RED BLOOD CELL RED BLOOD CELL ABNORMALITIESABNORMALITIES

(APPROACH TO THE(APPROACH TO THE DIAGNOSIS OF ANEMIA)DIAGNOSIS OF ANEMIA)

Section of Hematology-Oncology Section of Hematology-Oncology

ANEMIAANEMIA

Reduction below normal in the Reduction below normal in the concentration of hemoglobin or concentration of hemoglobin or

RBC’s in the bloodRBC’s in the blood

Anemia is not a diagnosis in Anemia is not a diagnosis in itself, but merely an itself, but merely an objective sign of disease.objective sign of disease.

First step in its diagnosis is First step in its diagnosis is detection of its presence. detection of its presence.

3 FUNCTIONAL CATEGORIES 3 FUNCTIONAL CATEGORIES OF THE ANEMIASOF THE ANEMIAS

• Disorders of ProliferationDisorders of Proliferation• Disorders in Erythrocyte MaturationDisorders in Erythrocyte Maturation• Disorders due Primarily to Disorders due Primarily to

Erythrocyte Destruction or Red Cell Erythrocyte Destruction or Red Cell LossLoss

PROBLEM: ANEMIA

SSubjective Dataubjective DataOObjective Databjective DataAAssessmentssessmentPPlans:lans:

Diagnostic/TherapeuticDiagnostic/Therapeutic

SUBJECTIVE DATASUBJECTIVE DATA

1.1. Severity of the anemiaSeverity of the anemia2.2. Rapidity of onsetRapidity of onset3.3. Patient’s age and CV statusPatient’s age and CV status

- capacity of the CV & pulmonary system - capacity of the CV & pulmonary system

to compensate for the anemiato compensate for the anemia4.4. Associated manifestations of the Associated manifestations of the

underlying disorderunderlying disorder- Endocrine disorder- Endocrine disorder- Renal disorder- Renal disorder- Hepatic disorder- Hepatic disorder

Sx of patients w/ anemia depend on the ff:Sx of patients w/ anemia depend on the ff:

•Onset & Duration of symptoms insiduous or acute•Previous prescription for hematinics & response•Medication history•Occupation, household customs & hobbies•Symptoms of hemolysis

jaundice, changes in urine color•Symptoms of blood loss melena, hematochezia, epigastirc pain

SUBJECTIVE DATASUBJECTIVE DATA

SUBJECTIVE DATASUBJECTIVE DATA

•Obstetric & Gynecologic history # of pads/day duration # of pregnancies, abortions - interval•Concomitant bleeding manifestations•Dietary history•Fever, Weight loss

I. Cardiac SignsI. Cardiac Signs• Hemic murmurs: mid or holosystolic Hemic murmurs: mid or holosystolic

often in the pulmonic or apical area, often in the pulmonic or apical area, due to increased blood flow and due to increased blood flow and turbulenceturbulence

• Gallop rhythmsGallop rhythms• Tachycardia/CardiomegalyTachycardia/Cardiomegaly• Strong peripheral pulses with wide Strong peripheral pulses with wide

pulse pressurepulse pressure

OBJECTIVE DATAOBJECTIVE DATA

II. Integumentary ManifestationsII. Integumentary Manifestations• Pallor: <8 to 10 mg/dL hemoglobinPallor: <8 to 10 mg/dL hemoglobin

Affected by:Affected by: - state of vasoconstriction/vasodilatation- state of vasoconstriction/vasodilatation - degree & nature of pigmentation- degree & nature of pigmentation - nature & fluid content of the subcutaneous - nature & fluid content of the subcutaneous tissuestissuesMost constantly detected in:Most constantly detected in: - mucous membranes of the mouth, pharynx, - mucous membranes of the mouth, pharynx, conjunctivae, lipsconjunctivae, lips - nailbeds- nailbeds

* * Areas where vessels are close to the skin surfaceAreas where vessels are close to the skin surface

Other Integumentary ManifestationsOther Integumentary Manifestations•Dry, Shriveled skinDry, Shriveled skin

•Thinning, loss of luster, Thinning, loss of luster,

premature graying of hairpremature graying of hair

•Brittle, lackluster nails, spooningBrittle, lackluster nails, spooning

III. Neuromuscular SignsIII. Neuromuscular Signs• HeadacheHeadache• VertigoVertigo• TinnitusTinnitus• FaintnessFaintness• Retinal Retinal

hemorrhagehemorrhage• ParesthesiasParesthesias

• ScotomasScotomas• Lack of mental Lack of mental

concentrationconcentration• DrowsinessDrowsiness• RestlessnessRestlessness

IV. GI ManifestationsIV. GI Manifestations GlossitisGlossitis Atrophy of the papillae of the tongueAtrophy of the papillae of the tongue DysphagiaDysphagia Oral ulcersOral ulcers Gingival hyperplasiaGingival hyperplasia HepatosplenomegalyHepatosplenomegaly

V. Sternal TendernessV. Sternal Tenderness LymphadenopathyLymphadenopathy

VI. Genitourinary Signs• Slight proteinuria

• Changes in urine color Always rule out primary disease of the GUT.Always rule out primary disease of the GUT.

Even the most expert clinical Even the most expert clinical appraisal does not supplant accurate appraisal does not supplant accurate

measurement of the blood for the measurement of the blood for the detection, quantification and detection, quantification and characterization of anemia.characterization of anemia.

Objective DataObjective DataLaboratory tests:Laboratory tests:

I. Red cell count- hgb, hct, reticulocyte I. Red cell count- hgb, hct, reticulocyte

count, RBC indicescount, RBC indices

II. White Blood cell count- diff’l, nuclearII. White Blood cell count- diff’l, nuclear

segmentation of neutrossegmentation of neutros

III. Platelet countIII. Platelet count

IV.Peripheral smear morphologyIV.Peripheral smear morphology

V. Iron StudiesV. Iron Studies

VI. Bone marrow examinationVI. Bone marrow examination

Changes in Normal Hemoglobin/Hematocrit Changes in Normal Hemoglobin/Hematocrit Values with Age and PregnancyValues with Age and Pregnancy

Age/SexAge/Sex Hemoglobin g/dl Hemoglobin g/dl Hematocrit % Hematocrit %At birthAt birth 17 17 52 52ChildhoodChildhood 12 12 36 36AdolescenceAdolescence 13 13 40 40Adult manAdult man 16( 16(++2)2) 47( 47(++6)6)Adult womanAdult woman 13( 13(++2)2) 40( 40(++6)6)(menstruating)(menstruating)Adult womanAdult woman 14( 14(++2)2) 42( 42(++6)6)(postmenopausal)(postmenopausal)During pregnancyDuring pregnancy 12( 12(++2)2) 37( 37(++6)6)

Red Cell IndicesRed Cell Indices IndexIndex Normal ValueNormal ValueMean Cell Volume(MCV):Mean Cell Volume(MCV): (hematocrit x 10)/(red cell ct. x 10(hematocrit x 10)/(red cell ct. x 1066)) 90 90 ++ 8 fL 8 fL

Mean Cell Hemoglobin (MCH):Mean Cell Hemoglobin (MCH): (hemoglobin x 10)/ (red cell ct. x 10(hemoglobin x 10)/ (red cell ct. x 1066)) 30 30 ++ 3 pg 3 pg

Mean Cell Hemoglobin Concentration:Mean Cell Hemoglobin Concentration: (hemoglobin x 10)/ hematocrit, (hemoglobin x 10)/ hematocrit, 33 33 ++ 2% 2% or MCH/MCVor MCH/MCV

RETICULOCYTE COUNTRETICULOCYTE COUNT

Normal ValueNormal Value: 0.5 – 1.5% (old): 0.5 – 1.5% (old) 5 – 15 x 10 5 – 15 x 10-3-3 (SI) (SI)

Correction:Correction: Patient’s HctPatient’s Hct x Reticulocyte count % = corrected x Reticulocyte count % = corrected 4545 reticulocyte reticulocyte

Corrected ReticulocyteCorrected Reticulocyte = RPI = RPI 22

WHITE BLOOD CELL COUNTWHITE BLOOD CELL COUNT

Normal Value: 4.5 – 10.0 x 10 Normal Value: 4.5 – 10.0 x 10 99/L/L PercentagePercentage Absolute No. Absolute No.

BandsBands 0-0.05 0-0.05 0-0.70-0.7SegmentersSegmenters 0.50-0.700.50-0.70 1.8-7.01.8-7.0LymphocytesLymphocytes 0.20-0.40 0.20-0.40 1.0-4.81.0-4.8MonocytesMonocytes 0-0.07 0-0.07 0-0.800-0.80EosinophilsEosinophils 0-0.05 0-0.05 0-0.450-0.45BasophilsBasophils 0-0.01 0-0.20 0-0.01 0-0.20

Normal Peripheral SmearNormal Peripheral Smear

Normal bone marrow (LPO)Normal bone marrow (LPO)

Normal bone marrow (HPO)Normal bone marrow (HPO)

ASSESSMENTASSESSMENT(Possible Cause of Anemia)(Possible Cause of Anemia)

CLASSIFICATION OF ANEMIAS CLASSIFICATION OF ANEMIAS BASED ON ETIOLOGYBASED ON ETIOLOGY

I.I. Increased Blood LossIncreased Blood Loss Acute and Chronic HemorrhageAcute and Chronic Hemorrhage

II.II. Excessive Blood Destruction ((Hemolysis)Excessive Blood Destruction ((Hemolysis)A. CongenitalA. Congenital 1. Red Cell Morphologic Defects 1. Red Cell Morphologic Defects (e.g. Congenital Spherocytosis)(e.g. Congenital Spherocytosis) 2. Hemoglobinopathies 2. Hemoglobinopathies (e.g. Thalassemias)(e.g. Thalassemias) 3. Enzyme Defects 3. Enzyme Defects (e.g. G6PD Deficiency)(e.g. G6PD Deficiency)

B. AcquiredB. Acquired 1. Immune Disorders1. Immune Disorders

(e.g. LE)(e.g. LE)2. Non-Immune Disorders2. Non-Immune Disorders (e.g. Infections, Allergy, etc.)(e.g. Infections, Allergy, etc.)

III.III. Marrow production defectsMarrow production defectsa. Hematinic deficiencies – iron, Vit. a. Hematinic deficiencies – iron, Vit.

B12, Folic AcidB12, Folic Acidb. Infiltrative Diseases – Leukemias, b. Infiltrative Diseases – Leukemias,

lymphomas, Cancerlymphomas, Cancerc. Aplasiac. Aplasiad. Miscellaneous – Endocrine, Renal, d. Miscellaneous – Endocrine, Renal,

InfectionsInfections

CASE STUDIESCASE STUDIES Case 1Case 1 Mr. Santos, 48 years old farmer consulted Mr. Santos, 48 years old farmer consulted

because of progressive weakness and pallor.because of progressive weakness and pallor. No jaundice nor hepatosplenomegaly on No jaundice nor hepatosplenomegaly on P.E. P.E. Petechiae noted on both L.E.’sPetechiae noted on both L.E.’s

CBC Result:CBC Result: Hb: 7 gm/dlHb: 7 gm/dl Hct: 21Hct: 21 WBC: 4,000WBC: 4,000

lymph: 48%lymph: 48% segs: 52%segs: 52% Platelet count: 80,000Platelet count: 80,000 Reticulocyte CountReticulocyte Count::5 x 105 x 10-3-3

Bone Marrow: FATTY MARROWBone Marrow: FATTY MARROW

APLASTIC ANEMIAAPLASTIC ANEMIA A type of hypoproliferative anemia A type of hypoproliferative anemia

characterized by pancytopenia with characterized by pancytopenia with marrow hypocellularitymarrow hypocellularity

Etiology:Etiology:1. Primary1. Primary

a. Congenitala. CongenitalFanconi’s AnemiaFanconi’s Anemia

b. Idiopathicb. Idiopathic

2. Secondary2. Secondarya. Radiationa. Radiationb. Drugs and Chemicalb. Drugs and Chemical Regular effectsRegular effectsIdiosyncratic effectsIdiosyncratic effectsc. Virusesc. Virusesd. Immune diseasesd. Immune diseasese. PNHe. PNHf. Pregnancyf. Pregnancy

Pathogenesis:Pathogenesis:

1.1. Depletion of hematopoietic cells by an Depletion of hematopoietic cells by an agent or event that kills stem cellsagent or event that kills stem cells

2.2. Suppression of proliferation and Suppression of proliferation and maturation of stem cells by an maturation of stem cells by an immunologic or lymphocyte mediated immunologic or lymphocyte mediated mechanismmechanism

Clinical Features:Clinical Features: - symptoms related to decrease RBC, - symptoms related to decrease RBC, WBC, plateletsWBC, platelets- Physical exam: lymphadenopathy and Physical exam: lymphadenopathy and splenomegaly not typicalsplenomegaly not typical- Laboratories: Pancytopenia, decrease Laboratories: Pancytopenia, decrease reticulocyte count reticulocyte count

Bone marrow: fatty marrowBone marrow: fatty marrow

Management Options:Management Options:

1.1. Transfusion supportTransfusion support2.2. Bone marrow transplantationBone marrow transplantation3.3. Immunosuppression with anti-Immunosuppression with anti-

thymocyte globulin, with or without thymocyte globulin, with or without steroidssteroids

4.4. Androgen stimulationAndrogen stimulation

Case 2Case 2 J.K., 35 year old housewife complains of J.K., 35 year old housewife complains of

progressive easy fatigability of about 3 progressive easy fatigability of about 3 months duration.months duration.

Review of System: (-) epigastric painReview of System: (-) epigastric pain (-) hematochezia nor (-) hematochezia nor

melenamelenamenses – 28 days cycle, 7 days duration,menses – 28 days cycle, 7 days duration,

3 days profuse flow consuming 3 days profuse flow consuming 5-6 fully soaked pads/day 5-6 fully soaked pads/day

(-) bruises/ecchymoses(-) bruises/ecchymoses

P.E. Pale, no jaundiceP.E. Pale, no jaundice (-) hepatosplenomegaly(-) hepatosplenomegaly

Laboratory results:Laboratory results: CBC: Hb: 60g/L WBC: 6 x 10CBC: Hb: 60g/L WBC: 6 x 1099/L/L Hct: .21Hct: .21 seg: 70%seg: 70%

MCV: 80fLMCV: 80fL lymph: 25%lymph: 25% MCH: 25 pgMCH: 25 pg eos:eos: 3% 3% MCHC: 28%MCHC: 28% mono: 2%mono: 2%

platelets: adequateplatelets: adequate Reticulocyte count: 1.5 x 10Reticulocyte count: 1.5 x 10-3-3

Peripheral smear: HYPOCHROMICPeripheral smear: HYPOCHROMIC

Iron studies:Iron studies:Ferritin: 8ug/LFerritin: 8ug/LIron: 10 (N.V.9 - 27 umol/L)Iron: 10 (N.V.9 - 27 umol/L)TIBC: 60 (N.V. 54 – 64 umol/L)TIBC: 60 (N.V. 54 – 64 umol/L)Percent Saturation: 17%Percent Saturation: 17%

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIA

Most common cause of anemia worldwideMost common cause of anemia worldwide Iron is absorbed primarily in the duodenumIron is absorbed primarily in the duodenum

and upper jejunumand upper jejunum

Picture : causes of iron anemiaPicture : causes of iron anemia

Case 3Case 3Mrs. Cruz, 75 year old female consulted Mrs. Cruz, 75 year old female consulted because of progressive weakness and loss of because of progressive weakness and loss of balance. She also complains of numbness and balance. She also complains of numbness and tingling sensation in all extremities. She has tingling sensation in all extremities. She has no gastrointestinal complaints.no gastrointestinal complaints.- not a diabetic but is hypertensive- not a diabetic but is hypertensive- prefers to eat vegetables and fish - prefers to eat vegetables and fish

because of poor dentitionbecause of poor dentition

P.E. P.E. Patient is pale with smooth, red Patient is pale with smooth, red tongue. tongue. No organomegaly notedNo organomegaly noted

Laboratory ResultsLaboratory Results

CBC: Hb: 80 g/LCBC: Hb: 80 g/L WBC: 9 x 10 WBC: 9 x 1099/L/L Hct: .26 Hct: .26 seg:seg: 74% 74%

MCV: 102fLMCV: 102fL lymph: 20%lymph: 20% MCH: 36 pgMCH: 36 pg eos:eos: 2% 2% MCHC: 38%MCHC: 38% mono: 4%mono: 4%

platelets: adequateplatelets: adequate

Peripheral Smear: MacrocytesPeripheral Smear: Macrocytes

MEGALOBLASTIC ANEMIAMEGALOBLASTIC ANEMIA

- disorder caused by impaired DNA disorder caused by impaired DNA synthesissynthesis

- Cell primarily affected: blood cellsCell primarily affected: blood cells GI epithelial GI epithelial

cellscells- slowed nuclear cell division with normal slowed nuclear cell division with normal

progression of cytoplasmic maturationprogression of cytoplasmic maturation MegaloblastosisMegaloblastosis

Folate sources: mainly fruits and Folate sources: mainly fruits and vegetablesvegetables

Cobalamin sources: meat & dairy foodsCobalamin sources: meat & dairy foods

Cause: B12 or/& Folate DeficiencyCause: B12 or/& Folate Deficiency

Clinical Manifestations:Clinical Manifestations:1.1. Anemia with slight icteresiaAnemia with slight icteresia2.2. GI manifestations – glossitis, smooth, GI manifestations – glossitis, smooth, beefy red tongue, malabsorptionbeefy red tongue, malabsorption3.3. Neurologic manifestations (Cobalamin) - subacute Neurologic manifestations (Cobalamin) - subacute

combined degeneration of CNScombined degeneration of CNSperipheral neuropathy – numbness, peripheral neuropathy – numbness,

weakness, ataxia, paresthesia,weakness, ataxia, paresthesia, disturbances of mentationdisturbances of mentation

Management:Management:1. Treatment of underlying problem1. Treatment of underlying problem2. Replacement therapy2. Replacement therapy

oral folic acidoral folic acidparenteral B12parenteral B12

Case 4Case 4 Mrs. Santos, 50 year old male was Mrs. Santos, 50 year old male was

referred for evaluation of anemia. She referred for evaluation of anemia. She begun to experience easy fatigability begun to experience easy fatigability about 5 weeks PTC. She also noticed about 5 weeks PTC. She also noticed passage of highly colored urine.passage of highly colored urine.(+) weight loss of about 5 lbs in the last 2 (+) weight loss of about 5 lbs in the last 2 monthsmonths(+) febrile episodes(+) febrile episodes

P.E. icteric scleraeP.E. icteric sclerae (+) cervical lymphadenopathy(+) cervical lymphadenopathy

(-) hepatomegaly(-) hepatomegaly(+) splenomegaly(+) splenomegaly

CBC: Hb: 70 g/LCBC: Hb: 70 g/L WBC: 13x 10 WBC: 13x 1099/L/L Hct: .21 Hct: .21 seg:seg: 80% 80%

MCV: 98fLMCV: 98fL lymph: 20%lymph: 20% MCH: 35pgMCH: 35pg MCHC: 36%MCHC: 36%

platelets: adequateplatelets: adequate

Reticulocyte count: 80 x 10Reticulocyte count: 80 x 10-3-3/L/LPeripheral smear: spherocytesPeripheral smear: spherocytesOther tests:Other tests:

Direct Coombs: +++Direct Coombs: +++

Peripheral Smear:Peripheral Smear: SPHEROCYTESSPHEROCYTES

IMMUNE HEMOLYSISIMMUNE HEMOLYSIS

Warm-antibody Immunohemolytic AnemiaWarm-antibody Immunohemolytic Anemia- induced by IgG or IgM Abs reacting induced by IgG or IgM Abs reacting

specifically on antigens on RBC specifically on antigens on RBC membranemembrane

Diagnosis: (+) Coomb’s testDiagnosis: (+) Coomb’s test

Management:Management:SteroidsSteroidsSplenectomySplenectomyImmunosuppresantsImmunosuppresants

Case 5Case 5JA, 18 year old male consulted JA, 18 year old male consulted

because of recurrent jaundice and pallor. because of recurrent jaundice and pallor. Jaundice was first noted when he was 4 Jaundice was first noted when he was 4 years old.years old.

No history of blood transfusions.No history of blood transfusions.Family history is positive for Family history is positive for

another sibling with similar problem.another sibling with similar problem.

P.E. Icteric scleraeP.E. Icteric scleraemoderate splenomegalymoderate splenomegaly

CBC: Hb: 81 g/LCBC: Hb: 81 g/L Hct: .30 Hct: .30 WBC: 11.5 x 10WBC: 11.5 x 1099/L/Lseg: 75%seg: 75%lymph: 24%lymph: 24%eos: 1%eos: 1%

platelets: adequateplatelets: adequate Reticulocyte count: 60 x 10Reticulocyte count: 60 x 10-3-3/L/L Peripheral smear: (+) spherocytesPeripheral smear: (+) spherocytes

HEREDITARY SPHEROCYTOSISHEREDITARY SPHEROCYTOSIS

- inherited RBC membrane abnormality – inherited RBC membrane abnormality – autosomal dominant pattern of autosomal dominant pattern of inheritanceinheritance

- Characterized by spherical RBC due to a Characterized by spherical RBC due to a molecular defect in one of the proteins of molecular defect in one of the proteins of the cytoskeleton of the RBC membranethe cytoskeleton of the RBC membrane

ankrinankrinProtein 3Protein 3SpectrinSpectrin

Clinical Manifestations:Clinical Manifestations:anemiaanemiajaundicejaundicecholelithiasischolelithiasis

Diagnosis: spherocytes on smearDiagnosis: spherocytes on smearreticulocytosisreticulocytosis(-) Coomb’s test(-) Coomb’s test(+) Osmotic fragility test(+) Osmotic fragility test

Management: Management: Splenectormy – for moderate to Splenectormy – for moderate to

severe severe hemolysishemolysis

Folic Acid supplementationFolic Acid supplementation

THANK YOUTHANK YOU

APPROACH TO THE APPROACH TO THE BLEEDING PATIENTBLEEDING PATIENT

SCREENING HISTORYSCREENING HISTORY• A history taken to evaluate hemostasis should A history taken to evaluate hemostasis should

answer these questions:answer these questions:• Has the patient experienced abnormal bleeding or Has the patient experienced abnormal bleeding or

bruising? If so, are symptoms recently acquired or bruising? If so, are symptoms recently acquired or do they date back to childhood?do they date back to childhood?

• Is there a history of an acquired disorder that Is there a history of an acquired disorder that would impair hemostasis? E.g., chronic liver would impair hemostasis? E.g., chronic liver disease, SLE, uremia or a hematologic malignancy.disease, SLE, uremia or a hematologic malignancy.

• Is the patient taking a drug that could interfere with Is the patient taking a drug that could interfere with hemostasis?hemostasis?

• Have other members of the family bled Have other members of the family bled abnormally?abnormally?

In questioning a parent about significant In questioning a parent about significant bleeding in a small child, one should ask bleeding in a small child, one should ask

specifically about:specifically about: • Bleeding from umbilical stumpBleeding from umbilical stump• Bleeding after circumcisionBleeding after circumcision• Bleeding from cuts in mouthBleeding from cuts in mouth• Frequency & size of hematomas of scalpFrequency & size of hematomas of scalp• Extent of bruising from minor trauma, eg. Extent of bruising from minor trauma, eg.

Falls from swings or bicycles or down stepsFalls from swings or bicycles or down steps• Nosebleeds that stop w/in mins, even if Nosebleeds that stop w/in mins, even if

frequent, suggest that hemostasis is N. frequent, suggest that hemostasis is N. Prolonged nosebleeds requiring medical Prolonged nosebleeds requiring medical intervention arouse suspicion of impaired intervention arouse suspicion of impaired hemostasis. hemostasis.

In assessing bleeding history of an adult In assessing bleeding history of an adult patient, one evaluates:patient, one evaluates:

• Abnormal bruising, ask specific questions: Abnormal bruising, ask specific questions: • How often do you notice a new bruise on your body?How often do you notice a new bruise on your body?• Do you develop bruises larger than a 1in dm without Do you develop bruises larger than a 1in dm without

remembering how you got the bruise? If so, how big was the remembering how you got the bruise? If so, how big was the largest of these bruises?largest of these bruises?

• Do you notice bruises after injections?Do you notice bruises after injections?

• Excessive bleeding from small cutsExcessive bleeding from small cuts• Bleeding after previous surgeryBleeding after previous surgery• Bleeding after dental extractions. Bleeding that lasts >24h Bleeding after dental extractions. Bleeding that lasts >24h

after extraction of a permanent tooth or that starts again after extraction of a permanent tooth or that starts again after 3-4 days is suggestive of a hemostatic abnormality.after 3-4 days is suggestive of a hemostatic abnormality.

DRUGS THAT INTERFERE DRUGS THAT INTERFERE WITH HEMOSTASISWITH HEMOSTASIS

• Aspirin, clopidogrel, dipyridamoleAspirin, clopidogrel, dipyridamole• Drugs that interfere with blood Drugs that interfere with blood

coagulation: heparin, oral coagulation: heparin, oral anticoagulants, (?) herbal medicationsanticoagulants, (?) herbal medications

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• Bleeding into skin and soft tissuesBleeding into skin and soft tissues

• Petechiae: characteristic of vessel & platelet Petechiae: characteristic of vessel & platelet problem. Usually pinhead size but maybe problem. Usually pinhead size but maybe bigger. Characteristically develops 7 regress bigger. Characteristically develops 7 regress in crops. Most conspicuous in areas of in crops. Most conspicuous in areas of increased venous pressure.increased venous pressure.

Must be distinguised from small telangiectsias Must be distinguised from small telangiectsias & angiomas& angiomas

• Ecchymoses, hematomas: large superficial Ecchymoses, hematomas: large superficial hematomas maybe seen in coagulation hematomas maybe seen in coagulation disorders. disorders.

• Palpable purpuras may be seen in vasculitisPalpable purpuras may be seen in vasculitis

• Hemarthorses – bleeding into synovial joints and Hemarthorses – bleeding into synovial joints and virtually diagnostic of a severe hereditary virtually diagnostic of a severe hereditary coagulation disorder. May develop without coagulation disorder. May develop without discoloration or other external evidence of discoloration or other external evidence of bleeding.bleeding.

• Traumatic bleedingTraumatic bleeding Response to trauma is an excellent “screening Response to trauma is an excellent “screening

test” for the presence of hereditary hemorrhagic test” for the presence of hereditary hemorrhagic disorder. A history of surgical procedures or disorder. A history of surgical procedures or significant injury w/o abnormal bleeding is equally significant injury w/o abnormal bleeding is equally good evidence against presence of such disorder. good evidence against presence of such disorder.

• Miscellaneous bleeding manifestationsMiscellaneous bleeding manifestations

spontaneous bleeding from body orificesspontaneous bleeding from body orificesmenorrhagiamenorrhagia melenamelena

metrorrhagiametrorrhagia epistaxisepistaxishematuria hematuria gingival bleedinggingival bleedinghematemesishematemesis hemoptysishemoptysis

Bleeding into serous cavities & internal fascial spacesBleeding into serous cavities & internal fascial spacesretroperitoneal spaceretroperitoneal spacepsoas sheathpsoas sheathCNSCNSretinaretina

CLINICAL DISTINCTION BETWEEN DISORDERS OF CLINICAL DISTINCTION BETWEEN DISORDERS OF VESSELS & PLATELETS & DISORDERS OF BLOOD VESSELS & PLATELETS & DISORDERS OF BLOOD

COAGULATIONCOAGULATIONFINDINGSFINDINGS COAG D/OCOAG D/O PLT OR VESSEL D/OPLT OR VESSEL D/O

PetechiaePetechiae RareRare CharacteristicCharacteristic

Deep dissecting Deep dissecting hematomashematomas

CharacteristicCharacteristic RareRare

Superficial ecchymosesSuperficial ecchymoses Common, usually Common, usually large & solitarylarge & solitary

Characteristic, usually Characteristic, usually small & multiplesmall & multiple

HemarthrosisHemarthrosis CharacteristicCharacteristic RareRare

Delayed bleedingDelayed bleeding commoncommon RareRare

Bleeding from sup. cuts Bleeding from sup. cuts & scratches& scratches

minimalminimal Persistent, often Persistent, often profuseprofuse

Sex of patientSex of patient 80-90% of 80-90% of hereditary forms Mhereditary forms M

Relatively more Relatively more common in Fcommon in F

(+) family hx(+) family hx commoncommon rarerare

THANK YOUTHANK YOU