Heme/Onc Flashcards
Best initial test for smoker presenting with palpable cervical lymph node
Panendoscopy
(esophagoscopy, bronchoscopy, laryngoscopy), then biopsy (suspected SCC of head and neck)
Empiric anticoagulation only for suspected ___, not for suspected ___
PE; DVT
Do not use apixaban (or direct factor Xa inhibitors) in ____
ESRD (severe renal disease)
Facial plethora (ruddy cyanosis)
Polycythemia Vera
+aquagenic pruritus
INH side effects
INH: Peripheral Neuropathy, Hepatotoxicity
Increased RBCs DDx
- PV
- Chronic hypoxia (e.g. OSA)
- EPO-producing tumors
Smudge cells on smear
CLL
Excessive bleeding after dental procedure
Hemophilia vs. vWF
B cell only disorders of immunodeficiency
XLA, CVID, IgA
B + T cell disorders of immunodeficiency
SCID, WAS, Hyper-IgM, Ataxia-telangiectasia
No response to vaccination
SCID, XLA, CVID
(Absent/low/dysfunctional B cells)
Recurrent disseminated bacterial infections (SHiN)
Complement deficiency
Recurrent GI infections, think these bugs:
Salmonella, Campylobacter
Blasts on smear
ALL
Recurrent respiratory infection general examples
PNA, sinusitis, otitis
T cell only disorders of immunodeficiency
- DiGeorge
- IL-12 receptor deficiency
- Hyper-IgE (Job)
- Chronic mucocutaneous candidiasis
Phagocyte dysfunction
CGD, LAD, Chédiak-Higashi
Hematopoietic stem cell transplantation treats:
SCID or WAS
Triphalangeal thumbs
Diamond-Blackfan Anemia
(Congenital pure RBC aplasia that presents within first 3 months of life as pallor, poor feeding, congenital anomalies such as thumbs, webbed neck, cleft lip, short stature, shielded chest)
Tx: Corticosteroids
Acquired RBC aplasia in healthy children between 6mo to 5yo
TEC (Transient erythroblastopenia of childhood)
(Labs: normocytic normochromic anemia and extremely low reticulocyte count)
Most common cause of anemia in preterm infants
Anemia of prematurity
(Diminished EPO levels, shortened RBC life span, +/- blood loss)
Path: Premature infant —> Increased O2 concentration in tissues after delivery —> Normal decrease in EPO (erythropoietin) —> decreased BM reticulocyte production —> Expected RBC nadir is worsened due to SHORTER RBC life span (40-50d) from prematurity +/- frequent phlebotomy in NICU —> Early-onset anemia
Low iron/high ferritin/low TIBC
ACID (Anemia of Chronic [Inflammatory] Disease)
Microcytic anemia DDx
LIT ASS
- Lead poisoning
- Iron deficiency
- Thalassemias
- Anemia of Chronic Disease
- Sideroblastic anemia
- Spherocytosis (normal to low MCV)
RBCs in OSA
Elevated (Reactive polycythemia)
(Hypoxemia —> Increased EPO from kidneys —> Elevated H&H)
Spinal mets DDx
Lung/breast/prostate cancer, MM
ABO/Rh risk to fetus:
AB “O” shit
“Rh negative Nancy” mom
Leukocyte alkaline phosphatase (LAP) levels
CMLow** vs. LeukeMORE reaction**
Low LAP = CML, High LAP = leukemoid reaction
Elevated MCHC
Hereditary spherocytosis
- AD North European
- Gallstones (pigmented)
- B19 Aplastic anemia
- AGLT (Acidified Glycerol Lysis Test)
- Osmotic fragility on AGLT
- EMA binding test (Eosin-5-Maleimide binding test)
- Tx: Folate, splenectomy, cholecystectomy, +/-transfusion
Elevated urinary VMA (vanillylmandelic acid)
Pheochromocytoma
Upper body edema + weight loss
SVC syndrome
(Mediastinal tumor malignancy–SCLC or NHL)
Elevated AFP + malignancy
Nonseminomatous germ cell tumor (4 T’s) vs. HCC
- 4 T’s = mnemonic for mediastinal mass (Teratoma in this case)
Increased in B12 deficiency, Normal in folate deficiency
Methylmalonic acid (MMA)
Absent/hypoplastic thumbs
Fanconi Anemia
- AR DNA repair defect presenting 8-16yo with bleeding, fatigue, hearing problems, and absent thumbs
- Other signs: Macrocytic anemia, short stature, absent thumbs, hypogonadism, microcephaly, hypopigmented areas, café au lait spots, large freckles, strabismus, low-set ears, and hearing problems 2/2 conduction abnormalities
- Dx: Chromosomal breaks on genetic analysis
- Tx: HCT
Howell-Jolly bodies
SCD or splenectomy
(nuclear remnants within RBCs that are normally removed by spleen; single/blue/round on Wright stain)
Basophilic stippling DDx
- Lead poisoning
- Heavy metal poisoning
- Thalassemias
- Alcoholism
Recurrent hemarthrosis
Hemophilia A/B/C
- A = XR, FVIII
- B = XR, FIX
- C = AR, FXI
Fever + hemolysis
TTP (Thrombotic thrombocytopenic purpura)
FAT RN
- Fever
- Anemia (MAHA)
- Thrombocytopenia
- Renal disease
- Neurological sx
- Tx: Emergent plasmapheresis! (plasma exchange)
FFP is used for:
- Warfarin reversal
- Factor V deficiency
- Factor VIII deficiency (Hemophilia A)
- ATIII deficiency
- TTP
Vitamin K-dependent coagulation factors
1972 + C & S
(II, VII, IX, X, Proteins C & S)
Procoagulant meds
- TXA
- Aminocaproic acid (Amicar)
Hemolysis (LDH/Bili/Haptoglobin) + Thrombosis
PNH
(Paroxysmal Nocturnal Hemoglobinuria)
- Genetic absence of CD55 & CD59 protein anchors on RBC surface, allowing complements to attach RBCs –> hemolysis
- Dx: Absence of CD55/59 on flow
- Tx:
- Iron & Folate supplementation
- Eculizumab (mAb that inhibits complement activation)
Osteoclast inhibitor
Bisphosphonates
(Alendronate, zoledronic acid, pamidronate)
- Tx for hypercalcemia
Anemia in ESRD
EPO deficiency
- Tx = EPO therapy *BUT* always try iron first!
Drugs that induce folate deficiency
TMP
- TMP-SMX
- Methotrexate
- Phenytoin
Smudge cells on smear
CLL
ALL = lymphoblastic;
CLL =lymphocytic
- ALL = blasts on smear;
- CLL = smudge cells on smear (+ mature lymphocytes)
Pinpoint bruises
Petechiae = LOW PLATELETS!!!
Excessive bleeding after dental procedure
hemophilia vs. vWF
Recurrent respiratory
e.g. PNA, sinusitis, otitis
Recurrent GI
e.g. Salmonella, Campylobacter
Recurrent disseminated bacterial infections (SHiN)
Complement deficiency
No response to vaccination
Absent/low B cells:
Absent/low B cells:
- SCID, XLA, or CVID
Primary immunodeficiency:
SCID, XLA, CVID, IgA, WAS, Hyper-IgM
B+T d/o:
- SCID
- WAS (Wiskott-Aldrich Syndrome)
- Hyper-IgM
- Ataxia-telangiectasia
B only (humoral):
- XLA
- CVID
- IgA deficiency
T only (cellular)
- DiGeorge
- IL-12 receptor def
- Hyper-IgE (Job)
- Chronic mucocutaneous candidiasis
Phagocyte dysfunction
CGD, LAD, Chédiak-Higashi
HCT Tx:
SCID or WAS
Triphalangeal thumbs
Diamond-Blackfan Anemia
Absent/hypoplastic thumbs
Fanconi Anemia
Howell-Jolly bodies
SCD or splenectomy
Hemarthrosis + easy bleeding + excessive post-dental bleeding
think hemophilia A or B (XR) or C (AR)
[VIII, IX, XI respectively]
TTP —> Fat nurse pentad (FAT RN):
Fever, Anemia, Thrombocytopenia, Renal symptoms, Neurologic symptoms
FFP Tx:
Warfarin reversal, Factor V deficiency, Factor VIII deficiency (Hemophilia A), antithrombin III deficiency, TTP
Vitamin K-dependent coag factors:
1972 + C & S
tPA vs. TXA vs. aminocaproic acid (Amicar)
- tPA = thombolytic
- TXA = clotting promoter
- Aminocaproic acid = clotting promoter
Hemolysis (LDH/Bili/Haptoglobin) + Thrombosis
PNH
Monoclonal antibody that inhibits complement activation
Eculizumab = Tx for PNH
Complement-mediated hemolysis of RBCs due to genetic defect of CD55 and CD59 on RBC membranes
PNH
Osteoclast inhibitor
bisphosphonates
(e.g. zoledronic acid, alendronate, pamidronate) = Tx for hypercalcemia
Hypercoagulability disorder associated with occult visceral malignancy
(e.g. pancreatic cancer)
Migratory superficial thrombophlebitis (Trousseau’s syndrome)
HIT Tx
- Stop heparin
- Start direct thrombin inhibitor (e.g. argatroban, dabigatran) or fondaparinux (synthetic pentasaccharide)
Carboxylates glutamic acid residues on prothrombin complex proteins
Vitamin K
Anemia in ESRD
Erythropoietin deficiency
(Tx: EPO therapy, but always try iron first)
Posterior knee pain/swelling/stiffness
Baker cyst
(popliteal cyst)
Avulsion of apophysis of tibial tubercle from overuse injury caused by repetitive strain in young children/adolescents w/ recent growth spurt
Osgood-Schlatter disease
Most common cause of anemia in chronic alcoholics
Folate deficiency
3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor
statins
Mediterranean thalassemia
beta
Southeast Asian thalassemia
alpha
Antibodies to platelet factor 4 (PF4)
Type 2 HIT
(immune-mediated response against PF4 complexed with heparin, leading to DIC-type reaction after >5d of heparin exposure).
Warfarin/Heparin:PT/PTT
PT prolongation, PTT nl; PT nl, PTT prolongation, respectively
BCR-ABL
CML translocation t(9,22) causing constitutively active tyrosine kinase
(tx = TKIs, e.g. imatinib).
Converts homocysteine to methionine
B12 & Folate
Important to rule out ____ before starting folic acid replacement
B12 deficiency
(can be masked until neuro sx begin)
Serotonin receptor antagonists treat:
chemotherapy-induced nausea
(e.g. ondansetron; 5HT3-antagonist)
Clubbing
CF, CV (Cyanotic), Crohn’s (IBD), hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome—also due to cyanotic shunt 2/2 pulmonary AVMs)
- Any chronic hypoxemia!
Elevations in tumor lysis syndrome
K+, Phos, Uric acid (KPU)
Hx of abd gunshot wounds
think splenectomy/SHiN-prone
Warm AIHA causes
SLE/CLL/PCN
(drugs)/Viral infections
Cold AIHA causes
Mycobacterial PNA, Mono
(EBV, CML/CLL)
High RBCs + low EPO
Polycythemia vera
Positive Giemsa stain
Malaria
(intraerythrocytic parasites)
Auer rods
AML
(40-60yo + acute presentation)
Tumor w/ elevated AFP, elevated B-hCG
Nonseminomatous germ cell tumor
- Yolk sac
- Choriocarcinoma
- Embryonal carcinoma
- Mixed germ cell
Tumor w/ normal AFP, normal to elevated B-hCG
Seminomatous germ cell tumor
Tumor w/ fat or calcium
Teratoma
(+/- tooth)
Mediastinal mass DDx:
4 T’s -
Thymoma,
Thyroid carcinoma,
Teratoma (+ seminomatous, nonseminomatous germ cell),
Terrible lymphoma
DDx of Testicular Cancer
Varicocele, torsion, spermatocele (cyst), hydrocele, epididymitis, lymphoma
Hypotensive crisis
think primary adrenal insufficiency
(Addison disease)
Hyperpigmentation in Addison disease is due to increased ____
ACTH
(melanocyte precursor)
Elevated LFTs + DM + Skin pigmentation
Hereditary Hemochromatosis
HIT Dx gold standard
Serotonin release assay
Necrosed (purple/black) lesions on abdomen
HIT Type 2
(2/2 heparin injection site thrombosis)
Microcytic anemia DDx
LIT ASS
Lead poisoning,
Iron deficiency anemia,
Thalassemias,
ACID (anemia of chronic inflammatory disease), Sideroblastic anemia, Hereditary Spherocytosis (or normal MCV)
Levels of this distinguish folate vs. B12 deficiency
Methylmalonic acid
(increased in B12 deficiency, normal in folate deficiency)
Elevated AFP
Nonseminomatous germ cell tumor (4 T’s) vs. HCC
Urinary VMA (vanillylmandelic acid)
Pheochromocytoma
Upper body edema + weight loss
Superior Vena Cava Syndrome 2/2 mediastinal
tumor malignancy
(SCLC or NHL)
Increased mean corpuscular Hb concentration
Hereditary spherocytosis
LAP in CML vs. Leukemoid Rxn
CMLow LAP;
High in Leuke”more” reaction
ABO/Rh risk variants in mother
AB “O” shit…; “Rh
negative Nancy” mom
Spine mets DDx
Lung/breast/prostate cancer, MM
RBCs in pts with OSA
RBCs in pts with OSA = Polycythemia (Hypoxemia —> Increased EPO from kidneys —> Elevated H&H)
Increased RBCs DDx
PV, 2/2 chronic hypoxia (e.g. OSA), or EPO-producing tumors
INH side effects
Neuropathy, hepatotoxicity
Facial plethora (ruddy cyanosis)
think PV
Do not use apixaban
(or direct factor Xa inhibitors) in
ESRD
Empiric anticoagulation only for suspected ___, not for suspected ___
PE; DVT
Best initial test for smoker presenting with palpable cervical lymph node
Panendoscopy
(esophagoscopy, bronchoscopy, laryngoscopy) —> then biopsy (suspected SCC of head/neck)
Tx of homocysteinemia
B6, B12, or folate
Hypocalcemia or hypomagnesemia post-transfusion
citrate chelation —> Treat with calcium gluconate following massive transfusions!
Rapid-onset vs. within a few hours post-transfusion reaction
IgA deficiency anaphylaxis and GVHD, respectively
Treatment of Cancer-related anorexia/cachexia syndrome (CACS)
progesterone analogue (megestrol acetate) or corticosteroids
Tx of RA
methotrexate, hydroxychloroquine, infliximab/etanercept
(TNF-inhibitors)
Fever + hemolytic anemia
Think TTP
(FAT RN)
Tx of TTP
Plasmapheresis
(plasma exchange)
Time course for transfusion reactions:
- Seconds to minutes - Anaphylaxis (IgA deficiency)
- First hour - Acute hemolytic rxn (GVHD)
- 1-6 hours - Febrile nonhemolytic or TRALI (transfusion-related acute lung injury)
- 2-10 days - Delayed hemolytic
Specialized RBC Tx:
- Washed: IgA deficiency; complement-dependent AIHA; Continued allergic rxns w/ RBC transfusion despite antihistamine Tx
- Irradiated: BMT; Cellular immunodeficiency (DiGeorge/IL-12/Hyper-IgE); 1st or 2nd degree relative is donor
- Leukoreduced: Chronically transfused; CMV seronegative at-risk pts (AIDS, transplant pts); Potential transplant recipients; Previous febrile nonhemolytic transfusion rxn
B12 deficiency results in impaired DNA synthesis due to
decreased purine synthesis
Deficiency following total or partial gastrectomy
B12 deficiency
Drugs that cause folate deficiency:
- Phenytoin
- Methotrexate
- TMP-SMX
Homocysteinemia complication
hypercoagulability
(DVTs)
NSAIDs + anemia
Iron deficiency anemia
How to diagnose TTP?
Peripheral blood smear
(schistocytes)
Normal liver span at R midclavicular line
6-12cm
HIV-associated nephropathy (HIVAN)
FSGS
(focal segmental glomerulosclerosis)
SCD nephritis
MPGN or FSGN
(long-term)
Northern European
Hereditary spherocytosis; Pernicious anemia
Hypoxia to 85% during anesthetic procedure
Acquired methemoglobinemia
(oxidization of iron in Hb due to topical anesthetic agents or dapsone.)
Shiny tongue + pallor
B12 deficiency
Megaloblastic
impaired DNA synthesis
(folate or B12 deficiency)
Hemolysis + hypercoagulability
PNH
(absence of CD55/59; complement-mediated RBC hemolysis)
Anticoagulation in AKI/CKD
Heparin only; AVOID LMWH, fondaparinux, rivaroxaban 2/2 reduced renal clearance.
Breast Cancer Screening in Women 50-75
Mammogram q2years
Cervical Cancer Screening in Women 21-65
Pap smear q3years
(or Pap + HPV testing q5years 30-65yo)
Colon Cancer Screening in 50-75yo:
- Annual FOBT or
- Colonoscopy q10years or
- Sigmoidoscopy q5years + FOBT q3years
Colon Cancer Screening in high-risk pts:
- FAP FHx: age 40 or 10 years before age of relative at CRC dx + colonoscopy q3-5years
- IBD: 8 years post-Dx + colonoscopy q1-2years
- FAP: Age 10-12 + annual colonoscopy
- HNPCC (Lynch Syndrome): Age 20-25 + Colonoscopy q1-2yrs
Lung cancer screening
Low dose CT annually for age 55-80 w/ >30-pack-year smoking hx + currently smoking or quit in past 15 years.
HIV in 15-65yo
HIV Ab screen 1 time
Hyperlipidemia Screen in Men 35+
Lipid panel q5years
HTN Screen in 18+
BP q2years
Bladder cancer screening
Not currently recommended in anyone
Osteoporosis in Women 65+
DEXA
(interval uncertain)
Lynch Syndrome (HNPCC):
AD predisposition to CRC, endometrial, & ovarian cancers.
An autoimmune process whereby the body produces IgG antibodies against the platelets
ITP
(Idiopathic Thrombocytopenic Purpura)
HIV pt with AMS, EBV DNA in CSF, & solitary, weakly ring-enhancing periventricular mass on brain MRI
Primary CNS Lymphoma
