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MED COMP PTS > hematologic dx > Flashcards

hematologic dx Flashcards

1
Q

anemia

A

Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood

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2
Q

anemia classifeid by:

A

cause and morphology

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3
Q

anemia causes

A
  • Blood Loss
  • Inadequate production
  • Excess destruction
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4
Q

anemia morph

A
  • Normocytic
  • Microcytic
  • Macrocytic
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5
Q

anemia lab test

shorthand?

A

** CBC (Complete Blood Count): **
* Hb
* Hematocrit*
* WBC
* Platelet
* RBC indices*

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6
Q

anemic Hb values

A

<13.5 g/dL (men) or <12.0 g/dL (women)

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7
Q

anemic hematocrit values

A

<41.0% (men) or <36.0% (women)

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8
Q

RBC indices*

A
  • MCV (mean corpuscular volume)= size
  • MCH (mean cell hemoglobin)= color
  • RDW (red cell distribution width)= sixe distribution
  • MCHC (mean cell hemoglobin concentratio
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9
Q
  • Microcytic anemias
A

– Iron Deficiency Anemia
– Thalassemias

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10
Q

macrocytic anemias

A

– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency

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11
Q

normocytic anemias

A

– Hemolytic Anemia
– Sickle Cell Anemia

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12
Q

Iron Deficiency Anemia
* cells app?
* More common in?
* Causes:
* Labs:

A
  • Microcytic anemia
  • More common in women of childbearing age and children
  • Causes: blood loss, poor iron intake, poor iron absorption, or increased demand for iron
  • Labs: Serum iron, ferritin, TIBC, transferrin
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13
Q
  • Folate Deficiency, cell size?
    – stored in the body?
    – Deficiency during pregnancy?
    – Labs:
A

Macrocytic
– Not stored in the body in large amounts; continual
dietary supply is needed
– Deficiency during pregnancy causes neural tube
defects in the child
– Labs: Serum folate level

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14
Q

Cobalamin (B12) Deficiency
* Deficiency of?
* dental office agent of etiology? effects?
– Labs:

A

– AKA Pernicious Anemia, macrocytic
* Deficiency of intrinsic factor which is necessary for B12 absorption

– Nitrous Oxide:
* Irreversible inactivation of B12
* Neurologic symptoms
– Labs: Serum B12

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15
Q

systemic presentation of anemia

signs and symptoms

A

– Symptoms: Fatigue, weakness, palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and spooning of fingernails

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16
Q

oral manifestations of anemia

A

– Atrophic glossitis with loss on tongue papillae, redness or cheilosis
– Mucosal pallor

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17
Q

anemia pts and dental tx

A

–Generally tolerate routine dental treatment well unless severe

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18
Q

severe anemia pts

A
  • Severe anemia (cardiopulmonary symptoms)
    –Defer routine dental care
    –Pulse oximeter and supplemental oxygen
    –Avoid strong narcotics
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19
Q

what should be avoidied in pts with b12 def

A

NO

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20
Q

What is important to determine in anemic pts?

A
  • Important to find the cause!
    –GI bleed, chronic inflammation pancytopenia
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21
Q

Sickle Cell Anemia
* inheritance?
* RBC sickling in what environments?
* results on hemodynamics?

A
  • Autosomal recessive inherited disorder
  • RBC sickling in low oxygen or low blood pH environments
  • Erythrostasis, increased blood viscosity, reduced blood flow, vascular occlusion, hypoxia= more sickling
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22
Q

Sickle Cell Anemia
* Systemic Signs and Symptoms:
– Result of?
– skin app?
– ulceration where?
– Cardiac?
– Delays in?
– Pain where/ why?
– crisis?

A

– Result of chronic anemia and small blood vessel occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac: Cardiac failure and Stroke
– Delays in growth and Development
– Pain: Abdominal (splenomegly) and Bone (aseptic necrosis)
– Sickle cell crisis

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23
Q

sickle cell crisis

A
  • Prolonged (hours-days) severe pain which pay require
    hospitalization for pain management
  • Causes: infection, higher altitude (hypoxia), dehydration, trauma
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24
Q

Sickle Cell Anemia
* Oral Manifestations
–Mucosal?
–Papilla?
–Delayed?
–Aseptic bone and pulpal?
– bone?
–Neuro?

A

–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal necrosis
–Osteomyelitis
–Neuropathy

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25
Q

radiogrpahic findings with sickle cell

A
  • Increased widening and decreased number of trabeculations
  • Generalized osteoporosis (thinning of the inferior border of the mandible)
  • Trabeculations and lamina dura appear more prominent
  • “Stepladder” trabeculae
  • “Hair on end
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26
Q

sickle cell pt dental care
– non-crisis states
– appt length?
– Emphasis on? infections?

A

– Routine care during non-crisis states
– Keep appointments short to reduce stress
– Emphasis on oral hygiene instructions to reduce risk of infection> If infection occurs, consider IM or IV antibiotics

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27
Q

sickle cell anesthetic
* Avoid what LA
* Epinephrine concentration?
* May consider using LA without?

A
  • Avoid prilocaine
  • Epinephrine 1:100,000-no stronger concentration
  • May consider using LA without epinephrine
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28
Q

sickle cell O2 in appt

A

– Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than 50% with high flow rates

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29
Q

with major surgical operations what should be done with sickle cell pts

A

Abx prophylaxis

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30
Q

pain control with sickle cell

A

Pain management: consult their primary care or hematologist (opioid contract)

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31
Q

Aplastic Anemia
* Causes
* Treatment

A
  • Bone marrow failure resulting in pancytopenia
  • Causes:
    – Chemotherapy and radiation
    – Autoimmune diseases
    – Toxic chemicals (benzene)
    – Viral
    – Medications (methotrexate)
    – Inherited (Fanconi anemia)
  • Treatment– Hematopoietic cell transplant
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32
Q

Aplastic Anemia oral manifestationa due to anemia

A
  • Atrophic glossitis with loss on tongue papillae, redness or cheilosis
  • Mucosal pallor
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33
Q

aplastic anemia oral manifestations due to thrombocytopenia

A
  • Petechia, spontaneous or prolonged bleeding
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34
Q

aplastic anemia oral manifestations due to neutropenia

A
  • Infection – Viral, fungal, bacterial
  • Ulceration
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35
Q

Aplastic Anemia & Bone Marrow Failure dental management:
* Thorough?
* Discussion with?
* Defer?
*setting?

A
  • Thorough medical history
  • Discussion with oncologist: Current status and goals
  • Defer routine care
  • Dental office vs hospital *
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36
Q

Aplastic Anemia & Bone Marrow Failure labs

A

* CBC
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)

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37
Q

Aplastic Anemia & Bone Marrow Failure
* Confirm patient is?
* Local hemostatic measures when pt is?

A
  • Confirm patient is afebrile
  • Local hemostatic measures for patients with thrombocytopenia
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38
Q
  • Thrombocytopenia
    –Causes
    –result
A

–Low platelet levels (CBC)
* Normal: 150,000-400,000
* Severe: <50,000
–Causes: decreased production, destruction, medications, blood loss
–Prolonged bleeding, petechia

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39
Q
  • Thrombocytopenia
    –Oral Manifestations
A
  • Petechia
  • Spontaneous gingival bleeding
  • Prolonged bleeding after procedures
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40
Q

Thrombocytopenia
– Dental Management:
* Thorough?
* routine dental care?
* CBC?
* Discussion with?
* Avoid?
* Local measures?

A
  • Thorough medical history
  • May defer routine dental care
  • CBC
  • Discussion with patient’s MD
  • Avoid block injections
  • Local hemostatic measures
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41
Q

thrombocytopenia med hx

A

– Cause of thrombocytopenia (acute cause? chronic cause?)
– Bleeding history, transfusion history

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42
Q

CBC results with thrombocytopenia

A

– Recent (<24 hours)
– Platelet >50,000 for most dental procedures reduces risk
– Higher for invasive surgical procedures (ex. multiple extractions)

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43
Q

thrombocytopenia MD discussion

A

– Platelet transfusions, timing
– Dental office vs hospital (<50,000 more appropriate in hospital setting)

44
Q
  • Von Willebrand Disease
    commonality?
A

– Missing or defective VWF (clotting protein)
* Required for platelet adhesion
– Most common inherited clotting disorder (1%
US population)

45
Q

VWD types

A

– Type 1 (20-50% normal levels), Type 2 (qualitative), Type 3 (quantitative, severe symptoms)

46
Q

VWD signs and symptoms

A

– SS: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis

47
Q

VWD tx

A

Tx: DDAVP (desmopressin)

48
Q
  • Von Willebrand Disease
    –Dental Management
A
  • Thorough medical history/bleeding history and physical exam
  • Discussion with patient’s MD
  • Avoid block injections
  • Local hemostatic measures
49
Q

Von Willebrand Disease Discussion with patient’s MD

A

– Confirm history and severity of disease
– DDAVP, aminocaproic acid
– Dental office vs hospital

50
Q
  • Hemophilia types/inheritence/severity?
A

–Hemophilia A (Factor 8 deficiency) and B (Factor 9 deficiency)
* X-linked recessive
–Severity
* Mild 6%-30% (A) or 49% (B), moderate 1%-5%, severe <1%

51
Q

SS of hemophilia

A

prolonged or spontaneous
bleeding, ecchymosis, hemarthrosis

52
Q

hemoplhilia tx

A

factor infusions, DDAVP (A)

53
Q
  • Hemophilia
    –Dental Management
A
  • Thorough medical history/bleeding history and physical exam
  • Discussion with patient’s hematologist
  • Avoid block injections
  • Local hemostatic measures
54
Q
  • Hemophilia discussion with MD
A

– Confirm history and severity of disease
– Dental office vs hospital
– Factor infusions, aminocaproic acid

55
Q

Plavix (clopidogrel)
–agent for?
–Reduce risk of?
–Increased risk of?

A

–Antiplatelet agent
–Reduce risk of MI and stroke
–Increased risk of bleeding and bruising

56
Q
  • Plavix (clopidogrel)–Dental Management
A
  • Medication list to evaluate bleeding risk
    – Other anticoagulants
  • Local measures– Low risk of bleeding far outweighs interrupting Plavix treatment
57
Q
  • Coumadin (warfarin)
    – mech?
    – For patients with?
    – Common side effect:
A

– Vitamin K antagonist
– For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history…
– Common side effect: bleeding

58
Q

warfarin monitoring
* PT/INR goals:
* Higher in patients with?

A
  • PT/INR goals: 2.0-3.0
  • Higher in patients with prosthetic heart valves (3.0-3.5)
59
Q

antidote for warfarin

A

K

60
Q
  • Coumadin (warfarin)
    –Dental Management
A
  • Dental procedures are generally considered low risk of bleeding
  • Review INR (within 24 hours) (<3)
  • Local hemostatic measures
  • Medications interactions
61
Q

dental tx bleeding with warfarin

A
  • Dental procedures are generally considered low risk of bleeding
    – Thromboembolic risk vs procedural bleeding risk
    – Discussion with patients MD for procedures with higher risk of bleeding
62
Q

warfarin med intreactions

A

– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers

63
Q
  • Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
    –Direct inhibitor of?
    –Class of?
  • Alternative to?
    – effective?
    lab monitoring?
    –Reversal?
    –cost?
A

–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants
* Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive

64
Q
  • DOAC and Direct Thrombin Inhibitors
    –Dental Management
A
  • No lab monitoring
  • Bleeding risk for dental procedures seems to be low
  • Local hemostatic measures
65
Q

good local measures for bleeding pts

A

gauze, gelfoam, cellulose, thrombin, tranexamic acid, amicar

66
Q

Hematologic Malignancies

A
  • Leukemia
  • Lymphoma
  • Myeloma
67
Q

Leukemia
* Cancer of?
* Affects?
* Proliferation of WBCs which can be? Or?

A
  • Cancer of WBCs
  • Affects bone marrow and circulating blood
  • Proliferation of WBCs which can be non-functional (blasts) or overtime overcrowd/suppress normal marrow production
68
Q

leukemia classes

A
  • Lineage: Myeloid vs Lymphoid
  • Timing: Acute vs Chronic
69
Q

common leukemias

A
  • Acute Myeloid (AML)
  • Chronic Myeloid (CML)
  • Acute Lymphocytic (ALL)
  • Chronic Lymphocytic (CLL)
    acute forms more likely to be symptomatic
70
Q

Leukemia causes

A
  • Radiation
  • Chemotherapy
  • Genetic
  • Down syndrome
71
Q

leukiemia diagnosis

A
  • CBC
  • Blood smear
  • Molecular studies
72
Q

leukemia tx

A
  • Chemotherapy
  • Radiation
  • Targeted therapy
  • Hematopoietic stem cell transplant
73
Q

Leukemia Signs and Symptoms

A
  • Fatigue, malaise, petechiae, ecchymoses, fever
  • Related to functional or treatment related neutropenia and thrombocytopenia
74
Q

Leukemia oral manifestations

A
  • Leukemia infiltrate
  • Spontaneous gingival bleeding
  • Oral ulceration (neutropenic ulcer, mucositis)
  • Infection: Viral, fungal, bacterial
  • Lymphadenopathy (chronic)
75
Q

leukemia dental management
* dx unknown/suspected?
* If Dx known:

A
  • Urgent referral to PCP or emergency room for leukemic infiltrate-CBC, smear, flow cytometry
  • If Dx known:
  • Thorough medical history
  • Discussion with oncologist
    1. * Current status and goals (comprehensive vs. palliative)
    1. * Dental office vs hospital
    1. * Timing of dental care-not on active chemotherapy for routine care
76
Q

important labs of leukemia

A

* CBC
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)

77
Q

leukemia
* Confirm patient is?
* Local hemostatic measures?

A
  • Confirm patient is afebrile
  • Local hemostatic measures for patients with thrombocytopenia
78
Q

Lymphoma

A
  • Cancer of lymphoid organs and tissues
79
Q

forms of lymphoma

A

HL and NHL

80
Q
  • Hodgkin Lymphoma
    *cell?
  • demo?
  • LAD?
  • LN feel?
  • > 50% affect where?
A
  • Hodgkin Lymphoma
  • Reed-Sternberg cell
  • Young adults
  • LAD
  • Non-tender, firm
  • > 50% affect mediastinal or neck
    nodes
81
Q
  • Non Hodgkin Lymphoma (NHL)
  • Median Age:
  • B-symptoms?
  • Over how many types?
A
  • Median Age: 67
  • B-symptoms: Fever, night sweats (drenching),
    weight loss (unintentional >10%)
  • Over 20 types
82
Q

Lymphoma causes

A
  • Autoimmune diseases
  • Hepatitis C
  • EBV
  • Sjogren syndrome
83
Q

lymphoma diagnosis/staging

A
  • Bone marrow or lymph node biopsy
  • MRI for staging
84
Q

lymphoma tx

A
  • Chemotherapy
  • Radiation
  • Immunotherapy
  • Stem cell transplant
  • Watching
85
Q

Lymphoma oral manifestations
* LAD?
* Extranodal involvement?
* radiographic lesions?
* Infection?

A
  • LAD (Waldeyers ring, neck)
  • Extranodal involvement:
    1. Oral Ulceration
    1. Localized infiltrate
    1. Osteolytic radiographic lesions
  • Infection: Viral, fungal, bacterial
86
Q

lymphoma tc related oral manifestations

A
  • Head and Neck Radiation (lymphomas in head and neck region only):
    1. * Hyposalivation
    1. * Trismus
    1. * Osteonecrosis
87
Q

Lymphoma dental management

A

– Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and generally treatment related (chemotherapy, radiation)
– Thorough medical history
– Discussion with oncologist

88
Q

lymphoma discussion with oncologist:
* Current?
* setting?
* Timing of dental care?

A
  • Current status and goals (comprehensive vs. palliative)
  • Dental office vs hospital
  • Timing of dental care: not on active chemotherapy for routine care
89
Q

lymphoma labs of interest

A

* CBC
– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (<500)

90
Q

lymphoma
– Confirm patient is?
– Local hemostatic measures?

A

– Confirm patient is afebrile
– Local hemostatic measures for patients with thrombocytopenia

91
Q

Multiple Myeloma

A
  • Cancer of plasma cells
    – Prevents normal production of antibodies
92
Q

MM s/s

A

– Hypercalcemia
– Renal damage
– Anemia
– Bone pain
– Infection

93
Q

MM tx

A

– Chemotherapy (RVD)
– Bisphosphonates
– Hematopoietic Stem Cell Transplant

94
Q

Multiple Myeloma
* Oral Manifestations

A

– Plasmacytoma
– Lytic bone lesions
– Infection: Viral, fungal, bacterial

95
Q

tx related MM oral manifestations
nn?
bone?
radiographic findings?

A
  • Neuropathy
  • MRONJ (IV Zometa)
  • Radiographic:
    1. – Thick lamina dura
    1. – Persistent extraction site
    1. – Sclerosis
    1. – Sequestra
    1. – Fracture
96
Q

Multiple Myeloma
* Dental Management, dx related

A
  • Soft tissue swelling, radiographic findings
  • Infection management
  • Pre-bisphosphonate exam
97
Q

MM Medication related management
what should be provided?

A
  • MRONJ
    – Bisphosphonate history (number of doses, active)
    – Chlorhexidine rinses
    – Oral Hygiene
    – Antibiotic regimen
    – Sequestration
98
Q

MM surgical procedures

A

– Informed consent
– As atraumatic as possible
– Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis
– Re-eval after surgical procedures to ensure healing

99
Q

Hematopoetic Stem Cell Transplant

A
  • Infusion of stem cells to re-establish hematopoietic
    function in patients whose bone marrow or immune
    system is damaged or defective
  • Treatment for solid or hematologic malignancies or other hematologic disorders
100
Q

Indications for Stem Cell Transplant

A
  • Leukemia
  • Lymphoma
  • Multiple Myeloma
  • Aplastic anemia
  • Fanconi anemia
  • Sickle Cell
101
Q

Pre-Transplant Evaluation (hematopoetic)

A
102
Q

Pre-Transplant Evaluation:
Dental Screening Goals

A
  • Remove active foci of infection and limit potential foci of infection
  • Dentition to be** stable for at least 12 months **
    – Urgent care only for 12 months post transplant
    – Risk of salivary GVHD and hyposalivation=caries
  • Patient education about home care
  • If planned correctly, pre-transplant evaluation + patient compliance=dental maintenance
103
Q

Dental Screening Pre-HSCT

A
  • Comprehensive hard and soft tissue exam
  • Full mouth series of radiographs
  • Treatment
    – Scaling and prophylaxis
    – Removal of caries
  • Restorations
  • Endodontic therapy
  • Extractions
    – Extraction of all hopeless teeth & 3rd molars with hx periocoronitis
  • Including teeth with questionable or poor prognosis
    – Caries risk assessment and need for adjuncts (fluoride)
    – Dental management based on primary disease
104
Q

Oral Manifestations HSCT (hemo stem cell transplant)
* Mucus mem?
* Bleeding?
* Infection?
* Medication side effects?
* Graft versus host disease?
* Increased risk of?

A
  • Mucositis – Acute; resolves after engraftment
  • Bleeding– Petechiae, ecchymosis, hematoma
  • Infection– Viral (ex. HSV), Fungal (ex. candidiasis), Bacterial
  • Medication side effect/toxicities
    – Gingival hyperplasia (cyclosporine)
    – Oral ulceration (sirolimus)
  • Graft versus host disease– Mucosal (lichenoid changes), Salivary-hyposalivation, caries
  • Increased risk of oral cancer
105
Q

Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications

A

– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD

– Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer

– Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital

– Labs
* CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia

– Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**

106
Q

Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications

A

– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD

– Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer

– Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital

– Labs
* CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia

– Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**

MED COMP PTS (9 decks)

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