Уважаемый papadoctor. Я не потешаюсь над Вами, ни в коем случае. Я не компетентен для этого. Я просто иронизирую, при этом свои пункты в конце привёл вполне искренне. Т.е. к онкологу собирался направить, правда yananshs отговаривает... Плохо понимаю почему, но вероятно ей виднее, т.е. доверюсь. К гинекологу - точно. Из анкетных данных (уверен, что имеется ввиду анамнез) что именно Вам может помочь? Мне - ничего, иначе бы я не обратился сюда. Я по американским меркам резидент, при чём не самый старательный... и тем более не такой знающий... Сделайте скидку,плз.
Анемии из Мерк мануал он лайн. Для начала приличное чтиво.
Anemias: Decreases in numbers of RBCs or Hb content caused by blood loss, deficient erythropoiesis, excessive hemolysis, or a combination of these changes.
The term anemia has been used incorrectly as a diagnosis; more properly, it denotes a complex of signs and symptoms. The type of anemia defines its pathophysiologic mechanism and its essential nature, allowing for appropriate therapy. Not investigating mild anemia is a serious error; its presence indicates an underlying disorder, and its severity reveals little about its genesis or true clinical significance.
The symptoms and signs of anemia represent cardiovascular-pulmonary compensatory responses to the severity and duration of tissue hypoxia. Severe anemia (eg, Hb < 7 g/dL) can be associated with weakness, vertigo, headache, tinnitus, spots before the eyes, fatigability, drowsiness, irritability, and even bizarre behavior. Amenorrhea, loss of libido, GI complaints, and sometimes jaundice and splenomegaly can occur. Finally, heart failure or shock can result.
Abbreviations Used in This Chapter
AdoCbl Adenosylcobalamin Hct Hematocrit
ag Attogram MCH Mean corpuscular Hb
AIHA Autoimmune hemolytic anemia MCHC Mean corpuscular Hb concentration
ATG Equine antihymocyte globulin MCV Mean corpuscular volume
MeCbl Methylcobalamin
C3 Complement NaCl Sodium chloride
CBC Complete blood count O2 Oxygen
EDTA Ethylenediaminetetraacetic acid PCH Paroxysmal cold hemoglobinuria
ELISA Enzyme-linked immunosorbent assay PNH Paroxysmal nocturnal hemoglobinuria
EPO Erythropoietin PO2 Partial pressure of oxygen
Fe Iron RBC Red blood cell
G6PD Glucose-6-phosphate dehydrogenase RDW RBC volume distribution width
Hb Hemoglobin WBC White blood cell
General diagnostic patterns can expedite the differential diagnosis (see Table 127-1). Anemia results from one or more of three basic mechanisms: blood loss, deficient erythropoiesis (RBC production), and excessive hemolysis (RBC destruction). Blood loss should be the first consideration. Once it is ruled out, only the other two mechanisms need to be considered. Because RBC survival is 120 days, maintenance of a steady RBC population requires daily renewal of 1/120 of the cells. Complete cessation of erythropoiesis results in a decline of about 10%/wk (1%/day) of RBCs. Deficient erythropoiesis results in relative or absolute reticulocytopenia. When RBC values fall > 10%/wk (ie, 500,000 RBCs/µL) without blood loss, hemolysis is a causative factor.
A convenient approach to most anemias that result from deficient erythropoiesis is to examine changes in RBC size and shape. Thus, microcytic anemias (see Laboratory Tests, below) suggest altered heme or globin synthesis (eg, iron [Fe] deficiency, thalassemia and related Hb-synthesis defects, anemia of chronic disease). In contrast, normochromic-normocytic anemias suggest a hypoproliferative or hypoplastic mechanism. Some anemias are characterized by macrocytes (large RBCs), which suggest a defect in DNA synthesis. These anemias are usually caused by defective vitamin B12 or folic acid metabolism or by an interference with DNA synthesis by chemotherapeutic cytoreductive drugs. Adequate marrow response to anemia is evidenced by peripheral blood reticulocytosis or polychromatophilia.
Similarly, a few common mechanisms of increased destruction (eg, sequestration by the spleen, antibody-mediated hemolysis, defective RBC membrane function, abnormal Hb) greatly aid in the differential diagnosis of hemolytic anemias.
A critical tenet in managing anemias is to give specific therapy, which implies that a specific diagnosis is necessary. The response to therapy corroborates the diagnosis. Although multidrug (or "shotgun") therapy may provide transient repair of the anemia, such therapy is not justifiable because it risks serious sequelae. RBC transfusion provides a form of instant repair that should be reserved for patients with cardiopulmonary symptoms, signs of active uncontrollable blood loss, or some form of hypoxemic end-organ failure. Transfusion procedures and blood components are discussed in Ch. 129.
Table 127-2 classifies anemias according to cause.
Laboratory Tests
Laboratory tests quantitate the severity of anemia and provide data for diagnosis.
Blood specimen collection: Blood is preferably collected by venipuncture, although fingertip puncture with a sterile lancet may sometimes suffice. The specific tests determine which anticoagulant, if any, should be in the collection tubes. Vacuum tubes are available with double-pointed needles to facilitate collection; they contain anticoagulants for most routine tests. However, most commercially available vacuum tubes are nonsterile; backflow of blood from the filled tube to the vein may permit bacteria to enter. To avoid such infections, the tourniquet should be removed before blood flow into the tube stops; the patient's arm should not be moved during collection (even a few centimeters' elevation after the tube draw is complete may lower venous pressure sufficiently to produce backflow); and no pressure should be exerted on the stopper end of the tube. Whenever possible, sterile tubes or needle and tube arrangements that have a check valve should be used.
Ethylenediaminetetraacetic acid (EDTA) is the preferred anticoagulant for blood collection because the morphology is less distorted and platelets are better preserved. It can be added to clean test tubes, or vacuum tubes containing EDTA may be obtained commercially. Slides should be prepared within 3 to 4 h after obtaining blood, or within 1 to 2 h for platelet counts.
For small amounts of blood or when venipuncture is infeasible, the finger, the earlobe, or, in infants, the plantar surface of the heel is punctured quickly with a sterile disposable lancet, piercing deeply enough to ensure spontaneous flow of blood. Undue pressure that might cause tissue fluids to dilute the blood should be avoided during collection.
In some circumstances, EDTA tubes are used for coagulation testing. Regardless of the anticoagulant used, because significant anemia (Hct < 20%) or polycythemia (Hct > 50%) may affect coagulation results, the sample volume must be adjusted after CBC data are known. For significant anemia, less blood can be added to the fixed amount of anticoagulant by drawing the blood in a syringe; for polycythemia, the amount of anticoagulant must be reduced (see Table 127-3).
Complete blood count: The CBC is a basic evaluation that usually includes Hb, Hct, WBC count, WBC differential count, platelet count, a description of the blood smear relative to RBC morphology and degree of polychromatophilia, and platelet spread and architecture. An RBC count is often included, especially when calculation of RBC indices is desired.
Indications for a CBC include suspected hematologic, inflammatory, neoplastic, or infectious disease and screening of infants < 1 yr, pregnant women, the institutionalized elderly, and patients with nutritional abnormalities. Its value during routine patient evaluation on hospital admission is controversial.
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