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RED BLOOD CELL ABNORMALITIES

RED BLOOD CELL ABNORMALITIES

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RED BLOOD CELL ABNORMALITIES
(APPROACH TO THE DIAGNOSIS OF ANEMIA)
ANEMIA

Reduction below normal in the concentration of
hemoglobin or RBC\u2019s in the blood
Anemia is not a diagnosis in itself, but merely an objective
sign of disease.

First step in its diagnosis is detection of its presence.
3 FUNCTIONAL CATEGORIES OF THE ANEMIAS

\u2022Disorders of Proliferation
\u2022Disorders in Erythrocyte Maturation
\u2022Disorders due Primarily to Erythrocyte Destruction or Red

Cell Loss
SUBJECTIVE DATA
\u2022
Severity of the anemia
\u2022
Rapidity of onset
\u2022
Patient\u2019s age and CV status
o
capacity of the CV & pulmonary system
\u2022
to compensate for the anemia
\u2022

Associated manifestations of the underlying disorder
- Endocrine disorder
- Renal disorder
- Hepatic disorder

\u2022
Onset & Duration of symptoms
insiduous or acute
\u2022
Previous prescription for hematinics
& response
\u2022
Medication history
\u2022
Occupation, household customs &
hobbies
\u2022
Symptoms of hemolysis
jaundice, changes in urine color
\u2022
Symptoms of blood loss
melena, hematochezia, epigastirc pain
\u2022

Obstetric & Gynecologic history
# of pads/day
duration
# of pregnancies, abortions - interval

\u2022
Concomitant bleeding manifestations
\u2022
Dietary history
\u2022
Fever, Weight loss
I. Cardiac Signs
\u2022Hemic murmurs: mid or holosystolic often in the pulmonic
or apical area, due to increased blood flow and turbulence

\u2022Gallop rhythms
\u2022Tachycardia/Cardiomegaly
\u2022Strong peripheral pulses with wide pulse pressure

II. Integumentary Manifestations
\u2022Pallor: <8 to 10 mg/dL hemoglobin

Affected by:
- state of vasoconstriction/vasodilatation
- degree & nature of pigmentation
- nature & fluid content of the subcutaneous

tissues
Most constantly detected in:
- mucous membranes of the mouth, pharynx,
conjunctivae, lips
- nailbeds
* Areas where vessels are close to the skin surface
\u2022
Dry, Shriveled skin
\u2022
Thinning, loss of luster, premature graying of hair
\u2022
Brittle, lackluster nails, spooning
III. Neuromuscular Signs

\u2022Headache
\u2022Vertigo
\u2022Tinnitus
\u2022Faintness
\u2022Retinal hemorrhage
\u2022Paresthesias
\u2022Scotomas
\u2022Lack of mental concentration
\u2022Drowsiness
\u2022Restlessness

IV. GI Manifestations

\u2022Glossitis
\u2022Atrophy of the papillae of the tongue
\u2022Dysphagia
\u2022Oral ulcers
\u2022Gingival hyperplasia
\u2022Hepatosplenomegaly

V. Sternal Tenderness
Lymphadenopathy

Even the most expert clinical appraisal does not supplant
accurate measurement of the blood for the detection,
quantification and characterization of anemia.

Changes in Normal Hemoglobin/Hematocrit Values with
Age and Pregnancy
\u2022Age/Sex
Hemoglobin g/dl
Hematocrit %
At birth
17
52
Childhood
12
36
Adolescence
13
40
Adult man
16(+2)
47(+6)
Adult woman
13(+2)

40(+6)
(menstruating)
Adult woman

14(+2)

42(+6)
(postmenopausal)
During pregnancy

12(+2)
37(+6)
Red Cell Indices
\u2022Index
Normal Value
Mean Cell Volume(MCV):
(hematocrit x 10)/(red cell ct. x 106)
90 + 8 fL
Mean Cell Hemoglobin (MCH):
(hemoglobin x 10)/ (red cell ct. x 106)
30 + 3 pg
Mean Cell Hemoglobin Concentration:
(hemoglobin x 10)/ hematocrit,
33 + 2%
or MCH/MCV
VI. Genitourinary Signs
\u2022
Slight proteinuria
\u2022
Changes in urine color
Always rule out primary disease of the GUT.
1

Even the most expert clinical appraisal does not
supplant accurate measurement of the blood for the
detection, quantification and characterization of
anemia.

Objective Data
Laboratory tests:
I. Red cell count- hgb, hct, reticulocyte
count, RBC indices
II. White Blood cell count- diff\u2019l, nuclear

segmentation of neutros
III. Platelet count
IV.Peripheral smear morphology
V. Iron Studies
VI. Bone marrow examination

RETICULOCYTE COUNT
\u2022Normal Value: 0.5 \u2013 1.5% (old)
5 \u2013 15 x 10-3 (SI)
Correction:
Patient\u2019s Hct x Reticulocyte count % = corrected
45
reticulocyte
Corrected Reticulocyte = RPI
2
WHITE BLOOD CELL COUNT
\u2022Normal Value: 4.5 \u2013 10.0 x 109/L
Percentage
Absolute
No.
Bands
0-0.05
0-0.7
Segmenters
0.50-0.70
1.8-
7.0
Lymphocytes
0.20-0.40
1.0-4.8
Monocytes
0-0.07
0-
0.80
Eosinophils
0-0.05
0-
0.45
Basophils
0-0.01
0-0.20
Normal Peripheral Smear
Normal bone marrow (LPO)
Normal bone marrow (HPO)
ASSESSMENT (Possible Cause of Anemia)
CLASSIFICATION OF ANEMIAS BASED ON ETIOLOGY
\u2022
Increased Blood Loss
Acute and Chronic Hemorrhage
\u2022
Excessive Blood Destruction ((Hemolysis)
A. Congenital
1. Red Cell Morphologic Defects
(e.g. Congenital
Spherocytosis)
2. Hemoglobinopathies
(e.g. Thalassemias)
3. Enzyme Defects
(e.g. G6PD Deficiency)
B. Acquired
1. Immune Disorders
(e.g. LE)
2. Non-Immune Disorders
(e.g. Infections, Allergy, etc.)
\u2022
Marrow production defects
a. Hematinic deficiencies \u2013 iron, Vit.
B12, Folic Acid
b. Infiltrative Diseases \u2013 Leukemias,
lymphomas, Cancer
c. Aplasia
d. Miscellaneous \u2013 Endocrine, Renal,
Infections
CASE STUDIES
\u2022Case 1
Mr. Santos, 48 years old farmer consulted
because of progressive weakness and pallor.
No jaundice nor hepatosplenomegaly on
P.E.Petechiae noted on both L.E.\u2019s

CBC Result: Hb: 7 gm/dl Hct: 21

WBC: 4,000
lymph: 48%
segs: 52%
Platelet count: 80,000
Reticulocyte Count:5 x 10-3
Bone Marrow: FATTY MARROW
APLASTIC ANEMIA
\u2022A type of hypoproliferative anemia characterized by
pancytopenia with marrow hypocellularity
\u2022Etiology:
2
1. Primary
a. Congenital
Fanconi\u2019s Anemia
b. Idiopathic

2. Secondary
a. Radiation
b. Drugs and Chemical

Regular effects
Idiosyncratic effects
c. Viruses

d. Immune diseases
e. PNH
f. Pregnancy

Pathogenesis:
\u2022
Depletion of hematopoietic cells by an agent or
event that kills stem cells
\u2022

Suppression of proliferation and maturation of stem
cells by an immunologic or lymphocyte mediated
mechanism

Clinical Features:
- symptoms related to decrease RBC,
WBC, platelets
-Physical exam: lymphadenopathy and
splenomegaly not typical
-Laboratories: Pancytopenia, decrease
reticulocyte count
Bone marrow: fatty marrow
Management Options:
\u2022
Transfusion support
\u2022
Bone marrow transplantation
\u2022
Immunosuppression with anti-thymocyte globulin,
with or without steroids
\u2022
Androgen stimulation
\u2022Case 2
J.K., 35 year old housewife complains of progressive
easy fatigability of about 3 months duration.
Review of System: (-) epigastric pain
(-) hematochezia nor
melena
menses \u2013 28 days cycle, 7 days duration,
3 days profuse flow consuming
5-6 fully soaked pads/day
(-) bruises/ecchymoses
P.E. Pale, no jaundice
(-) hepatosplenomegaly
Laboratory results:
CBC: Hb: 60g/L
WBC: 6 x 109/L
Hct: .21
seg:
70%
MCV: 80fL
lymph: 25%
MCH: 25 pg
eos:
3%
MCHC: 28%
mono: 2%
platelets: adequate
Reticulocyte count: 1.5 x 10-3
Peripheral smear: HYPOCHROMIC
Iron studies:
Ferritin: 8ug/L
Iron: 10 (N.V.9 - 27 umol/L)
TIBC: 60 (N.V. 54 \u2013 64 umol/L)
Percent Saturation: 17%
IRON DEFICIENCY ANEMIA
\u2022Most common cause of anemia worldwide
\u2022Iron is absorbed primarily in the duodenum
and upper jejunum
\u2022Picture : causes of iron anemia
\u2022 Case 3

Mrs. Cruz, 75 year old female consulted
because of progressive weakness and loss of balance.
She also complains of numbness and tingling sensation
in all extremities. She has no gastrointestinal
complaints.

- not a diabetic but is hypertensive
- prefers to eat vegetables and fish
because of poor dentition
P.E.
Patient is pale with smooth, red tongue.
No organomegaly noted
Laboratory Results
CBC: Hb: 80 g/L
WBC: 9 x 109/L
Hct: .26
seg:
74%
MCV: 102fL
lymph: 20%
MCH: 36 pg
eos:
2%
MCHC: 38%
mono: 4%
platelets: adequate
Peripheral Smear: Macrocytes
MEGALOBLASTIC ANEMIA
-disorder caused by impaired DNA synthesis
-Cell primarily affected: blood cells
GI epithelial cells
-slowed nuclear cell division with normal progression of
cytoplasmic maturation
Megaloblastosis
Folate sources: mainly fruits and vegetables
Cobalamin sources: meat & dairy foods
Cause: B12 or/& Folate Deficiency
Clinical Manifestations:
\ue000Anemia with slight icteresia
\ue000GI manifestations \u2013 glossitis, smooth,
beefy red tongue, malabsorption
3. Neurologic manifestations (Cobalamin) - subacute
combined degeneration of CNS
peripheral neuropathy \u2013 numbness,
weakness, ataxia, paresthesia,
disturbances of mentation
\u2022Management:
1. Treatment of underlying problem
2. Replacement therapy
oral folic acid
parenteral B12
\u2022Case 4

Mrs. Santos, 50 year old male was referred for
evaluation of anemia. She begun to experience easy
fatigability about 5 weeks PTC. She also noticed
passage of highly colored urine.
(+) weight loss of about 5 lbs in the last 2 months
(+) febrile episodes

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