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Subject: Medicine Topic: Pallor and Bleeding Lecturer:Ma.

Luisa Concepcion, MD Date of Lecture:10 Aug 2011 Transcriptionist: Teriyaki, Sushi and Brewed Coffee Pages: 6

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 body weakness. o hematologic disorders - generalized body weakness o neurologic - localized Weakness, easy fatigability, exertional dyspnea may also be manifestations of a cardiac problem; thus we must look at additional manifestations that go with the said symptoms. Especially when its associated with pallor, most likely it'll be a hematologic problem.  Pallor if combined with Ictericia can denote ANEMIA What about patients with bleeding manifestations?  PETECHIAE - pinpoint lesions less than 3mm in size.  ECCHYMOSIS - larger than petechiae.  HEMATOMA - can dissect muscle plains. With these manifestations, aside from the ecchymosis and hemarthrosis, bleeding in joints, is common in coagulation disorder, like hemophilia. Check the history. Check the P.E. Like when youre diagnosing someone, check this history and see if the physical findings support what you are thinking. Use the clues in history getting. You also check for associated manifestations and finally you do your laboratories. Its not backwards. You don't diagnose a patient with laboratories. You have a diagnosis then confirm with labs. We should first have a clinical diagnosis before. Because how would you know what laboratories you will ask for in the first place. Have something in your mind so you have a flow of work up. ANEMIA o A reduction in red cells (function of which is to carry oxygen to different parts of the body) so the capacity to deliver blood is also diminished. o Normal values based on WHO o males 14-18g/dL o females 12-16g/dL o 25% of elder males (>65) are physiologically anemic (because of deteriorating or diminishing testosterone). Can be categorized into: IMPAIRED ERYTHROPOIESIS 1. Insufficient Erythropoiesis  Decreased RBC production  Quantitative lack of erythroid precursors  Diagnosis confirmed with BAM/BONE MARROW BIOPSY  Bone marrow is replaced by : a. FAT CELLS - Aplastic anemia b. BLASTS (can be myeloblast or lymphoblast) - acute leukemia (20% or more of blasts to be considered acute leukemia) c. PLASMA CELLS - multiple myeloma d. FIBROSIS - myelofibrosis 2. Ineffective erythropoiesis  Erythroid precursors are present but erythropoiesis proceeds abnormally Examples: A. NUTRITIONAL DEFICIENCIES (IDA; Megaloblastic anemias, a folic or B12 deficiency) B. HEMOLYSINS - Can involve increased destruction, increased sequestration; can also be from hyperfunctioning of spleen *A patient may not appear anemic but the lab values show its anemia

SY 2011-2012

Conditions Associated with Significant Disproportion between HCT and RBC MASS 1. Relative increase in plasma volume (Hct disproportionately low) a. Hyperemia of pregnancy b. overhydration (oliguric CRF or CHF) c. Hypoalbumminemia

d. seen in edematous patient 2. Relative decrease in Plasma Volume  Hematocrit is disproportionately high  Seen in Dehydration 3. Decrease in both plasma and RBC mass  Acute blood loss  Myxedema, Addisons disease

Plasma RBC
A. Normal B. plasma volume C. Contracted D. Decrease in Plasma both Volume

*Doc drew this on the board remember? Understood?Just imagine that these are test tubes (green is air) A. Normal B. Increased Plasma volume y Seen in patient with chronic heart or renal failure y RBCs are normal but hematocrit is FALSELY LOW C. Contracted Plasma Volume y Seen in dehydrated patients (diarrhea) y RBCs are normal but hematocrit is FALSELY ELEVATED D. Decrease in both (look up!) y In cases of severe bleeding, CBC taken right after will give normal results so you have 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 lab results can give you false positive or false negative!

C. FACTORS AFFECTING MANIFESTATION OF ANEMIA 1. Reduction in O2 carrying capacity of the blood  RBC, the more prominent the manifestations  Patients will complain more of dizziness, easy fatigability etc. 2. 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. 3. Rate at which 1 and 2 occurs  Gradual or sudden

 The more sudden the bleeding is, the more symptomatic the patient becomes. (dizzy, fatigability)  Chronic/ insidious onset, the patient may not present any symptom because the body can already adapt to the condition.  100-120 Hb is often asymptomatic  No need for blood transfusion unless there is severe infection and hemolysis. 4. Associated manifestation of the underlying disorder.  If the patient has neuro, cardiopulmo problems, they may become more symptomatic.

5. Capacity of CardioPulmo to compensate  If no cardio problem, there may be no anemia manifestation unless >70 hb. D. EFFECTS OF ANEMIA A. INTEGUMENT 1. Pallor  Check for the mucous membrane, palm and soles especially in patients with dark skin.  If creases of the palm do not have color, 70 Hgb.

3. Nail  KOILONYCHIA- seen in patients with Iron Defiency Anemia, but this is rarely seen. B. CARDIOPULMONARY  70 Hgb, patient are given blood transfusion because patients become symptomatic.  In patients with CardioPulmo diseases, at 80-90 Hgb, transfusion is already given.  Do not rely only in CBC or lab results look for other manifestations.  Heart compensates by increasing the Heart Rate. CONDITION COMPENSATION Increased Cardiac Output  Palpitation  Tachycardia This may be present upon exertion  Dyspnea of Exertion  Easy fatigability  Angina  Edema  Bibasilar rate  S3 and S4 gallop murmur  Hepatosplenomegaly

Icteric sclerae

Decreased Exercise Tolerance LV Dysfunction (pre-existing Heart dse.)

L hand- creases have no color

 Most important thing here is to distinguish if there is PALLOR or NONE, and if it comes with jaundice and any other signs.  WAXY DEAD WHITE- acute blood loss  SALLOW- yellowish; chronic form of anemia  *PALLOR + **BLEEDING MANIFESTATION= Benign, aplastic anemia  *P + **BM + FEVER + WEIGHT LOSS = malignancy 2. Hair  Thinning  Loss of luster  Early graying (compared with other facial hair)

 If there is less RBC to transport oxygen, patient will experience palpitations and tachycardia.  Heart failure in more severe conditions.  ECG changes caused by anemia should be back to normal once anemia is corrected.  If not, it suggests that ECG changes were present even before the anemia. C. NEUROMUSCULAR  Hgb means O2 delivery to the brain HYPOXIA  HYPOXIA- patient may present with headache, dizziness, lack of mental concentration and drowsiness  TUMOR and BLAST CELLS- can also cause headache and dizziness  INTRACEREBRAL BLEEDING- can cause increase in ICP and Papilledema.  PAPILLEDEMA- edema of optic disc; can be seen through fundoscopy.

present hematuria and absence of RBC will present hemoglobinuria. III. HISTORY  Duration or onset of anemia or bleeding acute or chronic o Can start from birth to growing up years  Family history of anemia, spells of jaundice, splenectomy (hereditary splenocytosis) or bleeding o Negative family history of anemia or bleeding is not always an implication of the disease  Occupation, household customs, hobbies use of drugs or chemicals o Occupational hazards: for those who are constantly exposed to benzene paints and petroleum o For cancer patients who had chemotherapy using alkylating agents they may acquire another form type of malignancy after a few years this time the malignancy is caused by alkylating agents used in their previous cancer therapy  Menstrual/OB history abnormalities in flow and duration of menses, number of interval pregnancy and abortion  Rate of growth seen in infancy, childhood and teens, increase need of iron  Diet idiosyncrasies; cooking habits; vegetarians are at risk of IDA o For vegans: they do not eat meat which is the usual source of vitamin B12 and also iron o Some supplements are associated with bleeding disorders: Gingko biloba, fish oil, herb containing coumarines  Most common hereditary platelet deficiency; von willebrands disease which presents with menorrhagia - Most common hereditary platelet defieciency; Von WillebrandsDisease which present menorrhagia o Menorrhagia heavy /prolonged bleeding o Metorrhagia menstrual bleeding or more than 8

Papilledema (notice the ring at the center)  PARESTHESIA- tingling or numbness sensation due to Pernicious Anemia or can be seen in patients undergoing chemotherapy (ALL) D. GASTROINTESTINAL  GLOSSITIS inflamed tongue, shining  ATROPHY OF THE PAPILLAE of the tongue more common in pernicious anemia than Iron deficiency anemia (IDA)  DYSPHAGIA found in severe IDA because they have post cricoids web associated with it (if treated or mild dysphagia can be compensated, otherwise you have to rupture the web)  MEGALOBLASTIC ANEMIA prominent fissure lines in tongue (beefy looking tongue) E. GENITOURINARY  PROTENURIA seen inmultiple myeloma  HEMATURIA any condition in which the urine contains blood or RBC; example is during menstruation  HEMOGLOBINURIA presence of hemoglobin in the urine; seen in intravascular hemolysis or bleeding into the urinary tract; urine color may be reddish yellow to dark red; if the RBCis 0:1 then seek for urinalysis  EXTRAVASCULAR HEMOLYSIS splenomegaly  INTRAVASCULAR HEMOLYSIS hemoglobinuria  both hematuria and hemoglobinuria present with dark colored urine  Difference in hematuria and hemoglobinuria: If you request for urinalysis, presence of RBC will

days. Bleeding is not due to the normal menstrual cycle IV. REVIEW OF SYSTEMS Change in the bowel habits Early graying of hair Positive or negative fever Paresthesias (B12 deficiency) and bone pains  Abnormal urine color  Easy bruising  Weight loss, colonic CA, gastric lymphoma, multiple myeloma, hemoglobinuria     V. PHYSICAL EXAMINATION  Petechiae  Ecchymosis  Hematoma intramuscular or interfascial  Hemorrhages in optic fundi, mucous membrane  enlarged lymph nodes masses When do we send our patients for biopsy? If the node is:  enlarged, more than 2.25 cm malignant  fixed more like a metastatic cancer  not fixed movable (lymphoma)  hard  tender (inflammation or a rapid growth of a tumor)  sternal tenderness usual in ALL - examine by pressing the sternum; patient complains that it is painful - due to inflammation of the leukemic cells in the bone  rhythm irregularities and murmurs  hepatosplenomegaly / abdominal masses common in chronic form of leukemia or hematologic malignancies  pelvic and rectal exam findings this is not that important unless patient presents with vaginal bleeding HEMATOMA  can also transect muscles and fascia. It is not always limited to the skin.  can also be found in the tongue floor of the mouth or in the submental area. SPLEEN  should not be palpable. In normal conditions, the spleen is palpable

and this usually happens when the spleen is larger than its normal size. CHLOROMA  skin lesion present in patients with leukemia.  ectopic accumulation of the blasts in the skin.  is a manifestation of leukemia, if chronic, it can grow ectopically outside the bone marrow. GINGIVAL HYPERTROPHY  is common in Acute Myelogenous Leukemia VI. CLINICAL FEATURES Clinical findings Petechiae Dissectioning hematoma Superficial ecchymosis Hemarthrosis Delayed bleeding Coagulation Platelet/ vessel Rare Characteristic characteristic Rare

Common, large, solitary Characteristic Common when clotting factors are deficient (example: tooth extraction. Patient goes back to the dentist due to hematoma formation) Minimal

Characteristic; small; multiple rare Rare (example: in comparison to coagulation, bleeding is apparent immediately after tooth extraction

Superficial cuts Sex

Profuse and persistent Female (von Willebrands disease)

Male (hemophila Xlinked hemophilia is the common hereditary coagulation disorder Common

Family history

rare

Why is the bleeding delayed?  upon skin perforation, hemostatic mechanism comes into play right away aggregation of platelets and

adhesion formation of hemostatic plug which is unstable and must be reinforced by fibrin and other clotting factors bleeding is stopped temporarily since clotting factors re deficient, the hemostatic plug is destroyed and bleeding resumes A. CLINICAL FEATURES OF HEREDITARY DISORDERS  onset of bleeding signs and symptoms are noted in infancy and childhood  mild forms may not be evident only noticed when kids play and get cut persistent bleeding  family history reveals a consistent genetic pattern  a negative family history does not exclude the hereditary coagulation disorder

 lab evidence of an isolated abnormality B. CLINICAL FEATURES OF AN ACQUIRED BLEEDING DISORDER  bleeding manifestations are less severe and later onset  clinical feature dominated by the underlying disorder rather than bleeding alone.  positive history of exposure to chemicals or drugs *NSAIDS platelet dysfunction *Herbal Supplements ex. Liver disease: cirrhosis clotting factors are from the liver so derange coagulation  HYPRESLENISM sequestered platelets causing continuous bleeding

-END OF TRANSCRIPTIONNote: This tranx was based mostly on docs voice recording and previous tranx since doc didnt give us a copy of her powerpoint. So please read your very expensive book for more information! The transcribers would like to greet the following: Sheila for the voice recording! All IDK people! UST- Sampaloc Chapter Family and friends