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NURP 532 > 532 Wk 10 Hematology/oncology > Flashcards

532 Wk 10 Hematology/oncology Flashcards

1
Q

Hypoproliferative anemia

A
  • Decrease in RBC production
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2
Q

Non-hypoproliferative anemia

A

Not an issue with production but issue with RBC dying/lost

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3
Q

Mean Corpuscular Volume (MCV)

A
  • measure of size/volume of RBC
  • differentiate microcytic vs macrocytic
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4
Q

Reticulocyte count

A

of juvenile/young RBC in blood at any given time

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5
Q

High Reticulocyte count causes

Low reticulocyte count causes

A
  • High: Hemolytic anemia, nutritional deficiencies, folic deficiency, acute blood loss
    • think loss of blood = body pumps out MORE baby RBC’s to make up for it
  • Low: iron/vitamin deficiencies, bone marrow disorders, renal disease, anemia of chronic disease
    • think not enough nutrients or dz causes low RBC output
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6
Q

Red Cell Distribution Width (RDW)

A
  • measurement of variation in RBC size (higher= more variation)
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7
Q

Low MCV (< 80), High RDW

A

Microcytic anemia

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8
Q

causes of microcytic anemia

A
  • iron deficiency
  • thalassemia
  • lead poisoning
  • secondary to GI issues (IBD, malabsorption)
  • malignancy
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9
Q

Low iron

low ferritin

low reticulocyte count

high TIBC

A

iron deficiency anemia

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10
Q

Low MCV/MCH

High RBC

Normal RDW

Normal reticulocyte count

A

Thalassemia

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11
Q

lead poisoning

A
  • > 5 = poisoning
  • Peripheral smear → will see basophilic stippling (blue granules in cytoplasm of RBC)
  • Screening: assess risk factors
    • housing
    • Hx pica
    • Recent immigrants
    • Living in poverty
    • Eating paint chips
    • Caretaker working as painter/sanding, with lead on clothes and children inhale lead dust
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12
Q

High MCH/MCV (>100) & what causes

A

Macrocytic anemia

causes:

  • vitamin b12 deficiency (strict vegetarian, pernicious anemia, loss of IF, chronic PPI use)
  • folate deficiency (diet, alcohol, malabsorption)
  • non-hematologic causes: alcoholism, hypothyroidism, medications
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13
Q

non hypo proliferative and normal RBC, normal MCV (80-100):

A

normocytic anemia

then check reticulocyte count

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14
Q

causes of normocytic anemia

A
  • Sickle cell disease
    • Homozygous vs heterozygous
  • G6PD deficiency
    • Fever
    • Dark urine
    • Abdominal
    • Pale skin
    • African american
  • Hemolysis (RBC destruction)
  • Acute/large volume blood loss
  • Anemia of chronic disease
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15
Q

sickle cell anemia labs and management

A
  • Low HCT, Hgl, high reticulocyte count
  • Penicillin V prophylaxis for infants & young children (under 5 yrs old)
  • SEND TO ER IF
    • fever > 101.F (sepsis) - higher risk
    • pneumonia, chest, pain, other pulmonary sx’s
    • sequestration crisis (splenomegaly)
    • aplastic crisis
    • severe painful crisis, priapism
    • unusual headache, visual disturbances
  • Triggers: dehydration, ischemia, stress
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16
Q

once determine it’s microcytic anemia, order what?

A

Check iron studies, TIBC, ferritin, and transferrin to determine if its classic iron deficiency or not

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17
Q

life threatening from bone marrow stem cell failure, anemia

pancytopenia

fever, infection (neutropenia)

A

aplastic anemia

refer for bone marrow bx

tx: immunosuppressant if severe

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18
Q

key takeaways of anemia:

A
  • Anemia is a sign of another disease process
  • Your job does not stop with identifying and categorizing an anemia
  • Must find the source and treat the underlying cause
    • Upper GI bleed
    • Colon cancer/other cancers
    • heavy menstrual bleeding
    • alcohol dependence
    • absorption issue
      • Celiac
      • s/p bariatric surgery
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19
Q

Leukocytosis/philia causes

A
  • high WBC
  • infection, malignancy, acute stressors: surgery, trauma, strenuous exercise
  • Steroids (chronic prednisone)
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20
Q

neutrophilia

A
  • usually bacterial illnesses, “left shift”
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21
Q

Leukopenia

A
  • aka neutropenia
  • can be normal & asymptomatically in African American (benign ethnic neutropenia)
  • Common in pts with Hep C, TB, Lyme, HIV, lupus, rheumatoid arthritis, drug reactions (including chemotherapy)
  • If new, refer esp pancytopenia
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22
Q

Most common malignancies (top 3) in pediatric oncology

A
  • *Leukemia
    • pallor
    • Fatigue
    • Prolonged fever
    • Lymphadenopathy
    • Bone pain
  • *Central nervous system tumors
    • Morning h/a + n/v
    • Ataxia
    • Seizures
    • Change in behavior
    • IICP
  • *Lymphoma
    • lymphadenopathy
    • Fever
    • Night sweats
    • Epitrochlear nodes (elbow)
    • Supraclavicular nodes
  • neuroblastoma
  • retinoblastoma
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23
Q

Red flags in peds oncology

A
  • With benign conditions
    • Vomiting
    • Lymphadenopathy
    • Fever
  • Hx & pe
  • Persistent sx’s with repeated visits
    • Get very thorough exam
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24
Q

Constitutional symptoms in pediatric

A
  • Very non specific
  • Prolonged fever of unknown origin
    • Leukemia
    • Lymphoma
  • Pallor, fatigue, malaise
  • Anorexia that cannot be explained
    • FTT - decrease body weight 10% over 6 month period
  • “B symptoms”
    • Fever, night sweats, weight loss of hodgkin/non-hodgkin lymphoma
    • Lymphadenopathy
  • Hemorrhagic diathesis
    • Low platelet count
    • Ecchymosis
    • Recurrent nose bleeds
    • Bleeding gums
    • Thromboycytopenia
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25
Q

Lymphadenopathy in children

A
  • Common in children
    • Supraclavicular nodes
    • Voer clavicle
    • Upper trochlear elbow space
  • Infections or collagen vascular disease
    • Viral, bacterial, idiopathic
    • > 1.5cm for over 4 weeks = think cancer
  • ROS
  • Watchful waiting
  • Ten-day course of antibiotics
    • Only if have localized infection
  • Labs and diagnostic tests
    • CBC
    • Sed rate
    • Chest x ray
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26
Q

Neuro sx’s in peds; red flags for headache

A
  • 88% of CNS tumors
  • Red flags for headache:
    • Starts in AM/wakes up from sleep
    • a/s with vomiting
    • Occipital region
  • First seizure = CNS lesion
  • Changes in behavior or school performance
  • Conduct neuro exam with fundoscopy
27
Q

Abdominal mass < 5 years old, think

A
  • Neuroblastoma or nephroblastoma (tumor on adrenal or kidneys)
    • Or cyst
  • Check hepatosplenomegaly = get US
28
Q

HTN in children, think

A
  • Wilms tumor
  • Neuroblastoma
  • pheochromocytoma
29
Q

Subcutaneous nodules bluish in color is a/s with

A

leukemia or neuroblastoma

30
Q

These conditions warrant a referral to ped oncology:

A
  • Triggered by alt response to the immune system bc of neoplasm
  • Neuroblastoma
    • Catecholamine hypersecretion
    • Intractable watery diarrhea
      • Multi direction eye movement
      • Muscle jerks
    • Rheumatic symptoms
  • Hepatoblastoma
    • most common liver cancer in children
  • Wilms tumor
    • Hypertension
    • Erythrocytosis
    • Cushing syndrome
    • Acquired von Willebrand disease
  • Rheumatic sx’s
    • Leukemia • Lymphoma • Ewing sarcoma • Central nervous system tumors
31
Q

paraneoplastic syndrome

A

group of rare disorders that are triggered by an abnormal immune system response to a cancerous tumor

cancer-fighting antibodies or T cells mistakenly attack normal cells in the nervous system

32
Q

metabolic emergency: tumor lysis syndrome

A
  • mostly after chemo,
    • radiation
    • biologic therapies
  • Rapid lysis of intracellular products like Ca, K, uric acid into body rapidly = overwhelms
  • Common in leukemias , lymphomas
  • Happens within 7 days of tx
  • Renal insuff = higher risk
  • High risk of morbidity and mortality
  • sx
    • asymptomatic
    • N/V/D
    • decreased urine
    • muscle cramps
    • high K, uric acid
    • Low Ca
33
Q

metabolic emergency: hypercalcemia is a/s with

A

a/s with multiple myeloma, breast cancer, Squamous cell carcinoma

  • Ca > 11
  • c/b hyperparathyroidism or malignant disease. bone resorption resulting from metastatic bone lesions or from certain solid tumors
  • REFER! Poor prognosis
  • Aggressive rehydration
34
Q

Metabolic emergency: SIADH a/s with

A

paraneoplastic syndrome that develops when excessive amounts of ADH are present, causing excessive amounts of water retention

  • sx’s: hyponatremia (Na < 135), n/v, muscle weakness
  • a/s with small cell lung cancer
  • refer to onc, nephrology, palliative
35
Q

Hematologic oncology emergencies: Febrile neutropenia diagnosis criteria & management

A
  • common with chemotherapy
  • sustained temp > 100.4 with ANC < 500
  • Get blood cultures, empiric antibiotics ASAP until afebrile for 48-72 hrs and ANC recovered to at least 500 for 72 hrs
36
Q

Hematologic oncology emergencies: Hyperviscosity syndrome sx’s, a/s with?

A
  • elevated levels of circulating serum immunoglobulins
  • blood is thick and sluggish. = lead to decreased perfusion of the tissues
  • a/s Waldenstrom macroglobulinemia, leukemia and multiple myeloma.
  • sx’s:
    • spontaneous bleeding, SOB, peripheral neuropathies
    • sausage-like hemorrhagic retinal vein hemorrhages
37
Q

Hematologic oncology emergencies:
Superior vena cava syndrome

A
  • a/s with: lung cancer, lymphoma, metastatic mediastinal tumors or lymph nodes, indwelling venous catheters
  • hallmark sign: facial edema
    • cough, hoarseness, chest, shoulder pain, swelling and discoloration of neck
  • Get CT to confirm dx
  • tx: radiation, steroids, and chemotherapy to reduce the size of the lesion.
  • Stenting
38
Q

Hematologic oncology emergencies: Malignant Spinal cord compression

A
  • tumor compressing on the dural sac.
  • associated with breast cancer or multiple myeloma, lymphoma, or lung cancer, prostate cancer.
  • red flag: new onset back pain (esp worse when laying down)
    • paraplegia
    • lead to incontinence/loss of sensory function = caudal equine syndrome
  • refer ASAP! x-ray, mri, steroids, radiation
39
Q

Hematologic oncology emergencies: Malignant pericardial effusion sx’s & management

A
  • sx’s: dyspnea, chest pain, palpitations, pulsus paradoxus
  • beck triad:
    • muffled heart sounds
    • decreased BP
    • increased jugular venous pressure
  • get chest X-ray, echo
  • poor prognosis
40
Q

Complications that are related to therapy: Chemotherapy extravasation sx’s & tx

A

pain, erythema, swelling, blanching, blistering, discoloration, necrosis of skin

tx: debridement, skin grafting, possible amputation
refer: oncology, derm, plastic

41
Q

Complications that are related to therapy:

GI tx

A
  • give lactobacillus
  • Fluid resuscitation is important, antiemetics, antidiarrheals
42
Q

Complications that are related to therapy: current radiation therapy

A

dermatitis, cardiovascular disease, esophagitis, cystitis, sexual dysfunction, or depression

43
Q

Complications that are related to therapy: Immunotherapy

A
  • nonspecific symptoms, flu-like things, vague rashes, pneumonitis or pancreatitis
  • prompt referral to oncology and targeted speciality
44
Q

workup for thrombocytopenia

A
  • normal platelet: 150-450k
    • Repeat test immediately if < 50k
    • Repeat in 1-2 weeks if 50-100k
  • Repeat test 1-2 months if 100-150k
45
Q

idiopathic thrombocytopenia causes

A
  • Drug induced thrombocytopenia
    • Onset 5-10 days after starting causative agent
    • mucocutaneous bleeding
    • Platelets <20K
    • possible transfusion, stop med, resolves in 1 week
  • Immune thrombocytopenia
    • aka ITP
    • Platelets <100K without other cause
    • refer, steroids, IV immunoglobulin
  • viral infections (HIV, Hep C, Varicella, Epstein, CMV)
46
Q

acute leukemia

A
  • on blood smear, see:
    • Increased blast cells
    • Decreased granulocytes, RBC, and platelets PANCYTOPENIA
  • proliferate → inhibit normal hematopoiesis = organomegaly
  • sx’s: Low WBC (recurrent infxns), anemia sx’s, thrombocytopenia sx’s
47
Q

chronic leukemia sx’s

A

accumulation of mature appearing leukocytes that lost their ability to function efficiently and undergo apoptosis → accumulate in bone marrow and lymphatic tissue = organomegaly, anemia, neutropenia, thrombocytoepniea

sx: asx early stages, *splenomegaly (“fullness” LUQ or mass) compressing cause weightless, bone pain, fever, night sweats

48
Q

Lymphoma

A
  • arise from lymphocytes (T or B cells)
  • Painless, lymphadenopathy (>1.5 cm) for >4 weeks
  • sx depends on area involvement
    • mediastinal - cough / chest pain
    • abdominal adenopathy - abd pain
  • B symptoms
  • liver and/or spleen enlargement
49
Q

Hodgkins Lymphoma

A
  • Reed Sternberg
  • painless adenopathy in neck
  • usually involves mediastinum mass
  • B symptoms
  • Dx by bx
50
Q

Non Hodgkins Lymphoma

A
  • sx depends on type (40 different)
  • Rapid or insidious onset
  • cytopenia
51
Q

wilms tumor (nephroblastoma) sx’s

A
  • painless abdominal mass
  • Onset age 3-4 years
  • Usually unilateral, does not cross midline; displaceable
  • Usually no constitutional/systemic sx
  • WAGR syndrome
    • Wilms tumor
    • Aniridia (no iris color)
    • Genitourinary (hematuria)
    • Retardation mental
52
Q

Wilms tumor work up

A
  • Imaging
    • Ultrasound can determine cystic vs solid mass
    • CT scan chest, abdomen, pelvis
  • Urinalysis
    • CBC/Chem/ESR
  • Referral pediatric oncology
53
Q

Neuroblastoma sx’s

A
  • Painful Abdominal mass
  • Onset age < 2 years (younger)
  • Fixed/immobile but can cross midline
  • Usually has constitutional sx
  • More likely to be metastatic
54
Q

Retinoblastoma

A
  • onset before age 5
  • Unilateral or bilateral eyes
  • Screen neonate at discharge and at all well child exams (red reflex)
  • Dilated exam if high risk
  • Genetic testing if first degree relative
  • Leukocoria, strabismus, decreased visual acuity
  • DX: Ophthalmic exam, ultrasound or MRI
55
Q

My role as PCP for cancer care

A
  • Manage other chronic conditions and acute concerns
  • Make sure patient is up to date on all other cancer screenings
  • Establish relationship with patient’s oncologist
  • pain managenemt
  • support
56
Q

What is the most common cause of anemia in children <24 months old?

A
  • Iron deficiency anemia (esp 9 - 24 month)
  • Also consider
    • Physiologic anemia (shortly after birth to 3 months, prematurity)
  • order CBC, ferritin (confirms iron def if low)
57
Q

When are children at risk of developing iron deficiency anemia?

A
  • Periods of rapid growth (increased iron demands are not met in diet)
  • Large intake of cow’s milk or cow’s milk given before age 1
  • Exclusively breastfed infants after age 4-6 mons (in utero iron stores are depleted by now)
    • start iron supplements at 4 months
    • iron fortified foods
58
Q

premature and low birth weight infants in utero iron stores

A

are depleted sooner at 1-2 moths so start supplements sooner

59
Q

Iron def treatment

A
  • Ferrous sulfate drops
  • Educate about high iron foods:
    • Beans
    • Leafy greens
    • Fortified cereals/breads
60
Q

checking CRP along with CBC and iron studies bc

A

if CRP is normal, increased ferritin is truly from the use of iron and not from inflammation or infection

61
Q

if anemia has not responded to iron supplementation,

A

obtain hemoglobin electrophoresis (allows hemoglobin chains to be separated according to their charges)

  • can have more than 1 anemia
62
Q

what can be used to assess for thalassemia

A
  • Mentzer Index → MCV/RBC count
  • < 13 = thalassemia
  • >13 = iron deficiency anemia
63
Q

if anemia has only mildly improved and mild increase in ferritin despite iron supplements, suspect

A
  • GI malignancies
  • colonscopy
  • rectal exam
  • guaiac test

NURP 532 (13 decks)

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