[04.13a] Approach to Patient with Hematologic Complaint (Part 1) V2.pdf

Anemia, polycythemia, neutropenia, neutrophilia, and bleeding problems

What five patient conditions should the student be able to approach and evaluate, according to the learning objectives?

120 g/L

What is the Hemoglobin result in the Sample Introductory Case (Table 1)?

0.36

What is the Hematocrit result in the Sample Introductory Case (Table 1)?

4.57 x 10 power 12/L

What is the Red Blood Cell count in the Sample Introductory Case (Table 1)?

3.11 x 10 power 9/L

What is the White Blood Cell count in the Sample Introductory Case (Table 1)?

78 fL

What is the Mean Cell Volume (MCV) in the Sample Introductory Case (Table 1)?

Microcytic

How is the Mean Cell Volume (MCV) interpreted in the Sample Introductory Case (78 fL), given the normal range is 80-96 fL?

Hypochromic

What is the Erythrocyte Morphology finding listed for the Sample Introductory Case?

No presentation of anemia

What is the assessment regarding anemia status in the Sample Introductory Case, given the female patient's hemoglobin is 120 g/L?

Hypochromic, microcytic RBCs

How are the RBCs described overall in the Sample Introductory Case interpretation?

Around 1,800

What is the calculated Absolute Neutrophil Count (ANC) for the patient in the Sample Introductory Case?

Greater than 1000

What is the ANC threshold above which a patient is generally considered not neutropenic?

Normal

What is the interpretation of the Platelet count (240 x 10 power 9/L) in the Sample Introductory Case?

Lactation amenorrhea

Why does the patient in the Sample Introductory Case currently not have her menses?

Iron deficiency

What is the possible assessment for the patient in the Sample Introductory Case, characterized by microcytic and hypochromic RBCs?

A spectrum

Iron deficiency is described as being what?

Iron-deficient negative iron balance

What is the initial stage in the iron deficiency spectrum?

Iron-deficient erythropoiesis

What stage involves making microcytic and hypochromic red blood cells due to insufficient iron for hemoglobin?

Recently gave birth and breastfeeding

What two factors put the patient in the Sample Introductory Case at risk for iron-deficiency?

Give iron supplements and suggest lifestyle changes such as incorporating an iron-rich diet

What two main pieces of advice should be given to the patient in the Sample Introductory Case?

Myeloid lineage and Lymphoid lineage

What are the two lineages that come from the bone marrow?

Platelets, Red blood cells, White blood cells (Granulocytes and Monocytes)

What three main categories of cells are produced by the Myeloid lineage?

Lymphocytes (B-cells, T-cells) and Natural Killer cells

What two main types of cells are produced by the Lymphoid lineage?

Erythropoietin (EPO)

What hormone stimulates the production of red blood cells?

Kidneys

Where is Erythropoietin (EPO) produced?

Hypoxia or lack of oxygen

What stimulates the production of EPO?

The bone marrow

Where does EPO go to stimulate progenitors (colony forming units, pronormoblasts)?

Feedback mechanism

How is EPO production inhibited when red blood cell and oxygen levels return to normal?

Increased oxygen consumption, Less oxygen in the atmosphere, Lung or heart problems

Name three states that stimulate EPO production due to hypoxia.

Decrease in hemoglobin

Anemia is defined as what?

Decrease in oxygen carrying capacity

Anemia results in a decrease of what?

13.0-16.5 g/dL (130-165 g/L)

What is the normal hemoglobin range for males according to WHO standards?

12.0-16.0 g/dL (120-160 g/L)

What is the normal hemoglobin range for females according to WHO standards?

Laboratory value defined condition

Anemia is not a diagnosis but a what?

History taking

What is the first and most important step in confirming whether or not a patient has anemia?

NSAIDs

What type of drug is mentioned that can cause bleeding and potentially anemia?

Kidney disease or Diseases of absorption (Crohn's disease)

Name two types of underlying diseases that may be revealed through checking drug intake history.

Prior surgeries and hospitalizations

What part of the history provides context for occurrences of blood loss?

Interferes with folate and vitamin B12 absorption

How does heavy alcohol consumption increase anemia risk?

Erythrocytosis and polycythemia

Smoking induces hypoxia, which can lead to what two hematologic conditions?

Exposure to lead

What occupational exposure may interfere with iron absorption?

African descent

Sickle cell disease is common in those of what racial background?

Southeast Asians and Meditteranians

Beta-thalassaemia is common in those of what two racial backgrounds?

Fatigue

What common anemia complaint involves difficulty performing simple tasks that were easy to do before?

Lack of blood supply or anemia

A dizziness description of Para po bang nagdidilim ang paningin? (darkening vision) may indicate what underlying cause?

Vertigo

A rotatory sensation when describing dizziness may indicate what condition?

Orthostasis

What should be asked about regarding dizziness related to standing up quickly from sitting or lying down?

Poor amount of volume (Hypotension)

What may orthostasis suggest regarding poor blood volume status?

Splenomegaly

Abdominal pain or a heavy feeling at the left side may be due to what condition?

Pallor

What physical finding indicates Hgb is less than 8.0-10.0 g/dL?

Conjunctiva and Palms

Name two areas where pallor is specifically observed during physical examination.

Palmar creases are lighter than color

What specific finding occurs in the palms if Hgb is less than 8.0 g/dL?

Systemic "flow" murmur

What physical exam finding is a soft blowing/whooshing sound upon auscultation of heart sounds?

Turbulent flow because of low Hgb

What causes the systemic "flow" murmur in anemia?

Jaundice

What is the yellowing of the sclera called?

Sclera

What is usually the first part of the body that develops jaundice?

Eardrums

What part of the body develops jaundice earlier than the skin?

CBC, Peripheral Blood Smear (PBS), Reticulocyte Count

Name the three main laboratory tests done for anemia.

After you have already confirmed the diagnosis of anemia

When is a Reticulocyte Count only done?

Mature but young RBCs

What are reticulocytes?

Polychromasia

What is the term for the bluish (basophilic) dots in reticulocytes that indicate the presence of RNA?

0.5 - 1.5 percent

What is the normal range for Corrected Reticulocyte Count?

Corrected Reticulocyte Count equals retic percent multiplied by (pt Hct divided by N Hct)

What is the formula for calculating the Corrected Reticulocyte Count (Equation 1)?

45

What standard value is used for Normal Hematocrit (N Hct) in the corrected reticulocyte count formula?

Low retic count

If the corrected retic count is 0.49 percent, what does this suggest about the bone marrow?

Hypoproliferative Anemia

A low corrected retic count suggests what type of anemia classification?

Maturation Coefficient

What factor is used to calculate the Reticulocyte Production Index (RPI)?

2

What constant value is used for the Maturation Coefficient for uniformity in RPI calculation?

RPI less than 2

What RPI result indicates hypoproliferative anemia?

RPI greater than or equal to 2

What RPI result indicates hyperproliferative anemia?

Serum ferritin

What iron test measures the stored form of iron?

Total iron binding capacity (TIBC)

What iron test measures the amount of iron that can still bind with transferring?

Myeloid-Erythroid Ratio (M:E Ratio)

What ratio is checked during a Bone Marrow Aspiration and Biopsy?

3:1 to 5:1

What is the normal range for the M:E Ratio?

Hemosiderin

What is the iron storage of the bone marrow called?

RPI less than 2.5

What RPI threshold defines hypoproliferative anemia?

RPI greater than or equal to 2.5

What RPI threshold defines proliferative anemia?

Bone marrow is functioning properly

What does a high RPI in proliferative anemia indicate?

Iron deficiency, Bone marrow damage, Renal disease, Metabolic defects, Inflammation, Thalassemia, or Toxins

Name four potential causes of hypoproliferative anemia.

Blood loss, Hemolysis, Hemoglobinopathies, Immune destruction

Name four potential causes of proliferative anemia.

Parvovirus B19 infection

What specific toxin-induced cause targets erythroid precursor cells in the bone marrow, causing hypoproliferative anemia?

Low MCV, low MCH

What characteristic values define microcytic, hypochromic anemia?

Iron deficiency anemia and Thalassemia

What are the two most common presentations for microcytic, hypochromic anemia?

Angular Cheilitis

What clinical presentation of iron deficiency involves dryness-producing wounds at the angles of the mouth?

Koilonychia

What clinical presentation of iron deficiency involves spooning and flattening of the nails?

Pica

What is the general term for craving weird, non-food items?

Pagophagia

What specific type of pica involves craving crushed ice?

Males

In which sex is iron deficiency always considered pathological?

GI bleeding unless proven otherwise

Iron deficiency in males suggests what specific underlying pathology?

Hematochezia

What term describes gross, fresh blood in the stool, indicating lower GI bleeding?

Melena

What term describes black tarry, foul-smelling, and soft stool, indicating upper GI bleeding?

Not able to synthesize correct globin chains

What is the underlying pathophysiology of Thalassemia?

Bone marrow expansion

What process, resulting from increased erythropoietin, leads to bone deformities in thalassemia?

Chipmunk facies and Wide forehead

Name two specific bone deformities seen in children with thalassemia.

Excess iron

What condition results from increased iron demand in thalassemia, leading to deposition in organs?

Stunted growth and Secondary sexual dysfunction

What growth and endocrine issues can result from organ damage due to excess iron in thalassemia?

Splenomegaly

What condition results from the spleen becoming highly active due to deformed RBCs in thalassemia?

"Hair on end" appearance of the skull

What specific radiographic finding is observed on an x-ray of a thalassemic skull?

Hydrops fetalis

What is the fatal manifestation of severe thalassemia in newborns?

Vitamin B12 deficiency, Folate deficiency, Drug toxicities, Myelodysplastic syndrome, Reticulocytosis

Name four conditions that present as Macrocytic Anemia.