Hematology/Lymph MDTs Flashcards
What condition can poor diet lead to?
Folic acid deficiency, which can contribute to iron deficiency.
What is the most common cause of iron deficiency in adults?
Bleeding
Anemia is defined as a hematocrit level of?
Less than 41 in males.
Less than 37 in females.
Anemia signs and symptoms
Lymphadenopathy, hepatosplenomegaly, bone tenderness.
Smooth tongue (suggests megaloblastic anemia). Brittle nails, cheilosis.
Fatiguability, tachycardia, palpitations, tachypnea.
Pica (craving ice chips/food often not rich in iron).
A ferratin value of what indicates anemia?
<12 mcg/L
What is the most common cause of anemia worldwide?
Iron deficiency
What increases the chance of anemia?
Menstruation, pregnancy, and frequent blood donating.
Aspirin/NSAID use also contributes.
Medication treatment of anemia
Ferrous sulfate PO
- 325mg TID x 3-6 months
- Causes constipation, so stool softeners should be given. Constipation often leads to medication noncompliance.
Parenteral iron IM
-Indicated if patient has intolerance to PO iron, GI disease, or continued blood loss that cannot be corrected.
Serum levels of less than what indicate B12 deficiency
<100 pg/mL
B12 deficiency physical findings
Glossitis
Anorexia
Diarrhea
Late stages: paleness, paresthesia, difficulty with balance
B12 deficiency lab findings
CBC with differential will show a hallmark sign of megaloblastic anemia (large RBCs). A characteristic finding is macro-ovalocyte with hypersegmented neutrophils.
MCV will be strikingly elevated.
Abnormally low B12 serum level (<100 pg/mL).
Elevated LDH and bilirubin.
Treatment of B12 deficiency
IM injection of B12.
Daily for the first week
Weekly for the first month
Monthly for life
Hemophilia A is a congenital deficiency of what coagulation factor?
VIII
Hemophilia B is a congenital deficiency of what coagulation factor?
IX
This condition is a systemic process with the potential for causing thrombosis and hemorrhage
Disseminated Intravascular Coagulation
It is an acute, life threatening emergency.
In DIC, the processes of coagulation and fibrinolysis become abnormally activated leading to ongoing coagulation and fibrinolysis.
Common bleeding manifestations seen in DIC
Petechiae
Ecchymoses
Blood oozing from wound sites, IV lines, catheters, and mucosal surfaces
Venous thromboembolism
Arterial thrombosis
Symptoms and findings of DIC
Bruising without know incidence
Bleeding into joint spaces
Epistaxis
Bleeding from eyes
Very heavy vaginal bleeding
Labs to test for DIC
PT, PTT, INR, CBC
This is an X-linked recessive disorder commonly seen in black men, affecting __% of that population
G6PD
10-15%
G6PD is described as what?
Episodic hemolysis in response to oxidant drugs or infection
Reduced levels of glucose-6-phosphate dehydrogenase between those hemolytic episodes
What are Heinz bodies?
These occur when oxidized hemoglobin denatures and forms into precipitants that are called Heinz bodies. These cause membrane damage which leads to the removal of the Heinz bodies by the spleen.
Exposure to what drugs can cause oxidative stress seen in G6PD
Dapsone
Primaquine
Quinidine
Quinine
Sulfonamides
Nitrofurantoin
Aspirin
Ciprofloxacin
How will Heinz bodies be seen on a blood smear?
Crystal Violet
They are not seen on the usual Wright-Giesma stained blood smear
What is an important administrative measure for the care of G6PD personnel?
Red dog tags and the marking of HRECs
This is a recessive disorder in which abnormal hemoglobin leads to chronic hemolytic anemia
Sickle cell anemia (caused by Hemoglobin S)
The Hgb S gene is carried in what amount of the American population?
8% of black people, and 1 out of 400 black children.
Chronic hemolytic anemia produces what symptoms?
Jaundice, pigment, gallstones, hepatosplenomegaly, poorly healing ulcers over the lower tibia.
Acute, painful episodes in the bones (back and long bones) and the chest. These episodes last hours to days and may produce a low grade fever.
Cardiomegaly.
Non-healing ulcers of the lower leg and retinopathy.
Chronic pain.
A hematocrit value of ___-___% will typically be seen in people with sickle cell trait
20-30%.
A hallmark of hyposplenism seen in sickle cell trait is called what?
Howell-Jolly bodies and target cells
Allogeneic hematopoietic stem cell transplantation performed before the onset of significant end organ damage can cure more than __% of children with sickle cell anemia.
80%
What is the average life expectancy of a patient with chronic multi system damage due to sickle cell anemia?
40-50 years.
What activities can cause acute painful episodes of sickle cell trait?
Vigorous exertion at high altitudes and flying in unpressurized aircraft
What are the two types of leukemias and who do they primarily affect?
Acute lymphoblastic leukemia (ALL)
-80% of acute leukemias in children. Remaining 20% affects adults.
Acute myeloid leukemia (AML)
-Seen in adults aged 60
Symptoms and findings seen in leukemia
Fatigue
Bleeding in the skin and mucosal surfaces (gingival bleeding, epistaxis, menorrhagia)
Infection due to neutropenia - cellulitis, pneumonia, perirectal infections
Gum hypertrophy and bone/joint pain
Hepatosplenomegaly and lymphadenopathy
Bone tenderness in the sternum, tibia and femur
What is the hallmark lab result of leukemia
Pancytopenia with circulating blasts
More than 20% of blasts is enough to diagnose leukemia
Treatment of leukemia
MEDEVAC
Referral to hematologist
Chemotherapy and radiation
What is referred to as an abnormally low amount of circulating platelets
Thrombocytopenia
What factors can be used to evaluate thrombocytopenia
Location of bleeding Onset of symptoms Clinical context Personal history Family history
The risk of clinically relevant bleeding in thrombocytopenia does not increase until platelet count falls below what range?
10K-20K/mcL
Symptoms seen in thrombocytopenia
Petechia
Mucocutaneous bleeding
Thrombocytosis is an abnormally high amount of platelets above what amount?
> 450K
Symptoms of thrombocytosis
50-60 years of age
Elevated platelets (first sign)
Increased risk of thrombosis
Erythromelagia (painful burning of hands)
Spleomegaly seen in 25% of patients
When should you refer a thrombocytosis patient to hematology?
If there is no infectious cause or the condition does not resolve within 2-4 weeks
How large are normal lymph nodes?
<1cm
Lymphadenopathy can be categorized into what two groups?
Generalized - 2 or more regions
Localized - only one region involved (i.e. axilla)
What are common causes of lymphadenopathy?
HIV
TB
Lupus
Infectious Mono
Malignancy
Lymphadenopathy can commonly be associated with what things?
Infection
-Cat scratches, undercooked meat (toxoplasmosis)
Tick bites
-Lyme disease
Travel to endemic areas
High risk behavior
-HIV, IV drugs
Lymphadenopathy with constitutional symptoms such as fever, night sweats or weight loss indicate what disease processes?
TB, lymphoma, other malignancy
What medications can cause lymphadenopathy?
Atenolol, Cephalosporins, Penicillins, Sulfonamides
What are the 5 components of a lymphadenopathy exam?
Location
Size
Consistency
-Hard or Firm and Rubbery
Fixable vs. Mobile
Tenderness
What does the consistency of lymph nodes indicate?
Hard indicates cancer
Firm and rubbery indicates lymphoma
What do fixated vs. mobile lymph nodes indicate?
Normal lymph nodes are freely moveable in the subcutaneous space.
Abnormal nodes become fixed to adjacent tissue by invading cancer.
How long will patients with localized lymphadenopathy be observed for?
Three to four weeks if there is nothing else in the history, exam, or labs to suggest malignancy.
Biopsy is appropriate if an abnormal node has not resolved after four weeks.
What labs/imaging should be ordered for a patient with generalized lymphadenopathy?
CBC, CXR, HIV
This is a condition of painless, persistent edema in one or both lower extremities
Lymphedema
Essentials to diagnose are pitting edema without ulceration, varicosities, or stasis pigmentation. There may be episodes of lymphangitis and cellulitis.
Who does lymphedema primarily effect?
Young women.
What are the two generalized forms of lymphedema and what are their etiologies?
Primary form is due to congenital development abnormalities (lymphatic hypoplasia) that impairs lymph flow from the extremity.
Secondary form involves inflammation or mechanical lymphatic obstruction due to trauma, regional lymph node resection, irradiation, or malignancy/filariasis.
Symptoms of lymphedema
Aching discomfort with the sensation of heaviness or fullness
Hypertrophy of the limb with markedly thickened and fibrotic skin and subcutaneous tissue (late sign).
Pitting edema.
How many stages of lymphedema are there?
Four.
What imaging should you order for a patient with lymphedema?
MRI
Lymphangiography
US to evaluate for DVT
How do you treat lymphedema with medications?
Diuretic therapy
- Furosemide (Lasix) 40mg PO daily
- Bumetanide (Bumex) 1mg PO daily
Adverse reactions to diuretic therapy (lymphedema)
Hypokalemia
Metabolic alkalosis
Ototoxicity
Hypomagnesmia
Hypotension
Muscle cramps
Rash
Tinnitus
Contraindications to diuretic therapy (lymphedema)
Hypokalemia
Use caution if patient is in shock or severe renal disease
How can secondary cellulitis to a limb effected with lymphedema be avoided?
Good hygiene and treatment of any trichophytosis of the toes
Generalized allergic reactions generally occur how long after exposure?
60 minutes (immediate) or many hours to days after exposure (delayed).
This is a serious and life threatening manifestation of mast cell and basophil mediator release
Anaphylaxis
How is anaphylaxis defined?
Allergen exposure followed by acute onset of illness involving the skin or mucosal tissue and either respiratory compromise or hypotension.
Important: systolic blood pressure of less than 90 mmHg or 30% less than the known baseline.
How long does it take an immediate food reaction to manifest?
2 hours of ingestion of food.
Much less common in adults vs. children.
Most acute systemic food ALLERGY is caused by proteins in milk, egg, wheat, soy, fish, shellfish, peanuts and tree nuts.
Most common causes of ANAPHYLAXIS are shellfish, peanuts, and tree nuts.
What is required to diagnose a food allergy?
History, skin tests, and specific IgE tests.
How long does it take a medication reaction to manifest?
30 minutes after initial exposure.
What are the manifestations of the following body systems in a medication reaction?
Skin
Respiratory
GI
Hypotension
Skin: urticaria, flushing, blotchy rashes, pruritus
Respiratory: respiratory distress, wheezing, stridor, bronchospasm, airway angioedema
GI: cramping, emesis, diarrhea
Hypotension: lightheadedness, dizziness, syncope
Treatment of anaphylaxis
Epinephrine IM at the onset of anaphylaxis is the cornerstone of treatment
Dose: 0.2-0.5mg SC or IM q5-15 minutes, max dose is 1mg
Adverse reactions to epinephrine
Pulmonary edema, arrhythmias, hypertension, palpitations, tachycardia, anxiety, tremors
What antihistamines are recommended to treat allergies?
Loratadine (Claritin) 10mg PO once daily
Cetirizine (Zyrtec) 10mg PO once daily
Fexofenadine (Allegra) 60mg PO twice daily or 120mg PO once daily
What are adverse effects and contraindications of oral antihistamines?
Adverse effects: headache, dyspepsia, cough, myalgia, somnolence, dizziness
Contraindications: renal impairment, allergy to medication
Adverse reactions and contraindications of albuterol
Adverse reactions: hypertension, angina, arrhythmia, hypokalemia, nervousness, tremor, headache, tachycardia
Contraindications: ischemic heart disease, severe hypertension, arrhythmias
Adverse reactions and contraindications to corticosteroids
Adverse reactions:
- Adrenal insufficiency if taken longer than 7 days in a row.
- Cushings Syndrome with long term use.
- GI bleeding, hypertension, emotional lability.
Contraindications: systemic fungal infection, TB, uncontrolled hypertension, CHF, uncontrolled DM
How long must a patient treated for anaphylaxis be monitored?
4 hours, monitoring for delayed repeat anaphylaxis.
When should patients with anaphylaxis be evaluated by an allergist?
Patients with new or unexplained onset of anaphylaxis.
What is the definition of urticaria
Eruptions of evanescent wheals or hives
Itching is intense but rarely may be absent
Special forms have features such as dermatographism, cholinergic urticaria, solar urticaria, or cold urticaria.
How long do most incidents of urticaria last?
Acute and self limiting in 1-2 weeks
Chronic urticaria lasts longer than how many weeks?
6 weeks, and it may be due to an autoimmune issue.
Urticaria is most commonly caused by what immunologic mechanism?
IgE
Less commonly involves the complement cascade.
Individual lesions in true urticaria typically last how long?
<24 hours, often 2-4 hours.
What triggers cholinergic urticaria and how does it manifest?
Triggered by a rise in core body temperature (hot showers or exercise), the wheals are 2-3mm with a large surrounding red flare.
How does cold urticaria occur?
It is acquired or inherited and triggered by exposure to cold and wind.
Streaked urticarial lesions will be seen in what time frame before blisters appear due to what exposure?
Seen in the 24-48 hours before blisters appear in acute allergic plant dermatitis (exposure to poison ivy, oak, etc).
Complications of urticaria
Cellulitis from intense itching
Anaphylaxis
Asthma attacks
Angioedema is defined as what, and swelling will be seen in what parts of the body?
Swelling of vascular tissue involving deeper subcutaneous tissue with swelling of the lips, eyelids, palms, soles, and genitalia.
In hereditary angioedema, there is typically positive family history of angioedema, along with symptoms from what other body systems?
GI and respiratory symptoms.
What are common triggers of angioedema?
NSAIDs
ACEis
Estrogens
ASA
CCBs
Amiodarone
Treatment of angioedema
If it involves the mouth, face, or airway, then monitor for airway compromise and prepare for intubation if necessary
If it develops into anaphylaxis then give epinephrine, antihistamines and steroids
This is an inflammatory autoimmune disorder characterized by autoantibodies to nuclear antigens which can affect multiple systems.
Systemic Lupus Erythematosus
__% of SLE occurs in what gender?
85% of SLE occurs in females.
What are the signs and symptoms of SLE?
Butterfly (malar) rash seen in less than half of patients
Alopecia is common
Mucous membrane lesions occur during exacerbations
Fever, anorexia, malaise, weight loss
Joint symptoms are the earliest manifestation and occur in 90% of patients
What are ocular manifestations seen in SLE?
Conjunctivitis, photophobia, transient or permanent monocular blindness, blurred vision
Respiratory and Cardiac symptoms seen in SLE
Pleurisy, pleural effusion, bronchopneumonia, pneumonitis
The pericardium is affected in the majority of patients. Heart failure can occur from myocarditis and hypertension. Cardiac arrhythmias are common.
Neurologic symptoms of SLE
Psychosis
Cognitive impairment
Seizures
Peripheral and cranial neuropathies
Transverse myelitis
Strokes
What is a serious renal condition that can occur in a patient with SLE?
Glomerulonephritis
With proper treatment, survival rate is favorable but may require renal replacement therapy
What lab test is nearly 100% sensitive for SLE?
Antinuclear Antibody tests (ANA)
Nearly 100% sensitive for SLE but not specific.
What would you educate a patient with lupus about?
Avoid sun exposure, use protective lotion when out of doors.
Minor joint symptoms can be relieved by rest and NSAIDs.
