Clinical Lectures Flashcards
What kinds of things should you gather from history?
- Ask about bleeding with: surgery, trauma, menstrual period, dental procedures
- Meds (anticoagulants, NSAIDs, antiplatelets, corticosteroids, antibiotics, antidepressants, alcohol, fish oil, garlic, gingko, vitamin E all can cause easy bruising)
- Nutritional deficiency (vitamin C, K, protein)
- Family history of easy bleeding, bruising, or clotting disorders
What kinds of things should you gather from physical?
- Common sites for bruising are on the distal extremities
- Bruising on face, trunk, and back should raise suspicion for bleeding disorder or physical abuse
- Bruising on toddlers foreheads are probably normal
- Does the bruising pattern and mechanism correlate
- Bruises initially purple-blue then can turn red-brown and eventually will turn green-yellow
Petechiae
- Capillary bleeding
- 2-3 mm
- Mostly not normal
- Think abnormality in platelet number or function
- DOES NOT BLANCH
Purpura
- Larger than petechiae (4-10 mm)
- can be palpable or non-palpable (macular)
- Macular typically non-inflammatory
- Palpable lesion sign of vascular inflammation
- Also non-blanching with diascopy
Ecchymosis
- Larger than purpura or petechiae
- > 1 cm
- color can help date onset but use caution dating
Categories of rashes
- Infection (serious bacterial illness, viral infection, rickettsiae)
- Hematological (thrombocytopenia - ITP, TTP, vWD)
- Mechanical (coughing or vomiting, local pressure or traction)
- Vascular (Henoch-Schonlein purpura, scurvy, drugs)
Life-threatening conditions presenting with petechiae/purpura
- Meningococcemia
- Rocky mountain spotted fever
- Disseminated intravascular coagulation (DIC)
Hemathrosis
- Bleeding into a joint space
- Think about clotting factor deficiency
Hemophilia A
-Factor VIII deficiency
Hemophilia B
- Factor IX deficiency
- AKA Christmas disease
Platelet defects
- Mucocutaneous bleeding
- Excessive bleeding after minor cuts
- Petechiae common
- Ecchymoses generally small and superficial
- Hemarthroses and muscle hematomas uncommon
- Bleeding with procedures often immediate with degree of bleeding dependent upon severity of defect
Clotting factor deficiencies
- Deep tissue bleeding
- Not usual to have excessive bleeding after minor cuts
- Petechiae uncommon
- May develop large subcutaneous and soft tissue hematomas
- Hemarthroses and muscle hematomas common in severe deficiency states or in association with injury
- May be associated with procedural or delayed bleeding (surgery) depending on type and severity
Fatigue
- Difficulty initiating activity
- Reduced capacity with activity
- Mental fatigue
Sensation of difficult or labored breathing
Dyspnea
Feeling that extra effort is required to move limbs
Muscle weakness
Sleepiness or drowsiness
Somnolence
Fatigue >6 months differentials
- Hematologic
- Idiopathic
- Psychological (major depression, panic disorder, somatization)
Ferritin
- found in cytoplasm of cells
- directly proportional to total iron stores
- sensitive test for early Iron Deficiency
- acute phase reactant
Sequence of Fe depletion
First: iron stores depleted -Low ferritin -Normal Hb/Hct Second: normocytic mild anemia -Low ferritin, Hb, Hct Third: microcytic severe anemia -Low ferritin, Hb, Hct
Female athlete triad
- Low energy
- Menstrual dysfunction
- Low bone density
Expected labs in iron deficiency and IDA
- Low iron
- low ferritin
- high TIBC
What should be done for men and post-menopausal females when suspecting IDA?
Look in GI for cancer!!!
What could be a cause of IDA in kids?
Too much cow’s milk or cow’s milk before age 1
If what is less than 15 you should think IDA…
Serum ferritin
What will you see in a blood smear with lead poisoning?
Basophilic stippling
What would you see on blood smear with a macrocytic anemia likely due to folate/B12 deficiency?
Hypersegmented neutrophil
What is different about B12 deficiency versus folate deficiency?
B12 will present with neurologic symptoms as well
What labs are expected for hemolytic anemia?
Increased LDH, increased unconjugated bilirubin, decreased haptoglobin
What is a mono-spot test?
Determines if there are proteins in the blood called heterophile antibodies produced by the immune system as a response to EBV infection
What medications can make OCs ineffective?
- Erythromycin
- Rifampin
High overall WBC count would indicate…
Infection, inflammation
Increased neutrophil count (neutrocytosis) indicates…
Acute infection (bacterial, some viral, etc.)
Decreased neutrophil count (neutropenia) indicates…
Bacterial infection (brucellosis), or viral (hepatitis, measles, mono, rubella, flu, chicken pox, etc.)
Increased lymphocyte count (lymphocytosis) indicates…
Viral infection: infectious mono, herpes, measles, mumps
Bacterial: brucellosis
Other: toxoplasmosis
Senstivity
- Proportion of all people with disease who test positive
- Value approaching 100% is desirable for ruling OUT disease
Specificty
- Proportion of all people without disease who test negative
- Value approaching 100% is desirable for ruling IN disease
Centor Criteria for GABHS
- Swollen and tender anterior cervical LN
- Temp >100.4
- absence of cough
- tonsillar exudates or swelling
AGE
3-14 = +1
15-44 = 0
45+ = -1
Score
0 - no further testing or treatment
1-3 - perform rapid strep
4+ - empiric treatment with antibiotics (can do test if choose)
Most common cause of sore throat
VIRAL
Treatment for GAS
- Penicillin VK
- Azithromycin
Fusobacterium necrophorum (Lemierre’s syndrome) treatment
Penicillin VK
