Anemia under investigation

1. Guided by : Dr.Sarita Patel Dr.Sarita Mangukiya Dr.Manmeet Kochar Presented by : Group no. 2 Ankit bargujar-6 Antala harshvardhan-7 Badreshiya tarak-8 Bhalani shivani-9 Bhati virendra-10 Anemia under investigation

2. 64 year female patient admitted in new civil hospital with following chief complain. • Chief Complaints(since 3 month) -Tremor in hands -Weakness in body -Body pain -Fever -Loss of apetite

3. No significant family history • Medical History • Patient had typhoid 3 months ago before admitted • Patient was admitted in Pooja hospital before 15 days for 1 week with same complain. • In pooja hospital ,4 BT(blood transfusion) given.

4. General Examination • At the time of admission BP – 150/100 mmhg

5. MEDICAL REPORT

6. MEDICAL REPORT

7. Iron Lab Studies Ferritin - storage protien of iron Transferrin - plasma protien that transports iron to the bone marrow TIBC - total iron binding capacity

10. REPORT [23/01/2017] • SAMPL TYPE:(Blood serum,plasma)

11. REPORT [23/01/2017] COAGULATION PROFILE

12. REPORT [24/01/2017] • Sample Type : Blood (Serum,Plasma) SERUM IONIZED CALCIUM IONIZES CALCIUM 1.77 mmol/L 1.15-1.32 SERUM PHOSPHORUS ESTIMATION S. PHOSPHORUS 4.13 mg/dL 2.7-4.5

13. MCV-mean corpuscular volume • Measure of average size of a single RBC • Microcytic MCV<80 • Macrocytic MCV>100 • Normocytic MCV= 80-100

14. MCHC-mean corpuscular hemoglobin concentration • -Measure of the HgB within a single RBC • -Hypochronic-cell has a deficiency of HgB • -Normochromic-value are normal

15. TREATMENT • BT • Antibiotics • Tab. Lasix(Furosemide) • Antacid

16. Role of lasix After BT ,Lasix was given to reduce the fluid over-load. • Role of antibiotics Because patient has c/o of fever. • Role of antacids To reduce the gastric acid output

17. Hypokalemia • Drug induced- Diuratics(lasix)- inhibits sodium, potassium and chloride reabsorption from renal tubules. • Insulin- intracellular shifting of potassium • Inadequate potassium intake- it is uncommon • Gastrointestinal loss- diarrhoea, vomitting • kidney failure- rarely because mostly in kidney failure, loss the ability to remove potassium.

18. Symptoms of Hypokalemia • Abnormal heart rhytham • Muscle weakness • Tremor • Muscle cramps • Constipation

19. Hypercalcemia • Overactive parathyroid glands • hyperparathyrodism , • secondary hyperparathyrodism(kideny failure) • Cancer- Lung cancer and breast cancer, as well as some cancers of the blood, can increase your risk of hypercalcemia. • Cancer cell may secret Parathyroid hormone related protein(PTHrP) • Spread of cancer (metastasis) to your bones also increases your risk of hypercalcemia.

20. Immobility- People with cancer or other diseases that cause them to spend a great deal of time sitting or lying down may develop hypercalcemia. Over time, bones that don't bear weight release calcium into the blood • Medications-such as lithium-may increase the release of parathyroid hormone.

21. Supplements • Dehydration • High bone turnover rates- Breakdown of bone • Bone malignancy • multiple myeloma

22. Symptoms of hypercalcemia • Loss of appetite. • Fatigue, weakness, and muscle pain. • Nausea and vomiting. • Constipation and abdominal pain. • Increased thirst and frequent urination. • Confusion, disorientation

23. Anemia -defined as a decrease in the total amount of red blood cells (RBCs) or hemoglobin in the blood. • In Men <13 gm/dl • In Women <12 gm/dl

25. Classified based on • Cell size • Diminished Production • Accelerated loss

26. Types • Iron deficiency anemia. • Vitamin deficiency anemia • Aplastic anemia • Anemias associated with bone marrow disease • Hemolytic anemias

27. Causes of IRON deficiency anemia

28. Iron Deficiency Anemia Signs and symptoms • Fatigue • Tachycardia/Palpitations • Tachypnea on exertion • Pallor

29. Iron Deficiency Anemia Laboratory findings • Decreased serum ferritin • Decreased serum iron • Decreased MCV • Increased total iron binding capacity(TIBC)

31. Anemia of Chronic Disease Essentials of Diagnosis • Anemia (normochronic or microcytic) • Normal or Increased ferritin • Underlying Chronic Disease -chronic infection -chronic inflammation -Cancer -liver disease -Renal failure-decreased in EPO

32. Anemia of Chronic Disease Signs and symptoms • depends on causative condition Laboratory findings • Hb mildly or moderately reduced • MCV usually normal • Serum ferritin normal or increased

33. Macrocytic Anemias • Vitamin B12 deficiency • Folic acid deficiency • There is a defect in DNA synthesis that affects the rapidly dividing cells in the bone marrow.

35. Causes of vitamin B12 deficiency Dietary deficiency Decreased production pernicious anemia chronic atrophic gastritis Decreased B12 absorption surgical resection of the ileum

36. Vitamin B12 Deficiency Signs and symptoms • May be asymptomatic • As anemia becomes more severe • pallor • glossitis • Megaloblastic anemia (MCV>100) • In sever deficiency- neurological symptoms present

37. Vitamin B12 deficiency Diagnosis • -Macrocytic anemia • -Hypersegmented neutrophils on PBS • -Low Serum Vitamin B12 levels

39. Folic acid dificiencyLaboratory Findingsmacrocytic anemiahypersegmentednetrophils on PBS normal serum vitamin B12 levels reduced folate level 02-01-2020

40. Hemolytic anemiasautoimmune or related to drugs,infection,lymphoproliferativedisease,Rh or ABO incompatibility • abnormal hemoglobin:sicklecelldisease,thalassemia,metheoglobinemia • membrane defect: hereditary spherocytosis,herediatryelliptocytosis,paroxymalnocturalhemoglobinuria • enzyme defect:G6PD deficirncy,pyruvate kinase deficiency 02-01-2020

41. Autoimmune hemolytic anemiaSigns & Symptoms “ Rapid onset” anemia may be “life Threatening” fatigue jaudince splenomegaly 02-01-2020

42. Autoimmune hemolyticanemiaLaboratoryHb low elevated reticulocyte level elevated Total & indirect billirubin 02-01-2020

43. Aplastic Anemia pancytopenia no abnormal cells seen on PBShypocellular bone marrow 02-01-2020

44. Aplastic AnemiaLaboratory Testspancytopenia,although in early disease only one or two cell lines may be reducedAnemia may be severe Reticulocytes ALWAYS decreased Large RBC(macrocytosis) Neutrophils and platelets reduced in number, no immature or abnormal forms seen 02-01-2020

45. Causes of high total protien • Chronic inflammatory conditions • HIV/AIDS • Bone marrow disorder • Multiple myloma • Amyloidosis • Dehydration (which may make blood proteins appear falsely elevated

46. HypergammaglobulinemiaIncrease immunoglobulinsleval may result from stimmulation of many clones of B cells(polyclonal hypergammaglobulinemia) or monoclonal proliferation(paraproteinemia).Polyclonal hypergammaglobulinemia:Stimulation of many clones of B cells produce a wide range of antibodies that appear as diffuse increase in gammaglobulinon electrophoresis.e.g. acute and chronic infections & autoimmune diseasesMonoclonal hypergammaglobulinemia:Proliferation of a single immunoglobulin which appears as a discrete densely stained band(paraprotein or M band)on electrophoresis.Paraprotiens are characteristic of malignanat B-cell proliferation.Multiple myeloma is the commonest cause of paraproteinemia. 02-01-2020

47. About a : g ratio • A high total protein level may be seen with chronic inflammation or infections such as viral hepatitis or HIV. • Normal A:G Ratio <2 • In Our patient A:G Ratio- 3.9 (high)

48. A low A/G ratio- • 1)overproduction of globulins, • multiple myeloma or  • autoimmune diseases, • 2)Underproduction of albumin, • cirrhosis, • kidney disease (nephrotic syndrome). • .

49. A high A/G ratio • underproduction of immunoglobulins • genetic deficiencies and in some leukemias

50. ESR- causes and method to find ESR • ESR-Erythrocyte sedimentation rate is the rate at • Which RBC sediment in a period of one hour. • It is common hematology test and is a non specific nature of inflammation.