Anemia

Evaluation of anemia

male: Hb<13

famale, children: Hb<11

new born: Hb<15

Morphology 

macrocytic anemia: MCV>100, Vit. B12 or folic acid insufficiency, aplastic anemia, reticulocytosis, alcoholism, hypothyroidism, drug, other hematologic disease

normocytic anemia: MCV=80-100, uremia, endocrine disorder, leukemia, liver abscess

microcytic anemia: MCV<80, anemia of chronic disease, iron insufficiency, thalassemia

Reticulocyte productive index, RPI

RPI=Ret (%) X Hct / (45X maturation index)

Microcytic anemia

anemia of chronic disease

malignancy, chronic infection, chronic inflammation cause massive cytokine and hepcidin production and EPO production reduced

<Lab>

    serum ferritin: ─/↑

    serum iron: ↓

    TIBC: ↓

    transferrin saturation: ↓

Iron deficiency disease

most common, female predominal

<Lab>

    serum ferritin: ↓

    serum iron: ↓

    TIBC: ↑

    transferrin saturation: ↓

thalassemia

autosominal recessive, target cell or basophilic stippling in blood smear

alpha-thalassemia

1 alpha abnormal: carrier, no symptom

2 alpha abnormal: alpha thalassemia-minor, may disdiagnosised as iron deficiency anemia

3 alpha abnormal: alpha thalassemia-intermdiate=Hb H disease, jaundice, splenomegaly, hemochromatosis 

4 alpha abnormal: alpha thalassemia-major=hydrops fetalis=Hb Bart's disease: unable to born

beta-thalassemia

1 beta abnormal: beta thalassemia-minor, no symptom or mild anemia 

2 beta abnormal: beta thalassemia-major=Cooley's disease: Hb F>2% or Hb A2>3.5%, need transfusion to survive, and bone marrow transplant soon after birth

Macrocytic anemia

megaloblastic anemia

Vit. B12 or folic acid insufficiency, MCV>115, pancytopenia, reticulocyte↓, megaloblastic hyperplasia

* PANCYTO for pancytopenia: PNH, Aplastic anemia, Neoplasm, Cirrhosis,Y(Vit. B12 or folic acid), Toxin, Overwhelming sepsis

Aplastic anemia

Hb<10, neutrophil<1500, platelet<50K, autoimmune disease
* neutropenia: ANC(=WBC*(Seg%+band%)<1500/uL

Chest X Ray interpretation

Ordination of interpreting a chest X ray:

1. position:

    PA view: sitting or standing, scapula separated, gastric bubble
    AP view: lying, scapula separated not enough
    lateral view
    lordotic view: to see lung apex

2. quality:

    1) symmetric: distances between bilateral clavicles to stern are the same
    2) penetration: inter-spinal discs, trachea, carina, lung marking behind heart should be able to seen
    3) full inspiration: diaphragm anterior: 5th - 6th; posterior: 8th - 10 th

3. analysis

    basic information of the patient:

        gender: breast shadow can be often seen in females,
                     males' rib calcification starts from border while females' from medial
        age: rib 1 calcification >35 ; aorta calcification start at 60-70

    A: air way & adenopathy: 

        whether the trachea derives or not, may be atelectasis or effusion
        mediastum wide= 1/4 chest wall
        left hilum is higher than right hilum by 1 rib wide(3 cm)

    B: bone      

        scoliosis, osteoporosis or osteoblastic change

    C: cardiac: 

        heart size should normally < 1/2 chest wall
        carina angle =70~90, >90 if LA dilation
        water bag sign: for pericardiac effusion, hillum stay as normal site
              *compare with simple cardiacmegaly, hilum shift to lateral side

    D: diaphragm & pleura: 

         diaphragm: dorm shape, highest at medial 1/3

         right diaphragm is higher by 1 rib(4cm)
         Costophrenic angle clear or not? is the pleura thickening?
              *meniscus sign

    E: soft tissue

    F: lung field

        alveolar pattern:
            1. air bronchogram: black, tree-liked airway in the white background
            2. lorbar or segmental distrubution
            3. pneumonia
                (1) lobar pneumonia: k. pneumoniae is most common in Taiwan
                (2) round pneumonia:  child <8 years old, immature pore of kohn
                (3) Legionella pneumonia:  single or bilateral lower lung dense patch
                (4) Pseudomonas pneumonia:  patches consolidation
                (5) Aspergillosis pneumonia:  hemorrhage, ground glass capacity
                (6) aspiration pneumonia:  usually at right lower lung
                (7) TB: usually at apex, cavity
            4. pulmonary edema: bilateral symmetric
                (1) "butterfly" or "bats wing"
                (2) uremic lung: jugular vein engorgement (-), clear border
        interstitial pattern:
            1. pneumonitis
            2. Kerley's line