張貼日期：2017/10/19 下午 04:48:59
[Request and history review]
Anemia for ___ months
[Important information]
Anemia duration: ______ weeks, months, years
MCV:___ fL → Normocytic/Microcytic/Macrocytic anemia
Reticulocyte production index: ____ (< 2)
(Reticulocyte % x HCT/45, /mature index 45-36(1), 35-26(1.5), 25-16(2), <15(2.5)
(If prolonged duration or congenital etiology suspected)
Family history of anemia: yes/no
Ethnic: _____
Possible drug/toxin/heavy metal exposure: alcohol/lead/isoniazid
(Hint suggest thalassemia)
Mentzer index: MCV/RBC (million) < 13 → Thalassemia likely
PE: splenomegaly(+), bony deformities(+)
Blood exams: Serum Iron(), ferritin(), TIBC(), TIBC saturation(%, ↑)
Beta-thalassemia: Hb electrophoresis: HbA2 > 3.5%
Alpha-thalassemia: (exclude other etiology) (DNA sequence required for definite diagnosis)
(Hint suggest IDA)
Mentzer index: MCV/RBC (million) > 13 → Thalassemia unlikely
Past history: peptic ulcer disease, atrophic gastritis, menstration, menorrhagia, s/p gastrectomy, HP infection, glutena-induced enteropathy
PE: conjunctiva(pale), glossitis(+), angular cheilosis(口角炎,+), koilonychia(指甲凹陷,+)
Stool OB(_), Stool Ova(__), Hematuria(-), Pregnancy(-)
Blood exams: Serum Iron(), ferritin(), TIBC(), TIBC saturation(%), anti-parietal Ab(), gastrin(), transglutaminase Ab()
(For normocytic anemia etiology)
Acute blood loss
Chronic inflammation or disease
Chronic renal insufficiency
Hypothyroidism
Hemolysis
Blood exams: EPO(), LDH(), Bil-T/D(), haptoglobulin(), Direct/indirect Coomb's test()
(For macrocytic anemia etiology)
Immature RBC in peripheral blood
Reticulocytosis
Aplastic anemia/Fanconi anemia(rare autosomal recessive inherited disease)
Pure red cell aplasia
DNA metabolism abnormality
Vitamin B12 deficiency (PE: glossitis)
Folic acid deficiency (PE: oral ulcers)
Drugs(Zidovudine, Azathioprine, 6-MP, capecitabine, cladribine, Ara-C, Hydrea, Imatinib, Sunitinib, MTX)
Lipid abnormality
Liver disease
Hypothroidism
Unknown mechanism
Alcohol abuse
Multiple myeloma
Blood exams: vitamin B12(), Folic acid()
[Plans]
For anemia basic survey
Check reticulocyte count, serum iron, ferritin, TIBC, Bil-T/D, LDH, haptoglobulin, Direct/indirect Coomb's test, stool OB
Calculate reticulocyte production index
For iron deficiency anemia
Consider check anti-parietal Ab(), gastrin(), transglutaminase Ab()
Give oral iron supplement
For suspect thalassemia
Check Hb electrophoresis for beta thalassemia
If HbA2 < 3.5%, check gene sequence for alpha thalassemia (000P1629 [自費]Genetic diagnosis of alpha-Thalassemia) 3250 NTD
For normocytic anemia survey
Check serum EPO, haptoglobulin, Direct/indirect Coomb's test, TSH/free T4, free light chain kappa/lambda
If MM suspected, check serum IgA, IgG, IgM, serum IFE, urine IFE (electrophoresis)
Treat underlying disease as your expertise
For macrocytic anemia survey
Check folic acid, vitamin B12, TSH/free T4