I always Feel Tired

I always Feel Tired

1. Causes of generalized dyspnea

   • Acute coronary syndrome
   • Congestive heart failure
   • Chronic obstructive pulmonary disease
   • Asthma
   • Pneumothorax
   • Pneumonia
   • Pulmonary embolism
   • History Taking
     • Onset, duration and progress
       • Trauma?
     • Age & sex
       • (different Hb levels)
     • Associated symptoms
       • (pain? bleeding? ulcer? cancer?)
     • Occupation
     • Family history
       • (thalassemia?)
     • History of chronic illness
     • What to ask a patient when he complains of tiredness and dyspnea
     • Previous CBC
     • history of gastrointestinal
       • (Abdominal pain , consumption )
     • Changes in body weight
     • Changes in bowel habits
     • any complains of Abnormal urine color
       • (renal and hepatic disease )
     • Diet
       • deficiency of (Iron,B2,Folate)
     • Drug ingestion
       • NSAIDS
   • Investigations done
     • Blood Investigations
       • CBC
         • Hb
           • A hemoglobin test measures the amount of hemoglobin in blood
         • Hematocrit
           • The ratio of the volume of red blood cells to the total volume of blood.
         • RBC count
           • measure the number of red blood cells (RBCs) in the blood
         • RBC indices
           • MCV
             • Mean corpuscular volume (MCV) is the average volume of red cells.
           • MCH
             • mean corpuscular hemoglobin (MCH) is the average mass of hemoglobin per red blood cell in a sample of blood.
           • MCHC
             • Mean corpuscular hemoglobin concentration, a measure of the concentration of haemoglobin in a given volume of packed red blood cells
         • WBC count
           • measure the number of white blood cells (WBCs) in the blood.
         • Platelet count
           • a lab test to measure how many platelets are in blood
         • Peripheral blood film
           • Assessing red cell size
             • Microcytosis
               • If red cells are smaller than normal
               • MCV 62 fl.
             • Macrocytosis
               • If red cells are bigger than normal
               • MCV 105 fl
             • Normocytosis
               • Normal RBC size
             • Anisocytosis
               • If red cells show greater variation in size than normal the blood film is said to show
               • Severe anisocytosis; the MCV was 133 fl but the macrocytosis is not uniform
           • Assessing red cell shape
             • Poikilocytosis
               • If red cells show more than the normal degree of variation in red cell shape there is said to be poikilocytosis .
                 • Severe poikilocytosis; cells vary considerably in shape but no single shape dominates.
                   • Individual cells of a particular shape have names that identify them.Diagrammatic representation of different types of poikilocyte
           • Assessing red cell colour
             • Hypochromia
               • Cells that have an area of central pallor more than a third of the diameter of the cell are said to be hypochromic
             • Hyperchromia
               • more highly colored than normal
             • normochromic
               • Normal red cells are reddish-brown with approximately the central third to quarter of the cell being paler.
             • Anisochromasia
               • Cells which show a greater than normal variation in the degree of haemoglobinization are said to show anisochromasia
             • Polychromasia
               • Red cells that have a blue or lilac tinge are said to show polychromasia (‘many colours’) are young cells, newly released from the bone marrow
       • Iron studies
         • Serum iron
           • Measures amount of iron bound to transferrin.
             • HIGH/NORMAL
               • Liver disease, sideroblastic anemia, iron overload, hemochromatosis, Thalassemia, Vit B12 deficiency
             • LOW
               • Iron-deficiency, Anemia of chronic disease
           • Male (87-150µg/dL) Female(72-130 µg/dL)
         • Total iron-binding capacity
           • (240-450 ug/dL) Transferrin(2-4g/L)
             • High
               • Fe deficiency
             • low
               • Thalassemia, hemolytic anemia, sideroplastic , anemia of chronic infections
           • TIBC measures how well transferrin transports iron.
         • Ferritin
           • major iron storage protein
             • Reflects body iron stores
               • high/ normal
                 • Hemochromatosis(Fe overload) Chronic disease
           • Males( 30-400 ug/L) Females(13-150 ug/L)
     • Gel Electrophoresis
       • is the movement of molecules by an electric current.
         • Equipments
           • α-Thalassemia trait
           • Beta thalassemia major
             • both genes are beta-0
               • absence of hemoglobin A
                 • about 5 to 10% Hb A2
                 • and over 90% Hb F
                   • Co-inheritance of genetic factors :increasing g-chain production γ-chains will combine with excess chains resulting in high HbF.
           • Beta-thalassemia Minor
             • Hb A: 83.6% Hb A2: 6.2% Hb F: 1.1%
         • Gel electrophoresis is a laboratory method used to separate mixtures of DNA, RNA, or proteins according to molecular size.
     • Stool Analysis
       • Guaiac – Based ( hemoccult) test
         • Guaiac is a colorless compound that turns blue on exposure to hemoglobin
           • Sensitive for detecting hemoglobin in stool
       • Positive for occult blood
         • Peptic ulcer disease (gastric ulcers)
           • group of medications known as NSAIDs Ulcers that bleed slowly doesn’t show symptoms and by time the person be anemic.
           • infection with Helicobacter pylori
         • Angiodysplaslia(colon)
           • Its related to aging and breakdown of blood vessels And the most common is vascular abnormality. the bleeding occurs in the right colon usually.
         • Esophageal varices
           • abnormal, enlarged veins in the esophgus
         • colorectal cancer
           • Tumor enlarge, ulceration and hemorrhage
         • Crohn’s disease
           • inflammation of any part of the GI Tract usually the proixmal part. The cause is unknown.
         • Diverticular Disease
           • occurs when pouches (diverticula ) that have developed in the wall of the large intestine (colon) bleed. This condition is called:diverticulosis.
         • Iron Deficiency anemia
           • One of its symptoms: Dark, tar-colored stools or blood in the stool.
           • Symptoms
             • Angular cheilitis
             • Pika
             • Glossitis
           • Treatment
             • Pharmacological
               • ferrous sulphate, taken orally two or three times a day.
                 • side effects
                   • nausea /sickness abdominal pain heartburn constipation diarrhoea / black stools
                 • check-up two to four weeks after the patient has started taking iron supplements to assess how well he has responded to the treatment.
             • Nonpharmacological
               • Dietary advice
                 • Eat
                   • watercress and curly kale
                   • iron-fortified cereals
                   • wholegrain
                   • beans
                   • meat
                   • nuts
                   • Apricots
                   • prunes
                   • raisins
                 • Avoid
                   • Tea and coffee
                   • Calcium, found in dietary products
                   • antacids
                   • Proton pump inhibitors
                   • Whole grain cereals
           • Complications
             • Heart problems.
             • Problems during pregnancy.
             • Growth problems
         • Divecular bleeding
           • Large amount of blood appears in stool.

2. Anemia

   • An RBC consists of
     • Hemoglobin
       • Heme
         • Iron
           • any problem causes
             • Iron deficiency anemia
         • Porphyrin
           • any problem causes
             • Sideroblastic anemia
       • Globin
         • Any problem with it leads to
           • Thalassemia
           • Sickle cell anemia
     • Other problems relating to RBCS
       • Maturation
         • Megaloblastic anemia
       • Structure
         • Hereditary spherocytosis
       • Anemia of chronic disease
       • Hemolytic anemia
         • Number
         • Immune hemolytic anemia
         • RBC trauma:
           • Mechanical heart valves breaking RBC’s
           • MICROANGIOPATHIES: Hemolytic Uremic Syndrome
         • Hemolytic anemia due to G6PD deficiency
         • Parasitic hemolysis.
     • According to the MCV of the rbc, anemia can be classified to
       • Microcytic
         • MCV<80 fl
           • Iron deficiency
           • Anemia of chronic disease (some cases)
           • Sideroblastic anemia
       • Normocytic
         • MCV 80-100 fl
         • Many haemolytic anaemias
         • Anemia of chronic disease (some cases)
         • After acute blood loss
         • Renal disease
         • BM failure, post chemotherapy, infiltration by CA
       • Macrocytic
         • MCV>100 fl
         • Megaloblastic:Vitamin B12, or Folate deficiency
         • Non-megaloblastic: alcohol, liver disease, aplastic anaemia
   • Anemia symptoms
   • a condition in which there is a deficiency of red cells or of haemoglobin in the blood, resulting in pallor and weariness.
     • Insufficient oxygen transport
       • Tissue hypoxia
         • Brain
           • somnolence and fatigue
         • Heart
           • Chest pain
           • Angina
           • heart attack
         • Lung
           • Dyspnea and low respiratory reserve
         • Skeletal muscles
           • Weakness and fatigue

3. Life Span of Red Blood Cells

   • Erythropoiesis in the bone marrow(after birth)
     • Bone marrow is the flexible tissue found in the hollow interior of bones
       • produces the cellular elements of the blood, including platelets, red blood cells and white blood cells.
         • yellow marrow (consisting mainly of fat cells).
         • red marrow (consisting mainly of hematopoietic tissue)
           • Myeloid stem cells
             • give rise to erythrocytes, eosinophils, baso, neutrophils, monocytes and megakaryocytes
           • lymphoid stem cells
             • develop in the bone marrow
     • Differentiation of stem cells to mature cells is associated with:
       • Decreasing cell size
       • Hemoglobin production
       • Gradual decrease and loss of all cell organelles
       • Changing cytoplasmic staining
       • Condensation and eventual extrusion of the nucleus
   • after RBCs' degradation
     • Iron metabolism

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