The increase in Hb that occurs in men is largely attributed to the effect of androgens on

Clinical Oncology

2. The increase in Hb that occurs in men is largely attributed to the effect of androgens on

the release of erythropoietin EPO and the responsiveness of red blood cell RBC precursors to EPO. 3. The gender disparity in the normal range for Hb concentration is less significant in elderly individuals. B. Anemia is defined as Hb concentration more than to standard deviations below the normal range for age and gender. Using this definition, there is less than a 5 chance that a Hb concentration below the normal range is a “normal” value for the individual. Worldwide, almost one-third of the population is anemic. The first step in diagnosis of anemia is to establish whether the abnormality is isolated to a single cell line red blood cells only or whether it is part of a multiple cell line abnormality red cells, white cells and platelets. Abnormalities of to or three cell lines usually indicate one of the following :  bone marrow involvement, e.g., aplastic anemia, leukemia, or  an immunologic disorder e.g., connective tissue disease or immunoneutropenia, idiopathic thrombocytopenic purpura [ITP] or immune hemolytic anemia singly or in combination or  sequestration of cells e.g., hypersplenism. The blood smear is very helpful in the diagnosis of anemia. It establishes whether the anemia is hypochromic, microcytic, normocytic, macrocytic or show spezcific morphologic abnormalities suggestive of red cell membrane disorders e.g., spherocytes, stomatocytosis or elliptocytosis or hemoglobinopathies e.g., sickle cell disease, thalassemia. The mean corpuscular volume MCV confirms the findings on the smear with reference to the red cell size, e.g., microcytic 70 fl, macrocytic 85 fl or normocytic 72-79 fl. The mean corpuscular hemoglobin MCH and mean corpuscular hemoglobin concentration MCHC are calculated values and generally of less diagnostic. Learning task Patient of 2 years, girl with pale since 2 month ago, without fever and bleeding. Hemoglobin level is 6 gdL, MCV is 68 fl. Answer the following question : 1. Discuss what are steps you can perform on this patient anamnesis, physical examination, other laboratorium. 2. What the differential diagnosis of this patient ? Self Assessment a. Defined of anemia b. Describe the classification of anemia based on etiologi c. What is the differential diagnosis of patients microcytic anemia ? d. What is the differential diagnosis of patients normocytic anemia ? e. Give the differential diagnosis of macrocytic anemia f. Describe of historical factors of importance in evaluating patients with anemia DAY 3 Monday, November 28 th 2016 19 Udayana University Faculty of Medicine, DME, 2016 Clinical Oncology Learning task A 56 years old male, come with chief complain palpitation and feel very weak. Several days ago, he frequently had his stool with black color. He also suffered from nausea, vomiting, and pain on epigastrial. Laboratory findings are : Hb 7,6 grdl, MCV 72 fl, MCH 25 pg , MCHC 28, SI 50 ngdl, TIBC 525 ng Dl. Physical examination found with angular cheilitis, liver and spleen without any abnormality. 1. What is the type of anemia the patient suffered from? 2. Explain how is the patomechanism of the case above Self Asessment 1. Understand the iron metabolism in the body 2. Understand the absorbtion of the iron in the body 3. Understand the function and cycle of iron in the body DAY 3 Monday, November 28 th 2016 Learning Task A 56 years old male, come with chief complain palpitation and feel very weak. Several days ago, he frequently had his stool with black color. He also suffered from nausea, vomiting, and pain on epigastrial. Laboratory findings are : Hb 7,6 grdl, MCV 72 fl, MCH 25 pg , MCHC 28, SI 50 ngdl, TIBC 525 ng Dl. Physical examination found with angular cheilitis, liver and spleen without any abnormality. 1. What are the supporting examinations needed to confirm the dignosis above? 2. Explain the blood smear and bone marrow examinations finding will found at the patient above 3. What is the other possibility diagnosis of the case? Explain your answer 4. What are the possible etiology caused the anemic condition of the case? Self Asessment 1. Understand clinical manifestation of IDA 2. Understand the way to make diagnosis of IDA 3. Understand how to prevent the IDA DAY 4 Tuesday, November 29 th 2016 20 Udayana University Faculty of Medicine, DME, 2016 IRON DEFICIENCY ANEMIA The Epidemiology Pathophysiology Dr. dr. Ketut Suega, SpPD KHOM IRON DEFICIENCY ANEMIA The Diagnostic of Iron Deficiency Anemia Dr. dr. Ketut Suega, SpPD KHOM Clinical Oncology Abstract, Learning Task, Self Asessment Case Study on Lecture DAY 4 Tuesday, November 29 th 2016 Abstract, Learning Task, Self Asessment Case Study on Lecture DAY 5 Wednesday, November 30 th 2016 Abstract, Learning Task, Self Asessment Case Study on Lecture DAY 6 Thursday, December 1 st 2016 21 Udayana University Faculty of Medicine, DME, 2016 IRON DEFICIENCY ANEMIA Aspect of Therapy in Adults Dr. dr. Ketut Suega, SpPD KHOM Iron Deficiency Anemia Aspect of Therapy in Children dr. A.A. Widnyana, Sp.A HEMOLYTIC ANEMIA Sub Topic: Overview of Hemolytic Anemia Dr. Ketut Ariawati, SpAK Clinical Oncology Dr. Ketut Ariawati, SpAK Abstract Congenital hemolytic anemias result from mutations that quantitatively or qualitatively influence the function of red vlood cell proteins. These mutations can be broadly grouped into three categories : membrane defects, enzymatic defects, and hemoglobin defects. While many mutations have been described in each category, only a small number are commonly encountered in clinical practice. Clinical findings and specialized laboratory studies are often required to precisely define the underlying disease process. This general approach is true especially in the case of congenital hemolyitic anemias : In all patients with hemolytic anemia, a careful history and physical examination are important. 1. The history should explore the chronicity of the problem, ethnic and racial background, family history, underlying or associated medical conditions, and new medications. 2. Jaundice is a common finding. Splenomegaly may also be associated with a wide variety of hemolytic disorders. Various laboratory abnormalities are associated with hemolysis. 1. An elevated reticulocyte index is typical , consistent with a compensatory bone marrow response to anemia. Bone marrow examination is not necessary for most patients. 2. Increased lactate dehydrogenase, uncojugted bilirubin, and depressed or absent haptoglobin are also observed with hemolysis. 3. The red blood cell RBC morphology is frequently abnormal and provides an important clue to the underlying disease process. 4. The peripheral blood smear is rarely pathognomic. Learning task Patients of 2 years, male with pale since 2 month ago, not history of bleeding, and fever. The abdominal became more bigger since 1 months. History of transfusion ± six month ago because pale. Hemoglobin level is 3 gdL, MCV is 68 fl, reticulocyte is 3. Answer the following questions : 1. Would you like to explain what kind the abnormalities in patient above. 2. What the laboratorium test you need to confirm this disease ? 3. What the differential diagnosis in patient above ? Self assessment 1. Describe classification of congenital hemolytic anemia. 2. Explain clinical presentation and laboratory evaluation of congenital hemolytic anemias 3. Explain the principle management of congenital hemolytic anemias DAY 6 Thursday, December 1 st 2016 22 Udayana University Faculty of Medicine, DME, 2016 Lecture - 1 HEMOLYTIC ANEMIA Sub Topic: Congenital Hemolytic Anemia Clinical Oncology Abstract : Hemolytic anemias result from a shortened red blood cells RBC survival rate as a result of an increased rate of RBC destruction. Hemolytic disorders are generally limited to conditions in which the rate of RBC destruction is increased while the ability of the bone marrow to respond to the anemia remains intact. Bone marrow can increase its production rate 6-8 times normal; therefore, hemolytic disordes can be present in the absence of anemia. When bone marrow erythropoesis cannoyt keep up with the shortened length of RBC survival, hemolytic anemia result. Learning Task : Young female come with complain of yellowish eyes, feeling weak and dizzy since around 3 days before admitted to hospital. On physical examination found icteric on eyes, and pale on hand and foot. Patient without history of bleeding before. Laboratory results HGB 8.3 mgdL, Leukosit 5900mm 3 , thrombocyte 410.000mm 3 Total bilirubin 4.5, Indirect Bilirubin 3.5, and Coomb’s test positive. a. Mention the possibility diagnostic of the case above. b. Mention the examination supporting diagnostic. Self Assessment : 1. Explain about the principles of hemolytic anemias. 2. Mention the type of hemolytic anemias. 3. Mention the clinical manifestation and laboratory findings in Acquired Hemolytic anemia DAY 7 Friday, December 2 nd 2016 Abstract Aplastic anemia is one type of anemia with incidence worldwide is 2 to 5 casesmillion population per year in industrial countries. Characterized by pancytopenia and markedly hypocelluler marrow. The pathogenesis underlying anemia aplastic could be an immune suppression of marrow, toxic injury to stem and or progenitor cells, and inherited instrinsic stem cell defect. Clinical features of aplastic anemia shown anemic syndrome, bleeding or infection as 23 Udayana University Faculty of Medicine, DME, 2016 Lecture - 2 HEMOLYTIC ANEMIA Sub Topic: Acquired Hemolytic Anemia dr. Tjokorda Gde Dharmayuda, SpPD KHOM APLASTIC ANEMIA dr. Losen Adnyana, SpPD KHOM Clinical Oncology a consequences of cytopenias. Supporting examination recommended are complete blood count, and bone marrow aspiration. Learning Task : A 23 years old woman gives a 3 month history of progressively increasing tiredness with bruising, malaise and menorrhagia. On examination she is anemic and has multiple bruises. A full blood count shows HGB 6.9 gdL, WBC 1.1 x 10 9 l ANC 0.3 x 10 9 l, platelets 17 x 10 9 l. Her chest X ray shows pneumonia. a. What further investigations should be undertaken? b. What are the possibility diagnostic for this patient? c. What seems to be the cause of this case? Self Assessment : 1. Explain about the principles of pathogenesis of aplastic anemias. 2. Mention the type of aplastic anemias. 3. Mention the clinical manifestation and laboratory findings in Aplastic Anemia DAY 8 Monday, December 5 th 2016 ABSTRACT The macrocytic anemias are a morphological classification of anemias that have an MCV of greater than 100 fL. Broadly defined, the macrocytic anemias are divided into two categories megaloblastic and nonmegaloblastic processes. If the source of the anemia is a vitamin B12 or folic acid deficiency, the anemia is termed megaloblastic. If the source of the anemia is unrelated to a nutritional deficiency, the anemia is macrocytic but not megaloblastic. Vitamin B12 or folic acid deficiency leads to impaired DNA synthesis, a serious condition, and will affect all readily dividing cells, skin cells, hematopoietic cells, and epithelial cells. The effects on the bone marrow, peripheral smear, and the patient’s quality of life are dramatic and substantive. The megaloblastic anemias show striking similarities in their clinical and hematological presentations. Several tests are used to confirmed the diagnostic of B12 or folic acid deficiency anemia. They include serum B12, folic acid, or red cell folate determination by radioimmunoassay. Learning Task 1. How is the metabolism of B12 and folic acid in the body? 2. Explain the possible etiology of B12 and folic acid deficiency anemia 3. Explain the way of diagnostic B12 and folic acid deficiency anemia Self Assessment 1. Understand the metabolism of B12 and folic acid in the body. 2. Mention the etiology of B12 and folic acid deficiency anemia. 3. Mention the clinical presentation of B12 and folic acid deficiency anemia. 4. Understand the laboratorium examinations that supporting thr diagnostic of B12 and folic acid deficiency anemia. 24 Udayana University Faculty of Medicine, DME, 2016 MACROCYTIC MEGALOBLASTIC ANEMIAS dr. Losen Adnyana, SpPD KHOM Clinical Oncology DAY 9 Tuesday, December 6 th 2016 Learning task 1. What is definition of polisitemia? 2. Explain the pathophysiology of polisitemia? 3. Mention the sign and symptom of polisitemia