COMMON PROBLEMS IN PHC Presented by: Awatif K. Al-Mutairi Hind K. Bin-Drees Sarah N. Al-Gubaisi Supervised by: Dr. Al-Johara Al- Quaiz

Iron deficiencyAnaemia Red Eye Iron deficiencyAnaemia acne

RED EYE Outlines: What is red eye? Red eye in PHC. DDx. How to deal with pt. with red eye?

Anaemia What is Anaemia ? It is a Greek word = “ Bloodlessness” It is a ↓ in the level of Hb in the blood below the reference range for the age and sex of the individual . Usually there is reduction RCC and PCV

Normal Blood indices Hb (g/dl) ♂ 13 - 18 ♀ 12 - 16 PCV (Hct) (%) ♂ 42 - 52 ♀ 37 - 47 RCC (1012/ L) ♂ 4.7 – 6.1 ♀ 4.2 – 5.5 MCV (fL) 80 – 94 MCH (Pg) 27 – 32 MCHC ( g/dl) 32 – 36 RDW (%) 11.5 – 14.5 ESR (mm/hr) 0 – 10 Reticulocytes (%) 0.2 – 2.0

Cut Offs for WHO definition of Anaemia Age or sex group Heamoglobin Below (g/dl) Heamatocrit Below (%) Children 0 – 60 months 11.0 33 Childern 5 – 11 years 11.5 34 Children 12 – 15 years 12.0 36 Non-pregnant women Pregnant women Men 13.0 39

Iron Metabolism Absorption of iron occur primarily in the duodenum in the form of ferrous(Fe+2) , in a rate of 1-2mg/ day In serum Fe is bound to transferrin , & ⅓ is saturated Fe is stored as ferritin and haemosidrin in hepatocyte , Sk. Ms. , reticuloendothelial macrophages 1mg/day is lost through skin , mucosal cells , sweat, urine , faeces and menses

Daily requirements

Men 1 mg Adolescence 2-3 mg Women (reproductive age) Pregnancy 3-4 mg Infancy Maximum bioavailability from normal diet about 4 mg

Prevalence of IDA

Iron deficiency is the most common and widespread nutritional disorder in the world The World Health Organization estimated that about 40% of the world’s population (more than 2 billion individuals) suffer from anaemia, and that approximately 50% of all anaemia can be attributed to iron deficiency

Prevalence in Saudi arabia

Prevalence among women ranged from 20 -50% in a study of 1,210 primary school girls aged 7-14, in Riyadh, Saudi Arabia, an anaemia level of 55.4% was found. The highest level (71.4%) was found among 14 year-old girls Anaemia was reported among 20.5% of school students in general And it is about 36-37% in preschool children

Epidemiology Age : very young (6-24m), preschool children , during puberty and in old ages Gender : adolescent females are more prone than males Physiology : pregnant & lactating women

Etiology and Risk factors Chronic blood loss Uterine Gastrointestinal : peptic ulcer, esophageal varices , aspirin or NSAID ingestion , partial gastictomy , GIT Ca, Hookworm , angiodysplasia , colitis… Heamosidrenosis , self induced blood loss Increase demand Prematurity Growth Pregnancy

Malabsorption Celiac disease , gluten-induced enteropathy , atrophic gastritis ,gasterctomy , chronic diarrhea , IBD Poor diet

Clinical Features Symptoms Fatigue , feeling tired Faintness Breathlessness Angina pectoris , palpitation Intermittent claudication Decreased attention span , behavioral & developmental problems

Signs Pale skin & mucus membranes Spoon nails ( Koilonychias ) Painless glossitis Angular stomatitis Brittle hair & nails Dietary craving (Pica) Dysphagia Tachycardia Systolic flow murmur Cardiac failure signs

RDW = SD of RBC volume (fL) / MCV x 100 Investigations & DDx CBC & indices RBC MCV MCH MCHC RDW Reduced in relation to severity Of anaemia Increased RDW = SD of RBC volume (fL) / MCV x 100

Iron profile serum ferritin ( reflects stores )is low serum iron is low total iron binding capacity (TIBC) is High transferrin saturation < 19%

Deferential Diagnosis MCV < 80 fL ( Microcytic ) Anaemia of chronic disease Thalassaemia Sideroblastic Anaemia

Consequences of IDA Iron deficiency adversely affects the cognitive performance, behaviour, and physical growth , language of infants, preschool and school-aged children; the immune status and morbidity from infections of all age groups; and the use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults of all age groups. Specifically, iron deficiency anaemia during pregnancy increases perinatal risks for mothers and neonates; and increases overall infant mortality.

Management of IDA Find and treat the underlying cause Oral iron ferrous sulfate 200 mg/3/day/6m → ↑ reticulocytes count , then ↑ Hb 1 g/ dl / week Others ferrous fumarate, gluconate Liquid preparation → infants & children

Parentral iron IM or IV (iron dextran) → rarely used , when the patient cannot tolerate oral iron , OR poor response to oral e.g. sever malabsorption Blood transfusion ( Hb < 3mg/dl )

Possible side-effects associated with iron medication Epigastric discomfort, nausea, diarrhoea, or constipation may appear with a daily dose of 60 mg or more. If these symptoms occur, supplement should be taken with meals. Faeces may turn black, which is not harmful. Treatment should continue. All iron preparations inhibit the absorption of tetracyclines, sulphonamides, and trimethoprim. Thus, iron should not be given together with these agents.

Referral When ? Sever anaemia with pregnancy beyond 36 weeks respiratory distress + cardiac abnormalities no improvement or worsening with Rx Blood in stool or melena Evidence of chronic disease (TB , hepatosplenomegaly )

Prevention Supplementation with medical iron Education and associated measures to increase dietary iron intake Control of infections Fortification of food with iron

Preventive measures is given mostly to pregnant women and young children Others : schoolchildren, adolescent , and non-pregnant women( WHEN?) The best way to prevent IDA is . . . .? Iron is found in meat , liver , cereals , raw green vegetables, fortified food . It is best to eat food that contain vit. C with non-meat source of iron

For more information about IDA WHO http://www.who.int/ar/index.html

Case 1 Nora is a 25 years Saudi lady , a mother of 2 children aged 1.5 years , 3 months She came to the clinic complaining of decrease of her energy , weakness , and headache she is breast feeding her baby and there is no history of nausea ,vomiting , diarrhea or blood in her stool Review of other systems was not significant

on examination she was underweight with BP 120/70 Pulse 92 / min Temperature 37.0 C Pale mucus membranes, And no other significant findings What is your next step?

Nora’s lab results were: RBC 4*10.012/L Hb 77 g/dl Hct 25.5% MCV 61.1 fL MCH 18.5 pg MCHC 303 g/l RDW 20.1 % What is her diagnosis ? And how would you manage Nora ?

Case 2 Waleed is a 22 years old Saudi gentleman , a student Waleed is complaining of mild fatigue that gradually worsen over the last 6 months , he also noticed a decrease in his studying & working tolerance There is no Hx of change of sleep , mood ,appetite , concentration No diarrhea , vomiting , blood in the stool .

On his examination he was pale and had a BP 110/85 Pulse 82/ min Temp 37.1 C Other systems were normal What else you will do ?

Waleed’s lab results were RBC 3.8 *10.012/L Hb 110 g/ l Hct 37% MCV 75 fL MCH 30 pg MCHC 321 g/L RDW 13.4 %

After 2 weeks There was no improvement in his condition His iron profile was Ferritin level was normal 200 ng/ml Serum iron , normal 60ng/ml TIBC , normal 320 ng/dl What is next ?

Acknowledgment I am grateful to all the Haematology Lab team who provided me with the materials that I need for my presentation , especially Dr. Laila Al-Quaiz .

References INACG 1998 .Guidelines for the use of iron supplement to prevent and treat IDA. WHO, GENEVA 1989 .Preventing and controlling IDA through primary health care , a guide for health administrators and programme managers . Cook J.D.Defining optimal body iron . Proceeding of the Nutrition Society 1999 ; 58,489-495 Al-Quaiz J.M. IDA : a Study of risk factors. Saudi Med J 2001; vol. 22 (6):490-496 WHO 2001.IDA assessment , prevention , and control : a guide for programme managers Guidelines and Protocol Advisory Committee 2004 . Investigations and Management of ID UNICEF/ WHO Regional Consultation 1999 . Prevention and Control of IDA in Women and Children WHO 2004 .Focusing on anaemia , Towards an integrated approach for effective anaemia control

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