Heme/Onc Flashcards
Initial eval for patient with polycythemia?
EPO! –if elevated then think possible chronic hypoxia or possible renal cell carcinoma
Pt with polycythemia, you check —- & it comes back low. what would you check to test for PV?
Polycythemia Vera = Low EPO, JAK2 mutation
Osteo—- met’s will show up on plain XR. Where as Osteo— met’s often do not and require radioisotope bone scans.
Osteolytic = XR & PET (MM, some breast cancer) Osteoblastic = radioisotope (pancreatic cancer & some breast cancers)
Patient with a B 12 deficiency has a mildly elevated indirect bilirubin. Why?
Ineffective erythropoiesis is a well-known phenomenon that occurs in patients with vitamin B12 deficiency. The mechanism that leads to this phenomenon involves defective DNA synthesis with megaloblastic transformation of bone marrow and intramedullary hemolysis. Although intense erythroid hyperplasia occurs, the erythroid cells do not mature normally and subsequently die in the bone marrow. Markers of hemolytic anemia (eg, elevated lactate dehydrogenase, low haptoglobin, indirect hyperbilirubinemia) may become evident, but reticulocyte response is typically absent in such patients.
When switching from heparin to warfarin 2/2 HIT in a pt with a PE when can you start warfarin?
The first management step is to immediately stop all heparin products (including low molecular-weight heparin such as enoxaparin) and obtain confirmatory laboratory testing (eg, serotonin release assay). Alternate agents such as direct thrombin inhibitors (eg, argatroban, bivalirudin) or fondaparinux (synthetic pentasaccharide) should be given due to the high risk of thrombosis in type 2 HIT.
These agents are not administered orally; therefore, the patient with a pulmonary embolism would need to be transitioned to an oral anticoagulant. Initial treatment with warfarin is contraindicated, as rapidly dropping protein C levels cause a prothrombotic state. Warfarin is usually started after the patient is treated with a non-heparin anticoagulant and recovers a platelet count to ≥150,000/mm3.
How long after started heparin may u see HIT?
Type 2 heparin-induced thrombocytopenia (HIT) is an immune-mediated disorder resulting in platelet aggregation and thrombosis. HIT should be suspected clinically when platelet counts fall ≥50% from baseline 5-14 days after starting heparin, in new-onset unexplained thrombocytopenia, or with thrombosis in patients recently treated with heparin.
What test is used to monitor patients u der going chemotherapy with cardiotoxic agents? When is cardiotoxic agents C/I?
Radionuclide ventriculography, also known as a MUGA (multigated acquisition) scan, is typically used to monitor patients receiving cardiotoxic chemotherapy as it is a highly accurate and reproducible test for quantitating left ventricular ejection fraction. A radionuclide ventriculogram is generally performed at baseline before chemotherapy is initiated, and before each subsequent dose of chemotherapy. The therapeutic regimen is dependent on the baseline cardiac function, with anthracycline chemotherapy contraindicated in patients with baseline ejection fractions less than 30%, and modified dosing required for patients with baseline ejection fractions of less than 50%. A decrease in the ejection fraction by ten or more percentage points may warrant discontinuation of therapy.
Direct vs indirect Coombs test
Direct: antibody test to determine if antibodies are bound to the RBC membrane, indicative of hemolytic anemia
Indirect: serum test to determine if there are antibodies to Rh factor in the mothers blood
Causes of macrocytic anemia
B12 deficiency, folate deficiency, liver disease, thyroid disease
When should you be concerned for iron deficiency anemia and kids?
Kids who are greater than one year who were exclusively fed breast milk or whole cows milk
MCV, serum iron, Serum ferritin, TIBC, RDW with Iron deficiency anemia
Low MCV, high RDW, low serum iron, low serum ferritin, increased TIBC
How long after replacing iron stores should you continue treatment
3 to 6 months
Bone marrow aspiration a patient with sideroblastic anemia will show…
Ring sideroblast
Causes of acquired Sideroblastic anemia
Ethanol, chloramphenicol, cycloserine, pyrazinamide, metal toxicity(lead,zinc, copper)
Treatment of inherited sideroblastic anemia?
Pyridoxine
What role does hepcidin play in anemia of chronic disease?
Hepcidin blocks iron absorption. When iron is low hepcidin is normally low to stimulate iron absorption. Since chronic inflammation raises hepcidin levels it creates an iron deficiency due to decreased absorption
HUS sx
Hemolytic anemia, thrombocytopenia, AKI
TTP sx
FAT RN: fever, anemia(Microangiopathic hemolytic anemia), thrombocytopenia, renal dysfunction, neurologic signs
Bite cells & Heinz bodies dx?
G6PD
Heinz bodies are denatured hemoglobin
Howell-Jolly bodies
Dx?
Sickle cell disease
Howell-jolly bodies are nuclear remnants
RDW in hereditary spherocytosis
Increased
Methemoglobinema
Sx? Associated w/? Dx? Tx?
Sx: shortness of breath, normal CXR, dizziness, confusion, headache, seizures, normal pulse ox, chocolate brown blood
Associated with: benzocaine use, dapsone, sulfonamides, house fires, cheap wine
Dx: elevated methmemoglobin level
Tx: methylene blue, O2
Homocysteine and methylmalonic acid(MMA) leaves in folate vs b12 deficiency ?
Folate: elevated homocystine but normal MMA
B12: elevated homocystine and elevated MMA
4 myeloproliferative disorders
- Polycythemia vera - overproduction of RBC
- Essential thrombocytosis- overproduction of platelets
- Primary Myelofibrosis- excess collagen or fibrous bone tissue
- Chronic Myelogenous leukemia- overproduction of granulocytes
Symptoms, mutation and treatment of polycythemia vera?
Sx: headache, blurry vision, fatigue and itching especially after a hot shower, increase hematocrit greater than 52% in men, 48% in women and platelets greater than 400 K
Mutation: JAK2 —low EPO
Tx: serial phlebotomy with a goal hematocrit of less than 45% men and 42% in women
Symptoms and treatment of essential thrombocytosis
Sx: Visual complaints, headaches, pain in hands and feet with a platelet count greater than 450 K, Jack to positive and 50% of patients. No increase in RBC or WBC. +megakaryocyte hyperplasia on bone bx
Tx: Hydroxyurea to reduce platelet count, aspirin if associated with thrombocytosis
PT & PTT in factor 8 deficiency
Elevated PTT, normal PT
Deficiency in which factors will cause an isolated increase in PTT
Eight, nine, 11, 12
Deficiency in which factors will cause an isolated increase in PT
Seven, prolonged by warfarin
Deficiency of which factors will cause an increase in both PTT and PT/INR
Five, 10, two
Which coagulopathy is associated with a decrease in ristocetin cofactor
Von Willebrand disease
T/F Von Willebrand disease commonly causes mucocutaneous bleeding, increase bleeding time, joint bleeds & an increase PTT only
True
Standard duration of time for a warfarin bridge from heparin?
Five days to allow INR to rise to a therapeutic level as well as factors 2&10 to decline
What is the cause of a febrile reaction and a blood transfusion? How can you avoid this?
Interaction between the antibodies and the recipient in the cytokines from the donor. Presents with fevers, chills in malaise. For future transfusions use leukocyte reduced RBCs
Reed Sternberg cells Are associated with which kind of lymphoma?
Hodgkin’s lymphoma, has more bee symptoms, classically bimodel in age distribution and usually presents with mediastinal mass/lymph nodes
Electrolyte abnormalities associated with tumor lysis syndrome? Treatment?
Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia.
— prevent with IV hydration and reduction of your gas it with allopurinol or Rasburicase
— treat By correcting electrolyte abnormalities, using phosphate binders, calcium gluconate to stabilize cardiac membrane, insulin, sodium bicarb and dialysis if severe or non-responsive to traditional therapies
Common presentation of multiple myeloma?
CRAB:
Hypercalcemia(Stones, bones, abdominal groans and psychiatric overtones), renal failure, anemia/fatigue, bone lesions/lytic lesions
MGUS vs MM
MM: CRAB sx and M protein SPEP > 3g
MGUS: no CRAB sx and M protein SPEP <3g always
DCIS vs LCIS
Which one is benign?
LCIS - can be monitored however usually respected due to risk of developing into carcinoma. Consider tamoxifen for PPX
New onset diabetes is common with which type of G.I. cancer?
Pancreatic
Major side effect of metoclopramide for treatment of cancer
Dopamine agonist often used to treat nausea can be associated with extrapyramidal symptoms
Major side effect of cyclophosphamide when used for cancer treatment
Hemorrhagic cystitis
Major side effect of -platin* for cancer tx
Renal toxicity, ototoxicity and neuropathy
