heme onc Flashcards
*What is the difference between Mean Corpuscular Hemoglobin and Mean Corpuscular Hemoglobin Concentration?
Normals for each?
MCH: avg WEIGHT (amount) of hg in one erythrocyte
- normal: 26 - 34
MCHC: avg CONCENTRATION of hgb, ie, the % proportion of an RBC occupied by hgb MORE ACCURATE
- normal: 32 - 36
What is the percentage of a volume of whole blood that is erythrocytes?
hematocrit
hematocrit normals
M 40 - 54%
F 37 - 47%
What is Mean Corpuscular Volume? Normals?
avg vol & size of individual erythrocytes
MCV value 80-100
Mean Corpuscular Hemoglobin Concentrations (MCHC)
average Hgb concentration
MCHC normal value 32-36%
*Differentials for LOW MCV
iron deficiency anemia
thalassemia
*Differentials for HIGH MCV
the megaloblastic anemias: B12 & folate deficiency
alcoholism, liver failure, drug effects
*Differentials for NORMOCYTIC MCV
anemia of chronic disease sickle cell anemia renal failure blood loss hemolysis
microcytic hypochromic anemias
iron deficiency
thalassemia
macrocytic normochromic anemias
B12 (pernicious anemia)
folate deficiency anemia
normocytic normochromic anemias
anemia of chronic disease
sickle cell anemia
blood loss
What is iron deficiency anemia?
microcytic hypochromic anemia d/t overall decreased iron intake; less iron available for RBC formation
most common anemia
iron deficiency anemia: s/s x9
SLOW onset; symptoms really kick in when hct drops below 30
** pica **
dyspnea, mild exertional fatigue
palpitations, tachycardia, postural hypotension
weakness, pallor, HA
iron deficiency anemia: hallmark diagnostics x4
Low MCV & MCHC **
Low ferritin ** (stores)
High TIBC ** (capacity for more iron)
iron deficiency anemia: management
Ferrous Sulfate 300-325 mg PO 1-2 hours after meals
+ foods high in iron
Ferrous sulfate: indication and considerations x4
treatment for iron deficiency anemia
- take 1-2 hours after meals
- vitamin C increases absorption
- do not take with antacids (interfere with absorption)
- GI effects: n/v/d/ cramps
What is ferritin?
iron stores
What anemia is characterized by low ferritin and high TIBC?
iron deficiency anemia
What is thalassemia?
- microcytic hypochromic anemia
genetic disease = abn hgb production
thalassemia: s/s
unremarkable unless severe
thalassemia: diagnostics
Low MCV & MCHC **
Normal ferritin & TIBC **
Decreased hgb & alpha or beta chains in hgb
thalassemia: mgmt
none if moderate disease
if severe: RBC transfusion, splenectomy
NO IRON; IRON OVERLOAD RESULTS
What is contraindicated in the management of Thalassemia?
iron - the body will be overloaded with iron because it can’t use it
What is folic acid deficiency anemia?
macrocytic normochromic; anemia resulting from lack of folic acid, duh
** d/t either malabsorption or decreased intake **
folic acid is needed for RBC production
folic acid deficiency anemia: s/s
glossitis **
the standard other anemia s/s: fatigue pallor palpitations weakness headache
folic acid deficiency anemia: diagnostics
High MCV (100+)
Normal MCHC (32-36%)
Low serum folate
Decreased HCT & RBCs
folic acid deficiency anemia: mgmt
Folate 1 mg PO QD
+ foods high in folic acid: naners, PB, fish, leafy greens, iron-fortified shits
What’s an easy way you can differentiate between folic acid deficiency and pernicious anemia?
pernicious has neuro symptoms, folic acid deficiency does not
Which anemia is most important to ask alcoholic patients about?
folic acid deficiency: because of poor PO intake
What is pernicious anemia?
macrocytic normochromic, aka B12 deficiency anemia
buuuuuuuut really it isn’t d/t lack of B12, it’s d/t a deficiency of INTRINSIC FACTOR that results in MALABSORPTION of B12
pernicious anemia: s/s
NEUROLOGICAL SX EXPLOSION: parasthesis, loss of vibratory sense and fine motor control, + romberg and babinski
oh yeah, and glossitis** then all the typical anemia stuff
Your patient has a beefy ol’ red tongue. “Oh shit,” you say to yourself, “It might be…” ???
folic acid or pernicious anemia
pernicious anemia: diagnostics
↑ MCV
Normal MCHC
↓ serum B12 (less than 0.1)
↓ H&H + RBCs
anti-intrinsic factor (IF) and antiparietal cell ab test affirms deficiency
pernicious anemia: mgmt
cyanocobalamin (B12) 100 mcg IM QD x 1 wk
maintenance: continuous life long monthly injections. that sucks
What is the dose and route of B12 indicated for B12 Deficiency Anemia?
B12 100 mcg IM x 1 week
B12 100 mcg IM x 1 month for life
What the boop is anemia of chronic disease?
normocytic normochromic anemia in which the life span of erythrocytes is decreased
second most common cause of anemia, #1 in them ol’ folks
anemia of chronic disease: causes
the etiology is unclear, but it is associated with
chronic inflammation
infection
renal failure
malignancy
Renal failure is associated with what -cytic/-chromic of anemia?
normocytic normochromic
anemia of chronic disease: diagnostics
Normal MCV & MCHC
↓ iron & TIBC
↑ ferritin
anemia of chronic disease: mgmt x3
TREAT UNDERLYING CAUSE
Nutritional support
Epoetin alfa (Epogen) - super third line option
IRON IS A NO NO - the body is already carrying tons
What is the most common type of anemia in the elderly?
anemia of chronic disease
Which two anemias is iron contraindicated in management plan?
thalassemia - body can’t do shit with it
anemia of chronic disease - the body already got too mucha dat shit
sickle cell anemia: pathophys
genetically transmitted disease → hemolytic and sickle shaped RBCs
acute exacerbations: RBC sickle & clump & occlude blood vessels (hyperviscosity)
→ cellular hypoxia → tissue ischemia & acidosis
murky blood + ischemia = pain pain pain
sickle cell anemia: precipitating factors
dehydration ** emotional or physical stress ** infection blood loss surgery high altitudes acidosis
What makes sickle cell crises so damn painful?
tissue ischemia & blood hyperviscosity
sickle cell crisis: s/s
sudden, severe pain: back, chest, extremities, aching joints** d/t blocked circulation
sickle cell anemia: mgmt
IVF first
analgesia: IV morphine & hydromorphone (Dilaudid)
O2
Your patient is having a sickle cell crisis - what is your priority intervention?
IVF to increase production of RBC
What anemia is characterized by:
↓ iron
↓ TIBC
↑ ferritin
anemia of chronic disease
What is leukemia?
Neoplasms arising from hematopoietic cells in the bone marrow.
Acute Myelogenous Leukemia (AML)
Leukemia: neoplasms arising from hematopoietic cells in the bone marrow.
80% of acute leukemias in adults
Chromic Myelogenous Leukemia (CML) hallmark sign
philadelphia chromosome in leukemic cells
Acute Lymphocutic Leukemia (ALL): hallmark lab **
pancytopenia with circulating blasts
Chronic Lymphocytic Leukemia (CLL)
most common leukemia in ADULTS
lymphocytosis is disease hallmark
Pancytopenia with circulating blasts is the hallmark of what?
acute lymphocytic leukemia (ALL)
Philadelphia chromosome is associated with which kind of leukemia?
Chronic myelogenous leukemia (CML)
leukemia presentation
can be asymptomatic!
generalized lymphadenopathy
acute weight loss
fatigue, weakness, anorexia
leukemia diagnostics x3
definitive diagnosis: bone marrow aspiration
peripheral blood smear
bone marrow aspiration
What can you order to distinguish acute from chronic leukemia?
peripheral blood smear
leukemia: mgmt
chemotherapy
bone marrow transplantation
supportive care
RADIATION IS NOT A PRIMARY STRATEGY
What is lymphoma?
a lymphocytic malignancy - lymphocytes are a kind of leukocyte
- examples include NK and B cells
Describe Non-Hodgkin’s Lymphoma
most common neoplasm in 20-40 yo
often presents with lymphadenopathy, spread is less predictable than Hodgkin’s
advanced disease is usually apparent
Describe Hodgkin’s Lymphoma
more common in males; avg age 32
usually presents with cervical adenopathy + a predictable spread
hallmark: Reed Sternberg cells
Which cancer often presents as cervical adenopathy with a predictable spread?
Hodgkin’s lymphoma
How do you diagnose a lymphoma?
biopsy enlarged lymph nodes and staeg
lymphoma: general mgmt
radiation
chemo
bone marrow tx
Reed Sternberg cells are a hallmark sign of what type of cancer?
Hodgkin’s lymphoma
What is idiopathic thrombocytic purpura?
thrombocytopenia (platelet deficiency) caused by autoimmune destruction of platelets
sometimes thrombopoiesis can be suppressed
usually a chronic condition, can be asymptomatic for long intervals
ITP: s/s
↑ bleeding & bruising
low platelet count
idiopathic thrombocytic purpura
Where do adults bleed first?
gums
kidneys
(occult!)
What is Disseminated Intravascular Coagulation?
acquired coagulation disorder
- caused by intravascular activation of coagulation + fibrinolytic systems (thrombin + plasmin activated)
- simultaneous hemorrhage & thrombosis
** DIC: patho **
THROMBIN converts FIBRINOGEN → FIBRIN
= fibrin clots in microcirculation
= ↓ coagulation factors (fibrinogen, prothrombin, plts, V, VIII)
THROMBIN activates FIBRINOLYTIC SYSTEM
= lyses FIBRIN CLOTS → FIBRIN DEGRADATION PRODUCTS (FDP)
= FDP anticoagulant activity → hemorrhage + coag factor depletion
What lab values are pretty diagnostic for DIC?
+ D-Dimer
↑ FDPs
predictive accuracy 96%
DIC: mgmt *
TREAT UNDERLYING CONDITION
- plt transfusion
- FFP (replace clotting factors)
- cryoprecipitate (maintain fibrinogen levels)
OVERALL GOALS
1. stop bleeding 2. ↑ fibrinogen + plt, 3. ↓ FDP
What is the point of cryoprecipitate in DIC mgmt? *
maintain those fibrogen levels - this kills the crab I mean reverses the patho of DIC
What is the duration of Ferrous Sulfate therapy for the treatment of iron deficiency anemia?
4 - 6 months
What intervention is indicated in the correction of supra therapeutic PT and PTT?
FFP
What electrolyte abnormalities are associated with blood transfusions
hypocalcemia
hyperkalemia
Half life of warfarin (Coumadin)
36 - 42 hrs
20 mg IV morphine is the equivalent of __ PO morphine?
60 mg PO morphine
What is the most common type of anemia across all age groups?
iron deficiency
Why do we care about Total Iron Binding Capacity? Normal?
Transferrin is the protein that carries loose iron around in the blood. TIBC tells us if the transferrin molecules are carrying a lot of Fe or if the body has the capacity to bind more.
250 - 450 ug/dL
What are some examples of iron-rich foods?
raisins leafy greens red meat citrus iron fortified shit
Thalassemia is found mainly in which populations?
Mediterranean, African, Middle Eastern, Indian, Asian
Why does anyone care about folic acid?
Because it is needed to make RBCs.
What should you always think through when considering an anemia?
hgb & hct duh
MCV: volume of RBC
MCHC: % of an RBC that is hgb
What’s the big fancy word for B12?
cyanocobalamin
What’s a great analgesic combo for painful things like sickle cell crises or nephrolithiasis?
morphine + dilaudid
Why do joints hurt in sickle cell crises?
blocked circulation
sickle cell anemia: dx
↓ hgb
peripheral smear: classic distorted sickled RBCs
cellulose acetate and citrate agar gel electrophoresis confirm hgb genotype
What do you order to confirm diagnosis of leukemia?
bone marrow aspiration
What kind of cancer does not have radiation as a primary strategy?
Leukemia
How can you differentiate Hodgkin’s from Non-Hodgkin’s lymphoma?
look for Reed Sternberg cells (Hodgkin’s)
lymphadenopathy has a less predictable spread in Non-Hodgkins; Hodgkins is cervical adenopathy with a predictable pattern
How do you stage lymphomas?
biopsy enlarged node and decide:
Stage I: single node/group
Stage II: +1 group on 1 side of diaphragm
Stage III: spleen involved, nodes on both side of diaphragm
Stage IV: liver or bone marrow involved
Your patient is a 29 yo male who presents with sudden weight loss and cervical adenopathy. What is an important ddx to consider? What lab is important to order?
Hodgkin’s Lymphoma
- mostly males, avg age 32
- cervical adenopathy + predictable pattern
- order a lab to look for Reed Sternberg cells
How serious is idiopathic thrombocytopenia purpura?
eh - it can be asymptomatic for long periods and patients only occasionally develop bleeding requiring hospitalization
mgmt may not be necessary until plt less than 20000
ITP: mgmt
may not be necessary until platelets under 20,000
- high dose CORTICOSTEROIDS: ↑ plt w/in 2 - 3 days
- IV gamma globulin helps too
- plt transfusions = occasional benefit
Describe thrombocytopenic precautions *
- avoid constipation (fiber, laxatives)
- no flossing or shaving
- hold pressure 5+ minutes for cuts, line insertion, etc
Your patient has some thrombocytopenia going on. You have a few suspected etiologies, but how would you differentiate between idiopathic thrombocytopenia purpura from systemic lupus erythematosus? *
analyze dat bone marrow
fibrinogen normal *
170 - 400
FDP normal *
under 10 mcg/mL
40+ is considered critical
normal PT + PTT *
PT 11 - 14 sec
PTT 25 - 35 sec
RBCs normal *
just go with 4 - 5 million/uL
difference between PT + PTT + aPTT *
how long does it take blood to clot?
PT: measures extrinsic system integrity
PTT: measures intrinsic system integrity
aPTT: used to monitor heparin
how does heparin work? what do you use to monitor its efficacy?
inhibits factors X and thrombin, while activating anti-thrombin
aPTT
how do you distinguish thalassemia from a GI bleed?
↓ MCV + MCHC
microcytic, hypochromic anemia
what is considered high ferritin level in anemia of chronic disease? *
greater than 100 ng/mL
DIC think…
FDP
HIT tx *
direct thrombin inhibitor
argatroban
lepirudin
