ANEMIA anemia has been defined as a reduction

ANEMIA anemia has been defined as a reduction in one or more of the major red blood cell (RBC) measurements: hemoglobin concentration, hematocrit, or RBC count: Dr. Azarm

signs and symptoms n The signs and symptoms induced by anemia are dependent upon the degree of anemia and the rate at which it has evolved, as well as the oxygen demands of the patient. Dr. Azarm

n Weakness , dyspnea , chest pain , especially on exertion n pallor Dr. Azarm

n Hg = 12. 7 , MCV = 90 , MCH = 27 , MCHC = 32 Dr. Azarm

Special populations n high altitude n smoker n degree of environmental air pollution n The elderly n Athletes Dr. Azarm

History n Familial Hx n Hx of medical disease n Hx of drugs n Chronologic Hx n ethnicity and country of origin

Physical examination n Pallor n Jaundice n lymphadenopathy, hepatosplenomegaly, and bone tenderness, especially over the sternum n petechiae due to thrombocytopenia, ecchymoses,

LABORATORY EVALUATION n CBC with platelets, WBC differential, and reticulocytes. n PBS

MICROCYTIC ANEMIA n iron deficiency , thalassemia, and the anemia of chronic disease Dr. Azarm

Microcytic anemias

TREATMENT OF IRON DEFICIENCY n n n n identify and treat the cause of the deficiency (eg, blood loss, poor iron absorption) as well as the administration of iron Oral iron usually provides a safe, cheap and effective means of restoring iron balance. Iron is absorbed best from the duodenum and proximal jejunum. Therefore, the more expensive enteric coated or sustained release capsules, which release iron further down in the GI tract, are counterproductive. Iron salts should not be given with food because the phosphates, phytates, and tannates in food bind the iron and impair its absorption Iron should be given two hours before, or four hours after, ingestion of antacids. Patients with persistent gastric intolerance may tolerate ferrous sulfate elixir, which provides 44 mg of elemental iron per 5 m. L. Patients can titrate the dose up or down to the level at which the gastrointestinal symptoms become acceptable Gastrointestinal tract symptoms (eg, abdominal discomfort, nausea/vomiting, diarrhea/constipation) suffered by some patients seem to be directly related to the amount of elemental iron ingested. Thus, the reported low incidence of side effects for some preparations can be explained by their low elemental iron content. For example, a 325 mg tablet of ferrous gluconate contains 36 mg of elemental iron, or 55 percent of the amount of elemental iron in a 325 mg tablet of ferrous sulfate.

q Ferrous fumarate — 106 mg elemental iron q Ferrous sulfate — 65 mg elemental iron/tablet q Ferrous gluconate — 28 to 36 mg iron/tablet

Side effects n Approximately 10 to 20 percent of patients may complain of nausea, constipation, epigastric distress and/or vomiting after taking oral iron preparations n smaller dose of elemental iron n switch from a tablet to a liquid preparation n , increase the dose from one tablet per day to the recommended three to four times per day, as tolerated. n taken with meals

PARENTERAL IRON n rare patient who is unable to tolerate even modest doses of oral iron n in patients whose level of continued gastrointestinal bleeding exceeds the ability of the gastrointestinal tract to absorb iron n Occasional patients with inflammatory bowel disease and iron deficiency may give a history of severe intolerance to oral Fe, making therapy with parental iron necessary.

Macrocytic anemias n alcoholism, liver disease, folic acid and vitamin B 12 deficiency

n The evaluation of such patients should begin with a focused history including the extent of alcohol abuse, exposure to antimetabolites and other medications, nutritional status (especially in the elderly and alcoholics), and the possible presence of liver disease. n examination of the blood smear, reticulocyte count, and analysis of serum for cobalamin, folate, thyroid stimulating hormone (TSH), tests of liver function, and protein electrophoresis for the rare case of multiple myeloma

n use of high concentrations of EDTA n Osmotic swelling of RBCs within the counting apparatus can occur following an episode of hyperglycemia in diabetic patients n Cold or warm agglutinins in the patient, activated by temperature changes either in the sample prior to counting or to heating/cooling of the RBC solution within the apparatus itself, will cause RBCs to pass through the counter in small groups, rather than one by one, and will be counted as macrocytic cells.

n Vitamin B 12 and/or folate deficiency should be suspected in n n patients with one or more of the following clinical or laboratory findings : Macrocytic red blood cells (ie, mean corpuscular volume >100 f. L), and/or macro-ovalocytic red blood cells on the peripheral blood smear, with or without anemia The presence of hypersegmented neutrophils on the peripheral blood smear Pancytopenia (ie, the combination of anemia, thrombocytopenia, and neutropenia) of uncertain cause Unexplained neurologic signs and symptoms, especially dementia (seen only with Cbl deficiency) Special populations, such as the elderly, alcoholics, and patients with malnutrition