532 Wk 10 Hematology/oncology Flashcards
1
Q
Hypoproliferative anemia
A
- Decrease in RBC production
2
Q
Non-hypoproliferative anemia
A
Not an issue with production but issue with RBC dying/lost
3
Q
Mean Corpuscular Volume (MCV)
A
- measure of size/volume of RBC
- differentiate microcytic vs macrocytic
4
Q
Reticulocyte count
A
of juvenile/young RBC in blood at any given time
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
6
Q
Red Cell Distribution Width (RDW)
A
- measurement of variation in RBC size (higher= more variation)
7
Q
Low MCV (< 80), High RDW
A
Microcytic anemia
8
Q
causes of microcytic anemia
A
- iron deficiency
- thalassemia
- lead poisoning
- secondary to GI issues (IBD, malabsorption)
- malignancy
9
Q
Low iron
low ferritin
low reticulocyte count
high TIBC
A
iron deficiency anemia
10
Q
Low MCV/MCH
High RBC
Normal RDW
Normal reticulocyte count
A
Thalassemia
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
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
13
Q
non hypo proliferative and normal RBC, normal MCV (80-100):
A
normocytic anemia
then check reticulocyte count
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
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
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
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
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
19
Q
Leukocytosis/philia causes
A
- high WBC
- infection, malignancy, acute stressors: surgery, trauma, strenuous exercise
- Steroids (chronic prednisone)
20
Q
neutrophilia
A
- usually bacterial illnesses, “left shift”
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
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
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
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
25
Lymphadenopathy in children
* 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
26
Neuro sx's in peds; red flags for headache
* 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
Abdominal mass \< 5 years old, think
* Neuroblastoma or nephroblastoma (tumor on adrenal or kidneys)
* Or cyst
* Check hepatosplenomegaly = get US
28
HTN in children, think
* Wilms tumor
* Neuroblastoma
* pheochromocytoma
29
Subcutaneous nodules bluish in color is a/s with
leukemia or neuroblastoma
30
These conditions warrant a referral to ped oncology:
* 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
paraneoplastic syndrome
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
metabolic emergency: tumor lysis syndrome
* 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
metabolic emergency: hypercalcemia is a/s with
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
Metabolic emergency: SIADH a/s with
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
Hematologic oncology emergencies: **Febrile neutropenia** diagnosis criteria & management
* 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
Hematologic oncology emergencies: Hyperviscosity syndrome sx's, a/s with?
* 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
Hematologic oncology emergencies:
Superior vena cava syndrome
* 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
Hematologic oncology emergencies: Malignant Spinal cord compression
* 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
Hematologic oncology emergencies: Malignant pericardial effusion sx's & management
* 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
Complications that are related to therapy: Chemotherapy extravasation sx's & tx
pain, erythema, swelling, blanching, blistering, discoloration, necrosis of skin
tx: debridement, skin grafting, possible amputation
refer: oncology, derm, plastic
41
Complications that are related to therapy:
GI tx
* give lactobacillus
* Fluid resuscitation is important, antiemetics, antidiarrheals
42
Complications that are related to therapy: current radiation therapy
dermatitis, cardiovascular disease, esophagitis, cystitis, sexual dysfunction, or depression
43
Complications that are related to therapy: Immunotherapy
* nonspecific symptoms, flu-like things, vague rashes, pneumonitis or pancreatitis
* prompt referral to oncology and targeted speciality
44
workup for thrombocytopenia
* 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
idiopathic thrombocytopenia causes
* 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
acute leukemia
* 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
chronic leukemia sx's
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
Lymphoma
* 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
Hodgkins Lymphoma
* Reed Sternberg
* painless adenopathy in neck
* usually involves mediastinum mass
* B symptoms
* Dx by bx
50
Non Hodgkins Lymphoma
* sx depends on type (40 different)
* Rapid or insidious onset
* cytopenia
51
wilms tumor (nephroblastoma) sx's
* 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
Wilms tumor work up
* **Imaging**
* Ultrasound can determine cystic vs solid mass
* CT scan chest, abdomen, pelvis
* **Urinalysis**
* CBC/Chem/ESR
* Referral pediatric oncology
53
Neuroblastoma sx's
* Painful Abdominal mass
* Onset age \< 2 years (younger)
* Fixed/immobile but can cross midline
* Usually has constitutional sx
* More likely to be metastatic
54
Retinoblastoma
* 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
My role as PCP for cancer care
* 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
What is the most common cause of anemia in children \<24 months old?
* 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
When are children at risk of developing iron deficiency anemia?
* 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
premature and low birth weight infants in utero iron stores
are depleted sooner at 1-2 moths so start supplements sooner
59
Iron def treatment
* Ferrous sulfate drops
* Educate about high iron foods:
* Beans
* Leafy greens
* Fortified cereals/breads
60
checking CRP along with CBC and iron studies bc
if CRP is normal, increased ferritin is truly from the use of iron and **not** from inflammation or infection
61
if anemia has not responded to iron supplementation,
obtain hemoglobin electrophoresis (allows hemoglobin chains to be separated according to their charges)
* can have more than 1 anemia
62
what can be used to assess for thalassemia
* Mentzer Index → MCV/RBC count
* \< 13 = thalassemia
* \>13 = iron deficiency anemia
63
if anemia has only mildly improved and mild increase in ferritin despite iron supplements, suspect
* GI malignancies
* colonscopy
* rectal exam
* guaiac test
