Normal DNA That Tells You

14Oct – Anemia

Make RBC Normal DNA that tells you Right stuff in mouth (eat) Iron & Calories Interfere – Caffeine, Alcohol, Antacids, Some Antibiotics Help – Orange Juice, High Acid To the Intestines (Jejunum) Picked up by carrier – Transferrin TIBC – Total Iron Binding Capacity (how saturated the tranferrin isn’t) To bone marrow Packaged into Hemoglobin Made into RBC Baby Red Cells (reticulacytes) With Iron, count will go up with in a day or two Kidney makes - EPO – Erythropetin (senses BP and saturation) Erythropetin – signal to make more RBC Iron is stored in Farritin (protein that holds excess Iron) – Stored in liver & Bone marrow Can measure (Iron deficient – Farritin is low) Serum Iron is not a good test (recent food / supplements)

One cause of jaundice – RBC dies off quickly in newborns Causes – Heavy Period &Bleeding

If Anemic – Low Hct (Hematocrit) Always do a CBC MCV (mean corpuscular value) – How big each red cell is B12 & Folate are vitamin factors import for production of RBC Loss of RBC Viral infection – Parvo Cancer Rapid Loss – Menstrual GI Bleed (55 year old man) Pulmonary hemosiderosis Blood Donation Occult loss in retroperitoneal bleed Destruction of RBC Severe Hypertension RES (reticuloendothelial system) – Garbage man of the body If RBC look a little different – then eaten by RES Intra - Pink Urine, Pink Blood Extra - Big Spleen

Folate – everywhere in environment (Green Veggies) – easy one to get (because not stored well in body) Kids, Alcoholic / Need more – Pregnant / Alcoholics / Older. Can be quickly corrected – B12 – from animal source (body stores it well) – hard to get deficiency (long time to get) Vegan – nursing – passes to infant (yeast has enough) Stomach makes – Intrinsic Factor (keeps from being digested – absorbed in terminal Ileum)–pinocytosis Fish Tape worms / Bacteria Affect IF - No stomach / Antacids / Pernicious Anemia Perital Cells in Stomach secrete IF MCV in Accessing Anemia

Microcytic Anemia Microcytic Anemia (too small RBC) Certain amount of hemoglobin ratio in cell – if doesn’t have – will make smaller cells Hypochromia – turn pink (pail) Small pail Cells

Cheilosis – cracks on side of mouth Kids eating weird things – work up for Iron

Heme Iron – in meat Non Heme – packaged or other foods

Thalassemia (Inherited condition) Lots of small cells – smaller MCV (60’) – very high RBC count (lots of small red cells)

Macrocytic Anemia Greater then 100 MCV Megaloblastic anemia (most of time) or myelodysplastic syndrome Hypersegmented Neutrophils (many, many lobs – Classic Sign) Folate Deficiency Give Folate (don’t miss B12 deficiency – nervous system issues) Lack B12 - Burning tongue / dementia / Nervous issues

Spinabifita and CNS problem if Folate deficiency in pregnant women

If High MCV >100 and Hypersegmented Neutrophils – Above – if not below

Myelodysplastic Syndrome MCV > 100

Normocytic Anemia – Cells are right size, just not enough of them Most treatment is EPO

Aplastic Anemia – bone marrow has had it (empty bone marrow)

Read Shilling Test – 468 in currents

Inherited Disorders and Anemia DNA Messed up Problems in the Hemoglobin Change – most common Most common - G6PD, Sickle cell & Thalassemias (know populations)

Hemoglobin – 4 chains and 4 heme groups

Hgb AS (Sickle trait) More URI & Infarctions in high altitude (mostly NO problem) Dx - Hemoglobin electrophoresis Defect in one or two beta globins chains in HgbA = heterozygote Hgb S Disease (Sickle Cell Disease) Defect in both beta (b) globin chains in HgbA = homozygote Functional aspleenia - Vaccine against - Step Pneumonia – Homophiles Influenza B – Meningococcal Lot of turn over from hemoglobin in destroyed cells – causes gallstones

Thalassemias disorders – (don’t have enough chains) – lots of little cells and low MCV Alpha & Beta most common

Alpha – All hemoglobin have A Not abnormal, just not enough Alpha Chains Dx - Can’t Diagnosis by Hemoglobin electrophoresis Family History (fetal hydrops) – need large genetic story

Beta – defect in less common B chain Dx by Hemoglobin electrophoresis (different migration)

G6PD – Enzyme deficiency Women are carriers Men with 1 gene will fully express disease Hemolysis (red cells break apart) from toxic substance – sulfa drug – fava beans (rapid) Jaundice common Quick onset – pink urine / serum Death is possible Peripheral Artery Disease – not coronary artery or carotid artery

Atherosclerosis Sludge in artery R & L Iliac is the biggest bifurcation Within lining of the Wall itself SMOKING High BP – more turbulence and damage Gravity is your friend

Claudication – look at Feet Calcium Channel Blocker – after load reducer

Acute 6 – P’s Pain Pallor Pulselessness Paresthesias Paralysis Poikilothermia (Cool) Embolism – Comes from someplace else – forms and wanders Emergency - Acute

Thrombus formation - Happens at the site of damage Therapy – melt clot or remove or stint

Better if hanging down Know the 6 P’s Stop Smoking Keep platelets from clotting – Aspirin / Clavix

Venous Insufficiency and DVT

Varicose veins – blood flows wrong way – valve failure Inherent problem Thrombophelbitis – TX – Give up BCP Hemorrhoids are Varicose Veins in rectal area DVT - Clot in Deep Veins (femoral & Pelvic – or any deep one) Broken bone Grey Hound Leg – on bus (like plane) Measure it – if bigger then may have DVT

Chronic Venous Stasis/Venous Insufficiency – Pressure that causes edema in periphery (causes ulcers) Consequence of DVT Pressures overcome the tissue counter pressure Leg is blue, but warm Better if legs up at end of Day Allen Test – pinch hand arteries off Dorsalis Pedis test Homan’s sign COPER & SILVER arteries