HEME/ONC Flashcards
What is the MCV, Iron Level, Ferritin level, and blood smear for Iron Deficiency anemia?
Low, Low, Low, and significant pallor
What is the MCV, Iron Level, Ferritin level, and blood smear for anemia of chronic disease??
low, low, normal or high. Normochrmic that progress to hypo chromic
What is the MCV, Iron Level, Ferritin level, blood smear, and Hg electrophoresis for alpha thalassemia?
Low, High, High, nothing on peripheral blood smear. Mostly HgA2 and a little more fetal than normal
What is the MCV, Iron Level, Ferritin level, blood smear, and Hg electrophoresis for beta thalassemia major?
low, high, high, nucleated RBCs, target cells, Heinz bodies. Increased HbF
What is the MCV, Iron Level, Ferritin level, blood smear, and Hg electrophoresis for beta thalassemia minor?
low, high, high, nucleated RBCs, target cells, Heinz bodies. Increased HgA2, with a little more fetal than normal
What is the MCV, Iron Level, Ferritin level, and blood smear for sideroblastic anemia?
High, High, High, and Pappenheimer bodies and bone marrow biopsy shows ringed sideroblasts
Associated disordes with Heinz bodies
Beta Thalassemia Major, Hemoglobin H disease
Associated disorder with Pappenheimer bodies
Sideroblastic anemia
associated disorder with Howell Jolly Bodies
sickle cell anemia
associated disorder with basophilic stippling
lead poisoning
If the etiology isn’t clear for Normocytic/ normochromic anemias, what can we do?
In the setting of anemia, the bone marrow should increase production of RBCs. Therefore, we should see an increase in reticulocytes
No increase increase in retics indicates the bone marrow isn’t responding → decreased production
Increase in retics indicates the bone marrow is responding appropriately → either increased destruction or acute loss
What are reticulocytes?
They are the precursors to erythrocytes. No nucleus, but do still contain RNA and mitochondria. Approximately 1% of total RBCs in blood are reticulocytes.
What is a retic count?
% of retics to total RBC count that will appear artificially elevated in anemia
How can we interpret a retic count in the presence of anemia?
Calculate corrected reticulocyte count (you have to do this, the lab won’t)
Corrected= retic count* (pt’s Hct/45)
Corrects for degree of anemia
Reflects level of bone marrow production
Low reticulocyte index ( <2) indicates the bone marrow isn’t responding → decreased production
Normal/high corrected retic index (>3) indicates the bone marrow is responding appropriately → increased destruction or loss
What is a Reticulocyte Production Index (RPI)?
In the setting of anemia, reticulocytes are released from bone marrow earlier than usual
Will last longer in the peripheral blood, which will inflate the retic count
RPI adjusts for longer maturation time
RPI used in MDCalc, but interpretation is similar to reticulocyte index
What are the appropriate labs for autoimmune hemolytic anemia?
positive DAT aka Coombs Test will detect significant amouns ot IgG and C3 complement on RBCs
Schistocytes on peripheral smear, Hemoglobin electrophoresis
Increased: RDW, K, bilirubin, LDH
Decreased: haptoglobin
What are the appropriate labs for beta thalassemia major?
CBC: severe microcytic, hypochromic anemia
Smear: Nucleated RBCs, target cells, Heinz Bodies
Electrophoresis: Increased HbF and Hgb A2, minimaal Hgb A
What are the appropriate labs for sickle cell anemia?
CBC: severe normocytic, normochromic anemia, increased WBCs and platelets
Smear: sickle cells, target cells, nucleated RBCs, Howell-Jolly bodies
Retic count: 10-20%
Hemoglobin electrophoresis shows only Hgb S
What are the appropriate labs for vitamin B12 deficiency?
CBC: macrocytic with hypersegmented neutrophils (>5 nuclear lobes per cell)
Smear: oval macrocytes
Descreased Serum B12 level
Increased Homocystein and Methylmalonic acid
List the possible causes of bleeding disorders
Medications like heparin, antibiotics, NSAIDS, anti-epileptics
Sepsis
Infection- HIV, Hepatitis C
Liver disease
Microangiopathic disorders- DIC, TTP, HUS
Autoimmune-ITP
Systemic diseases- Lupus
What factors are involved in the intrinsic pathway?
TENEX
Tweleve, Eleven, Nine, Eight
work on Factor X
What factors are involved in the extrinsic pathway?
Factor VII
common pathway
actor X is cleaved into Xa which activates prothrombin → thrombin → fibrin → fibrin monomers → fibrin polymers
What would you suspect would be the bleeding disorder(s) and follow-up testing for each of these values?
What would the associated labs be for these values?
Explain the workup for a patient with suspected hypercoagulability disorder
Protein C and Protein S levels
Prothrombin level
Antithrombin level
Homocysteine level
Factor V Leiden and prothrombin G2021A mutations
Antiphospholipid syndrome tests
→ antibodies to cardiolipin and GP1
→ presence of lupus anticoagulant (which causes blood clots)
Workup will be skewed if pt is on anticoagulant meds
What labs are used to monitor coumadin, aka warfarin?
It is a vitamin K antagonist that works on Factors II, VII, IX, X that require Vitamin K as a cofactor
PT/INR (extrinsic and common)
Will be elevated initially and over time stabilize with treatment
Proper dosage= 2-3 times pre-therapy level
INR= 2.0-3.0 (may be different for pt w/ mechanical heart valve)
How does Heparin work in the coagulation cascade?
Unfractionated (UF- ex: heparin)
LMWH like lovenox tends to have fewer side effects
Synthetic LMWH (fondaparinux- Arixtra)
What are the monitoring anticoagulant therapeutic tactics for Heparin?
PTT (intrinsic and common)-nursing protocol driven
Proper dosage PTT 1.5-2.5 times normal (45-75 secs)
Other monitoring Anti-Xa assay or Activated Clotting Time assay
Need to monitor platelet count: heparin can induce HIT via stimulation of auto-antibodies, so platelet count needs to be monitored
Heparin-Induced Thrombocytopenia (HIT)
What are labs for monitoring direct thrombin inhibitors?
No monitoring usually necessary
Labs can develop in-house anti-factor Xa assay for direct factor Xa inhibitors
Thrombin time can be used with direct thrombin inhibitors
PTT may be elevated if levels are too high
What are the signs and sx of a transfusion rxn?
We don’t want a hemolytic reaction to occur, because in this circumstance, they can be prevented
Fever and chills are the most common
Renal failure-dark urine
DIC
Back pain
What lab tests can help confirm a transfusion rxn?
Hgb/Hct - Hgb will be decreasing
CMP - checking kidney function
DAT (Coombs)
Peripheral Smear
Blood cultures, if infection suspected
Urinalysis
Complete the table
What disorder would you expect with > 20% blast cells on bone marrow biopsy
Leukemia
What disorder would you expect with Auer rods on bone marrow biopsy
AML
What disorder would you expect with Reed-Sternberg cells on lymph node biopsy
Hodgkin’s Lymphoma
What disorder would you expect with Smudge cells on peripheral blood smear
CLL
What disorder would you expect with Philadelphia chromosome (t9;22)
CML
What disorder would you expect with Elevated WBCs, mainly lymphocytes
ALL
What disorder would you expect with Elevated WBCs, mainly neutrophils, basophils, eosinophils
CML
What disorder would you expect with Multiple enlarged lymph nodes in the same body region
Hodgkin’s Lymphoma
What disorder would you expect with Lytic lesions on x-ray
Plasma cell Myeoloma
What disorder would you expect with M spike on SPEP
Plasma cell Myeoloma
What are Neutrophils?
Non-specific pagocytic cells that cna be segmented (segs) and more mature form with a lobed nucleus
Bands-less mature form and look like a horseshoe-shaped nucleus, increased in bacterial infections
What is a “left shift”?
Metamyelocytes and myelocytes are immature cells usually found only in bone marrow. Presence of metamyelocytes and/or myelocytes indicated either an overwhelming infection or a bone marrow disorder
What are the ranges of cell types for WBCs?
What is the absolute neutrophil count (ANC)?
Total number of segmented and bands combined
What is the predominate cell type in adults?
Neutrophils
What is plasma cell myeloma?
Uncontrolled proliferation and uncontrolled production of monoclonal antibodies by plasma. Malignant plasma cells invade the bone marrow, leading to lytic lesions in bone. Rouleaux seen in peripheral blood
What is the testing for plasma cell myeloma?
CMP= elevated total protein, maybe elevated calcium
Imaging= lytic lesions in bone
Protein electrophoresis
Serum protein electrophoresis (SPEP)-shows M (monoclonal) band from IgG or IgA (“M spike”)
Urine protein electrophoresis (UPEP)- shows free light chains (Bence Jones protein) band
Pathophysiology of TTP
ADAMTS13 inhibiting vWF and promoting clot formation
Pathophysiology for Sideroblastic Anemia
Heme isn’t being broken down properly so it will cause neuro development issues. Leading causes are lead and copper toxins.
Pathophysiology of Hemochromatosis
iron isn’t metabolized and gets dropped off in different organs. elevated liver enzymes and elevated iron panel
Pathophysiology of anemia of chronic disease
tissues are holding onto iron stores. Causing systemic anemia, because it wants to save iron for its chronic inflammation
DX workup for Beta Thalassemia Minor
retic count will be high, target cells, loss of beta globin chains. Hemoglobin electrophoresis is the gold standard and will have mostly HgA2 and moe HgF than normal
DX workup for Beta Thalassemia Major
retic count will be high, target cells, loss of beta globin chains. Hemoglobin electrophoresis is the gold standard and will have mostly HgF
DX workup for G6PD Deficiency?
serum levels of G6PD
decreased hemoglobin, normocytic, increased retics, negative Coombc, elevated bilirubin will lead to jaundice. ASK IF THEY HAVE HAD JAUNDICE BEFORE, if not during a crisis.
DX workup for TTP
CBC: low platelets, sick, using up all their platelets, decreased hemoglobin because they are hemolytic, schistocytes, elevated LDH, elevated retics, decreased haptoglobin and elevated bilirubin
DX workup for Hemophilia A
decrease in Factor VIII. CBC w/ diff is normal, PT/INR is normal, but PTT is elevated. We will need to do a mixing study to confirm
What are the indications for packed red blood cells?
Hemoglobin less than 7
Look for heart disease and heart muscle disorders because these are the one exception (prior CAD as well)
SX: chest pain, SOB, lightheaded
What are the indications for platelets?
<10,000, we transfuse platelets because they are at risk of spontaneous bleeding. May want a patient going into surgery to be >50,000. Platlets only survive up to 5 days after donation because they must be kept at room temperature. LARGE RISK OF INFECTION
What are the causes and sx of acute hemolytic transfusion reaction?
Occurs within hours, increased retics, significant back pain, fever, decreased hemoglobin, increased bilirubin. This occurred, because they got the wrong type of blood. Blood cells are starting to clump together, shreds capillaries in organs, especially kidneys and can lead to kidney failure.
What are the causes and sx of nonhemolytic febrile transfusion reaction?
fever
not a reaction to receiving blood
What are the causes and sx of an anaphylaxis transfusion reaction?
NAUSEA/VOMITING. swelling, angioedema, hives, HYPOTENSION. something is causing a big histamine reaction
With which drug is HIT most likely to occur?
LMWH
