l Sideroblast屬於頑固型貧血
l Thalassemia:鐵太多,打鐵劑會anaphylaxis
l 如何approach一個anemia的病人
age, S/S, duration, past hx, diet:酗酒、結石、G6PD, medication, PE:tongue、sclera、pulse、LN、skin、摸肚子、指甲、BT、敲sternum
l 血管內溶血可看眼睛看尿液(快)
l 在台灣sickle cell幾乎是零,endemic area是約旦
l Billroth I比II容易造成IDA
l 發酵越深焙,單寧越多,會抑制二價鐵的吸收(正常在胃酸作用下Fe3+→Fe2+),普洱>紅茶>日本清茶,Vit. C可以促進二價鐵的吸收,所以英國人在伯爵茶裡加佛手柑
l 腳上有紅點,platelet約兩萬
l 敲sternum痛→Periosteal reaction→CBC速件→leukemia
l 貧血在各種人最常見原因
young boy: thalassemia爸媽帶來開兵役診斷書
young women: Hypermenorrhea:滴滴答答>7天or夜用型>3天
man with HTN: 有chronic renal disease
school girl: tea + on diet
middle age women: vegetarian
any age: peptic ulcer
elderly farmer: parasite (tape worm在ileum→B12; A. scariasis在duodenum→Fe2+)
from sanitarium安養院: 缺B12要三年,坐輪椅; 缺folic acid要三個月
>60y/o with IDA: cancer esp. GI
l Colon cancer最多>>lung or hepatoma,>60y/o一律作screen
l RI=reticular cytex Hct/45 x 1/maturation,要>2.3%
骨髓正常:bleeding
<1%很低:leukemia, aplastic, metastasis
l 皮膚不好非該年齡該有,LN腫,有藝術氣息→驗CBC, HIV
l Pancytopenia→多器官、年輕女性→SLE,malar rash出來已經是晚期
l APML(M3)易合併DIC
l Poikylocytosis, anisocytosis代表骨髓無效造血
l IDA舌苔黃,papilla還在,偏白
B12缺乏舌頭像牛肉
l MCV>100→B12>folic>酒精中毒>reticulocyte過多>MDS
l 病人來時anemia with icteric skin,檢查indirect bilirubin, reticulocyte, Coomb’s test
l 看到spherocytosis想hemolytic anemia,溶血時缺O2,造血更小更圓,polychromasia表示正在溶血
l Thalassemia major隨時都在溶血,糊糊的
tear drop形狀:myelofibrosis,擠出來
target狀:thalassemia
bird cell:uremia
l Microangiopathy:DIC, 人工mitral valve打碎RBC, 小孩HUS, (conscious怪)TTP
l Ferritin和iron低,MCV不低→suspect PNH,會溶血,從尿中排掉不吸收,reticular cell不高,LDH非常高(血球不斷破壞&再造)
l Anemia合併jaundice和腹背痛→AIHA(止痛藥induce)合併lymphoma
l Anemia with gout→吃止痛藥造成的peptic ulcer
l IDA不會造血,都不成熟;thalassemia會造血但死的快,RBC幾乎正常甚至稍多
l Ascending colon cancer較常見anemia,因為稀便出血快,descending出血還沒anemia就被發現了
l HIVD常在頸、下背→坐時更痛,站走不痛
metastasis常在腰→平躺痛,動作更痛,坐時不痛
osteoporosis常在胸
脊椎狹窄→走動痛,坐躺不痛
l Epidural spinal cord compression中80%是bone metastasis,脊體壓痛、漸漸無痛性下肢癱瘓
Brown-Sequard:同側 下肢癱瘓,震動、定位感lost;異側 痛、溫感lost
posterior column壓迫:bilateral震動、定位感lost,痛、溫感、運動不影響
l H. pylori
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