Clinical Care of the Hematologic System

Question 1

What is usually the cause of iron deficiency in adults?

Answer 1

bleeding

Question 2

how is anemia defined in regards to hematocrit levels with adult males and females?

Answer 2

less than 41% (Hemoglobin 13.5g/dL) in Males

less than 37% (hemoglobin 12g/dL in Females

Question 3

what are the symptoms/PE findings of of anemia?

Answer 3

lymphadenopathy, hepatosplenomegaly, or bone tenderness.

Mucosal changes such as smooth tongue suggests megaloblastic anemia

Question 4

What labs would you do for anemia?

Answer 4

CBC with diff
Iron with total iron biding capacity (TIBC)
Microscopic analysis
Hemoglobin electrophoresis

Question 5

what will be your findings on TIBC for anemia?

Answer 5

Ferritin value <12 mcg/L indicates iron (Fe) deficiency anemia

Question 6

what is the treatment if the cause of anemia is not identified?

Answer 6

referral to internal medicine

Question 7

What are some of the specific anemias?

Answer 7

Iron Deficiency Anemia

Vitamin B12 Deficiency

Question 8

Physical exam findings of Iron deficiency anemia?

Answer 8

fatigue, tachycardia, palpitations, tachypnea on exertion.

smooth tongue, brittle nails, cheilosis. dysphagia, and pica (craving foods not rich in iron, like ice chips).

Question 9

What is the most important treatment with anemia?

Answer 9

identification of blood loss….

after Oral Iron (ferrous sulfate, 325 mg, 3x day, 3-6 months)
or parenteral iron (dosage derived by hematologist)

Question 10

What are the essentials of diagnosis for Vitamin B12 Deficiency?

Answer 10

hype segmented neutrophils on peripheral blood smear.
Serum B 12 < 100pg/ml

Hallmark is megaloblastic anemia (large RBCs)

Question 11

vitamin b12 deficiency normally develops more than how many years after vitamin b 12 ceases?

Answer 11

3 years.

because the body has 2000-5000 mcg of b12 stored.

Question 12

what population is most likely to see B12 deficiency?

Answer 12

vegans

Question 13

what are some rare causes of b12 deficiency?

Answer 13

fish tapeworm
pancreatic insufficiency
Severe Crohn disease that destroyed much of the ileum

Question 14

physical findings of B12 deficiency?

Answer 14

glossitis
anorexia
diarrhea
late stages will be pale, w paresthesia and difficulty w balance

Question 15

what is the hallmark of Vitamin B 12 deficiency?

Answer 15

megaloblastic anemia on CBC with diff.

Question 16

What is the treatment of Vitamin B12 deficiency?

Answer 16

IM injection of B12. Daily for a week, Weekly for a month, monthly for life.

Question 17

three stages of blood clotting?

Answer 17

Formation of prothrombinase
prothrombin into thrombin
thrombin converts soluble fibrinogen into insoluble fibrin threads

Question 18

Hemophilia A is a congenital deficiency of which coagulation factor?

Answer 18

VIII

Question 19

Hemophilia B is a congenital deficiency of which coagulation factor?

Answer 19

IX

Question 20

what is a condition where the process of coagulation and fibrinolysis become abnormally activated within the vasculature, leading to ongoing coagulation and fibrinolysis?

Answer 20

Disseminated intravascular coagulation (DIC)

Question 21

what are some manifestations of DIC?

Answer 21

petechia, ecchymoses, blood oozing from wounds.

Question 22

causes of DIC?

Answer 22

sepsis
malignancy
obstetrical complications
intravascular hemolysis

less common, but seen in heat stroke, crush injuries and rattlesnake and viper bites.

Question 23

what medications would you give for DIC?

Answer 23

heparin

coumadin

Question 24

symptoms of DIC

Answer 24

bruising
epistaxis
bleeding from eyes
heavy vaginal bleeding

Question 25

what drugs could cause a episodic hemolytic anemia in patients with g6pd?

Answer 25

Primaquine, aspirin, ciprofloxacin

Question 26

what do you call the "bite" cells that appear in patients with g6pd under oxidative stress?

Answer 26

Heinz bodies.

Question 27

how do you see heinz bodies on a blood smear?

Answer 27

stain with Cresyl Violet or they will not be visible.

Question 28

Symptoms/Physical Exam findings of Sickle Cell:

Answer 28

jaundice, pigment, gallstones, hepatosplenomegaly, and poor healing ulcers over the lower tibia non healing ulcers in the lower ley. cardiomegaly painful episodes in the bones (especially long bones and chest) low grade fever

Question 29

if you have Sickle Cell Trait, you are clinically normal, but what can cause acute painful episodes?

Answer 29

extreme conditions such as vigorous exertion at high altitudes (or in unpressurized aircrat)

Question 30

what percentage of blasts will be in the bone marrow with acute leukemia?

Answer 30

20%

Question 31

two classifications of acute leukemia?

Answer 31

Acute myeloid leukemia (AML) is an adult disease with median age of 60 years old. Acute Lymphoblastic leukemia (ALL) 80% in childhood and 20% of adults.

Question 32

You will have blasts in what percentage of acute leukemia patients?

Answer 32

90%

Question 33

vast majority of AML patients are diagnosed at what age?

Answer 33

20

Question 34

symptoms of acute leukemia

Answer 34

fatigue bleeding on mucosal surfaces, gingival bleeding, epistaxis, menorrhagia infection gum hypertrophy and bone and joint pain patients may appear peale and have petechia. enlarged liver, spleen, and lymph nodes sternum, tibia, and femur tenderness

Question 35

DDX of acute leukemia

Answer 35

mono pertussis anemia hypothyroid

Question 36

what is the hallmark of acute leukemia with labs/studies/EKG?

Answer 36

pancytopenia with circulating blasts patients with ALL may have mediastinal mass visible with x ray

Question 37

what percentage of blasts is required to make a diagnosis of acute leukemia?

Answer 37

20%

Question 38

How many achieve remission with AML diagnosed under 60 years old?

Answer 38

70-80%

Question 39

what is a high white cell count called?

Answer 39

leukocytosis

Question 40

what is a low white cell count called?

Answer 40

leukopenia

Question 41

what are some etiologies of neutrophils leukocytosis?

Answer 41

bacterial infection inflammation metabolic disease stress

Question 42

what are some etiologies of lymphocyte leukocytosis?

Answer 42

viral infection immune disease stress leukemia

Question 43

what are some etiologies of eosinophil leukocytosis?

Answer 43

skin disease drug reaction parasite infection asthma

Question 44

what are some etiologies of basophil leukocytosis?

Answer 44

chronic myeloid leukemia

Question 45

signs and symptoms of leukocytosis or leukopenia are varied and depend on underlying cause. name some

Answer 45

``` Infectious symptoms: fever skin erythema, ulcerations, fissure, gingivitis, swelling, oral ulceration dental pain abnormal respiratory exam ``` Other findings: jaundice joint pain

Question 46

how do you determine the cell being affected with either leukocytosis or leukopenia?

Answer 46

CBC with diff

Question 47

what is the disease with abnormally low amount of circulating platelets?

Answer 47

thrombocytopenia

Question 48

the risk of spontaneous bleeding with thrombocytopenia does not increase until the platelets fall below what range?

Answer 48

10,000 to 20,000 /mcl

Question 49

potential causes of thrombocytopenia?

Answer 49

``` bone marrow failure DIC chemo nutritional deficiencies bone malignancy meds ```

Question 50

symptoms of thrombocytopenia

Answer 50

Petechia*** | mucocutaneous bleeding

Question 51

treatment for thrombocytopenia?

Answer 51

stop offending medications evaluate for cause refer to internal medicine or hematologist MEDEVAC

Question 52

What is thrombocytosis?

Answer 52

abnormally high amount of circulating thrombocytes n(450,000)

Question 53

what are the two different categories of thrombocytosis?

Answer 53

Reactive- anemia, blood loss, infection, inflammation, post splenectomy Autonomous- primarily cancers of bone marrow

Question 54

symptoms of thrombocytosis?

Answer 54

``` 50-60 years of age elevated platelets increased risk of thrombosis erythromelagia- painful burning of hands with erythema splenomegaly in 25% of patients ```

Question 55

Treatment for thrombocytosis?

Answer 55

refer to hematology if there is no infectious cause and does not resolve in 2-4 weeks