1. 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

2. Iron deficiencyAnaemia
Red Eye
Iron deficiencyAnaemia
acne

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

4. 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

5. Normal Blood indices Hb (g/dl) ♂ 13 - 18 ♀ 12 - 16 PCV (Hct) (%)♂ ♀
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

6. 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

7. 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

8. Daily requirements

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

10. Prevalence of IDA

11. 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

13. Prevalence in Saudi arabia

14. 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

15. 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

16. 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

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

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

19. 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

20. 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

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

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

23. 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.

24. 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

25. 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 )

26. 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.

27. 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 )

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

29. 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

31. For more information about IDA
WHO

32. 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

33. 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?

34. Nora’s lab results were:
RBC *10.012/L
Hb g/dl
Hct %
MCV fL
MCH pg
MCHC g/l
RDW %
What is her diagnosis ? And how would you manage Nora ?

35. 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 .

36. 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 ?

37. Waleed’s lab results were
RBC *10.012/L
Hb g/ l
Hct %
MCV fL
MCH pg
MCHC g/L
RDW %

38. 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 ?

39. 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 .

40. References
INACG Guidelines for the use of iron supplement to prevent and treat IDA.
WHO, GENEVA 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,
Al-Quaiz J.M. IDA : a Study of risk factors. Saudi Med J 2001; vol. 22 (6):
WHO 2001.IDA assessment , prevention , and control : a guide for programme managers
Guidelines and Protocol Advisory Committee Investigations and Management of ID
UNICEF/ WHO Regional Consultation Prevention and Control of IDA in Women and Children
WHO Focusing on anaemia , Towards an integrated approach for effective anaemia control

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