysis).
heptoglobin: low b/c they bind RBC
TIBC:
amt of
tranferring
around to transport Fe
INC transferring/TIBC: ifron deficinent aneiam
dc: anemia of chornic disease (overloaded state)
TIBC sat: % saturated w/ iron
ferritin: stores FE (decreased if low Fe)
low: fe deficient
high: anemia of chornic isease
Fe
differentiate fe deficinecy from chronic disease
fe deficiney: low ferriting and high tibc
chronic: high ferritin and low tibc
Tx:
Labs: low hg/hmct
reticulocyte count: immautre RBC
>2: destruction
(+ coombs): blood loss/hemolytic
<2: decrease RBC
production.
Microcytic: Fe, chornic dz, lead, thalessemia
macrocytic: B12 or folate
normocyctic: anemia of chronic disease- but it can be all three
MCV: 80-100
Retic's: <2
sxs:

pica
. brittle nails. pallor. smooth tongue. angular chilitis
easily fatigued.
cheilosis. spoon nails.
palmaer crease.
esohageal webs, dysphagia, atrophic glossitis(
plummer vinson syndrome)

Labs: EVERYTHING IS LOW
:
RBC: hypochromic and microcytic
due to lack of Fe
LWO FE
LOW FERRITIN
LOW RETICS
LOW TIBS
high platletes
HIGH TIBC AND RDW

smear:
poikilocytosis: shape
anisocytosis: size
tear drop morphology
TX: FE SUPPLEMENTS
better w/ oj.
thalassemia:

cause:
lead posioning
, chornic alcoholism
abnormal rbc/fe metabolism
dx:
basohillic
--> lead poisioning
prussian blue stain-> stripled,
ringed siderblast
labs
increased:
Fe, Ferritin, tibc
tx:
remove agent
cheltain for lead overdosing

what:
chronic infection:
organ failure, impaired marrow function, acute blood loss, chornic disease
infections, mediations, chemo, radiation, aplastic anemia, pure red cell aplasia
dx:
labs: can be normocyctic anemia
low: fe, tibc
normal/high: ferritin
high ESR
normocrhomic or microchromic
tx: underlying disease-
do not give Fe
epo: anememia or renal failure cancer inflammaotry diorders
aplastic: transfusions of RBC na dplateltes.
pancytopenia: aplastic, leukemia, myelofirbosis
Sickle Cell Anemia:
what:
AR trait- in blacks
make
SS instead of a hgb A and Hgb S.
sxs: jaundice. pallor.
vascular occlusion/pain. hypoxia.
avoid high altitdues due to exacerbation of crisis
AVN femoral head.
gallstones. CHF.
aplastic crisis: due to b19. bone marrow ant compenstae- transfuse
hand foot syndroem: dactylitis: painful swelling of hands, feet
acute chest pain: ArDs, hypoxia, pulmonary infiltreats
splenic infarctions splenomegly
priapism- erection is long
strokes
ulcers.
retinopahty/bildness.

reanla
necorsis with painless hematuria
liver dz. MI.
irisks/complicatlions:
osteo, AVN, priapism, retinopahty, blindness

abs: leukocytosis. reticulocytosis.
definitive: electrophoresis shows S RBC
smear: sickled cells, target cells,
howell jolly bodies, nucleated RBC.
high indirect Bilie, LDH, reticus
tx:
fluids.
folic acid. oxygen. analgeics.
vaccinations:
flue, meningitis, pneumonia
PCN-prophylaxis from birth until age 6
hydroxura: vaso-occulsive events - lifelone therapy
G6PD:
what:
x-linked recessive
: AA, males, jews

cause:
fave beans.
methelen blue. ASA.dapsone.
AVOID: quinidine. sulfonamides. nitrofurantoid. hydroxycholoroquine. primaquin
e. nitrofuroeantoin

ss: dark urin
e. jaundice. no spelnomegaly. women rate.

labs:
bite cells. heniz bodies (also seen in iron).
l
low Gd6P,
high retic, high bili
dx: gdp6 assay
tx: supportive. hydration and RBC if needed
hemolytic anemia--> high retics!
what: premature destruction of RBC = high retic b/c they are kicking them out but no replacig them fast enough
bone marrow is normal and responds with high epo output
Types:
Herditary: G6PD, sickel cell, thalassemia
Immunice attack: TTP, DIC, HUS
Trauma
sxs:
jandice f
rom elevated indirect bilirubin. bilirubin gallstones. petchiae and purpura
Labs:
high reticu count w/ falling hemoglobin
immature RBC- RBC with antibodies on them.
high indirect bili (heme degredation). high LDH.
low heptoblobin: binds to hemoglobin
shistocytes: hemolysis/trauma
sperhocytes/helmet cells: hemolyisis- extravascular
coombs positive!

Hemohila B
x-linked
recessive
d/o: factor
IX
-
jewish population
aka:
xmas disease
tx: factor IX. FFP.
Vit K definciency
what: factors
2,7,9,10 and protein C and S.
cause: TPN, antibiotics,
warfain, malabsorption of fat souluble vits
post opt. not eating well. borad spectrum antib
features:
PTT and PT is prolonged.
serious bleeding
normal: firbingoen, thrombin time, platelet counts:
tx: vit K and maybe FFP. diet high in green leafy veggies
Thrombocytopenia:
platlets <130,000
decrease in plate formation;destruction;production
bone marrow failure:
aplast anemia, rubella
bone marrow invasion:
tumors, leukemia, fibrosis
marrow injury: ethanol,
chemo, gold, cehmicals, radiation
desturction: I
TP, SLE, HIT, HIV, TTP
features: petchia bleeding, purpura, hemorrhagic bullae
epistxi, menorrhagi, hemotpysis, bleedin in GI tract
dx: decreaseplateles, eosinohilia, milk lymphocytosis
megathrombocytes. normal goalulations
t
x: splenctomy is defnitive
d/c nsaids, asa, antiplatlets
Plate consumption disordersS:
1. ITP
rare, fetal in otherwsie healthy ppl w/ HIV/children with URI
sxs; thrombcytopenia, high BT, purpura, pethcial, pallor, suddne onset, meglothombosites. abnormal neuro signs. renal failures. nosebbleed
labs: shixtocytes, high retic, coombs negative, LDH high
tx: prednisone. splenectomy. rituximab
2. HUS/TTP:
children.
preggers/estrogen precitptial. quinine(HUS).
<10yrs with e.coli infection, slamonella, shigella
microangiobastic clots hemolyit anemia,
neg. coombs,
thrombcytopenia,
tx: asap:fluids, luts, plasmapheresis, steroids, and rituximab
3. DIC
ge
neralized hemorrages: sepsis, tissue injury, cancer
skin/mucosal bleeding, shock, digtial ischemia and gangrene, nose bleeding
labs:
elevated firbin/d-dimer, thrombocytopenia, proloned Pt/PTT
tx: blood transfussion via FFP
4. PT/INR:
extrinsic pathwa
y
increase PT/INR
5. Heparin
intrinsic- PTT/aPTT.
6. thrombophilia: hypercoaguable state
factor 5: increase in thrombin = incrase clotting risk for dvt and pe.
polycyvera
7. HITT: >4
days on hepartin = antib against platelts for factor 4 = attach heparin = thrombus/decrease paletes.
stop heparin. dx: elisa ft4. tx: warfarin.
Aplastic anemia: no cell devlopment!
Bone marrow fialure -->
pnacytopenia:
a
nemia, neutorpneia, thrombocytopenia
cuases: radiation, sulfur/seizure medications, viral infections

features:
fatigue, dyspnea, petechia, easy brusing, high infections (nuetropenia),
ALL
dx:
low platletes. low WBC. low RBC. , normocyctic normochromic anemia,
definitive: bone marrow bx showing hypocellular/hyplastic marrow

tx: tranplant and tranfusion of RBCs and platelets

HITTS: "PVC PIPES"
platelet problem + vWD
:
excessive bleeding--> epistaxis, gum bleeding, menorrhagie.
drugs: asa, NSAIDS, uremia, genetic cuases
cogulaion problems
: skin/muscle have hemarthrosis
hemophilia
P-
sculities, scurvy, ehlers-danolos, hereditary telangiectasias, steroids, and palpable purpura
aPTT: intrinsice
INR: extrinsice
d-dimer: TTP, HUS, DIC, HIT is necessary
Platelet function disorders:
cause: congential, asa, nsaids, uremia, etho use, hypothermia
prolonged bleeding time. skin/mucosal bleeding
labs: normal pletlets, function is banomral.
ITP: thrombocytopenic purpura
what:
self limitied
AI in children w/ a preceding viral URI
chronic: HIV, hep C, AI disease in older women
features: normal exam except for bleeding issues
a
brupt: petchia, purpura, hemorrhagic bulla
epistaxia, oral bleeding
heparin causes a ITP like reaction
Labs:
low platlets: 10,000-20.000
eosinophila
lymphocytosis
normal coagulation
treatment:
usually resolves spontaneoulsy
otherwise: steroids. splenectomy. no asa
Platlet Conumption:

TTP:
rare and fetal.
ags 20-50 OWH, HIV.
cause: estrogen, pregnancy clopidogrel s
severe thrombcytopien w/
purpura,
petichia,
pallor, abd pain,
fever, neuro signs,
pancreatitis, renal failure
labs:
problonged BT. {TT: normal. Dimer: normal. INR normal.
s
histocyes,
high LDH, high indirect bili,
normal WBC, coombs negative
tx: emergency large plasmaperesis. prednisone. antiplatelets

HUS:
like
TTP but in children + adults exposed to e.coli, shigella, slamonella, viruses
no nuero findings. lots of renal
porblems. childs <10 after e.coli, shigella salmonella.
labs: same as TTP
tx: emergency plasma exhchnage fluids. lytes.

DIC:
generalized hemorrhages in those w/ systemic illnesses like sepsis, tissue injury, burns, obstetric complications, cancer and transfusions
labs: anemia. low palteletes. proonged BT,
increased: PT, aPTT, TT
hypofirinogemia,
elevated D-Dimer,
tx: blood tranfusions.
TICS: thalassemia, Iron, Siderolblastc
Normocytic anemia:

Acute: trauma, bleed, menorrhagei, sickle crsis
not due to bone marrow or inheritated bpromebls
RBC are lost: due to GI bleed, menorrhagia, hematoma, splenomegaly, chronic disease states
sxs: tachycardia,palme, clmammy, hypotensive
labs: low RBC, normal MCV, norwal RDQ
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