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Slide 1 :

ANAEMIA Prepared & Presented by Dr. Sayem IMO Dept. Of Medicine EMCH

Slide 2 :

DEFINITION Anaemia is a clinical condition due to reduction of Hb level below the normal range in the peripheral blood for the age & sex of the individual. Normal level of Hb%: Men - 14.0–18.0 g/ dl Women - 12.0–16.0 g/dl Full Term – 13.5–19.5 g/dl Children(1 Year) – 11.0–13 g/dl Children(10-12 Years) – 11.5–14.5 g/dl

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GRADING WHO Grading of anemia: Grade 1 (Mild Anemia): 10 g/dl - cutoff point for ages Grade 2 (Moderate Anemia): 7-10 g/dl Grade 3 (Severe Anemia): below 7 g/dl

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CLASSIFICATION Morphological Classification Aetiological Classification 1. Impaired Red Cell Production 2. Blood Loss 3. Haemolytic Anaemia

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Morphological Classification A. Microcytic Hypochromic Anaemia MCV(<80fL), MCHC(<30g/dl) & MCH(<27pg) are below normal. Causes: Iron deficiency anaemia, Thalassemia, Anaemia of chronic diseases, Sideroblastic Anaemia. B. Macrocytic Anaemia MCV is above normal(>96fL). MCHC is normal. Causes: Megaloblastic anaemia. C. Normocytic Normochromic Anaemia MCV, MCHC & MCH are within normal range. Causes: Acute Blood Loss, Haemolytic Anaemia.

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2. Aetiological Classification 1. Impaired Red Cell Production A. Deficiency of essential nutrients a. Iron deficiency (Most Common) b. Vitamin B12 deficiency c. Folic acid deficiency B. Depression Of Erythropoiesis a. Anaemia of chronic disorder b. Disseminated malignancy c. Invasion of bone marrow (Leukemia, Lymphoma, Secondary Carcinoma) d. Anaemia due to inherited disorder (thalassaemia) e. Aplastic anaemia 2. Blood Loss A. Acute blood loss (RTA) B. Chronic blood loss (Bleeding Peptic Ulcer, Piles, Menorrhagia, Hookworm Infection)

Slide 7 :

3. Haemolytic Anaemia a. Intracorpuscular deffect Membrane deffects (Heareditary spherocytosis) Haemoglobin deffects (Sickle cell anaemia) Thalassaemia Enzyme deffects (G6PD deficiency) b. Extracorpuscular deffect Immune- Auto-immune acquired haemolytic anaemia (Warm antibody, Cold antibody) Haemolytic disease of newborn Incompatible blood transfusion Non-immune- Micro-angiopathic haemolytic anaemia Cardiac haemolytic anaemia March haemoglobinuria

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CLINICAL FEATURES OF ANAEMIA SYMPTOMS Fatigue Headaches Faintness Breathlessness Angina Intermittent claudication Palpitation SIGNS Pallor Tachycardia Systolic flow murmur Cardiac failure

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Specific Signs in IDA Koilonychia Smooth tongue Angular stomatitis Dysphagia and Glossitis Plummer Vinson Syndrome Specific Signs in Haemolytic Anaemia Jaundice Specific Signs in Sickle Cell Disease Leg ulcer Specific Signs in Thalassaemia Bone deformities Spleenomegaly

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Aplastic Anaemia Features of pancytopenia present. Anaemia Bleeding disorder Infection Hepatosplenomegaly Lymphadenopathy Autoimmune Hemolytic Anemia (AIHA) Warm Type Cold Type

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Warm AIHA Most frequent in middle age female May present by episode of anemia+jaundice Intermittent chronic pattern Spleen often palpable Infection/folate deficiency provoke severe anemia Unknown cause in > 30% SLE/RA/Lymphoid malignancy association Cold AIHA Intravascular hemolysis Association with mycoplasma,CMV,EBV Acrocyanosis Raynaud’s phenomenon

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CLINICAL APPROACH IN ANAEMIA Age, sex of the pt. Occupation (Metal dusts, solvent fumes) Chief complaints Duration of symptoms Rate of onset (Rapid or slow) Alimentary system (Wt. loss, Dysphagia, Soreness of tongue) History of blood loss (hematemesis, melaena) Family history of bleeding disorder (Anaemia, Reccurent jaundice, intra-uterine & childhood death)

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History of blood transfusion History of Reproductive System (Menstrual history, Number & interval of pregnancies, Miscarriage) History of CNS (Paraesthasia, difficulty in walking) History of Skeletal system (Bone pain, Arthritis) Social History (Alcoholism) History of drug intake (Previous & current) History of worm infestation History of diet History of swelling in the neck/axilla/groin

Slide 15 :

PHYSICAL EXAMINATION OF ANAEMIC PATIENT Skin (Color, Texture, Petechie, Scratch Marks) Nails (Koilonychia) Conjunctiva & Sclera (Pallor, Icterus) Retina (Haemorrhage, Hypertensive/Renal Failure) Mouth ( Mucous Membrane – Pallor; Petechie, Gum Bleeding or hypertrophy, Tongue – Atrophy of Papillae) Abdomen (Hepatomegaly, Splenomegaly) CVS (BP, Valvular/Vuscular Prosthesis) CNS (Peripheral Neuritis, Sub Acute Combined Degenerations) Superficial lymphnodes (Enlargement of Cervical/axillary/inguinal) Bones (Tendeness - Specially of Sternum, Tumor) Legs (Ulcers/Scars) Rectal Exm. (Haemorrhoids, Ca of Rectum) Urine (Protein, Urobilinogen)

Slide 16 :

INVESTIGATIONS CBC (Hb%, ESR, RBCs, WBCs, Platelets, MCV, MCH, MCHC) PBF Bone Marrow Study Others Tests To Detect The Cause: Serum Vitamin B12 Assay (Megaloblastic anaemia) Serum & Red Cell Folate Assay (Megaloblastic anaemia) Schilling Test (Megaloblastic anaemia) Serum Iron (Iron deficiency anaemia) TIBC (Iron deficiency anaemia, Chronic disease anaemia) Serum Feritin (Iron deficiency anaemia, Chronic disease anaemia) Transferrin Saturation (Iron deficiency anaemia, Chronic disease anaemia) Serum Bilirubin (Haemolytic anaemia) Urinary Urobilinogen (Haemolytic anaemia) LDH (Haemolytic anaemia) Hb Electrophoresis (Thalassaemia) Endoscopy (To exclude PUD) Small Bowel Biopsy

Slide 17 :

Bl. Pic IDA MA APA HA THA SCA Hb% dec dec dec dec dec dec MCV dec in N N dec N MCH dec N N N dec N MCHC dec N N N dec N

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Investigations to differentiate Iron Deficiency Anaemia, Anaemia of Chronc Disease, Thalassaemia & Sideroblastic Anaemia Feriritin Iron TIBC Transferrin Soluble saturation transferrin receptor Iron deficiancy dec. dec. Incr. dec. Incr. anaemia Anaemia Of chronic incr./nor. dec. dec. dec. dec./nor. disease Thallassaemia N N N N N Sideroblastic anaemia N/incr. N/incr. N N/incr.

Slide 19 :

TREATMENT Iron Deficiency Anemia (IDA) Treat the underlying cause Give ferrous sulphate 200mg 8 hrsly(180mg Fe++) OR ferrous gluconate 300mg 12 hrsly(70mg Fe++) Parental Iron if Oral iron intolerance Sever mal-absorption syndrome IBD Non-compliance

Slide 20 :

Chronic Disease Anemia (CDA) Treat the underlying condition Erythropoitine may help in some Thalassaemia Keep Hb above 10g/dl Blood transfusion up to every 4-6 weeks Desferrioxamine – Iron chelating agent Ascorbic acid+desf – increase urinary Iron exc Splenectomy If high transfusion required Consider after 6 year of age Bone marrow transplantation In HLA matched siblings

Slide 21 :

Megaloblastic Anemia Inj. Hydroxy cobalamine 1mg I/M Or oral B12 - 2mg/d Supplements of potassium if required Manage iron deficiency & hyperuricemia Folic acid – 5mg/d for 4months (not before B12) Coeliac disease should be managed Prophylaxis during pregnancy – 400mcg/d For normoblastic macrocytic – look for cause Aplastic Anemia Supportive care Blood/platelet transfusion Bone marrow transplantation Under 40y of age HLA identical sibling donor immunosupression Hemopoitic factors ineffective Thymectomy (thymoma) in pure red cell aplasia

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Hemolytic Anemia Splenectomy Folic acid orally prophylacticaly Autoimmune Haemolytic Anaemia Warm Type Corticosteroids – 80% effective Decrease antibody production Decrease RBC destruction Splenectomy – if steroids not effective/relapse Azathioprin/Cyclophosphamide – if steroid fail Cold Type Avoid exposure to cold Treat underlying cause Steroids/splenectomy INEFFECTIVE Rituximab may be effective

Slide 23 :

T H A N K Y O U

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