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General Medicine > Hematology - Full Spreadsheet Info Only > Flashcards

Hematology - Full Spreadsheet Info Only Flashcards

1
Q

Iron Deficiency Anemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Inadequate supply of iron for synthesis of hemoglobin

Etiology Iron absorption >1-1.5 mg/day (after absorption) due to:

  • GI tract bleeding (acute or chronic)
  • Chronic asprin or NSAID use
  • Low iron intake
  • Increased Fe demands
    • Pregnancy/lactation
    • Heavy menstrual bleeding

**Pathophysiology **Heme molecule cannot bind oxygen without sufficient oxygen

Symptoms

  • Brittle nails
  • Koilonychia (spoon shaped nails)
  • Pale conjunctiva
  • Smooth tongue (typical of all malnutrition anemias)
  • Tachycardia

Signs

  • Fatigue
  • Weakness
  • Palpitations
  • SOB
  • Pica

Differential Dx c differentiating factors

  • Anemia of chronic disease
    • Normal ferritin levels
    • Low Serum Fe
  • Thallesemia
    • Sig. low MCV
    • Normal or inc. RBC
  • Sideroblastic anemia
    • Inc. serum Fe
    • Inc. % saturation

Diagnostic Tests Listed in order of appearance of sig finding c disease progression

  1. CBC – microcytic hypochromic RBC in late anemia progression
  2. Serum ferritin – <12 mcg/dl is highly reliable (labs will provide norm. ranges)
  3. Serum Fe
  4. Total Iron Binding Capacity (TIBC)
  5. % Saturation (of Fe in proteins)

Medical Tx Dependent on cause. Ultimately tx underlying reason

  • Ferrous sulfate 325 mg pot id
    • Expect normal hematocrit within 3 weeks
    • Expect baseline within 2 mo
    • Continue 6 mo to restore Fe stores in liver and heart
  • Parenteral Fe (only if oral fails)

Surgical Tx None

Emergency Tx None

Pt Education/Prevention Once levels are returned to normal, practice etiology-specific practices to prevent recurrence

Misc.

  • Most common cause of anemia worldwide (20% of white female Americans)
  • Parenteral Fe must be delivered in hospital due to high risk of anaphylaxis
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2
Q

Anemia of Chronic Disease

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Anemia from inflammatory disease à impaired marrow response to EPO

Etiology Associated c chronic diseases that chronically inflame

  • Rheumatoid arthritis
  • Chronic infection
  • Malignancy
  • Chronic renal disease

Pathophysiology

Disruption originating from macrophages (still in research)

  • Macrophage release of cytokines (interleukins)
    • IL-6, IL-1β
      • Increased liver production of hepcidin
      • Hepcidin decreases iron absorption form GI epithelium
      • Hepcidin decreases recycled iron export from macrophages due to inhibited ferroportin
    • TNF-α, IL-1β
      • Inappropriate EPO production in kidney
      • Reduced erythropoiesis in BM

Bone marrow dysfunction due to various causes

  • T-cell mediated autoimmune suppression of hematopoiesis (most common)
  • Radiation therapy
  • Chemotherapy
  • Toxins

Symptoms

  • Fatigue
  • Weakness
  • Symptoms consistent c underlying cause

Signs

  • Pallor
  • Signs consistent c underlying cause

Differential Dx

  • Iron deficiency anemia
  • Thallesemia
  • Sideroblastic anemia

Diagnostic Tests Order varies dependent on history

  1. CBC – normochromic normocytic anemia or microcytic, hypochromic anemia (90% of time microcytic)
  2. Serum Fe – decreased, iron sequestered in macrophages
  3. TIBC – decreased
  4. Serum ferritin – normal or increased, adequate iron in body but hepcidin prevents uptake

Medical Tx Treat the underlying disease and give EPO injections

  • CRI – hemodialysis + EPO
  • Malignancy – chemo, radiation, EPO
  • Inflammation (RA) – NSAIDs, DMARDs, EPO

Surgical Tx None

Emergency Tx None

Pt Education/Prevention Understanding of underlying disease

Misc.

  • Chronic renal insufficiency (CRI) chronic anemia comorbid c iron and folate deficient anemias due to loss of RBCs
  • Differentiation between this and iron deficiency is often on boards
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3
Q

Thalasemias, group of diseases

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Hereditary disorders characterized by reduction in synthesis of globin chains (α or β)

Etiology

  • α thal – HBA1 and HBA 2 gene deletion causing reduced α-globin chain synthesis. Severity depends on how many present alleles out of 4
  • β thal – gene mutation terminating DNA chain responsible for β-globin prdctn. May be homozygous (major) or homozygous (minor)

Pathophysiology Reduced globin chain synthesis → reduced hemoglobin synthesis → hypochromatic mircocytic anemia

Symptoms Typical anemia symptoms c varying severity depending on etiology

Signs

  • α Thalasemia, severity depends on number of missing alleles
    • 4 alleles – normal hbg
    • 3 alleles – silent carrier, asymptomatic
    • 2 alleles – “trait” exhibits mild microcytic anemia symptoms
    • 1 allele – “Hbg H Disease” variable severity splenomegaly and pallor
    • 0 alleles – “hydrops fetalis” stillborn fetus
  • β Thalasemia
  • Major – symptom development upon unsuccessful Hbg F à Hbg A conversion
    • Growth failure
    • Bone deformities
    • Hepatosplenomegaly
    • Jaundice
  • Minor –clinically insignificant microcytic anemia (often discovered in routine physical

Differential Dx c differentiating factors

Iron deficient anemia, due to microcytic hypochromatic cells

  • Higher MCV
  • Abnormal Fe studies

Diagnostic Tests

  1. CBC –
    • Microcytosis out of proportion to degree of anemia, RBCs also hypochromatic
      • MCV 55-70 fl
      • Poikilocytosis – abnml RBC shape
    • Hgb between 3 and 6 gm/dL
  2. Serum Fe – normal
  3. Hemoglobin electrophoresis – definitive dx

Medical Tx

  • Mild (α thal trait or β thal minor) – no tx
  • Hgb disease – folic acid supplementation
  • β Thalasemia major
    • Chelation therapy
    • Transfusions
    • Folate supplementation

Surgical Tx Stem cell/bone marrow transplantation for β Thalasemia major

Emergency Tx None

Pt Education/Prevention

  • Highly inheritable, take a thorough hx
  • Avg patient populations
    • α thal – SE Asian
    • β thal – Mediterranean (Greek, Sicilian)

Misc. Pts usually live to 30’s until overcome c heart failure

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4
Q

Sideroblastic Anemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Genetic or acquired defective heme synthesis

Etiology

  • Lead
  • EtOH abuse
  • Myelodysplasia (umbrella term)

Pathophysiology Reduced Hgb synthesis due to inability to incorporate heme into protoporhyn. Results in iron accumulation in mitochondria.

Symptoms Consistent c anemia, no identifying s/sx

Signs Consistent c anemia, no identifying s/sx

Differential Dx

  • Iron deficiency anemia
  • Thallesemia
  • Anemia of chronic disease

Diagnostic Tests

  1. CBC
    • Normochromatic, micro AND macrocytic anemia
    • Basophilic stippling of RBC – rRNA remnants from impaired hgb synth
  2. Serum Fe – increased
  3. Bone marrow biopsy – diagnostic
    • Erythroid hyperplasia
    • Ringed sideroblasts (iron ring within nucleated RBC)

Medical Tx Manage offending agent

Surgical Tx None

Emergency Tx None

Pt Education/Prevention None

Misc. None

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5
Q

Vitamin B12 (Cobalamine) Deficiency

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Inadequate supply of vitamin B12 for erythrocyte DNA synthesis

Etiology

  • Pernicious anemia (autoimmunity directed at parietal cells)
  • Strict vegan diet (decreased B12 intake)
  • Gastric surgery (bypass parietal cells)
  • Crohn’s Disease

Pathophysiology Inadequate B12 absorption due to

  • Lack/dysfunction/bypass of terminal ilium parietal cells responsible for B12 absorption
  • Lack of intrinsic factor (IF) in parietal cells
  • Lack of B12 intake

Leads to impaired erythroblast DNA assembly, despite normal cytoplasm proliferation. Results in macrocytic cells c poor oxygen carrying capacity.

Symptoms Typical anemia symptoms

Signs

  • Glossitis c burning sensation
  • Neuro dysfunction
    • Stocking glove parathesia** **
    • Loss of sensation in position, fine touch, vibration
    • Clumsiness and ataxia

Differential Dx Folic Acid Deficiency Anemia

Diagnostic Tests

  • CBC
    • Severe anemia
    • MCV >100 (macrocytic)
    • Hypersegmented neutrophils
    • Anisocytosis
    • Poikilocytosis
    • Howell Jolly bodies
  • Vitamin B12 assay = decreased
  • Folate assay = normal
  • Shilling test – antiquated

Medical Tx

  • Vitamin B12 supplimentation
    • First month = weekly IM injections
    • Remainder of life = monthly IM injections, 1000 mcg
  • Oral cobalamin, 0.5-2 mg/day
    • Only if pt is lacking B12 intake due to necessity of functional parietal cells to absorb
  • OTC SQ tablet, not as effective
  • Nightly nasal spray, not as effective and expensive

Surgical Tx None

Emergency Tx None

Pt Education/Prevention

  • Hemostalogic correction usually occurs within 6 weeks
  • Neurologic improvement may take up to 18 months, if at all

Misc.

  • Patients may try to self-treat the glossitis c oral rinses. Since this is a neuro sign the rinces will not work but the bacteria in the mouth will be eliminated, often resulting in Candida
  • Cells may never appear macrocytic. In suspicion of B12 anemia, the most reliable test is the B12 assay
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6
Q

Folic Acid Deficiency

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Inadequate supply of vitamin B12 for erythrocyte DNA synthesis

Etiology

  • Poor dietary intake
    • Alcoholics
    • Anorexia (psychological or secondary to comorbidity like cancer)
    • Diet low in citrus fruits and dark leafy greens
  • Malabsorption (celiac, Crohn’s)
  • Pregnancy
  • Hemolytic anemia

Pathophysiology Inadequate folic acid absorption leads to impaired erythroblast DNA assembly, despite normal cytoplasm proliferation. Results in macrocytic cells c poor oxygen carrying capacity.

Symptoms Typical to anemia

Signs

  • Glossitis
  • Vague GI complaints
    • Anorexia
    • Nausea
    • Abd Pn
    • Constipation/diarrhea
  • No neurologic s/sx (differentiating factor from B12)

Differential Dx B12 Deficiency

Diagnostic Tests

  • CBC
    • Severe anemia
    • MCV >100 (macrocytic)
    • Macro-ovalocytes
    • Hypersegmented neutrophils
    • Howell Jolly bodies
  • Vitamin B12 assay = normal
  • Folate assay = decreased

Medical Tx

  • Folic acid 1 mg po daily
  • Avoid alcohol
  • Avoid folic acid antagonists, or supplement if avoidance is unreasonable
    • Methotrexate
    • Trimethoprim sulfate (antibiotic)
    • Phenytoin (dilantin)

Surgical Tx None

Emergency Tx None

Pt Education/Prevention Pregnant women c folic acid anemia may lead to fetuses c neural tube defects. Recommendation: start folic acid tx 3 mo before consuming

Misc. None

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7
Q

Hereditary Spherocytosis

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Genetic hemolytic anemia due to fragile spherical erythrocytes

Etiology Autosomal dominant disorder

Pathophysiology

  1. RBCs produce deficient number of membrane PRO
  2. RBC form c decreased surface:volume ratio and fragile spherical shape
  3. Decreased flexibility causes hemolysis when passing through spleen

Symptoms

  • RUQ Pain
  • Family history

Signs

  • Jaundice noted by scleral icterus
  • Gallstones c predominating bilirubin crystal composition
  • Palpable spleen

Differential Dx Other hemolytic anemias

  • G6PD deficiency
  • Sickle cell disease
  • Autoimmune hemolytic anemia
  • Microangiopathic hemolytic anemia
  • Aplastic anemia

Diagnostic Tests

  • CBC
    • Variable anemia c aplastic crises concurrent c BM stress
    • Dimorphic population including spherocytes
    • Microcytosis c increased MCHC (>36 g/dl)
  • Reticulocyte count increased
  • Indirect bilirubin increased
  • Osmotic fragility test – positive

Medical Tx Folic acid 1 mg/d

Surgical Tx Splenectomy

Emergency Tx None

Pt Education/Prevention Genetic counseling for future children

Misc. None

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8
Q

G6PD Deficiency

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Episodic hemolytic anemia due to glucose 6 phosphate dehydrogenase deficiency

Etiology X-linked recessive disorder, common among African black men who encounter an oxidative stress:

  • Infection (viral or bacterial)
  • Hypoxia
  • Drugs
    • Quinidine
    • Sulfa drugs (trimethoprim sulfa)
    • Nitofurantoin (macrodantin)
    • Asprin

Pathophysiology

  1. RBC lose G6PD as they age
  2. Lack of G6PD decreases RBC’s ability to deal c oxidative stress (crisis)
  3. Oxidized hgb denatures to form Heinz bodies
  4. Heinz bodies formation damages the membrane
  5. Damaged RBCs removed by spleen

Symptoms Asymptomatic until oxidative stress. Stress induces SOB and organ specific hypoxia complaints

Signs Without signs until oxidative stress

  • Hypoxia
    • SOB
    • Cyanosis
  • Jaundice noted by scleral icterus
  • Organ specific s/sx related to hypoxia

Differential Dx Other hemolytic anemias

  • Hereditary spherocytosis
  • Sickle cell disease
  • Autoimmune hemolytic anemia
  • Microangiopathic hemolytic anemia
  • Aplastic anemia

Diagnostic Tests

  • CBC and blood smear
    • Heinz bodies
    • Bite cells
  • Reticulocyte count increased
  • Indirect bilirubin increased
  • G6PD assay
    • During crisis – non revealing
    • Weeks after crisis – deficient

Medical Tx Remove hypoxia source

Surgical Tx None

Emergency Tx Only if hypoxia is severe

Pt Education/Prevention Educate on how to avoid triggors

**Misc. **None

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9
Q

Sickle Cell Disease/Trait

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Chronic illness resulting in anemia from abnormal hemoglobin

Etiology Autosomal recessive genetic disorder where Valine substitutes for glutamine on beta chain. Most common in Africans (1/400 are homozygous)

Hemoglobinopathy Variations:

  1. Hgb SS – sickle cell disease
  2. Hgb AS – sickle cell trait

Pathophysiology

  • Infants are born normally c predominating Hgb F levels
  • S/sx appear as Hgb f is replaced by abnormal Hgb S
  • Underlying anemia due to splenic attempt to clear abnormal cells
  • Crises – Upon oxidative stress Hgb S crystallizes and sickles RBC shape. These get caught throughout system causing pain and potential organ swelling, dysfunction, and infarction

Symptoms Asymptomatic unless in crisis. Crisis symptoms may occur in varying frequency/duration and are characterized as acute pain due to vaso-occlusive episodes:

  • Hypoxia
  • Infarction
  • Dehydration

Common pain sites

  • Spine
  • Long bones
  • Chest

Signs Asymptomatic unless in crisis. Crisis signs may occur in varying frequency/duration and are characterized as

  • Jaundice
  • Pigment gallstones
  • Splenohepatomegaly (esp in peds)
  • Blood pooling in extremities – edema/ecchymosis/ulcer
  • +/- low grade fever
  • Vaso-occlusive crisis may lead to
    • CVA
    • Priapism
    • MI
    • PE
    • Ischemic necrosis
      • Liver
      • Bone – Staph related osteomyelitis

Permanent anatomic changes due to repeated crises

  • Poorly healing ulcers overlying distal tibia
  • Scull “towering” and “bosses”

Associated Mortality

  • Infections
  • Pulmonary emboli
  • Occlusion of vital vessel
  • Renal failure

Crisis stimulation for sickle cell trait is much more extreme – ie rigorous exercise at high altitude

Differential Dx Other hemolytic anemias

  • Hereditary spherocytosis
  • G6PD deficiency
  • Autoimmune hemolytic anemia
  • Microangiopathic hemolytic anemia
  • Aplastic anemia

Diagnostic Tests

  • CBC
    • Hct increased
    • WBC count increased – 12,000-15,000/mcl
    • Nucleated RBC’s
  • Peripheral blood smear
    • 5-50% RBC are sickled
    • Howell Jolly bodies
    • Target cells
  • Reticulocyte count increased
  • Bilirubin assays – both total and indirect increased
  • Hbg electrophoresis –confirmatory test
    • Sickle Cell Disease
      • Hgb S 85-98%
      • Hgb F 5-15%
      • Hgb A2 1-3%
      • Hgb A 0%
    • Sickle Cell Trait
      • Hgb A 60%
      • Hgb S 40%

Medical Tx

  • Folic acid supplementation
  • Pneumococcal vaccine
  • Transfusions as needed
  • Hydroxyurea to inc. Hgb F levels

Surgical Tx Allogenic hematopoietic stem cell transplant from sibling donor

Emergency Tx Crisis Tx

  • Vigorous oral or IV hydration
  • Analgesics (morphine)
  • Narcotics
  • Treat precipitating factor – Oxygenate for hypoxia
  • Blood transfusions
    • If Hgb < 5mg/dl
    • Cardiac failure

Pt Education/Prevention

  • Life expectancy for disease = 40-50 years
  • Behavior change to avoid crises if possible

**Misc. **None

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10
Q

Microangiopathic Hemolytic Anemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Group of disorders characterized by RBC fragmentation

Etiology

  • Disseminated intravascular coagulopathy
  • Thrombotic thrombocytic purpura
  • Hemolytic uremic syndrome
  • Malfunctioning cardiac valve prosthesis
  • Malaria
  • Drugs
    • Nitrofurantoin
    • Sulfonamide
    • Chloramphenicol
    • Primaquine

Pathophysiology Variable source of fragmentation; most popular is RBC interaction c abnormal intravascular fibrin strands. RBC fragments are not useful and are disposed of in spleen

Symptoms Depends on underlying cause. May resemble iron deficiency in heart valve-related cases

Signs Depends on underlying cause. May resemble iron deficiency in heart valve-related cases

Differential Dx

  • Iron deficiency anemia
  • Other hemolytic anemias
    • Hereditary spherocytosis
    • G6PD deficiency
    • Sickle cell disease
    • Autoimmune hemolytic anemia
    • Aplastic anemia

Diagnostic Tests

  • Peripheral Smear indicates fragmented RBCs
  • CBC may reveal decreased Hct and Hgb

Medical Tx Treat the underlying disorder

Surgical Tx None

Emergency Tx None

Pt Education/Prevention None

Misc. None

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11
Q

Aplastic Anemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Pancytopenia due to bone marrow failure

Etiology

  • Idiopathic
  • SLE (lupus) or any autoimmune disease
  • Chemotherapy
  • Radiation therapy
  • Toxins
    • Benzenes (organic)
    • Toluenes (organic)
    • Insecticides (inorganic)
  • Drugs
    • Chloramphenicol
    • Sulfonamides
    • Phenytoin
    • Carbamazepine
  • Pregnancy (uncommon)

Pathophysiology Hematopoeitic stem cell injury/abnormal expression causes defects in all blood cell lines

Symptoms Anemia effects

  • Fatigue
  • Weakness

Signs

  • Anemia effects
    • Pallor
  • Leukopenia effects
    • Increased infections
  • Thrombocytopenia effects
    • Mucosal/skin bleeding
    • Purpura
  • Petechiae

Differential Dx

  • Increased Blasts - Acute Leukemia
  • Sepsis
  • Normomarrow pancytopenia
    • SLE (lupus)
    • Hypersplenism
    • Disseminated infection

Diagnostic Tests

  • CBC
    • Pancytopenia
    • Blast cells decreased
  • Reticulocyte count decreased
  • Bone marrow biopsy hypocellular

Medical Tx

Refer to hematologist, who will do the following

  • Blood Transfusion
  • Platelet transfusion
  • Antibiotics
  • Cyclosporine and antithymocyte globulin
    • Tx of choice for pts > 50 yo

Surgical Tx Allogenic bone marrow transplant if < 50 yo

Emergency Tx None

Pt Education/Prevention None

Misc. None

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12
Q

Acute Lymphocytic Leukemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Acute unrestricted growth of lymphocytes and their precursors

Etiology

  • Most common pediatric leukemia (80%), years 3-7
  • Adult, 20% of leukemias
    • Family hx
    • Ionizing radiation exposure
    • Benzene
    • Some alkylating agents (cyclophosphamide)
  • Prognosis varies upon
    • Age
    • WBC
    • Presence of Philadelphia chromosome

Pathophysiology Mutation to only the lymphocyte precursor. Produces excess and ineffective T, B, and NK cells. Excess cells “clog” the body and do not

Symptoms Reflective of dysfunctional lymphoid cells

  • Fatigue
  • Lethargy
  • HA
  • Bone pain
  • Joint pain

Signs Reflective of dysfunctional lymphoid cells

  • Fever
  • Pallor
  • Lymphadopathy
  • Hematosplenomegaly

Differential Dx

  • CLL
  • Aplastic Anemia
  • Bacterial Infection
  • Sepsis

Diagnostic Tests

  • CBC – high WBC count (lymphocytosis)
  • Bone marrow biopsy > 20% nucleated BM cells are lymphoblasts
    • Confirmatory test
  • CXR – mediastinal mass
  • Genetic testing – Philadelphia chromosome sometimes present
    • Unfavorable dx

Medical Tx

  • Intensive chemotherapy

Surgical Tx None

Emergency Tx None

Pt Education/Prevention

  • Prognosis – remission rate >70%
  • Goal is to achieve high quality of life. If this is present without tx (especially in geriatric pts) then tx is not necessary

Misc. None

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13
Q

Acute Myelogenous Leukemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Acute unrestricted growth of myelocytes and their precursors, characterized by short duration of s/sx

Etiology

  • Age – primary leukemia of people >60 yo
  • Risk factors
    • Family hx
    • Ionizing radiation exposure
    • Benzene
    • Some alkylating agents (cyclophosphamide)

Pathophysiology Mutation to only the myelocyte precursor. Produces excess and ineffective granulocytes, monocytes, thrombocytes, and erythrocytes. Excess cells “clog” the body and do not

Symptoms Reflective of dysfunctional myeloid cells

  • Bleeding
    • GI
    • Epistaxis
    • Skin
    • Menorrhagia
  • Bacterial infections
  • Joint pain
  • Bone Pain

Signs Reflective of dysfunctional myeloid cells

  • Pallor
  • Gingival hyperplasia
  • Purpura
  • Petechiae
  • Lymphadopathy

Differential Dx

  • CML
  • Aplastic Anemia
  • Bacterial Infection
  • Sepsis

Diagnostic Tests

  • CBC – high WBC count (leukocytosis)
  • Bone marrow biopsy > 20% nucleated BM cells are myeloblasts
    • Confirmatory test
    • Auer Rods
  • Peripheral smear contains myeloblasts

Medical Tx Chemotherapy

Surgical Tx Bone marro transplant

Emergency Tx None

Pt Education/Prevention

  • Prognosis – c chemotherapy, complete remission in (depending on severity)
    • 80-90% pts < 60 yo
    • 50-60% pts > 60 yo

Misc. None

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14
Q

Chronic Myelogenous Leukemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Myeloproliferative disorder of extended duration

Etiology

  • Young to middle aged adults (median age 55)
  • Risk factors
    • Family hx
    • Ionizing radiation exposure
    • Benzene
    • Some alkylating agents (cyclophosphamide)

Pathophysiology Abnormal myeloid cell production c normal cell differentiation. Bone marrow function persists in early disease. Occurs in three phases

  1. Chronic
    • Normal BM function
  2. Accelerated
    • Impaired neutrophil differentiation
    • WBC uncontrollable by chemo
  3. Acute (blast crisis)
    • Myeloid blast proliferation
    • Resembles AML

Symptoms

  • Fatigue
  • Weight loss
  • Low grade fever
  • Night sweats
  • Abdo fullness

Signs

  • Splenomegaly
  • Sternal tenderness

Differential Dx

  • AML
  • CLL
  • Bacterial Infection
  • Sepsis

Diagnostic Tests

  • CBC
    • Increased WBC (leukocytosis > 150,000/mcl) c severe left shift
    • Anemia – present in later stages
    • Thrombocytosis – present in later stages
  • Genetic testing
    • Philadelphia chromosome (95% of the time)
    • Bcr/abl gene*

Medical Tx Refer to hematologist, who will do the following

  1. First line – Imatinib
  2. Second line – Dasatinib

Surgical Tx Third line – BM transplant

Emergency Tx None

Pt Education/Prevention Imatinib often achieves remission x 8 years

Misc. Pts c unexplained leukocytosis < 150,000 can be referred to hematology/oncology for monitoring. They may start chemo at lower threshold

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15
Q

Chronic Lymphocytic Leukemia

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Clonal malignancy of B lymphocytes

Etiology Most prevalent leukemia

  • Median age > 70 yo
  • Risk factors
    • Family hx
    • Ionizing radiation exposure
    • Benzene
    • Some alkylating agents (cyclophosphamide)

Pathophysiology B lymphocyte clone will uncontrollably proliferate, creating ineffective B cells, thus ineffective plasma cells and antibodies. Note – B cell only, not entire lymphocyte line

Symptoms

  • Fatigue
  • Recurrent infections

Signs

  • Splenomegaly
  • Lymphadopathy

Differential Dx

  • ALL
  • Infection
  • CML
  • Sepsis

Diagnostic Tests

  • CBC
    • High WBC count (leukocytosis > 20,000/ml)
    • +/- anemia
    • +/- thrombocytosis
    • peripheral lymphocytosis
  • Peripheral smear reveals smudge cells

Medical Tx

  • Early disease – observation
  • Tx indications – S/sx that interfere c quality of life
    • Progressive fatigue
    • Symptomatic lymphadopathy, anemia, thrombocytopenia
  • Chemotherapy
    • Fludarabine
    • Rituxamib (Retuxan)

Surgical Tx Allogenic stem cell transplant for pts who do not respond to chemo

Emergency Tx None

Pt Education/Prevention Mean survival time = 6 years. Choice to treat depends on quality of life and is completely up to the patient . Prognoses:

  • Stages 0 or 1 = 10-15 years
  • Stages 3 or 4 = 2 years

Misc. None

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16
Q

Hodgkin’s Lymphoma

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Neoplasm (cancer) of the lymphatic system characterized by the presence of Reed Sternberg cells

Etiology

  • Largely unknown, although Epstein Barr virus is suspected
  • Bimodal age distribution (ages vary depending on source)
    • 15-45 yo c mean age in 20’s
    • > 50 yo

Pathophysiology

  • Tumor formation due to specific cell proliferation
    1. Normal lymphocytes (majority)
    2. Malignant B lymphocytes
    3. Reed Sternberg cells
  • Lymph node enlargement from cell infiltration
    1. Eosinophil
    2. Plasma cells
  • Presents in stages
    1. Stage I – singular lymph node or extralymphatic site
    2. Stage II – 2+lymph nodes and/or extralymphatic tissue on ipsilateral side of diaphragm
    3. Stage III – lymph nodes on contralateral sides of diaphragm. May include spleen or extranodal disease
      • III1 – limited to upper abdomen (spleen, celiac, portohepatic nodes)
      • III2 – limited to lower abdomen (periaortic, pelvic, inguinal nodes)
    4. Stage IV – diffuse extralymphatic disease. Commom sites include
      • Liver
      • BM
      • Lung
      • Skin

Symptoms

  • Fever
  • Night sweats
  • Fatigue
  • Weight loss
  • Pruritis

Signs

  • Painless, rock hard, swollen lymph nodes. Disease usually starts in the following nodes:
    • Cervical
    • Supraclavicular
    • Mediastinal
  • Splenomegaly
  • Potential hepatomegaly

Differential Dx

  • Non-Hodgkin’s Lymphoma
  • HIV
  • Hypersensitivity Rxns
  • Other solid tumors

Diagnostic Tests

  1. Lymph node biopsy
    • Reed Sternberg cells
    • Necrosis
    • Fibrosis
  2. Bone marrow biopsy
    • Lymphocytosis only present in progressive disease
  3. Scans to evaluate disease stage
    • CXR or chest CT
    • Abdo CT
    • Bone scan

Medical Tx

  1. Chemotherapy and/or radiation (varies c histologic interpretation/staging)
    • AVBD – front line
    • MOPP – alternative
  2. Experimental – targeted therapies
    • Monoclonal antibodies
    • Target-specific aids
  3. Symptomatic tx
    • Antiemetics
    • Sedatives

Surgical Tx Autologous bone marrow transplant

Emergency Tx None

Pt Education/Prevention None

Misc. Keep a high index of suspicion due to vagueness of symptoms

17
Q

Non-Hodgkin’s Lymphoma

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Hematogenous group of malignancies originating in l ymph nodes and other lymph node tissues

Etiology

  • Common pt populations
    • Autoimmune disorders
    • HIV
    • Immunosuppressive tx
  • Definitive etiology unknown. Some patterns in pts c
    • Viral etiology (virus may alter B cell)
    • Toxin exposure
      • Benzene
      • Pesticides
      • Herbicides

Pathophysiology

  1. Oncogene becomes juxtaposed next to
    • Immunoglobulin gene (B-cell lymphoma)
      • 85% of cases
    • T-cell receptor gene (T-cell lymphoma)
  2. Oncogene over-expression
  3. Excess T- or B-cell production, causing lymphoma

Symptoms

  • “B Symptoms” (present in B- and T-cell lymphomas)
    • Weight loss
    • Fever
    • Drenching night sweats
  • Other
    • Fatigue
    • Pruritis
    • Abdo pn

Signs

  • Uneven enlargement of tonsils and adenoids
  • Painless uneven lymphadenopathy
    • Cervical
    • Suprascapular
  • Dramatic infections

Differential Dx

  • Hodgkin’s Lymphoma
  • Infectious mononucleosis

Diagnostic Tests

  1. Lymph node biopsy – No Reed Sternberg Cells
  2. Tissue biopsy or enlarged lymphatic tissues
    • Tonsils
    • Adenoids
  3. Scans to evaluate disease stage
    • Bone scan
    • Chest CT
    • Abdo CT
    • PET scan

Medical Tx Varies c histology and disease progression

  • Radiation therapy, if localized
    • In combo c chemotherapy if advanced
  • Chemotherapy
    • CHOP
    • Advanced cases only
  • Rituximab – binds to B cell receptors to stim. apoptosis
    • For relapse or refractory follicular lymphoma

Surgical Tx None

Emergency Tx None

Pt Education/Prevention None

Misc.

  • 3x more common than Hodgkin’s lymphoma
  • History – could not differentiate b/w any lymphoma that lacked Reed Sternberg cells so all lymph node malignancies were deemed Hodgkin’s or Non-Hodgkin’s
  • Classification system is still evolving. Existing systems
    • Clinical features
    • Pathologic features
18
Q

Multilple Myeloma

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Disseminated malignant neoplasm of plasma cells that infiltrates BM

Etiology

  • Male > female
  • Exact etiology unknown. Some hypotheses
    • Genetics
    • Autoimmune disease
    • Environmental toxins
    • Agricultural chemicals
    • Herbicides
    • Pesticides

Pathophysiology

  1. Malignant plasma cells invade BM
  2. Abnormal cells consume BM and progress to invade bone matrix (cortex)
  3. Formation of osteolytic lesions
  4. Simultaneous co-infiltrations due to wide distribution of plasma cells
  5. Plasma cells produce excessive immunoglobulins
  6. High circulating protein from immunoglobulins degrade kidney and bone
  7. Result in various complications
    • Dec. functional antibodies - infection
    • Protein overload in kidney
      • Pyelonephritis
      • Renal failure
      • Renal calculi (stones due to inc. calcium or uric acid)
    • Bone destruction
      • Hematologic imbalance (anemia, abnml WBC leukocytosis)
      • Fractures at osteolytic lesions
      • Hypercalcemia from bone degradation byproduct
      • Hyperuricemia from cell degradation products

Symptoms

  • Pts typically present c complaints concerning
    • Anemia
    • Bone pn, most severe in
      • Back
      • Ribs
      • Hips
  • Infection
  • Fever
  • Malaise
  • Weight loss

Signs

  • Anemia s/sx
    • Pallor
  • Bone destruction
    • Osteoporosis
    • Pathologic fx
    • Vertebral compression fx

Differential Dx

  1. Anemia
  2. MSK dysfunction
  3. Malignant lymphoma
  4. Metastatic carcinoma
  5. Monoclonal gammopathies or uncertain origin
  6. Waldenstrom Hypergammaglobulinemia

Diagnostic Tests

  1. X-ray – lytic lesions in skull, pelvis, spine
  2. CBC
    1. Moderate-severe anemia
    2. Rouleaux formation
  3. Bence Jones urinalysis – positive
  4. Electrolyte levels - Hypercalcemia
  5. Serum protein electrophoresis – hallmark test
    • Monoclonal spike in beta or gamma region (“M spikes”)
      • Monoclonal = only one antibody
    • Note- can be spiked in other diseases, must go with other dx tests
  6. Bone marrow aspirate – inc. plasma cell precursors

Medical Tx Only with more progressive disease. May be monitored at first

  1. Chemotherapy to suppress plasma cell growth, thus dec. pn
    • VAD
    • TD
  2. Adjunctive radiation
  3. Dialysis if kidneys fail

Surgical Tx BM transplant

Emergency Tx None

Pt Education/Prevention

  • Prognosis is improving. Currently 4 – 6 years c tx
  • Avoid the following to prevent irritation
    • Heavy lifting
    • Dehydrating

Misc. None

19
Q

Essential Thrombocytosis

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Myeloproliferative disorder characterized by increased platelets with no other direct cause

Etiology

  • Median age 50-60 yo
  • Correlation c JAK2 mutation (same mutation as CML)

Pathophysiology

  • Excessive platelet formation without trigger
  • Abnormal and excess platelets c attempted removal by spleen

Symptoms Increased bleeding

Signs

  • Thrombosis in normal and abnormal venous clotting locations
    • Typical (for other clotting disorders) – DVT
    • Atypical (for other clotting disorders)
      • Mesenteric vein
      • Hepatic vein
      • Portal vein
  • Bleeding, mucosal
  • Splenomegaly

Differential Dx

  • Chronic myelogenous leukemia
  • Agnogenic myeloid metaplasia c myelofibrosis
  • Myelodysplastic syndrome
  • Polycythemia vera
  • Secondary thrombocytosis

Diagnostic Tests

  1. CBC
    • Platelet count > 500,000/mcl (can be in the millions)
    • Large, abnormal platelets on peripheral smear
    • WBC count – slightly increased c increased blasts
  2. Bone marrow biopsy – increased megakaryocytes
  3. Genetic testing – No Philadelphia chromosome, unless this is a manifestation of early CML

Medical Tx Refer to hematologist, who will prescribe

  • Hydroxyurea for myelosuppression
    • Requires regular monitoring via CBC

Surgical Tx None

Emergency Tx None

Pt Education/Prevention

  1. 5% cases transform to leukemia, esp CML
  2. Prognosis, avg >15 years

Misc.

  • Test for Philadelphia chromosome to R/O CML
  • If platelet count in the realm of 500,000 and there are no other s/sx you can have your pt return in a couple weeks to retest platelet counts
    • Decreased – continue to monitor
    • Increased/remained – refer to hematologist
20
Q

Immune Thrombocytopenia Purpura (ITP)

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Isolated thrombocytopenia secondary to anti-platelet antibodies

Etiology Diagnosis of exclusion

  • Usually idiopathic
  • Associated c the following
    • Lupus
    • Lymphoma
    • Hep B
    • Hep C
    • HIV
    • Drugs
      • Sulfa
      • Thiazides (anti-convulsive)
      • Cimetidine

Pathophysiology

  1. Anti-platelet antibodies attach to normal platelets
  2. Macrophages in liver and spleen phagocytize platelets
  3. Resulting thrombocytopenia

Symptoms Spontaneous bleeding

Signs Mucocutaneous bleeding, spontaneous when plt count < 20,000-30,000

  • Bruising
  • Nosebleeds
  • Gingival bleed

Differential Dx

  • Thrombotic microangiopathies
    • Thrombotic Thrombocytopenic Purpura
    • Hemolytic Uremic Syndrome
  • Heparin Induced Thrombocytopenia
  • Disseminated Intravascular Coagulopathy

Diagnostic Tests

  1. CBC – Isolated thrombocytopenia
    1. Platelet Count
      1. Acute: 10,000 – 20,000/mcl
      2. Chronic: 25,000 – 75,000/mcl
  2. RBC studies – potential mild anemia
  3. Coagulation studies – normal
  4. Disease specific testing, varies upon etiology
    1. Hep B
    2. Hep C
    3. HIV

Medical Tx Refer to a hematologist who will

  1. Monitor, if chronic. Spontaneous resolution often occurs
  2. Steroids
  3. IV immunoglobulin
  4. Rituximab
  5. Splenectomy
  6. Treat underlying co-morbidity or eliminate offending agent

Surgical Tx Platelet transfusion for life threatening bleeding

Emergency Tx None

Pt Education/Prevention None

Misc. More strict than thrombocytopenia. If pts drop below normal values refer immediately

21
Q

Thrombotic Thrombocytic Purpura

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Thrombocytopenia due to incorporation of plts into thrombi in microvasculature

Etiology

  • Viruses (HIV)
  • Bacteria
  • Pregnancy
  • Autoimmune
  • Cancer
  • Medications
    • Cyclosporine
    • Clopidogrel

Pathophysiology

  1. Antibodies against vonWillenbrand factor cleaving protease (ADAMTI-13)
  2. Multimer accumulation within vasculature
  3. Bridging of multimer
  4. Excessive plt aggregation
  5. Circulating clots prevent platelet use in necessary clots

Symptoms Anemia symptoms, bleeding difficulties, DVT

Signs 25% of patients will have pentad:

  1. Thrombocytopenia
  2. Hemolytic anemia
  3. Fever
  4. Neuro defects (HA, somnolence, delirium, seizures)
  5. Renal insufficiency

Differential Dx

  • Immune thrombocytopenia purpura
  • Thrombotic microangiopathies
    • Hemolytic Uremic Syndrome
  • Heparin Induced Thrombocytopenia
  • Disseminated Intravascular Coagulopathy

Diagnostic Tests

  1. CBC
    • Hemolytic anemia
      • Schistocytes s sickled cells
      • Normocytic, normochromic RBC
      • Elevated WBC count
    • Thrombocytopenia, platelets < 20,000
  2. LDH – increased
  3. Bilirubin (direct and indirect) – increased
  4. Reticulocyte count – increased
  5. Coagulation studies – normal
  6. BUN/Cr – increased only in very severe TTP

Medical Tx

  • Plastmapheresis
  • Steroids
  • IV immunoglobulin

Surgical Tx Splenectomy

Emergency Tx None

Pt Education/Prevention Prognosis – 5% s Plasmapheresis

Misc.

  • Avoid platelet transfusions – worsens thrombotic microangiopathy
  • Vicious cycle – these pts need platelets because they are bleeding but platelets will advance the disease
22
Q

Hemolytic Uremic Syndrome

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Thrombocytopenia due to incorporation of plts into thrombi in microvasculature c associated RBC shearing in microcirulation

Etiology

  • Predominantly pediatric population
  • Usually associated c current/recent diarrhea (usually due to food poisoning)
  • Typical causative agents
    • Toxigenic E. Coli (0157:H7)
    • Viruses (HIV)
    • Bacteria
    • Pregnancy
    • Autoimmune
    • Cancer
      • Medications
      • Cyclosporine
      • Clopidogrel

Pathophysiology

  • Endothelial damage from toxigenic E Coli (0157:H7), cancer, HIV
  • Circulating small platelet aggregations
  • Extension of aggregates throughout vessel walls
  • RBC lyse when passing through vessels, creating ineffective schystocytes
  • Platelets unavailable for necessary clotting
  • Renal insufficiency

Symptoms Anemia symptoms, bleeding difficulties, DVT

Signs 25% of patients will have pentad:

  1. Thrombocytopenia
  2. Hemolytic anemia
  3. Fever
  4. Neuro defects (HA, somnolence, delirium, seizures)
  5. Renal insufficiency

Differential Dx

  • Immune thrombocytopenia purpura
  • Thrombotic microangiopathies
    • Thrombotyc Thrombocytic Purpura
  • Heparin Induced Thrombocytopenia
  • Disseminated Intravascular Coagulopathy

Diagnostic Tests

  1. CBC
    • Hemolytic anemia
      • Schistocytes s sickled cells
      • Normocytic, normochromic RBC
      • Elevated WBC count
    • Thrombocytopenia, platelets < 20,000
  2. LDH – increased
  3. Bilirubin (direct and indirect) – increased
  4. Reticulocyte count – increased
  5. Coagulation studies – normal
  6. BUN/Cr – increased

Medical Tx

  • Avoid antibiotics c E. Coli etiology, due to risk of resistance and increased toxin release from lysed cells
  • Plastmapheresis
  • Steroids
  • IV immunoglobulin

Surgical Tx Splenectomy

Emergency Tx None

Pt Education/Prevention Prognosis – 5% s Plasmapheresis

Misc.

  • Avoid platelet transfusions – worsens thrombotic microangiopathy
  • Vicious cycle – these pts need platelets because they are bleeding but platelets will advance the disease
23
Q

Heparin Induced Thrombocytopenia (HIT)

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Decline in baseline platelet count of 50% or greater within 5-10 days of heparin exposure

Etiology Heparin patients

Pathophysiology

  1. IgG antibody formation against heparin platelet factor 4 (PF4) complexes
  2. Antigen-antibody complex formation and activation
  3. Macrophage phagocytosis, destroying the platelet
  4. Inability of BM to keep up c destruction, thus thrombocytopenia an dpro-thrombic state

Symptoms Pain in the event of thrombosis

Signs

  • Usually asymptomatic
  • Thrombosis – 50% cases
  • Bleeding is uncommon

Differential Dx

  • Immune thrombocytopenia purpura
  • Thrombotic microangiopathies
    • Thrombotyc Thrombocytic Purpura
    • Hemolytic Uremic Syndrome
  • Disseminated Intravascular Coagulopathy

Diagnostic Tests

  1. CBC – significant thrombocytopenia, >50% decline from baseline
    • This is carefully monitored when heparin is initiated; often caught before s/sx occur
  2. Heparin PF4 antibodies – present only after thrombocytopenia (order after thrombosis)

Medical Tx

  1. Discontinue heparin
  2. Anticoagulate c argatroban until platelet count >100,000
    • This is the threshold for safe Warfarin initiation, contraindicated otherwise

Surgical Tx Limb amputation is thrombosis is significant and untreated

Emergency Tx Initiate medical tx quickly as to avoid emboli

Pt Education/Prevention Monitoring will be done by hospital staff

Misc. Continue close monitoring upon Warfarin initiation via PT/INR

24
Q

Disseminated Intravascular Coagulopathy (DIC)

(Definition, Etiology, Pathophysiology, Symptoms, Signs, Differential Dx, Dx Studies, Medical Tx, Surgical Tx, Emergency Tx, Pt Education/Prevention, Misc.)

A

Definition Platelet consumptive syndrome characterized by simultaneous thrombosis and bleeding

Etiology Severe underlying systemic illness

  • Sepsis
  • OB complications
  • Cancer
  • Severe transfusion rxn
  • Trauma
  • Burns

Pathophysiology

  1. Systemic blood coagulation activation
  2. Fibrin generation and deposition
  3. Microvascular thrombi in various organs
  4. Consumption and subsequent exhaustion of coagulation PRO and platelets via microclot formation

Symptoms Extreme discomfort

Signs

  • Mucocutaneous bleeding at multiple sites (all orifices)
  • Shock
  • Digital ischemia leading to gangrene (depending on thrombosis location)

Differential Dx

  • Immune thrombocytopenia purpura
  • Thrombotic microangiopathies
    • Thrombotyc Thrombocytic Purpura
    • Hemolytic Uremic Syndrome
  • Heparin Induced Thrombocytopenia

Diagnostic Tests, all are vital for dx

  1. PT/INR – prolonged
  2. PTT – prolonged
  3. CBC
    • Thrombocytopenia
    • Hemolytic anemia
    • Schystocytes on peripheral smear
  4. D-Dimer assay – elevated
  5. Fibrinogen assay – decreased

Medical Tx All tx for DIC is emergent

Surgical Tx Only in pts c trauma or burns

Emergency Tx

  1. Correct underlying problem
    • Antibiotics for sepsis
    • Surgery for trauma/burns
  2. Blood product in the presence of clinically significant hemorrhage
    • Goal = plt count 20,000 – 30,000
  3. Fresh Frozen Plasma (FFP) in patients c
    • Inc PT
    • Inc PTT
    • Significant bleeding
  4. Cryoprecipitate to replace fibrinogen

Pt Education/Prevention None

Misc.

  • Primary goal is to achieve hemodynamic balance in these pts
  • Prognosis is very low
  • Paradoxical condition; the tx will worsen the condition

General Medicine (4 decks)

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