Heme

Question 1

Acute hemorrhage

Answer 1

Class 1: up to 15% blood loss
-minimal changes in vitals

Class 2: 15-30% blood loss
- tachycardia, tachypnea, dec pulse pressure

Severe hemmorrhage
-big drop in BP, tachycardia, weak pulse, elevated RR. Dec urine output, mental status changes

Normal for reticulocytosis after blood loss

Question 2

Neutropenia

Answer 2

Most common causes: benign ethnic neutropenia and drug-induced neutropenia. Medication induced.
If febrile and you suspect bacterial infection - need urgent eval

Dx: CDC w/ diff and blood smear

Question 3

Vit B12 Deficiency

Answer 3

S&S: Gradual onset symmetric peripheral neuropathy in feet/arms. Numbness, ataxia (positive Romberg), loss of vibration, and position sense, impaired memory, and dementia (severe cases)

Dx: Peripheral smear shows macro-ovalocytes, some megaloblasts, and multisegmented neutrophils (>5 or 6 lobes). The mean corpuscular volume (MCV) is >100 fL.

Question 4

Hodgkin’s Lymphoma

Answer 4

Cancer of beta lymphocytes (B cells)

S&S: Night sweats, fevers, and pain with ingestion of alcoholic drinks. Generalized pruritus with painless enlarged lymph nodes (neck). Anorexia and weight loss.

Dx: Identified by the presence of Reed–Sternberg cells.

Question 5

Non-hodgkin’s Lymphoma

Answer 5

Cancer of B-cells

S&S: night sweats, fever, weight loss, generalized lymphadenopathy (painless).

The prognosis is poor.

Question 6

Multiple Myeloma

Answer 6

Cancer of plasma cells

S&S: fatigue, weakness, and bone pain that is usually located in the back or chest.

Dx: Causes proteinuria with Bence–Jones proteins, hypercalcemia, and normocytic anemia.

Question 7

Thrombocytopenia

Answer 7

Defined as a platelet count of <150,000/μL.

Symptoms usually do not show until the platelet count is <100,000/μL.
Look for easy bruising (ecchymosis, petechiae), bleeding gums, spontaneous nosebleeds, and hematuria.

Question 8

Hemophilia A

Answer 8

X-linked recessive dz, factor VIII deficiency

S&S: easy bruising, excessive bruising, bleeding into joints (hemarthrosis), bleeding for several hours to days (circumcision, dental extractions), severe bleeding with trauma, heavy menses, and hematuria.

Dx: activated partial thromboplastin time (aPTT) is prolonged, and the prothrombin time (PT), fibrinogen, and platelets are normal.

Question 9

Normal lab values

Answer 9

Hemoglobin
Males: 14.0 to 18.0 g/dL
Females: 12.0 to 16.0 g/dL

Hematocrit
The proportion of red blood cells (RBCs) in 1 mL of plasma
Males: 42% to 52%
Females: 37% to 47%

Mean Corpuscular Volume (MCV)
Normal: 80 to 100 fL (femtoliter)

MCHC
Normal: 31.0 to 37.0 g/dL

MCH
Normal: 25.0 to 35.0 pg/cell

TIBC

Normal: 250 to 410 mcg/dL

Question 10

Secondary Polycythemia

Answer 10

Common w/ chronic smokers, COPD, and people living at high altitudes

Hematocrit in adults of more than 48% in women and more than 52% in men
Hemoglobin in adults of more than 16.5% in women and more than 18.5% in men

Question 11

Iron-Deficiency Anemia

Answer 11

Cause: usually blood loss, heavy periods, low diet intake

S&S: asymptomatic if mild.
Moderate-to-severe cases may have pallor of the skin, conjunctivae, and nail beds. Complaints of daily fatigue and exertional dyspnea. May have glossitis (sore and shiny red tongue) and angular cheilitis (irritated skin or fissures at the corners of the mouth). Cravings for nonfood items such as ice or dirt (pica).
Severe anemia will cause spoon-shaped nails (koilonychia), systolic murmurs, tachycardia, or heart failure.

Dx:
MCV (size) and MCHC (color) can still be in the normal range, and the RBCs will be normocytic and normochromic.
Decreased hemoglobin and hematocrit

Tx:
Correct cause if possible
Ferrous sulfate (take with vit C for absorption)
Increase fluid/fiber
H&H will normalize in 2 months
SE: constipation, black-colored stools
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Question 12

Thalassemia Minor

Answer 12

Genetic disorder, bone marrow produces abnormal hemoglobin

S&S: asymptomatic

Dx: hemoglobin electrophoresis
In beta-thalassemia, abnormal (elevated hemoglobin A2 [HbA2] and Hb F, or fetal hemoglobin)
In alpha thalassemia, abnormal (Hb Barts, absence of Hb A)

MCV <80 fL (microcytic)
MCHC ↓ (hypochromic)

TX: none needed

Question 13

Anemia of Chronic Disease

Answer 13

Autoimmune diseases (e.g., rheumatoid arthritis [RA], lupus) or chronic inflammatory disorders impair bone marrow function and cause normocytic anemia (MCV 80–100 fL).

The erythrocyte sedimentation rate (ESR or sed rate) or C-reactive protein (CRP) are elevated.

Treatment of underlying autoimmune disease will reduce systemic inflammation and may help the bone marrow recover.

Question 14

Anemia of Chronic Kidney Disease

Answer 14

Occurs due to the decrease in renal EPO production secondary to the CKD

Obtain CBC, serum ferritin, serum transferrin saturation, vitamin B12, folate, and reticulocyte count.

Tx: The anemia should be treated using conventional methods. If not improving, then erythropoiesis-stimulating agents should be used.

Question 15

Vitamin B12–Deficiency Anemia

Answer 15

Cause: malabsorption, pernicious anemia

Chronic can cause nerve damage and brain damage when severe

Question 16

Pernicious Anemia

Answer 16

Cassation of intrinsic factor (needed to absorb vit B12)

S&S: Gradual onset
Tingling/numbness of hands and feet
Neuropathy starts in peripheral nerves and migrates centrally
Difficulty walking (gross motor)
Difficulty in performing fine motor skills (han
Decreased reflexes in affected extremity, decreased vibration sense, abnormal Romberg

Dx: Always check both serum B12 and serum folate levels in macrocytic anemias
Antibody tests: Antiparietal and anti-intrinsic factor (IF) antibody
Homocysteine level: Elevated
24h urine MMA elevated

TX:
Initially, give B12 injections
Alternative is very high oral doses of B12

Question 17

Aplastic Anemia

Answer 17

destruction of the pluripotent stem cells inside the bone marrow and has multiple causes (e.g., radiation, adverse effects of a drug, viral infection).
Bone marrow production slows or stops

S&S: fatigue and weakness. Skin and mucosa are a pale color. Tachycardia and systolic flow murmur. Thrombocytopenia results in large bruises from trauma and bleeding

Dx: pancytopenia (leukopenia, anemia, thrombocytopenia).
Gold standard is the bone marrow biopsy.

Tx:
Refer to hematologist

Question 18

Hemochromatosis

Answer 18

intestinal absorption of iron increases, leading to total-body iron overload

S&S: chronic fatigue, skin hyperpigmentation (bronze), swelling of the second and third metacarpal phalangeal joints (fingers), and generalized joint stiffness

Tx:
therapeutic phlebotomy

Question 19

Folic Acid–Deficiency Anemia

Answer 19

damage to the DNA of RBCs, which causes macrocytosis

Cause: Inadequate dietary intake (elderly, infants, alcoholics, overcooking vegetables, low citrus intake)

S&S: same as anemia, no neurological complaints

Dx: Decreased hemoglobin and hematocrit, increased MCV

Tx: Correct primary cause. Improve diet.
folic acid PO