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6/5/12
APPROACH TO PATIENT
WITH ANEMIAdr. Srie Harti Soelistio
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Definition
in RBC mass
men : Ht < 41 % or Hb < 13.5 g/dl
Women : Ht < 36% or Hb < 12g/dl
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CLINICAL MANIFESTATION
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SIGN
O2 delivery
pallor (skin & mucous membranes)
tachycardia orthostatic hypotension
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SYMPTOMS
O2 delivery
Fatigue
Malaise Fever
weight loss
night sweats
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OTHER FINDINGS
jaundice (hemolysis)
splenomegaly (thalassemia,
neoplasm, chronic hemolysis) petechiae/purpura (bleeding
disorder)
glossitis (iron, folate, vit B12 defic.) koilonychia (iron defic.)
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DIAGNOSTIC EVALUATION
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HISTORY
Is the patient bleeding?
Actively? In past? Is there evidence for increased RBC
destruction?
Is the bone marrow suppressed? Is the patient nutritionally deficient?
Pica?
PMH including medication review, toxinexposure
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RIVIEW THE SYMPTOMS
Decreased oxygen delivery to tissues
Exertional dyspnea
Dyspnea at rest
Fatigue
Signs and symptoms of hyperdynamic state
Bounding pulses
Palpitations Life threatening: heart failure, angina,
myocardial infarction
Hypovolemia
Fatiguablitiy, postural dizziness, lethargy,
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LABORATORY EVALUATION
Bleeding
Serial HCT or HGB
Iron Deficiency
Iron Studies
Hemolysis
Serum LDH, indirect bilirubin, haptoglobin,coombs, coagulation studies
Bone Marrow Examination
Others-directed by clinical indication
hemo lobin electro horesis
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DIFFERENTIAL DIAGNOSIS
Classification by Patophysiology
Blood Loss
Decreased Production Increased Destruction
Classification by Morphology
Normocytic
Microcytic
Macrocytic
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Blood Loss
Acute
Traumatic
Variety of sources Melena, hematemesis, menometrorrhagia
Chronic
Occult bleeding Colonic polyp/carcinonma
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Decreased Production
Infectious
Neoplasm
Endocrine Nutritional Deficiency
Anemia of Chronic Disease
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Increased Destruction
M ti
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MacrocyticAnemia
MCV > 100
Megaloblastic: Abnormalitiesin nucleic acid metabolism
B12, Folate
Non megaloblastic:AbnormalRBC maturation
Myelodysplasia
liver dz, hypothryroidism,chemotherapy/drugs
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Microcytic Anemia
MCV
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Microcytic Anemia
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Microcytic AnemiaREDUCED IRON AVAILABILTY Iron Deficiency
Deficient Diet/Absorption
Increased Requirements
Blood Loss
Iron Sequestration
Anemia of Chronic Disease
Low serum iron, low TIBC, normal serum ferritin
MANY!!
Chronic infection, inflammation, cancer, liver disease
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Microcytic AnemiaREDUCED HEME SYNTHESIS
Lead poisoning
Acquired orcongenitalsideroblasticanemia
Characteristicsmear finding:Basophylicstippling
croc c nem a
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crocy c nem aREDUCED GLOBIN
PRODUCTION Thalassemias Smear
Characteristics
Hypochromia
Microcytosis
Target Cells
Tear Drops
a es s
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a es sof iron deficiency of
increased severity
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Normositic Anemia
Sideroblastic anemia
Anemia of chronic disorders
Anemia of chronic inflamation Renal failure epo
Edocrine deficiencies
Hypometabolism Pure red cell aplasia
Ineffective erythropoiesis
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TREATMENT
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Iron deficiency
Fe supplementation
6 weeks to correct anemia
6 month to replete Fe stores
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Thallasemia
Folate
Tranfusion + deferoxamine ( oral ionchelator)
Splenectomy if > 50% intranfusions
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Anemia of chronicinflamation
Treat the underlying disease
Erythropoietin
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Sideroblastic anemia
Treat reversible causes
Supportive transfusion for severeanemia
High doses pyridoxine for someheriditery cases
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Folate deficiencies
Folate 1-5 mg po qd
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Vit B12 deficiencies
1 mg B12 IM qd for 7 days
1 mg B12 IM once a week untill 4-8weeks
1 mg B12 IM once a month for life
Neurologic abnormalities are
refersible if treated with in 6 months Folate can reverse hematologic
abnormalities of B12 deficiencies but
not neurologic changes
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Sickle cell anemia
Supportive care
Follic acid
hydration, oksigen and analgesia Simple change transfusion
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THANK YOU