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Pallor Bleeding

Pallor Bleeding

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Published by: Iñaki Delos Santos Ramos on Aug 14, 2011
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05/23/2012

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“I can do all things through Christ who strengthens me…” Philippians 4:13
When you are presented with a pale patient,patients may go to you just because of bodyweakness.
hematologic disorders - generalizedbody weakness
neurologic - localizedWeakness, easy fatigability, exertionaldyspnea may also be manifestations of acardiac problem; thus we must look atadditional manifestations that go with thesaid symptoms. Especially when it’sassociated with pallor, most likely it'll be ahematologic problem.
Pallor if combined with Ictericia candenote ANEMIA
What about patients with bleedingmanifestations?
PETECHIAE - pinpoint lesions less than3mm in size.
ECCHYMOSIS - larger than petechiae.
HEMATOMA - can dissect muscleplains.With these manifestations, aside from theecchymosis and hemarthrosis, bleeding in joints, is common in coagulation disorder,like hemophilia.
Check the history. Check the P.E. Likewhen you’re diagnosing someone, check this history and see if the physical findingssupport what you are thinking. Use theclues in history getting. You also check for associated manifestations and finally you do your laboratories. It’s not backwards.You don't diagnose a patient withlaboratories. You have a diagnosis thenconfirm with labs. We should first have aclinical diagnosis before. Because howould you know what laboratories you will ask for in the first place. Have something inyour mind so you have a flow of work up.
 
ANEMIA
A reduction in red cells (function of which is to carry oxygen to differentparts of the body) so the capacity todeliver blood is also diminished.
Normal values based on WHO
males
14-18g/dL
females
12-16g/dL
25% of elder males (>65) arephysiologically anemic(because of deteriorating or diminishing testosterone).Can be categorized into:IMPAIRED ERYTHROPOIESIS
1.Insufficient Erythropoiesis
Decreased RBC production
Quantitative lack of erythroidprecursors
Diagnosis confirmed with
BAM/BONE MARROW BIOPSY
Bone marrow is replaced by :a. FAT CELLS - Aplastic anemiab. BLASTS (can be myeloblast or lymphoblast) - acute leukemia (20%or more of blasts to be consideredacute leukemia)c. PLASMA CELLS - multiplemyelomad. FIBROSIS - myelofibrosis2.
Ineffective erythropoiesis
Erythroid precursors are present buterythropoiesis proceeds abnormallyExamples:A. NUTRITIONAL DEFICIENCIES(IDA; Megaloblastic anemias, a folicor B12 deficiency)B. HEMOLYSINS - Can involveincreased destruction, increasedsequestration; can also be from
Subject: Medicine Topic: Pallor and BleedingLecturer: Ma. Luisa Concepcion, MDDate of Lecture: 10 Aug 2011 Transcriptionist: Teriyaki, Sushi andBrewed CoffeePages: 6
 S   0 - 0 
 
hyperfunctioning of spleen
*A patient may not appear anemic but thelab values show its anemia
Conditions Associated with SignificantDisproportion between HCT and RBCMASS
1. Relative increase in plasma volume (Hctdisproportionately low)a. Hyperemia of pregnancyb. overhydration (oliguric CRF or CHF)c. Hypoalbumminemiad. seen in edematous patient2. Relative decrease in Plasma Volume
Hematocrit is disproportionately high
Seen in Dehydration3. Decrease in both plasma and RBC mass
Acute blood loss
Myxedema, Addison’s disease
*
Doc drew this on the board remember? Understood?Just imagine that these are test tubes (green is air)
A.NormalB.Increased Plasma volume
Seen in patient with chronic heart or renal failure
RBCs are normal but hematocrit is FALSELY LOWA.Contracted Plasma Volume
Seen in dehydrated patients (diarrhea)
RBCs are normal but hematocrit is FALSELY ELEVATEDA.Decrease in both (look up!)
In cases of severe bleeding, CBC taken right after will give normal results so youhave to wait 3-6 hours to see the real count.
***Important Reminder (doc repeated this 4 times): Treat your patient not the lab result. Because labresults can give you false positive or false negative! 
C. FACTORS AFFECTINGMANIFESTATION OF ANEMIA
1.
Reduction in O
2
carrying capacity of theblood
RBC, the more prominent themanifestations
Patients will complain more of dizziness, easy fatigability etc.1.Degree in change of Blood Volume
If the blood loss is occurring slowly,cardiopulmonary can compensate.
≥70 Hb - no manifestation
<70 Hb - palpitation or loss of consciousness.1.Rate at which 1 and 2 occurs
Gradual or sudden
The more sudden the bleeding is,the more symptomatic the patientbecomes. (dizzy, fatigability)
Chronic/ insidious onset, the patientmay not present any symptombecause the body can already adaptto the condition.
100-120 Hb is often asymptomatic
No need for blood transfusion unlessthere is severe infection andhemolysis.1.Associated manifestation of theunderlying disorder.
If the patient has neuro,cardiopulmo problems, they maybecome more symptomatic.1.Capacity of CardioPulmo to compensate
If no cardio problem, there maybe no anemia manifestationunless >70 hb.D.EFFECTS OF ANEMIAA.INTEGUMENT1.Pallo
 
Check for the mucousmembrane, palm and solesespecially in patients with darkskin.
If creases of the palm do nothave color, ≤70 Hgb.Icteric scleraeL hand- creases have no color 
Most important thing here is todistinguish if there is PALLOR or NONE, and if it comes with jaundice and any other signs.
WAXY DEAD WHITE- acuteblood loss
SALLOW- yellowish; chronicform of anemia
*PALLOR + **BLEEDINGMANIFESTATION= Benign,aplastic anemia
*P + **BM + FEVER + WEIGHTLOSS = malignancy1.Hai
Thinning
Loss of luster 
Early graying (compared withother facial hair)1.Nail
KOILONYCHIA- seen in patientswith Iron Defiency Anemia, butthis is rarely seen.A.CARDIOPULMONARY
≤70 Hgb, patient are given bloodtransfusion because patientsbecome symptomatic.
In patients with CardioPulmodiseases, at 80-90 Hgb,transfusion is already given.
Do not rely only in CBC or labresults look for other manifestations.
Heart compensates byincreasing the Heart Rate.CONDITIONCOMPENSATIONIncreased CardiacOutput
Palpitation
Tachycardia
This may be present upon exertion
DecreasedExercise Tolerance
Dyspnea of Exertion
Easy fatigability
AnginaLV Dysfunction(pre-existing Heartdse.)
Edema
Bibasilar rate
S3 and S4 gallopmurmur 
Hepatosplenomegaly
If there is less RBC to transportoxygen, patient will experiencepalpitations and tachycardia.
Heart failure in more severeconditions.
ECG changes caused by anemiashould be back to normal onceanemia is corrected.
If not, it suggests that ECGchanges were present evenbefore the anemia.A.NEUROMUSCULAR
Hgb means
O
2
delivery to thebrain
HYPOXIA
HYPOXIA- patient may present withheadache, dizziness, lack of mentalconcentration and drowsiness
TUMOR and BLAST CELLS- canalso cause headache and dizziness
INTRACEREBRAL BLEEDING- cancause increase in ICP andPapilledema.
PAPILLEDEMA- edema of opticdisc; can be seen throughfundoscopy.

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