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[[User:Asra|Asra Firdous,M.B.B.S.]][mailto:asra.firdous21@gmail.com]
[[User:Asra|Asra Firdous,M.B.B.S.]][mailto:asra.firdous21@gmail.com]
==Anemia==
==Management==
{{familytree/start |summary=Anemia Algorithm}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01 =INDICATIONS FOR TESTING<br>
'''Fatigue, weakness, pallor, dizziness, fainting''' }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=Check '''routine Labs''',
'''CBC''' , '''smear''' and '''reticulocyte count and index'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01= Diagnosed as anemia if <br> '''Hgb in males < 13g / dl''' and in '''females if Hgb < 12g / dl'''<ref name="-1968">{{Cite journal  | title = Nutritional anaemias. Report of a WHO scientific group. | journal = World Health Organ Tech Rep Ser | volume = 405 | issue =  | pages = 5-37 | month =  | year = 1968 | doi =  | PMID = 4975372 }}</ref><ref name="Rodgers-2008">{{Cite journal  | last1 = Rodgers | first1 = GM. | last2 = Becker | first2 = PS. | last3 = Bennett | first3 = CL. | last4 = Cella | first4 = D. | last5 = Chanan-Khan | first5 = A. | last6 = Chesney | first6 = C. | last7 = Cleeland | first7 = C. | last8 = Coccia | first8 = PF. | last9 = Djulbegovic | first9 = B. | title = Cancer- and chemotherapy-induced anemia. | journal = J Natl Compr Canc Netw | volume = 6 | issue = 6 | pages = 536-64 | month = Jul | year = 2008 | doi =  | PMID = 18597709 }}</ref><ref name="Beutler-2006">{{Cite journal  | last1 = Beutler | first1 = E. | last2 = Waalen | first2 = J. | title = The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? | journal = Blood | volume = 107 | issue = 5 | pages = 1747-50 | month = Mar | year = 2006 | doi = 10.1182/blood-2005-07-3046 | PMID = 16189263 }}</ref>
<br> Check whether ''' corrected reticulocyte index ≥ 2.5''' }}
{{familytree | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | | | | D02 | | | | | | | | | | | | | | | | | | | | | | |D01=  If '''No'''<br> Check '''RBC indices'''|D02= If '''Yes''' then}}
{{familytree | | | | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | E01 | | | | | | E02 | | | | | E03 | | | | | | | | | | | | | | | E04 | | | | | | | | | | E01='''Normal MCV / MCHC '''<br> Normocytic Normochromic|E02= '''Low MCV / MCHC''' <br>  Microcytic Hypochromic|E03= '''High MCV''' <br> Macrocytic<ref name="Davenport-1996">{{Cite journal  | last1 = Davenport | first1 = J. | title = Macrocytic anemia. | journal = Am Fam Physician | volume = 53 | issue = 1 | pages = 155-62 | month = Jan | year = 1996 | doi =  | PMID = 8546042 }}</ref><ref name="Inelmen-1994">{{Cite journal  | last1 = Inelmen | first1 = EM. | last2 = D'Alessio | first2 = M. | last3 = Gatto | first3 = MR. | last4 = Baggio | first4 = MB. | last5 = Jimenez | first5 = G. | last6 = Bizzotto | first6 = MG. | last7 = Enzi | first7 = G. | title = Descriptive analysis of the prevalence of anemia in a randomly selected sample of elderly people living at home: some results of an Italian multicentric study. | journal = Aging (Milano) | volume = 6 | issue = 2 | pages = 81-9 | month = Apr | year = 1994 | doi =  | PMID = 7918735 }}</ref>
|E04=Check peripheral smear}}
{{familytree | | | | | | |!| | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | |!| | | | | | |!| | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | | |}}
{{familytree | | | | | | F01 | | | | | | F02 | | | | | F03 | | | | | | | | | F04 | | | | | | | | | | F05 | | | | | | | | | | |F01=↓ '''EPO''' production or improper response to '''EPO'''<ref name="Gomes-2003">{{Cite journal  | last1 = Gomes | first1 = ME. | last2 = Deinum | first2 = J. | last3 = Timmers | first3 = HJ. | last4 = Lenders | first4 = JW. | title = Occam's razor; anaemia and orthostatic hypotension. | journal = Lancet | volume = 362 | issue = 9392 | pages = 1282 | month = Oct | year = 2003 | doi = 10.1016/S0140-6736(03)14572-2 | PMID = 14575973 }}</ref><ref name="Perera-1995">{{Cite journal  | last1 = Perera | first1 = R. | last2 = Isola | first2 = L. | last3 = Kaufmann | first3 = H. | title = Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure. | journal = Clin Auton Res | volume = 5 | issue = 4 | pages = 211-3 | month = Sep | year = 1995 | doi =  | PMID = 8520216 }}</ref>
|F02=Maturation defect<ref name="Camaschella-2013">{{Cite journal  | last1 = Camaschella | first1 = C. | title = How I manage patients with atypical microcytic anaemia. | journal = Br J Haematol | volume = 160 | issue = 1 | pages = 12-24 | month = Jan | year = 2013 | doi = 10.1111/bjh.12081 | PMID = 23057559 }}</ref>
|F03=Maturation defect|F04='''Fragmented cells on peripheral smear''' |F05='''No fragmented cells on peripheral smear'''}}
{{familytree | | | | | | |!| | | | | | | |!| | | | | | |!| | | | | | | | | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | |!| | | | | | |!| | | | | | | | | | |!| | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | G01 | | | | | | G02 | | | | | G03 | | | | | | | | | G04 | | | | | | | | | | G05 | | | | | | | | | | | | | | | |G01=*Bone marrow disorder <br>[[Inflammation]]<br>*[[Autoimmune disease]]<br>*[[Chronic renal disease]]<br>*Critical illness<br>*Chronic endocrine disorders<br>*[[Aplastic anemia]]<br>*Pure red cell aplasia|G02=*[[Iron deficiency]]<br>*Chronic disease<br>*[[Thalassemia]] (Hemoglobinopathies)<br>*[[Sideroblastic anemia ]]<br>*[[Lead toxicity]]|G03=*Folate, B12 deficiency ([[Megaloblastic Anemia]]) <br>* Drug effect <br> *Excessive alcohol use <br> *[[Hypothyroidism]]|G04= '''Suggests hemolytic process'''<br>*Metabolic defect <br>*[[Hemoglobinopathies]] (eg,
[[sickle cell]])<br>*Autoimmune destruction<br>*Splenic sequestration<br>*[[RBC membrane defect]]<br>*[[Intravascular hemolysis]]<br> See [[Hemolytic Anemia]] |G05=Suspect hemorrhage and acute blood loss<ref name="Salisbury-2011">{{Cite journal  | last1 = Salisbury | first1 = AC. | last2 = Reid | first2 = KJ. | last3 = Alexander | first3 = KP. | last4 = Masoudi | first4 = FA. | last5 = Lai | first5 = SM. | last6 = Chan | first6 = PS. | last7 = Bach | first7 = RG. | last8 = Wang | first8 = TY. | last9 = Spertus | first9 = JA. | title = Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | journal = Arch Intern Med | volume = 171 | issue = 18 | pages = 1646-53 | month = Oct | year = 2011 | doi = 10.1001/archinternmed.2011.361 | PMID = 21824940 }}</ref>
}}
{{familytree | | | | | | |!| | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |`|-|-|-|-|-|-|-|+|-|-|-|-|-|-|'| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | H01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H01=Abnormal peripheral smear}}
{{familytree | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | I01 | | | | | | | | | | | | | I02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |I01='''If yes''' <br>then work up based on smear <br>'''bone marrow biopsy''' may be necessary |I02= '''If no'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | J01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | J01=ORDER<br>'''Iron and Iron Binding Capacity''' and '''Ferritin'''<br> check '''B12, Folate levels'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | K01 | | | | | K02 | | | | K03 | | | | | | | | | | | | | | | | | | | | | | | | |K01=Start Vit B12,Folate <br>If low|K02='''Low / normal TIBC'''<br>'''Normal / high ferritin'''<br>'''Low / normal iron''' |K03='''High TIBC'''<br>'''Low iron'''<br>'''Low ferritin'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | L01 | | | | L02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | L01=Inflammation / <br>Chronic Disease<br>'''Consider Biopsy in this case''' |L02=[[Iron Deficiency anemia]]}}
{{familytree/end}}


==Vomiting Diagnosis==
==Vomiting Diagnosis==

Latest revision as of 20:43, 30 August 2020

Asra Firdous,M.B.B.S.[1]

Anemia

Management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INDICATIONS FOR TESTING
Fatigue, weakness, pallor, dizziness, fainting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check routine Labs, CBC , smear and reticulocyte count and index
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosed as anemia if
Hgb in males < 13g / dl and in females if Hgb < 12g / dl[1][2][3]
Check whether corrected reticulocyte index ≥ 2.5
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If No
Check RBC indices
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If Yes then
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal MCV / MCHC
Normocytic Normochromic
 
 
 
 
 
Low MCV / MCHC
Microcytic Hypochromic
 
 
 
 
High MCV
Macrocytic[4][5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check peripheral smear
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EPO production or improper response to EPO[6][7]
 
 
 
 
 
Maturation defect[8]
 
 
 
 
Maturation defect
 
 
 
 
 
 
 
 
Fragmented cells on peripheral smear
 
 
 
 
 
 
 
 
 
No fragmented cells on peripheral smear
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Bone marrow disorder
Inflammation
*Autoimmune disease
*Chronic renal disease
*Critical illness
*Chronic endocrine disorders
*Aplastic anemia
*Pure red cell aplasia
 
 
 
 
 
*Iron deficiency
*Chronic disease
*Thalassemia (Hemoglobinopathies)
*Sideroblastic anemia
*Lead toxicity
 
 
 
 
*Folate, B12 deficiency (Megaloblastic Anemia)
* Drug effect
*Excessive alcohol use
*Hypothyroidism
 
 
 
 
 
 
 
 
Suggests hemolytic process
*Metabolic defect
*Hemoglobinopathies (eg, sickle cell)
*Autoimmune destruction
*Splenic sequestration
*RBC membrane defect
*Intravascular hemolysis
See Hemolytic Anemia
 
 
 
 
 
 
 
 
 
Suspect hemorrhage and acute blood loss[9]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal peripheral smear
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If yes
then work up based on smear
bone marrow biopsy may be necessary
 
 
 
 
 
 
 
 
 
 
 
 
If no
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ORDER
Iron and Iron Binding Capacity and Ferritin
check B12, Folate levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start Vit B12,Folate
If low
 
 
 
 
Low / normal TIBC
Normal / high ferritin
Low / normal iron
 
 
 
High TIBC
Low iron
Low ferritin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflammation /
Chronic Disease
Consider Biopsy in this case
 
 
 
Iron Deficiency anemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Vomiting Diagnosis

 
 
Check ABCDE
Airway
Breathing
Circulation
Deformity
Exposure
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess vital signs
❑ Obtain IV access
❑ NPO (if persistent vomiting)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs of dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
Fluid replacement therapy
 
Electrolyte imbalance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat electrolyte imbalance
 
Detailed history and physical examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regurgitation
 
True Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance and Follow-up in OPD
 
❑Frequency
❑ Effect on oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent and Hampering oralintake
 
Occasional and does not hamper oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiemetics
❑ Ondansetron
❑ Domeperidone
 
Observation and Reassurance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigate and treat the underlying cause
 

Vomiting

 
 
 
 
 
 
 
 
❑Assess vital signs
❑Obtain venous access
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize hemodynamics
 
 
 
 
 
 
 
 
 
 
 
 
 
History and Physical Examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regurgitation
 
 
 
 
 
 
 
True Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance and follow-up in OPD
 
 
 
 
 
 
 
Red flag signs
❑ Unstable vital signs
Acidotic breathing
Bile and Blood present in vomiting
❑ Clinical features suggestive of GI obstruction
❑ Inconsolable cry and excessive irritability
Altered sensorium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ICU admission
❑ Stabilise
❑ Investigate for the underlying cause
 
 
 
 
 
 
 
Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying cause
 
 
Present
 
 
 
 
 
 
 
 
Absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infections
 
 
 
 
 
 
 
 
Frequency of vomiting
Effect on oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying cause
 
 
 
Persistent/Recurrent vomiting
Hampering oral intake
 
 
 
 
 
 
 
Occasional vomiting
Not hampering oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiemetics
Ondansetron
Domeperidone
 
 
 
 
 
 
 
Observation
and
Reassurance
 


Ewing's sarcoma Microchapters

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [3];Assistant Editor(s)-In-Chief: Michael Maddaleni, B.S., Asra Firdous, M.B.B.S.

Overview

Ewing's sarcoma is the second most common malignant bone neoplasm commonly affecting children and adolescents. It usually affects patients in the second decade of life with a peak incidence around 15 years of age. It comprises 3% of all malignancies in pediatric patients and about 10-15% of childhood bone cancers. The overall incidence of Ewing's sarcoma is approximately estimated at 2.9 cases per million population in the U.S. Ewing's sarcoma is more common in males than females. It is more prevalent in whites than Africans.

Epidemiology and Demographics

Incidence

Mortality/Morbidity

The overall 5-year survival rate for patients with Ewing's Sarcoma is approximately 70% in primary lesions and 30% in metastatic disease.

Race

  • Ewing's Sarcoma is more prevalent in Caucasians than Asians or Hispanics.
  • African Americans and Africans are less likely to develop Ewing's Sarcoma.
  • The incidence in the Caucasians is 1.5 cases per million population.
  • The incidence in the Asians is 0.8 cases per million population.
  • The incidence in Africans is 0.2 cases per million population.

Age

  • Ewing's Sarcoma commonly affects children and adolescents between 10 and 20 years of age.
  • The median age at diagnosis is 15 years
  • In patients younger than 5 years, diagnosed in about 0.6 cases per million population.
  • In patients aged 10-14 years, diagnosed in about more than 5 cases per million population.

Gender

  • Males are more commonly affected than females. The male to female ratio is around 3:2.

Reference

Anemia of Prematurity Symptoms

The majority of patients with Anemia of Prematurity are asymptomatic. In premature infants with severe disease, symptoms are usually vague or non-specific.

  • Common symptoms of Anemia of Prematurity include
    • Tachycardia
    • Tachypnea
    • Decreased activity or lethargy
    • Difficulty feeding
    • Pallor
  • Less common symptoms of Anemia of Prematurity include
    • Poor weight gain despite adequate calorie intake
    • Breathing difficulties
    • Metabolic acidosis due to increased lactic acid production from anaerobic metabolism in the cells
    • Heart murmurs


Pathophysiology of Anemia of Prematurity

The pathogenesis of anemia of prematurity is multifactorial. Anemia of prematurity is the result of a combination of decreased erythropoietin production, increased erythropoietin metabolism, deficient iron stores, decreased RBC lifespan, and blood loss during phlebotomy.[11][12]

Physiological anemia in newborns

Normally, all the newborns experience a fall in the haemoglobin concentration during the first few weeks of life. Healthy, fullterm infants usually develop anemia around 10-12 weeks of life after birth. Hemoglobin concentration never falls below 10 g/dl in healthy infants. Physiological anemia is well tolerated by and does not require any therapy.[12]

Pathological Anemia of Prematurity

In preterm infants, multiple physiological factors exaggerate and combine to result in pathological anemia. Hemoglobin levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. Infants with 1-1.5 kg of birthweight have hemoglobin levels around 8 g/dl, whereas infants with birthweight less than 1 kg have hemoglobin levels around 7 g/dl or less. The profound decrease in hemoglobin levels in premature infants produce abnormal signs and symptoms and require a blood transfusion. [12]


Vomiting

 
 
 
 
 
 
 
 
❑Assess vital signs
❑Obtain venous access
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize hemodynamics
 
 
 
 
 
 
 
 
 
 
 
 
 
History and Physical Examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regurgitation
 
 
 
 
 
 
 
True Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance and follow-up in OPD
 
 
 
 
 
 
 
Red flag signs
❑ Unstable vital signs
Acidotic breathing
Bile and Blood present in vomiting
❑ Clinical features suggestive of GI obstruction
❑ Inconsolable cry and excessive irritability
Altered sensorium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ICU admission
❑ Stabilise
❑ Investigate for the underlying cause
 
 
 
 
 
 
 
Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying cause
 
 
Present
 
 
 
 
 
 
 
 
Absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infections
 
 
 
 
 
 
 
 
Frequency of vomiting
Effect on oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat the underlying cause
 
 
 
Persistent/Recurrent vomiting
Hampering oral intake
 
 
 
 
 
 
 
Occasional vomiting
Not hampering oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiemetics
Ondansetron
Domeperidone
 
 
 
 
 
 
 
Observation
and
Reassurance
 
  1. "Nutritional anaemias. Report of a WHO scientific group". World Health Organ Tech Rep Ser. 405: 5–37. 1968. PMID 4975372.
  2. Rodgers, GM.; Becker, PS.; Bennett, CL.; Cella, D.; Chanan-Khan, A.; Chesney, C.; Cleeland, C.; Coccia, PF.; Djulbegovic, B. (2008). "Cancer- and chemotherapy-induced anemia". J Natl Compr Canc Netw. 6 (6): 536–64. PMID 18597709. Unknown parameter |month= ignored (help)
  3. Beutler, E.; Waalen, J. (2006). "The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration?". Blood. 107 (5): 1747–50. doi:10.1182/blood-2005-07-3046. PMID 16189263. Unknown parameter |month= ignored (help)
  4. Davenport, J. (1996). "Macrocytic anemia". Am Fam Physician. 53 (1): 155–62. PMID 8546042. Unknown parameter |month= ignored (help)
  5. Inelmen, EM.; D'Alessio, M.; Gatto, MR.; Baggio, MB.; Jimenez, G.; Bizzotto, MG.; Enzi, G. (1994). "Descriptive analysis of the prevalence of anemia in a randomly selected sample of elderly people living at home: some results of an Italian multicentric study". Aging (Milano). 6 (2): 81–9. PMID 7918735. Unknown parameter |month= ignored (help)
  6. Gomes, ME.; Deinum, J.; Timmers, HJ.; Lenders, JW. (2003). "Occam's razor; anaemia and orthostatic hypotension". Lancet. 362 (9392): 1282. doi:10.1016/S0140-6736(03)14572-2. PMID 14575973. Unknown parameter |month= ignored (help)
  7. Perera, R.; Isola, L.; Kaufmann, H. (1995). "Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure". Clin Auton Res. 5 (4): 211–3. PMID 8520216. Unknown parameter |month= ignored (help)
  8. Camaschella, C. (2013). "How I manage patients with atypical microcytic anaemia". Br J Haematol. 160 (1): 12–24. doi:10.1111/bjh.12081. PMID 23057559. Unknown parameter |month= ignored (help)
  9. Salisbury, AC.; Reid, KJ.; Alexander, KP.; Masoudi, FA.; Lai, SM.; Chan, PS.; Bach, RG.; Wang, TY.; Spertus, JA. (2011). "Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction". Arch Intern Med. 171 (18): 1646–53. doi:10.1001/archinternmed.2011.361. PMID 21824940. Unknown parameter |month= ignored (help)
  10. Ewing's sarcoma. National cancer institute.http://www.cancer.gov/types/bone/hp/ewing-treatment-pdq#section/_1
  11. Stockman JA, Graeber JE, Clark DA, McClellan K, Garcia JF, Kavey RE (1984). "Anemia of prematurity: determinants of the erythropoietin response". J Pediatr. 105 (5): 786–92. doi:10.1016/s0022-3476(84)80308-x. PMID 6502312.
  12. 12.0 12.1 12.2 Strauss RG (2010). "Anaemia of prematurity: pathophysiology and treatment". Blood Rev. 24 (6): 221–5. doi:10.1016/j.blre.2010.08.001. PMC 2981681. PMID 20817366.
  13. Widness JA, Veng-Pedersen P, Peters C, Pereira LM, Schmidt RL, Lowe LS (1996). "Erythropoietin pharmacokinetics in premature infants: developmental, nonlinearity, and treatment effects". J Appl Physiol (1985). 80 (1): 140–8. doi:10.1152/jappl.1996.80.1.140. PMID 8847295.
  14. Dame C, Fahnenstich H, Freitag P, Hofmann D, Abdul-Nour T, Bartmann P; et al. (1998). "Erythropoietin mRNA expression in human fetal and neonatal tissue". Blood. 92 (9): 3218–25. PMID 9787158.