Midterm Review Flashcards
- Which factor will have an increased PT but normal aPTT?
factor 7 (factor 7 has an extremely low half life)
- What test is the most early and most sensitive indicator of iron deficiency?
ferritin
- Chronic dz vs iron deficiency: (is the anemia d/t chronic dz or Fe deficiency?)
TIBC/transferrin and ferritin tests.
a. Transferrin levels will be low in chronic dz but high in Fe deficit
b. Ferritin testing: sensitive APR, up with inflammation but low in Fe deficit
- Exudate vs Transudate
a. Exudate is cellular, “malignant” in nature, high cell and high protein (>3g), high LDH.
b. Transudate occurs under hydrostatic conditions (heart failure), has low LDH and low protein (< 3g) and low cell count.
- Good marker for folate deficiency:
homocysteine concentration
normal values white cells
4-11,000
Immediate action PLT
< 50,000
● Immediate action Hb (child vs adult)
<7 child, <5 adult
● Immead action ANC
< 500 absolute count
● INR should not be higher than…
> 4
what is TACO
transfusion associated circulatory overload—too much fluid and it overflows them
- Common transfusion rxn, causes pulmonary edema due to volume excess or circulatory overload
- Causes hypoxia/hypertension, tachycardia, wide pulse pressure/JVD, S3 Heart sound, possible rales/wheezing
- Seen with pts who received large volume of transfused product over a short time or with underlying CV or renal disease.
- Slower to develop sxs, after multiple volumes of blood
Rh antibodies are/are not naturally occurring?
Are NOT. Must be immunized against Rh to have Rh antibodies.
O blood has what antigens
-A and -B
what are minor RBC antigens (3)
kell, lewis, duffy
● How do you get immunized against a minor RBC antigen?
Must be immunized with the red cells. Never match the minor Ab unless the person has a positive antibody screen whose been previously transfused. These minor Ab won’t cause a life-threatening immune rxn
● Diagnostic sensitivity, definition and equation
TP/TP+FN
○ measures a test’s ability to detect positivity in the presence of dz. high rate of FN kills the sensitivity
● Diagnostic specificity: definition and equation
TN/TN+FP; measure of a test’s negativity in absence of disease. high rate of FP kills the specificity
● ROC curve: perfect test hugs __ then hugs ___ at the top. Area under curve tells you what cut off point gives you the idea sensitivity and specificity.
hugs y and then x
l~
____________ is on the X axis and ________ is on the Y
X: specificity
Y: sensitivity
Red tube additive, purpose, and example
no additive; allows blood to clot permits seperation of blood and serum (to test serum); for chemistry, billirubin, BUN, Ca+2
red/black tube additive, purpose, and example
no additive; serum seperator tube; chemistry and serology
purple/lavender tube additive, purpose, and example
EDTA added, prevents blood from clotting(preserves cellular morphology and suspension in solution); hematology CBC, platelet count
gray tube additive, purpose, and example
sodium flouride oxalate added; prevent glycolysis(enzyme inhibitor); chem, glucose, lactose tolerance
green tube additive, purpose, and example
heparin added; prevents blood from clotting to test plasma(does not change the pH); chem, ammonia, carboyhemoglobin, uric acid and blood gas
blue tube additive, purpose, and example
sodium citrate added; prevent blood from clotting when plasma needs to be tested (coag studies min fill level important); PT(prothrombin), PTT(partial thromboplastin time),
black tube additive, purpose, and example
sodium citrate; binds Ca+2 to prevent blood clotting; for ESR
yellow tube additive, purpose, and example
citrate added; preserves red cells; blood cultures
gold serum separator tube (SST) additive, purpose, and example
no additive; collects serum; chemistry
what tubes are in a “rainbow”
red, blue and purple tubes for blood testing; useful for ER and covers many hematology/chemistry and hemostasis tests
More confirmatory test, more ______, the _______ would lower most likely
more specific
sensitivity would likely decrease
a ROC curve is used for….
Used for selecting a cutoff point that maximizes sensitivity and specificity
W/a ROC curve the area under the curve is good for…
Area under the curve is useful for estimating overall efficacy of the test
normochromic ____MCHC (mean cell Hb concentration) and normal color
32-36
hypochromic ___ MCHC with pale coloring
< 32
normocytic ___MCV
80-100 MCV
microcytic ____ MCV
<80
macrocytic ___ MCV
> 100 MCV
Low MCV (microcytic) is indicative of…(2)
Fe deficiency, thalassemia
High MCV (macrocytic) indicates…(3)
folate/B12 deficit, liver dz, hyperlipidemia
central paleness of RBC shouldn’t be more than ___ of the diameter of the RBC
1/3 (hypochromic)
MCHC indicates…
shows mean concentration of Hb inside the RBC)
Norm Hb for women
12-16
norm Hb for men
13-17
immeadiate action values for Hb in child and adult
<7 in children
<5 in adult
>20
immead action value for hematocrit
> 60%
Hb x __ = hematocrit (+/- 3 points)
3
Hematocrit/Packed Cell Volume (PCV) normal
36-54% (males higher)
hematocrit is…
the ratio of the volume of red blood cells to the total volume of blood
Normal Mean Cellular Hb (MCH)
27-33 pg
normal Mean cellular Hb concentration (MCHC)
32-36 g/dL (rarely see anything over 36, will indicate hereditary spherocytosis)
normal WBC
4000-11,000 (children will have more than adults)
WBC immediate action
> 50,000 (varies)
immediate action ANC
<500 (absolute neutrophil count, normal is 60% of WBC)
norm PLT
150,000-400,000
risk for mucocutaneous bleeding if platelet is
<50,000
risk for intracranial bleeding if PLT
<10,000
risk for myeloproliferative dz if platelet is
> 1,000,000
ESR norms for _____males, ____ females normals (increased with inflammation)
males: <10 mm/hr
females: <5 mm/hr
Reticulocyte Production Index :
___ in hypoproliferative anemias
___ in hemolytic anemias
<2% (not producing) - hypo
>2% (premature destruction) - hemolytic
ANC (absolute neutrophil count)
neutropenia : ___
Agranulocytosis: ____ (increased risk of infection )
penia: <1500/uL
agranulocytosis: <500/uL
Reticulocytes are:______________
________ in hemolytic anemias (RBC destruction) ________ in hypo-proliferative anemia (“block” – vitamin/nutrient deficiency, anemia of chronic inflammation)
RBC freshly released from bone marrow
Increased in hemolytic
decreased in hypoprolif
how does ESR detect inflammation?
increased fibrinogen and IG in plasma
what are the three components of Iron testing?
serum iron, TIBC(transferin), and ferritin
Serum immunoglobulin and complement levels are useful in working up….
immunodeficiency
__________ and _________are best to discriminate Fe deficiency from ACI(anemia of chronic dz).
Total iron binding capacity (TIBC)(transferin) and ferritin
_______ can mimic Fe deficiency, CBC can show both.
anemia of chronic dz
__________ is the earliest and most sensitive indicator of iron deficiency
ferritin
Basophilic stippling is evident in….
RBCs with lead poisoning and also apparent in many forms of anemia (not in all anemias)
________ (crystallized granules) visible in blast cells in the cytoplasm -> pathopneumonic for AML
Auer-Rods
left shift inc the probability of…. (3) (when paired with meaningful vital signs
sepsis, meningitis or appendicitis when paired with meaningful vital signs and symptoms (90% sensitivity)
Classic left shift parameters (4)
Immature granulocytes, bands, myelocytes, promyelocytes
In regards to left shift you’re likely to see:
- increased circulating WBC
- band count = ___(immature cells)
- _________ (“arming up” of neutrophils)
- ___________ (precipitated RNA)
- __________ (indicates active phagocytosis occurring)
increased circulating WBC
band count >700/ug–immature cells
Toxic granulation (“arming up” of neutrophils)
Döhle bodies (precipitated RNA)
Vacuoles (indicates active phagocytosis occurring)
If WBC counts are normal….
do not jump to rule out infectious disease if the WBC results are normal- do not use as sole parameter for left shift (can be low or normal in many infections)
Iron deficiency HALLMARK = ____ will be low, MCHC is _____
MCV low (microcytic) MCHC <32 (hypochromic)
Megaloblastic Anemia: B12/folate deficiency:
MCV ___,
intramedullary hemolysis,
RPI (reticulocytes production index) is ______
MCV: >100 (macrocytic and normochromic)
RPI: <2%
Beta thalassemia major- MCV \_\_\_\_\_ MCHC \_\_\_\_\_\_ normal iron status. Electrophoresis to detect high \_\_\_\_\_\_ Do DNA testing.
MCV <80 (microcytic)
MCHC <32 (hypochromic)
Hgb f
sickle cell dz-
>10% of the Hb is ____- monoclonal antibodies are also helpful
1.family history
2. kids with 2 copies of succeptible Hb become _____ after 6 months of life
3. electrophoresis to determine
HgB S
anemic
Anemia of chronic dz/inflammation:
RPI (reticulocytes production index) is ____
C-Reactive protein is more expensive
ESR - just as sensitive and cheaper
increase in ________ & immunoglobulins (>RVs) and increase APRs
______ levels: informative in working up inflammatory dx (H)
TIBC is ____(inc/dec) in inflammatory states
microcytic, hypochromic
______ and _________ are the two most important to determine inflammation vs. iron deficiency
<2% fibrinogen C3/C4 decreased Ferritin and TIBC
G6PD deficiency:
RPI (reticulocytes production index) ___
________(identifies common G6PD deficiency mutations) - gold standard test should be performed on patients at risk before antimalarial therapy or prophylaxis is initiated to avoid reaction
> 2%
Rapid PCR
Ethnicities that are at risk for _________ are: North African, mediterranean, asian
G6PD deficiency
Aplastic/hypoplastic of the marrow:
RPI(reticulocyte production index) is ____
aplastic anemia = _______penia
Evaluate ________________ to diagnose
=2.0%
pancytopenia
core biopsy of bone marrow
chronic unresolved infections, constitutional symptoms, abnormal and reproducible WBC findings, bruising/bleeding, pancytopenia (RBC, PLT, WBC), presence of immature cells in peripheral blood including blasts and or immature granulocytes and acutely can present with high white counts.
What disease process is this?
Leukemia
What is sepsis? what should you order?
disseminated infection, left shift
get a PT(prothrombin time)/aPTT (activated partial thromboplastin time)
Left shift and signs of ________ activation have 90% sensitivity for predicting neonatal sepsis
neutrophil
_____________ presents with left shift, high WBC (neutrophil), protein, sometimes low glucose.
what should you order?
Bacterial meningitis
get a PT/aPTT
High RBC, Evidence of erythrophagocytosis
spinal tap: principle finding - red blood cells; same ratio of white to red, no platelets in any fluid.
what disease process is this?
hemorrhagic stroke
what is Thrombopoietin
TPO, aids in sensing of the platelet count.
Name 9 things that can cause thrombocytopenia
Heparin induced thrombocytopenia (HIT) DIC ITP--immune thrombocytic purpura Hypersplenism- sequesters platelets in an enlarged spleen Liver disease leukemia medications, chemotherapy autoimmune dz (SLE, RA) pregnancy
______ may be “platelet sensor” in the body = low Factor 7 (factor 7 has a short half life)
liver
what is ITP?
immune thrombocytic purpura: common in kids after a viral infection - then two weeks later platelets crash and that’s the only one that lowers
INR aka PT- prothrombin time
tests what?
2, 5, 7, 10, fibrinogen
aPTT-activated partial thromboplastin time tests what?
factors 2, 5, 8, 9, 10, 11, 12, fibrinogen, prekallikrein and HMWK
Describe specimen collection protocol for drawing blood in tubes containing sodium citrate
(blue top)
a. must be drawn to precise amount–10:1 ratio
b. do not mix tubes
c. invert gently after draw (mix the blood & anticoagulant)
Define DIC
Acute disseminated intravascular coagulation (DIC) caused by: Brain injury, vascular injury (vasculitis, connective tissue diseases, infections), complicated pregnancy, malignancy, meningitis, sepsis, severe transfusion reaction, acute promyelocytic leukemia (APL) and other conditions
Simultaneous bleeding (and oozing of plasma) and clotting in microcirculation
Life-threatening disorder
Treatment depends on cause (ex. uterine evacuation for pregnancy complications)
Explain what you would expect for DIC tests (3)
prolonged clotting time tests (PT, aPTT) (takes you longer to clot because all your clotting factors are used up)
decreased (consumed) PLTs and fibrinogen
increased fibrin turnover (increased d-dimer levels- fibrin degradation product).
deficiency of _____ or ______ increases risk of DVT/clotting/PE
Antithrombin + heparin
what do protein C and protein S do?
(S acts a cofactor of protein C) deficiency increases risk of DVT/clotting/PE, both are VitK dependent
Name the 6 vitamin dep coagulation factors
Protein C, protein S, Factor: 2, 7, 9, 10
_______ doesn’t interfere with Vit K dependent clotting
_________ does, low on protein C and other VitK dependent
Heparin
coumadin(warfarin)
the most common inherited thrombosis risk is _____ mutation
factor 5 leiden
describe HIT (heparin induced thrombocytopenia)
d/t presence of autoantibody to PLT factor 4 (PF4) in complex with heparin.
Causes PLT activation→ clotting → consumption of clotting factors & platelets
20% mortality, use high or low molecular weight heparin to treat
what’s vonwilibrand disease
inhibits PLT adhesion to injured endothelium (first step of platelet activation).
VWfactor binds and protects factor 8 from proteolysis from protein C.
With vW deficiency, factor 8 is destroyed (can’t start clotting cascade) and bleeding results (platelet adhesion/platelet plug cannot occur).
what is TTP?
Thrombotic thrombocytopenic purpura. Problem with the enzyme ADAMTS13. Clotting occurs abnormally. platelets clump together, leaving fewer available to clot other parts of the body, leading to bleeding (purpura) under the skin.
what is Warfarin induced skin necrosis?
warfarin causes easy bruising but rarely will cause necrotic purple lesions. Warfarin affects vitK (procoagulant) which is essential in making a functional protein C. He doesn’t think it has anything to do with clotting.
what are the two theories on how warfarin induced skin necrosis works?
Theory 1: Occurs d/t acquired deficiency of protein C. Imbalance btwn coagulation and anticoagulation creating a hypercoagulable state. Generation of thrombotic occlusions of microvasculature, resulting in necrosis
Theory 2: suggest warfarin has a direct toxic effect on capillaries. Capillaries dilate and rupture, petechiae develop. veins distal to injured capillaries thrombose, creating stasis and blood, causing tissue necrosis
How does coumadin/warfarin work to prevent clotting? risks/disadvantages?
decreases ability to form clots by blocking formation of vitamin K dependent clotting factors.
i. Side effects include bleeding, warfarin induced skin necrosis, hard to dose a person as well because we are genetically polymorphic for cytochrome P450 metabolism. A lot of trial and error and lab tests, to reach therapeutic range.
How does heparin work to prevent clotting? risks/disadvantages?
Increases binding of antithrombin to its targets by 1000x. Without heparin, antithrombin will not be an effective anticoagulant.
i. disadvantage: using higher molecular forms- the HIT causes clotting due to autoantibody that recognizes clotting factor 4 induces clotting mechanism
therapeaudic range for INR while on coumadin/warfarin?
INR: Therapeutic range 2-3, maybe 4
what’s the physio behind factor V leiden mutation clotting?
Single amino acid substitution in factor 5 results in resistance to proteolysis by Protein C. Factor 5 builds up—promotes clotting
s/s for antiphospholipid antibody syndrome
DVT in weird places, multiple miscarriages, strokes, PE
labs for antiphospholipid antibody syndrome
i. Prolonged clotting time tests, esp. PTT? most sensitive, paradoxically prolong PTT. Snake venom is useful stimulator, factor 10 activator.
1. antibodies displace the coagulation complexes so it takes longer to clot
ii. Tests for anticardiolipin, beta-2 glycoprotein I (β2GPI), and lupus anticoagulant -> but they cause clotting.
what are lupus anticoags
Lupus Anticoagulants: cause clotting, only act as anticoagulant in low phosphate containing environments; better to call them phospholipid dependent anticoagulants
Extrinsic pathway starts with factor ____ then moves to factor ____
3 then 7 (calcium carries it into the common pathway)
INTRINSIC PATHWAY starts with ____ then moves to _____ next is ____
12, 11, 9 (factor 8 carries into the common pathway)
What are deficiencies in these factors called? Factor 8? Factor 9? factor 11? Factor 12?
Factor 8: classic hemophilia A
Factor 9: Christmas dz (hemophillia B)
factor 11: hemophilia C
Factor 12: bleeder not clotter
Increase TPA, but keep everything else constant, will it cause bleeding or clotting?
It causes bleeding, by increasing fibrinolysis
High levels of plasminogen activator = _________
Not enough plasminogen activity = ___________
High levels of plasminogen activator: bleeding
Not enough plasminogen activity: clotting
what is PAI1
risk assessment marker for coronary artery disease -> clotting
__________ expressed on the damaged tissue
Tissue factor (thromboplastin)
what is TRALI - Transfusion Related Acute Lung Injury?
- Respiratory distress/hypoxia, hypotension, fever, transient elukepenis, diffuse bilat infiltrates on CXR, high protein level, exudate in edema
- Occurs close in time to the initiation of the transfusion before significant volume is infused
_______ is the most important RBC parameter to evaluate
Hb
what is Physiologic anemia of infancy
baby is born with high Hb b/c they must be able to convert mothers Hb to fetal to receive O2. Hb tails off after birth (can be 11 when kids are 4-6 yr old) but creeps up through puberty when it plateaus (d/t androgen production).
WBC counts: • Adult total • Neutrophils % • Lymphocytes % • Monocytes % • Eosinophils % • Basophils %
Adult total: 4-11 x 10^3/μL • Neutrophils: 50-70% • Lymphocytes: 20-40% • Monocytes: < 8% • Eosinophils: < 5% Basophils < 2%
___________ provide quicker index of recovery (1-2 weeks after therapy) in non-hemolytic anemia than CBC
Reticulocytes
anti ds-DNA/ and anti-Smith antibodies are useful in dx of _________
Lupus
anti-CCP is useful in dx of _____
RA
o Total Serum iron? o Transferrin? o Transferrin saturation? o Ferritin? Ferritin levels
o Total Serum iron: 30-170ug/dL F, 65-180 M
o Transferrin: 200-350ug/dL (total serum iron is carried on transferrin)
o Transferrin saturation: 25-45% (~1/3)
o Ferritin: 12-150 ng/mL W, 12-300 M
Ferritin levels <10 indicate depleted iron stores
o Common cause of megaloblastic anemia is __________ anemia (autoimmune)
-Test with _________ factor autoantibody (gold standard)
pernicious anemia
-Test with anti-intrinsic factor autoantibody
Immeadiate action value for INR
> 4
Patient has confirmed prolonged PT and normal PTT. Which coagulation factor deficiency can produce this result?
Factor 7
What if pt has prolonged PTT but normal PT?
think factor 8, 9—“intrinsic pathway factors”
