ANEMIA

Jimeno, Josefa Ramos

OBJECTIVES
To be able to do a proper history taking and physical examination on a patient presenting with anemia To be able to give a differential diagnoses to arrive at a primary diagnosis To be able to present the proper work up and management for anemia

OUTLINE
I. CASE PRESENTATION II. DISCUSSION OF ANEMIA

The investigation of any anemia involves a series of basic steps:

History and physical examination Identification of the anemia Classification of the anemia

ANEMIA CASE
General Data R.E. is a 51 year old, Roman Catholic, married male, residing at San Pedro, Laguna who came in with a chief complaint of weakness.

Chief complaint
weakness

History of Present Illness

2 months PTA - Patient experienced progressive generalized body weakness, accompanied by sudden onset epigastric pain which lasted for a few minutes, characterized as humihilab, relieved by rest, severity of 4/10, nonradiating, occuring any time of the day,unaffected by food intake

History of Present Illness

2 months PTA - No other associated signs and symptoms: loss of consciousness , fever, diarrhea, constipation, hematemesis, melena , hematochezia , belching, fever, flatulence, changes in stool caliber, Loss of consciousness, Night sweats - No medications were taken. No consult was done.

History of Present Illness

Interim, patients symptoms would persist, patient was able to tolerate weakness still.

History of Present Illness

2 weeks PTA - Patients generalized body weakness with epigastric pain persisted with increasing severity of 6/10, patient would awaken at night, and feel restless in the morning. -Patient sought consult in the morning at a clinic. CBC results revealed low hemoglobin count (unrecalled exact amount) - Patient was prescribed Ranitidine 150mg tab and FeSO4 which gave no relief.

History of Present Illness

6 days PTA -Patient felt generalized body weakness still, associated with epigastric pain, pain scale of 8/10 radiating to the whole abdomen characterized as humihilab continuous unrelieved by medication - also associated with loss of appetite, anorexia

History of Present Illness

6 days PTA - This prompted consult at the ER of another institution where he was given unrecalled medications and was admitted subsequently for 2 days. - Patient was advised to see a specialist, therefore opted to transfer at MCM.

Past Medical History

Patient had been Diabetic for 5 years, was prescribed Metformin 500mg, compliant, last FBS, CBG, HBA1C all unrecalled. Patient claimed to have Allergic Rhinitis since his early 20s, with no maintenance medications. Patient is nonhypertensive, nonasthmatic. Patient has (+) history of NSAID intake for 20 years everytime he has headache (approx. three times a week) Patient has no known allergy to foods, however allergic to Amoxicillin.

Personal and Social History

Patient is a non smoker, occasional alcohol beverage drinker (4 bottle of beer/ weekend) Patient is also a (+) coffee drinker for 30 years, consuming 2 cups of coffee a day. Patients usual meal consists of 3 tbsps of cooked rice, and meats Patient manages his own business, financing for more than 5 years already, (+)skips meals most of the time due to busy schedule.

Family History
Father Unkown Mother Hypertension, DM, Cancer

ROS
General: (+) significant weight loss (documented,lost 50 lbs since December, 2011), (+) weakness, (+) fatigability, no fever. Skin: (+) pale hands and feet, no flushed skin, no rashes, no lumps Head: no headache, no dizziness, no head injury, no lightheadedness Eyes: no pain, no redness, no excessive tearing no blurring of vision,

ROS
Ears: no hearing problems, no tinnitus, no vertigo, no earaches Nose: (+) colds, no discharge, no epistaxis Throat: no sore throat, no hoarseness Respiratory: no cough, no shortness of breath Cardiovascular: no chest pain, no palpitations, no pnds Gastrointestinal: no changes in stool caliber

ROS
Genitourinary: no nocturia, no polyuria, no dribbling Musculoskeletal: no pain, no stiffness, no arthritis, no gout Nervous System: no loss of consciousness, no paralysis

Physical Examination
General: awake, conscious, coherent, not in cardiorespiratory distress, and cooperative. Vital Signs:
sitting BP-120/80 HR- 76 supine 130/80 HR-80

RR-20 Temp- 36C Wt- 60

Ht.- 56

BMI- 23 - Normal

Physical Examination
Skin- (+) pale, (-) petechiae, no lesions, no rashes and cold to touch on both hands and feet, (+) pale nail beds HEENT- (+) pale palpebral conjunctivae, anicteric sclerae, no hearing disabilities, no discharge, no septal deviation, no obstruction, no sinus tenderness, no lump ,no mass no mass, Neck veins not distended, JVP at 7cm at 45deg, no cervical lymphadenopathy

Physical Examination
Chest- No scars, No lesions, symmetrical chest expansion, No retractions, equal tactile fremitus, Both lung fields resonant to percussion, clear breath sounds, (-)crackles, all lung fields, (-) wheezing, (-) ronchi Heart- adynamic precordium, normal rate, regular rhythm, S1>S2 at the apex, S1<S2 at the base, PMI heard at 5th ICS MCL, no heaves, no thrills, no murmurs

Physical Examination
Blood Vessel- full, equal pulses Abdomen- flat, normoactive bowel sounds, no bruit, tympanitic on all quadrants, no shifting dullness, no fluid wave, Traubes space not obliterated, Liver span at 8cm, (+) direct epigastric tenderness, Liver edge smooth, No mass palpated. Extremities- Full and equal pulses, no cyanosis, no clubbing, no edema Neurological- CN intact

Subjective 54 year old Male From Surigao Body weakness epigastric pain sudden in onset characterized as humihilab occuring any time of the day unaffected by food intake pain scale of 10/10 radiating to the whole abdomen continuous unrelieved by medication (+) DM Type II, Controlled (+) weight loss of >10%, fatigue, night sweats (+) changes in bowel movement 4days PTA (-) bleeding, fever, diarrhea, changes in stool caliber,

Objective VS: BP- sitting 120/80, SALIENT FEATURES HR 76 supine 130/80, HR 80 RR-20 temp- 36 Wt- 60kg Ht.- 56 BMI- 23 - Normal PE: (+) Pale palpebral conjunctivae, Pale nailbeds (+) Direct epigastric tenderness (-)cyanosis, no clubbing, Lymphadenopathy, Splenomegaly,Petechiae

DIFFERENTIAL DIAGNOSIS PIVOT POINT: ANEMIA

Rule IN Anemia Sec to Diabetes Mellitus (+) DM for >5 years, pale skin,weakness, Rule OUT Controlled DM, chest pain, irritability, numbness or coldness in the hands and feet, a fast heartbeat, shortness of breath with activity, and headache Cannot be ruled out

Anemia Sec to GI bleeding

(+) NSAID Use for 20 years, epigastric pain, pale skin color, shortness of breath and weakness,

DIFFERENTIAL DIAGNOSIS PIVOT POINT: ANEMIA

Rule IN Anemia Sec to Malignancy (+) significant weight loss, fatigue, pallor Rule OUT (-) Fam history of CA, No palpable abdominal mass (-)progressive dysphagia or odynophagia, persistent vomiting, lymphadenopathy. No CT done

INITIAL IMPRESSION
ANEMIA SECONDARY TO GI BLEEDING

The investigation of any anemia involves a series of basic steps:

History and physical examination Identification of the anemia Classification of the anemia

COURSE IN THE WARDS

1st HD Medications were continued Diphenhydramine 25mg/IV 30 minutes prior to bed time (+) FOBT Hgb 9.8 2 packed RBC/4 hours CBG- 112

COURSE IN THE WARDS

2nd HD Endoscopy results revealed bleeding peptic ulcer disease

FINAL DIAGNOSIS
ANEMIA SECONDARY TO GI BLEEDING

Reticulocyte Count

Reticulocyte Count Interpretation

the number of reticulocytes as a percentage of the number of red blood cells. The reticulocyte index (RI) should be between 1.0% and 2.0% for a healthy individual. RI < 1% with anemia indicates decreased production of reticulocytes and therefore red blood cells. RI > 2% with anemia indicates loss of red blood cells (destruction, bleeding, etc.) leading to increased compensatory production of reticulocytes to replace the lost red blood cells.

Red blood cell indices

are blood tests that provide information about the hemoglobin content and size of red blood cells. Abnormal values indicate the presence ofanemia and which type of anemia it is

Red blood cell indices

Red blood cell indices

ANEMIA
The physiologic response to anemia varies according to acuity and the type of insult. compensatory mechanisms to take place In the medullasympathetic outflow is enhanced, while parasympathetic activity is diminished. Increased sympathetic outflow norepinephrine release from sympathetic nerve endings and discharge of epinephrine and norepinephrine from the adrenal medulla.

ANEMIA
Sympathetic connection to the hypothalamic nuclei increases antidiuretic hormone (ADH) secretion from the pituitary gland. ADH increases free water reabsorption in the distal collecting tubules. In response to decreased renal perfusion, juxtaglomerular cells in the afferent arterioles release renin into the renal circulation, leading to increased angiotensin I, which is converted by angiotensin-converting enzyme (ACE) to

ANEMIA SECONDARY ACUTE BLOOD LOSS

a reduction in oxygen-carrying capacity occurs along with a decrease in intravascular volume, with resultant hypoxia and hypovolemia. Hypovolemia hypotension detected by stretch receptors in the carotid bulb, aortic arch, heart, and lungsreceptors transmit impulses along afferent fibers of the vagus and glossopharyngeal nerves to the medulla oblongata, cerebral cortex, and pituitary gland.

ANEMIA
strictly defined as a decrease in red blood cell (RBC) mass. accomplished by using hemoglobin (Hb), a tetramer protein composed of heme and globin. impairs the bodys ability for gas exchange by decreasing the number of RBCs transporting oxygen and carbon dioxide

ANEMIA
a symptom that requires investigation to determine the underlying etiology. Often, practicing physicians overlook mild anemia. quantified by measurement of the RBC count, Hb concentration, and hematocrit (Hct)

ANEMIA

SIGNS AND SYMPTOMS

Nonspecific Symptoms feeling of weakness Fatigue general malaise poor concentration. dyspnea on exertion. very severe anemiaincreasing cardiac output palpitations, angina intermittent claudication of the legs, and symptoms of heart failure.

Signs
General pallor (pale skin, mucosal linings andnail beds) koilonychia (in iron deficiency), jaundice bone deformities leg ulcers

Signs
severe anemia tachycardia bounding pulse cardiac ventricular hypertrophy signs of heart failure

Classification of Anemia
I. Etiologic Classification 1. Impaired RBC production 2. Excessive destruction 3. Blood loss II. Morphologic Classification 1. Macrocytic anemia 2. Microcytic hypochromic anemia 3. Normochromic normocytic anemia

1. Abnormal bone marrow 1.1 Aplastic anemia 1.2 Myelophthisis : Myelofibrosis, Leukemia, Cancer metastasis 2. Essential factors deficiency 2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc 2.2 Anemia in renal disease : Erythropoietin 3. Stimulation factor deficiency 3.1 Anemia in chronic disease 3.2 Anemia in hypopituitarism 3.3 Anemia in hypothyroidism

I. Etiologic Classification A. Impaired RBC Production

2.Excessive Destruction of RBC(

Hemolytic anemia 1. Intracorpuscular defect 1.1 Membrane : Hereditary spherocytosis Hereditary ovalocytosis, etc. 1.2 Enzyme : G-6PD deficiency, 1.3 Hemoglobin : Thalassemia, Hemoglobinopathies

Excessive Destruction of RBC

2. Extracorpuscular defect 2.1 Mechanical : March hemolytic anemia MAHA (Microangiopathic HA) 2.2 Chemical/Physical 2.3 Infection : Clostridium tetani 2.4 Antibodies : SLE 2.5 Hypersplenism

3. Blood Loss
1. Acute blood loss : Accident, GI bleeding 2. Chronic blood loss : Hypermenorrhea Parasitic infestation

MCV > 94 MCHC > 31 1. Megaloblastic dyspoiesis 1.1 Vit. B12 deficiency : Pernicious anemia 1.2 Folic acid deficiency : Nutritional megaloblastic anemia, Sprue, Other malabsorption 1.3 Inborn errors of metabolism : Orotic aciduria, etc. 1.4 Abnormal DNA synthesis : Chemotherapy, Anticonvulsant, Oral contraceptives

II. Morphologic Classification A. Macrocytic Anemia

1.

2.

3.
4.

MCV < 80 MCHC < 31 Fe deficiency anemia : Chronic blood loss, Inadequate diet, Malabsorption, Increased demand, etc. Abnormal globin synthesis : Thalassemia with or without Hemoglobinopathies Abnormal porphyrin and heme synthesis : Pyridoxine responsive anemia, etc. Other abnormal Fe metabolism :

B. Microcytic Hypochromic Anemia

C. Normocytic Normochromic Anemia MCV 82 - 92

1. 2. 3. 4. 5. MCHC > 30 Blood loss Increased plasma volume : Pregnancy, Overhydration Hemolytic anemia : depend on each cause Hypoplastic marrow : Aplastic anemia, RBC aplasia Infiltrate BM : Leukemia, Multiple myeloma, Myelofibrosis, etc. Abnormal endocrine : Hypothyroidism, Adrenal insufficiency, etc. Kidney disease / Liver disease / Cirrhosis

6.
7.

Treatments
depend on severity and cause. Iron deficiency from nutritional causes is rare in men and postmenopausal women. diagnosis of iron deficiency mandates a search for potential sources of loss, such as gastrointestinal bleeding from ulcers or colon cancer. Mild to moderate iron-deficiency anemia is treated by oral iron supplementation with ferrous sulfate, ferrous fumarate, or ferrous gluconate.

Treatments
Vitamin supplements given orally (folic acid) or intramuscularly (vitamin B12) will replace specific deficiencies. In anemias of chronic disease, associated with chemotherapy, or associated with renal disease, some clinicians prescribe recombinant erythropoietin or epoetin alfa, to stimulate RBC production. In severe cases of anemia, or with ongoing blood loss, a blood transfusion may be necessary.

Treatments
Blood transfusions

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