Anemia Medical Infographic

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Benevolent Attending Peyronie Attending : Anemia Testing Anemia Mnemonics ABCD: Anemia (normocytic): causes Acute blood loss Bone marrow failure Symptoms of Anemia Chronic disease Destruction (hemolysis) Central • Fainting Fatigue • Dizziness TAILS: Microcytic Anemias (types) Thalassemia Anemia of chronic disease Iron deficiency Eyes • Yellowing Lead poisoning Sideroblastic Skin • Coldness • Yellowing • Paleness Autoimmune Hemoytic Anemia IgG is warm (Guatamala is warm) IgM is cold (Maine is cold) Blood vessels • Low blood pressure HALT: Target Cell HBC Disease Respiratory • Shortness of breath Asplenia Liver Disease Thalassemia Heart • Chest pain • Heart attack • Angina Palpitations • Rapid heart FAT RBC: Macrocytic anemia: differential Muscluar • Weakness Fcute blood loss Aone marrow failure Thronic disease Restruction (hemolysis) Gestruction (hemolysis) Bestruction (hemolysis) rate Spleen • Enlargement LEAD: Intestinal • Changed stool color Lead lines gingivae Encephalophthy/ erythrocyte basophilis stippling Anemia sideroblastic/ abdominal colic Red = In severe anemia Drops - wrist/foot Can't Synthesize Normal Blood Cells Aplastic Anemia Chloramphenicol Sulfonamides NSAIDS gold salts Indications for testing Fatigue, weakness, pallor, dizziness, fainting Benzeno Chlorpromazine ORDER • CBC with Platelet Count and Automated Differential (including RBC indices and morphology on manual differential) • Reticulocytes, Percent & Number Anemia present on CBC (males Hgb <13g/dL, females Hgb<12g/dL) AND Corrected reticulocyte index 22.5 no Fragmented cells on peripheral smear Classify by RBC indices yes no Macrocytic (high MCV) (suggests maturation defects) Normocytic, normochromic (normal. MCV, MCHC) (suggests hypoproliferation) (suggests maturation defects) Mircocytic, hypochromic (low MCV MCHC) Suspect hemorrhage and acute blood loss Suggests hemolytic process: • Autoimmune destruction • Hemoglobinopathies (eg, sickle cell) • Intravasculat hemolysis • Metabloic defect (see PNH consult topic) • RBC membrane defect • Splenic sequestration • Drug effect • Excessive alcohol use • Folate, B., deficiency • Hypothyroidism • Myelodysplasia (see Myelodysplastic Syndromes Constult topic) • Aplastic anemia, pure red cell aplasia • Autoimmune disease • Bone marrow disorder (infiltration, aplasia) • Chronic renal disease • Chronic endocrine disorder • Chronic disease • Thalassemia • Sideroblastic anemia • Lead toxicity disorders • Critical illness • Inflammation Abnormal peripheral smear Abbreviations and Formula MCV = mean cell volume MCHC = Mean cell hemolglobin concentration TIBC = total iron binding capacity ORDER olron and Iron Binding Сарacity •Ferritin no yes no Viatmin B,, & Folate Reticulocyte correction for anemia: Hgb HtC Workup based on smear characterstics ReticCount% X Matuation time correction (use 2 or most patients) High TIBC Low ferritin Low iron Low/normal TIBC Normal/high ferritin Low/normal. iron Bone marrow biopsy may be necessary Iron deficiency anemia Suggests: • Chronic disease • Inflammation nsider bone marrow biopsy, if no obvious chronic disease High Yield Clinical Presentations 1. A young woman complains of a recent onset of fatiue and weakness after being treated with an antibiotic for gonorrhea. Blood smear shows blast cells, few RBCS, and reticulocytes. Aplastic anemia, likely caused by chloramphenicol. 6. Obvious clinical vignette cues for G6PD include anemia/fatigue/Heinz bodies especially after being given an oxidizing agent, but a more subtle cue is the family history where males are affected, but fe- males are not (X-linked). present 2. An AA male complains of mild anemia, mild jaundice, and a UTI. G6PD deficiency. Never give oxidizing agents like nitofurantonin/sulfa drugs like Bactrim to treat the UTI since it will further hemolyze the RBC cells, worsening the anemia (Remember, G6PD deficient patients lack the ability to protect against oxida- tion). 7. Şickle cell anemia is easy to identify (low Hgb, AA child, severe intermittent periods of pain, and sickled cells in peripheral blood smear), but they may ask for the gene mutation (single amino acid substitution of valine for glutamic acid. 8. 25 ylo male incurs blunt force trauma to the ab- domen resulting in a splenectomy. What peripheral blood smear findings would be present. RBC inclusions (Howell-Jolly bodies and Pappen- heimer bodies). Prevalance of 3. 60 y/o male, hx of gastrecomy, c/o of leg weakness/hx of falls. PE shows increased DTRS, mild weakness of legs, and decreased vibratory sense in toes. B12 deficiency. Anemic Disorders 9. Erythroblastosis normally affects the 2nd child first because an Rh negative mother creates anti- bodies during the first child birth. 4. 7 year-old boy with gradual onset of fatigue, irritability, and pale skin within starting daycare in a "run-down" part of town. Labs show- low HgB and peripheral blood smear shows microcytic RBCS with basophilic stippling. Lead poisoning. Iron deficiency 10.A sickle cell patient with a salmonella infection is prone to? Osteomyelitis. Maturation • Inflammation • Neoplasia • Chronic disease disorders 5. Unlike most other types of anemia, microcytic anemia is not associated with a history of drug ingestion (the drug didn't lead to the anemia). 11. Patients with sickle cell trait (heterozygotes) are Hemolytic anemias resistant malaria Marrow damage Acute bleeding Scrub Pearls - Anemia Key points - historical points to consider evaluating patients for anemia: • Family history (G6PD, hemophilia, thalassemia) • Alcoholism (Fe deficiency, folate/B12/Fe deficiency) • Bleeding (melena, recent surgery/trauma, hematemesis) • Chronic illnesses (i.e. renal failure). Determine whether patients with megaloblastic anemia (MCV>100) have folate or B12 deficiency. If a patient with B12 deficiency is given folate, then the anemia will improve, but untreated B12 defi- ciency will lead to irreversible neurological damage. Serum methylmalonic acid levels are only in- creased with B12 deficiency, but serum homocyste- ine levels are increased in both folate and B12 defi- If Hb/Hct suggests anemia, order a retic count and MCV, but not MCH/MCHC since they are not sensi- tive/specific for any diagnosis. ciency. Ferrioxamine (iron chelating agent) is given to de- crease iron in cases of iron overload with patients who have transfusion-dependent thalassemia. A patient with a history of mechanical heart valves inserted through surgery are at risk of he- molyti c anemia as the valves can hemolyze RBCS. Thalassemia minor (beta more common than alpha) is the most common thalassemia and often mistaken for iron deficiency. Key lab tests in hemolytic anemia are: • Increased LDH/elevated retic count • Decreased haptoglobin/Hb/Hct Determine whether patients with megaloblastic a (MCV>100) have folate or B12 deficiency. If a patient with B12 deficiency is given folate, then the anemia will "Painful crises" is caused by ischemia of various organs due to the impaired RBC circulation from sickled RBCS. improve, but untreated B12 deficiency will lead to irre- versible neurological damage. REFERENCES Le T& Bhushan V (2013). First Aid.for the USMLE Step 1 for 2013. McGraw Hill. Ågabegi SS & Agabegi ED (2013). Step-UP to Medicine. Third Edition. Lippincott Williams & Wilkins.