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4. Anemia, Bleeding, Thrombosis
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HOMER U. CO, M.D.
Hematology Lectures
HOMER U. CO, M.D.
AnemiaA Clinical Approach
Objectives
To discuss important physiology related to anemia Basic Red Blood Cell physiology Compensatory mechanisms
To provide a clinical context for studying anemia Features in history: what to ask Features in physical examination: what to look for Laboratory work-up algorithm
PHYSIOLOGY
Anemia
Basic Red Blood Cell Physiology
Compensatory Mechanisms
Increased cardiac outputIncreased respiratory driveShunting of blood away from the ff:
Kidneys Skin Gut
Compensatory Mechanisms
Increased 2,3 DPG in RBCs
HISTORY AND
PHYSICAL EXAMINATION
Anemia
History
Duration Acute (recent)
Sudden drops in Hgb levels Etiologies? Clinical presentation?
Sub-acute-chronic (weeks to months) Slow and progressive/plateau drop in Hgb Etiologies? Clinical presentation?
Key Points
Acute massive hemorrhage – symptoms due to hypovolemia Tachycardia Postural Hypotension Cold-clammy extremities
Chronic blood loss - symptoms due to decreased oxygen carrying capacity of blood Easy fatigability Shortness of breath
History
Other unusual signs/symptoms Due to other cell-line problem (WBC/Platelet problem)
Bleeding/petechiae/hematomas Fever
Inflammation Joints, skin, muscle, etc.
Other chronic systemic/organ dse Liver, kidneys, spleen, etc.
Medical History Co-morbid conditions Medication use Nutrition status
Key Points
Isolated RBC problem Iron deficiency RBC destruction RBC production problem
With WBC/Platelet problem Hematologic malignancy Bone marrow function
Systemic problem Chronic inflammation – CTDs, other rheuma condition Liver, kidney diseases
LABORATORY WORK UP
Anemia
Basic Concepts
Three (3) Functional Classification of Anemia Bone marrow production defects
hypoproliferative Red cell maturation defects
Ineffective erythropoiesis Decreased red cell survival
Blood loss/ hemolysis
Anemia Algorithm
CLINICAL SCENARIOSWHAT TO ASK AND LOOK FOR
Anemia
Scenario 1
A 75 year old Male presents at the ER with pallor and hypotension. He has 3 days of melena and generalized body weakness.
Scenario 2
A 45 year old female consults you at the clinic for pallor. She seems well except for easy fatigability in performing the usual household chores.
Scenario 3
A 35 year old male consults at the clinic for elevated blood pressure. He has had on and off bipedal edema and easy fatigability. He has also lost some weight due to anorexia since a month ago. He looks pale with white nailbeds and palms.
Scenario 4
A 23 year old female presents with prolonged and heavy menstrual bleeding and pallor.
HOMER UY CO, M.D.
Platelet and Coagulation Disorders
Objectives
To discuss important physiology related to bleeding and thrombosis Platelets, coagulation and anti-coagulation factors
To provide a clinical context for studying bleeding and thrombosis Features in history: what to ask Features in physical examination: what to look for Laboratory work-up algorithm
PHYSIOLOGY
Bleeding and Thrombosis
Platelet Plug Formation
Fibrin Clot Formation
Coagulation Factors
Anti-thrombotic Mechanisms
Fibrinolytic System
Causative Factors
Bleeding disorders (Inherited or Acquired) Platelet disorders Coagulation factor deficiency
Thrombotic disorders (Inherited or Acquired) Protein C/S deficiency Factor V Leiden Anti-thrombin deficiency Other Risk Factors
HISTORY AND PHYSICAL EXAMINATION
Bleeding and Thrombosis
History
Bleeding Chronicity
Inherited vs acquired Sites of bleeding
Mucosal/superficial vs deep tissue/joints Co-morbid medical conditions
Renal/hepatic failure/sepsis Exposures
Drug – antiplatelets, anti-coagulants Food/supplements
Spontaneous or Provoked Severity of underlying bleeding disorder
History
Thrombosis Predisposing conditions
Malignancy Immobilization Pregnancy Medications
Past occurences
LABORATORY WORK UP
Bleeding and Thrombosis
Bleeding Parameters
Platelet countBleeding timeProthrombin Time (ProTime) / INRActivated Partial Thromboplastin Time (aPTT)
Thrombophilic tests
Protein C/ Protein S“APAS” tests
Anti-phospholipid anti-body tests (anti-cardiolipin) Dilute Russell Viper Venom Test (dRVVT) aPTT with mixing (“Lupus” anti-coagulant)
Specific factor assaysScreen for malignancy (if likely)
CLINICAL SCENARIOSWHAT TO ASK AND LOOK FOR
Bleeding and Thrombosis
Scenario 1
A 24 year old female presents with a 2 week history of petechial and purpuric rashes over the extremities and gum bleeding.
Scenario 2
A 32 year old female develops a painful and swollen right leg. She is perfectly well before. She has no history of recent trauma, prolonged air travel nor immobilization.
THANK YOU!