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pediatric physical assessment exam 2 > exam 4- cbc > Flashcards

exam 4- cbc Flashcards

1
Q

When to order a CBC

A

– Screening for anemia
– Suspect hematological disorder
– Toxic child
– Caution: well visit, well child with negative history
• Road to CBC Hell
• Well child with mild viral illness has transient abnormalities

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2
Q

How 1To Approach the CBC

A

evaluate RBC line
evaluate WBC line
Evaluate platelets
Look at smear (cell morph)

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3
Q

Normocytic RBC

A

rbc size is normal but not enough of them (anemia)

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4
Q

Microcytic

A

RBC size is smaller than normal

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5
Q

Macrocytic

A

RBC size is larger than normal

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6
Q

MCV

A

Mean corpsucle volume

avg volume of red cells

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7
Q

RDW

A

Red cell distribution width

Coefficient of ariation of RBC volume distribution

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8
Q

3 important questions for red cell line

A

1) is child anemic
2) what kind of anemia does pt have? micro/normo/macro
3) if it is microscopic anemia, do one of the following indices

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9
Q

Mentzer Index

A

RBC/MCV:

> 13: iron def.

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10
Q

Rule of 3s

A

Measured Hgb calc should be 3x RBC

calculated HCT is 3x HgB

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11
Q

Eleven Plus 1 point rule

A

11= 00.1 x (age in year) is lower limit of normal (3rd percentile) for hgb

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12
Q

normocytic

A

RBC size normal but not enough of them

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13
Q

Microcytic

A

RBC size is smaller than normal

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14
Q

macrocytic

A

RBC size is larger than normal

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15
Q

seventy plus 1 rule

A

70 + 1 x age years is lower limit of normal for MCV

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16
Q

What values help you determine anemia?

A

– RDW (Red Blood cell distribution width)
– MCV (Mean corpuscle volume)
• What is low of normal?
• LLNL (MCV) = Age (yrs + 70)
– Only use once child is 2 years and up to 10
• After 10 values for adolescent are the
same.

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17
Q

RDW

A

• Red Cell Distribution Width (RDW)
Coefficient of variation of the red cell volume
histagram distribution, i. e how much does the red
cell vary
– Very helpful in diagnosis of microcytosis
– RDW Normals
• In thalassemia minor may be 1 or 2 points over the
upper normal
• However in iron deficiency, frequently very elevated
ranging from 14-25

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18
Q

Causes of Microcytic anemia

A 
• Most	Common:			
– Iron	Deficiency	and	Thalassemia	
• Less	Common:		
– Hemoglobin	C	disease,	Hemoglobin	D	disease,	anemia	of	inflammation	
– Hereditary	pyropoikilocytosis	(Lead Poisoning Rare	
– SideroblasCc	anemia	
– Copper	deficiency	
– Pyridoxine	deficiency
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19
Q

Causes of Iron Deficiency- dec absorption

A 
Achlorhydria	(producCon	of	gastric	acid	in	the	
stomach	is	absent	or	low)
Celiac disease	
Competing	metal	
Fe	deficiency	
Clay	
starch
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20
Q

increased losses

A 
GI
GU
Lung (pulm emosiderosis)
joints
facticious
pregnancy
lbood donation
newborn exchange
iatrogenic
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21
Q

physio anemia in infancy

A 
• Term	Infant:	Anemia	in	the	first	2	to	3	months	
of	life	
– physiologic	anemia	of	infancy	
– not	due	to	iron	deficiency		
– Does	not	respond	to	iron	therapy.		
• Preterm	infants		
– appears	at	1	to	2	months	of	age	and	is	oten	more	
severe.
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22
Q

Normochromic anemias

A 
Normochromic	
– Hereditary	Spherocytosis	
– Hereditary	Elliptocytosis	
– G6PD	deficiency	
– Aplas)c	anemia	
– Acute	blood	loss
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23
Q

Macrocytic

A

– Vitamin B12 deficiency
– Folate deficiency
– Liver disease
– Lots of re)culocytes (due to hemolysis)

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24
Q

Hemolytic Anemia

A

Sickle Cell disease
SC disease
Sickle Cell anemia
Sickle Thalassemia

25
Q

White Cell line

A

• Suspected hematological disorder
• Evaluation of systemic disease or infection
• There is poor sensivity and specificity in
differenciating bacterial from viral infection

26
Q

Factors that Interfere with the Normal

WBC

A 
AGE	
– High	neutrophil	count	
during	the	first	several	
days	of	life	
• RACE	
– African	Americans	have	
lower	WBC	
• MINOR	ILLNESS	
– Widely	variable	
leukocyte	count	
– Neutropenia	is	not	
uncommon	during	a	viral	
illness	
• MEASUREMENT	
METHOD	
– Inherent	error
27
Q

Neutrophils fx

A 
• First line of defense against bacterial
infection
– Major function:
• Phagocytosis
• Killing of microorganisms
–Enzymatic degradation
• At birth, decrease rapidly after birth within
first few days
• Infancy 20-30% of circulating WBC
• At age 5 years, equal neutrophil and
lymphocytes
• At puberty reaches 70% predominance
found in adult. 
• Most	abundant	type	of	WBC	
• Also	known	as	Polymorphic	Nuclear	
Leukocyte		
• Can	see	granules	when	stained	
• Band	is	the	immature	Neutrophil	
– Is	an	acute	phase	response
28
Q

Neutropenia

A 
• Add the neutrophils and Bands together
and multiply by the total WBC count
• What is neutrophil count if WBC is 4,500
with 2 Bands, and 10 neutrophils? 
4,500	
X	.12	
540	is	the	ANC
29
Q

Classification of Neutropenia

A 
In African Americans, 30% may have 1000
as normal
• Caucasian 8000 to 1500 normal
• Mild neutropenia: 1500-1000
• Moderate neutropenia: 1000-500
• Severe neutropenia:
30
Q

Increased Neutrophils

A

– Physiologic – newborn, stress exercise
– Acute hemorrhage
– Acute bacterial infecCon
– Metabolic derangement—diabetes, acidosis, anoxia, burn,
seizures
– Drugs-epinephrine, steroids, lithium
– ConnecCve Cssue disease-JIA, Inflammatory Bowel disease
– Hematological disorders—Cancers, hemolysis splenectomy

31
Q

WBC Eval

A

• Shit to the let is an increase in the number of
immature neutrophils—bands and metamyelocyte -
>5% bands
• Absolute lymphocytosis
– Physiologic 2 months to 4 year
– Increased in pertussis, TB, mononucleosis, CMV, measles,
adenovirus, syphilis
– Leukemia
• Lymphopenia

32
Q

Lymphocytes:

A 
Small	mononuclear	cells	
• Coordinate/execute	immune	response	via	
release	of	inflammatory	cytokines	
• Bone	marrow/Thymus	are	primary	
lymphoid	organs	
• Secondary	organ	is	spleen
33
Q

Lymphocytosis

A 
greater	than	5000)	
• Response	to	acute	viral	infections	
• Chronic	infections	states	such	as	TB,	
Syphilis	
• Also	seen	in	ALL,	Non	Hodgkin's	Lymphoma
34
Q

Monocytes

A

1- 10 % of Leukocytes
• Large cells with blue-gray cytoplasm
• Reniform (kidney) shaped (i.e. folded nuclei)
• Efficient at digesCon of fungi and
microbacteria
• Return of Monocytes precedes return of
neutrophils by 1-2 days

35
Q

Basophils

A

Less than 1% of Leukocytes
Contain large cytoplasmic granules and sulfated
acidic proteins
• Express IgE receptors
• Release Histamine when stimulated
• Above 150u/L= Basophilia which is associated
with hypersensitivity reactuions

36
Q

Basophilia is associated w viral infections such as

A

varicella
flu
TB

37
Q

Eosinophils

A 
Bilobed nucleus with a red
granulocyte filled cytoplasm
• Fight parasites
• Control Allergic Reactions
• Eosinophilia usually seen when
Eosinophils make up more than 10% of
WBC’s
• Hypereosinophilia persisting for months can cause tissue damage
38
Q

WBC Evaluation: Eosinophilia

A

500 cells per mm2
• N – Neoplasm
– Hodgkin’s lymphoma (HL) is commonly associated with eosinophilia.
– Can also occur with carcinomas,
– Can be related to the breakdown of tumor cells
– Neoplastic cells have shown to produce factors that increase eosinophil producCon.
• A - Addison’s disease
– Decreased cortisol levels lead to eosinophilia, because normally cortisol sequesters
eosinophils back into the lymph nodes.
• A - Allergy/asthma
– asthma, allergic rhinitis, and drug reacCons. (remember eosinophilic esophagiCs, too)
• C - Collagen vascular (autoimmune) disease
– Eosinophilia can be associated with rheumatoid arthritis, polyarteriCs nodosa, and ChurgStrauss
syndrome, among others.
• P- Parasites -Typically associated with parasites that invade tissues, like T. canis and
helminthes (worms).

39
Q

Platelet line

A 
• Life	span	is	8-9	days	
• One	third	are	
sequestered	in	the	spleen	
• Normal	count	150,000	to	
450,000	
• Pseudothrombocytopenia	
– ArCficially	low	count	due	
to	clumping	
– EDTA-dependent	
anCbody	against	
platelets	
– Suspect	if	the	low	
platelet	count	and	
paCent	is	well	
– Clumps	of	platelets	on	a	
blood	film	from	EDTA	
specimen
40
Q

platelet and bleeding categories

A

> 100,000
– No bleeding

50,000 to 100,000
– Small amount of
bleeding may offer
ater trauma

20,000 to 50,000
• Mild cutaneous
bleeding

5,000 to 20,000
• Moderate cutaneous
and mucosal bleeding

41
Q

Thrombocytosis

A

• ACUTE PHASE REACTANT
• DefiniCon: platelet count >450,000/mm3
• Causes:
– InfecCon, collagen disease malignancy, stress, post
operaCve, iron deficiency, following marrow recovery
or splenectomy or in myeloproliferaCve disease (rare)
• Manage by treaCng the underlying disease and/
or benign neglect unless over 1 million
repeatedly

42
Q

RBC shapes

A 
• Red	blood	cells	
– Poikilocytosis	(difference	in	shapes)	
– Anisocytosis	(difference	in	size)	
– Hypochromia	(pale	cells)	
– Microcytosis	(small	cells)		
– membranopathies	(spherocytosis,	
ovalocytosis,	elliptocytosis)	
– Basophillic	sCppling	(aggregated	 ribosomal	DNA	and	mitochondrial	
fragments)	seen	in	lead	poisoning	
and		thalassemia	
• Red	Blood	Cells	
– Spherocytes
• ArCfactual,	immune	mediated	 hemolyCc	anemia,	spherocytosis	
– Nucleated	erythrocytes-hemolyCc	
disease	
– Schistocytes	and	helmet	cells	 (microangiopathic	hemolyCc	 anemia	
– Speculated	erythrocytes	and	
acanthoctyes	(spur	cells)	in	
pyruvate	kinase	deficiency	
– Bite	or	blister	cells	in	Glucose-6-
phosphate	deficiency	
– Target	cells	in	iron	deficiency,	liver	
disease	hemoglobinopathies,	
postsplenoectomy
– Howell	jolly	bodies	splenic	
hypofuncCon
43
Q

WBCs

A

• White blood cells
– Atypical lymphocytes (predominately an acCvated T
lymphocytes responding to the B-cell infecCon)
– Metamyelocyte
– Blasts
– Dohle Bodies are bluish cytoplasmic inclusions in
neutrophils in bacterial infecCon, burns,
myelodysplasia, pregnancy
– Chediak Higashi syndrome: giant azurophilic granules
in lymphocytes

44
Q

ThALASSEMIA

A

• Prevalent in America – estimates of 2 million carriers in US
• Likely related to protective effect of thalassemia traits on
malarial disease
• Hemoglobinopathy – dysfunction of the synthesis of
hemoglobin
– Thalassemias -deficit in the production of one of the hemoglobin
chains
• Iron Deficiency Anemia and Thalassemia Trait are the most
common causes of microcytic anemia in Peds.

45
Q

Hemoglobin Production

A 
• Four globin chains
• In utero fetal hemoglobin (HbF)
– Two alpha globin chains
– Two gamma globin chains
• Hemoglobin A (HbA)
– Two alpha chains
– Two beta chains
• Hemoglobin A2
– Two alpha chains
– Two delta chains
46
Q

Normocytic Anemia

A

• Blood loss
• Decreased production of red blood cells
– Marrow failure
• Increased destruction of red blood cells
– Hemolytic Anemia
Distinguished by reculocyte count
Decreased in states of decreased production
Increased in destruction of red blood cells

47
Q

Reticulocyte count- reasons to order

A

• Reasons for ordering this test
– Normocytic anemia
– Acute blood loss ( usually doubling of reticulocyte
count in first 24 hours)
– Problems with bone marrow
– Response to anemia therapy
– Infections
• Parvovirus causes aplasia of bone marrow since there
is no new RBC production for 7 days
– Drugs causing hemolysis or bone marrow aplasia

48
Q

Reticulocyte Production Index

A

• Corrected reticulocyte count
• Raw reticulocyte count: misleading in anemic
patients.
– Reticulocyte count is a percentage
• Number of reticulocytes as a percentage of the number
of red blood cells.
• In anemia, the patient’s red blood cells are
depleted, creating an erroneously elevated
reticulocyte count.
• Corrects the reticulocyte count for the
degree of anemia
– evaluates whether the bone marrow’s
response is appropriate.
• ReCculocyte producCon should increase in
response to any loss of red blood cells
• Increase within 2–3 days of a hemorrhage
• Will peak in 6–10

49
Q

RPI=

A

RPI = reticulocyte count X the patient’s
hemoglobin/ normal hemoglobin X .5
• Or Reticulocyte Index = Hematocrit/normal Hematocrit
• RPI >3: increased production of reticulocytes
suggesting either hemolysis or blood loss
• RPI

50
Q

Lab signs of Hemolysis

A 
Increased lactate dehydrogenase
(LDH)
• Increased unconjugated bilirubin
• Decreased serum haptoglobin
• RBC indices demonstrate an increase
in MCHC.
51
Q

Urine dipstick

A 
– PH	
– Blood	
– Protein	
– Leukocytes	
– Nitrites	
– Urobilogen	
– Specific	gravity
52
Q

Urine Dipstick pH

A

Alkaline specimen is indicaCve of urinary tract infecCon but in late
aternoon, may have higher pH and be normal
• Normal range is 4.5-8.5
• Alkaline (>7.0)
– Bacteriuria
– renal failure
– presence of anCbioCcs, sodium bicarbonate
– diet high in vegetables, citrus fruits and dairy products
• Acidic (

53
Q

Urine dipstick-blood

A

Extremely sensitve and so will detect clinically
insignificantly amounts of hemoglobin or
myoglobin
• Mild
• Moderate
• Severe

54
Q

Urine Dipstick nitrate and leukocyte Esterase

A

Negative nitrite result
– does not rule out UTI (poor sensitivity)
• Positive result is likely true-positive
– high specificity—whatever the collection method.
• Leukocyte esterase
– More sensitive (positive in disease) indicator of
infection than nitrites are
– Better when tested using a catheterized, rather
than a bagged, specimen.
• Negative nitrite result
– does not rule out UTI (poor sensitivity)
• Positive result is likely true-positive
– high specificity—whatever the collection method.
• Leukocyte esterase
– More sensitive (positive in disease) indicator of
infection than nitrites are
– Better when tested using a catheterized, rather
than a bagged, specimen.

55
Q

Urine dipstick glucose/bili

A

• Urine should not contain glucose
• False posiCve can occur with ascorbic acid
• Most common reason for posiCve bilirubin is
old or poorly sealed dipsCck

56
Q

urine dipstick-protein amounts

A 
• trace (about 15 mg/dL)
• 1+ (about 30 mg/dL)
• 2+ (about 100 mg/dL)
• 3+ (about 300 mg/dL)
• 4+ (2,000 mg/dL or
greater).
• Urine dipstick measures
albumin
– Does not measure low
molecular weight
protein
57
Q

dipstick interp.

A 
• Urinary dipstick method
measures the concentration
of urine protein,
– false-negative resultsvery
dilute urine
specimen.
• If the urine sample has
specific gravity of ≤ to 1.015,
then 1+ is considered
positive
• If the urine sample has a
specific gravity of ≥ to 1.015
then >/= to 2+ is positive
• False-positive results
– Very alkaline or
concentrated specimens
– Gross hematuria
– Pyuria
– Bacteriuria
– Presence of contaminating
antiseptics
– Radiographic contrast
– Presence of heavy mucus,
blood, pus, semen or
vaginal secretion
• Trace positive proteinuria by
dipstick does not imply
pathologic proteinuria
58
Q

quantitative urine tests

A 
• Urine protein/creatinine ratio
– Random urine specimen
– More accurate quantification
– Normal ratio is  .03 mg of albumin per milligram of
albumin is abnormal
59
Q

Asymptomatic microscopic Hematuria

A

• In a study of 20,000 school aged children, 274
had a negative history and normal exam
• 0 had UTI
• 57 had hypercalcuria
• 3 had recent episode of poststreptococcal
glomerulonephritis

pediatric physical assessment exam 2 (3 decks)

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