7 Heme Onc Flashcards
B12 deficiency:
think what 4 causes for the test
- pernicious anemia–no IF
- crohn’s–attacks TI (absorption)
- pancreatic insuff (need proteases to release from salivary R-binder)
- Fish tapeworm
B12 vs Folate equivocal, get what?
Get MMA. If elevated, then B12 deficiency
Schilling’s test for B12
- give IM nonradioactive B12, saturate liver binding sites.
- give oral radioactive B12, then check if radioactive excreted in urine. If radioactive is present in urine, then it can be absorbed in gut.
- If not, then add other things to aid absorption: IF, abx if bacterial overgrowth, and pancreatic enzymes
Fe deficiency anemia.
-what is normal Fe daily requirement and max?
- how long to replace serum Fe, and how long to replace Fe stores?
- How much Fe in 1 PRBC unit?
1 mg/day, max 3 mg/day
serum Fe: 6 weeks
stores: 6 mo
350g Fe in 1 PRBC unit. So, 1 year’s supply.
anemia of chronic dz
-tx and decision making
Tx underlying dz. (eg SLE, RA). If can’t, can give EPO. helps body utilize Fe stores.
If Hgb>10, f/u labs in 3 mo
If <10, give EPO
Pt with microcytic anemia on blood test, but normal Fe studies. Think what. then do what/look for what
Thalassemia.
To dx, get Hgb electrophoresis. Can show B-Thal positive. But if neg, then A-thal is dx of exclusion
Also, LDH normal, but retic count low.
Thalassemia: how to think about it.
Classic vignettes
Pt either presents:
MILD: Asx–no tx.
-Asian person with isolated anemia and low retic count, LDH normal. Told couldn’t donate blood. (if Hgb electrophoresis negative, must be A-thal)
SEVERE: severe anemia–transfusion required, + deferoxamine
-16yoM comes with Hgb 3.2
Pt with microcytic anemia. Fe studies show elevated serum Fe.
do what
Sideroblastic anemia
Get pt away from lead, give B6, Confirm dx with bone marrow bx. (ringed sideroblasts)
Sideroblastic anemia:
causes to know (5)
Lead ETOH INH B6 def AML/myelodysplastic
Normocytic hemolytic anemias: (4)
name each, smear, confirm test, tx
- Spherocytosis
- smear +
- osmotic fragility test
- Folate and Fe if mild, splenectomy if severe - PNH
- smear -
- flow cytometry
- steroids, eculizumab - G6PD
- Smear: Heinz bodies and Bite cells
- G6PD levels 6-8 wks after attack
- avoid triggers - Autoimmune hemolytic anemia
- Smear: spherocytes
- Coombs test (IgG)
- steroids, IVIG, splenectomy
Blood smear: you see spherocytes. think what
Either spherocytosis, or AIHA.
Do Coombs. If positive AIHA. negative, spherocytosis.
PNH: what to remember
can have venous thrombosis in intra-abdominal veins, causing abd pain.
Sickle cell:
what test for avascular necrosis of hip/femur to know
DEXA scan screening
Leukemias, ages?
7, 47, 67, 87
ALL, CML, AML (must be older than CML for blast crisis), CLL
You suspect AML or ALL. What dx tests to do and not do
CBC not helpful, could be up or down
Blood smear, look for blasts.
Confirm with BM bx, >20% blsts
Auer rods
-what associations?
M3 subtype of AML.
Can go into DIC
Tx with ATRA (vit A)
Leukemias: what special thing to remember about each?
ALL: CNS PPx with intrathecal Ara-C. Also scrotum
AML: Auer rods, DIC
CML: Blast crisis to AML. imatinib to delay.
CLL: do no harm if old.
Lymphoma staging
-how affects tx?
1: 1 group lymph nodes
2: >1 group nodes on same side of diaphragm
3: >1 group nodes, opposite side of diaphragm
4. diffuse dz (blood, bone marrow)
2a or less: radiation (can add chemo IRL)
2b or more: chemo
B means B-sxs present
Lymphoma:
-common classic sxs (3)
-uncommon sxs to know (2)
fevers, night sweats, weight loss.
- Pel-Epstein fevers: cyclical over weeks
- ETOH tender LAD
chemo tox man (5)
cisplatin: oto and nephrotox
bleomycin: lung fibrosis
doxorubicin, adriamycin: cardiomyopathy
Cyclophosphamide: hemorrhagic cystitis (mesna)
Vincristine, vinblastine–
peripheral neuropathy
Multiple Myeloma
-sxs mnemonic
CRAB
Ca, hyper
renal insuff (myeloma kidney)
anemia
bone lesions/pain
multiplel myeloma
-3 mechs to know, their sxs, and diagnostic findings
Bad plasma cells make these:
- bad monoclonal Ab.
- infections
- Protein gap, with M-spike on SPEP - Bence Jones proteins (bad Ig’s)
- renal failure
- protein gap, UPEP - Osteoclast activating factor
- hyperCa, bone lesions
- imaging shows
you suspect multiple myeloma. do what tests:
- SPEP: m spike
- UPEP: bence jones proteins
- skeletal survey
-BM Bx to confirm. >10% plasma cells
MGUS
- definition
- conversion rate to MM, how often check labs
- SPEP+ but no other MM findings
- Conversion to MM 2%/year. check labs q6mo.
Waldenstrom’s macroglobulinemia
- classic vignette
- dx finding
- tx
-hyperviscosity syndrome (HA, AMS, blurry vision, mucosal bleeding)+peripheral neuropathy.
62yo male with gum bleeding when brushing teeth, sleeping more. Trouble driving with blurry vision. Feet tingling
- > 10% lymphs on BM bx
- plasmapheresis to prevent stroke. also chemo.
von willebrand’s disease
- dx
- tx
- tx in severe acute bleeding
low vWF, also low F8
-vWF assay or platelet fxn test
- desmopressin (vWF)
- acute severe: can give Cryo (F8)
general platelet transfusion rules
Transfuse for:
<20k
<50k and bleeding
when in thrombocytopenia to NOT give platelets
TTP/HUS. just eats more of it. do plasmapheresis
TTP, HIT, DIC, ITP:
-tx
TTP: plasmapheresis, no plt
HIT: stop Hep, do argatroban
DIC: give cryo, FFP, plt, blood
ITP: IVIG, steroids. refractory splenectomy
TTP sxs
FAT RN
fever, anemia, thrombocytopenia
renal, neuro sxs
Also think HUS with diarrhea
Pt with bleeding because low VitK. causes to know other than warfarin (3)
- cirrhosis
- Abx. killed intestinal K-producing bacteria
- Low PO intake (think ICU pt)
always think: If microcytic anemia, then what test?
Iron studies, specifically Ferritin.
high–ACD
low–Fe def
normal–thalassemia
Chemo for lymphoma:
Any lymphoma 2b.
(ABC)
Hodgkin’s, not severe: ABVD
Hodgkin’s severe: BEACOPP
Non-H: Rituximab or CHOP-R, with CNS ppx with MTX
NOACs: brand names, indications and contraindications
Lepirudin Argatroban Dabigatran Rivaroxiban Apixaban
which can be reversed, with what?
Both: HIT, transition to Coumadin.
- HIT, cannot use in renal dz (renally cleared)
- HIT, ok in renal fail. (hepatic)
All 3: nonvalv Afib, DVT
- Pradaxa
- Xarelto
- Eliquis
Pradaxa can be reversed with Praxbind (Idarucixumab)
