Module 10: Hematologic Diseases Flashcards
1
Q
Anemia
-Definition/Epidemiology
A
- Reduction in # of RBC’s, hemoglobin concentration, or hematocrit
- Anemia diminishes capacity of blood to carry oxygen
- Diagnosis is often based on lab data alone*
- Women <65 yrs and adult men >85yrs MOST at risk
2
Q
Anemia
-Causes
A
- RBC production disorders —aplastic anemia, ⬇️epoetin production, Bone marrow infection/malignancy
—Ex: Anemia of CKD & Iron deficiency anemia - RBC destruction disorders — Autoimmune, mechanical, or enzymatic factors present
—Ex: Sickle Cell & Thalassemia - RBC blood loss —Trauma, mensuration, GI bleed, hematuria, hemorrhage
3
Q
Anemia Pathophysiology
A
- When Anemia occurs there is a ⬇️ in blood viscosity causing it to flow faster (Turbulent flow)
- Hemoglobin releases oxygen to tissues more rapidly causing hypoxia of tissues causing Respiratory and cardiovascular dysfunction
- Cardiac response to hypoxia and viscosity causes dilation of heart and vessel damage
—Increase Contractility occurs and increase in respiratory rate and depth —SOB - Hemodilution occurs to expand plasma volume
—Anemia becomes evident when the MAX amount of hemodilution occurs (Usually 3 days) s/p acute blood loss - Blood is shunted to vital organs — Heart and brain
- Renin-angiotensin system activation
4
Q
Diagnosis and Treatment of Anemia
-Ferritin
A
- Used to measure Iron Storage
- Ferritin concentration less than 12 indicates absence of iron stores
5
Q
Diagnosis and Treatment of Anemia
-Transferrin Saturation
A
- Measures dietary iron absorption in transport
2. Transferrin is the protein that iron is bound for transport w/in the body
6
Q
Diagnosis and Treatment of Anemia
-Most useful test for type of anemia?
A
- MCV
7
Q
Microcytic Anemia’s
-Definition/Causes*
A
- Small, hypochromic, RBC’s — LOW MCV <80fL
- Most common cause is IRON Deficiency — affects women of reproductive age and older adults
—Most common cause is chronic blood loss* — GI, Menorrhagia, surgery, trauma, excessive blood donation - Iron deficiency anemia is more likely to occur when — Increase Iron metabolism, or stores become depleted
—Conditions include: Pregnancy, childhood and adolescent growth through milestones
8
Q
Iron-Deficiency Anemia
-Clinical Presentation
A
- Fatigue/Weakness, HA, Tachycardia
- Chest pain
- Jaundice
- Orthostatic BP changes
9
Q
Iron-Deficiency Anemia
-Subjective Hx
A
- Physiologic blood loss
- Recent trauma
- Meds? — NSAIDS, Oral steroids, ASA
- Alcohol abuse
- Fam hx
- PMH
- Change in bowel habits & Diet
10
Q
Iron-Deficiency Anemia
-Conditions contributing to New Iron-deficiency Dx
A
- Blood disorders
- Cancer
- HIV
- Liver & Autoimmune disorders
- Lead exposure
- Gastritis
11
Q
Iron-Deficiency Anemia
-PE
A
- General ROS — Fatigue, weight loss, irritability
- CV — Systolic Flow Murmur, tachycardia — More forceful apical pulse (severe)
- Respiratory — SOB
- HEENT — Pale conjunctiva, glossitis, Cheilitis
- Integumentary — Pallor, koilonychia
- Lymph — lymphadenopathy
- GI — Liver/spleen enlargement, FOBT, mass, neoplasia
- GU — pelvic mass, neoplasia
12
Q
Iron-Deficiency Anemia
-Diagnostics
A
- CBC w/diff + Anemia Profile
- Start with MCV — If <80, suspect iron deficiency
- Low Hgb ,14 g/dl in MALE, <12 g/dl in FEMALE
- Low Ferritin <12 g/dl
- Low Iron <10
13
Q
Thalassemia
-Presentation on Labs**
A
- Moderate to severe microcytosis w/ varying degrees of anemia
- Most have normal RDW & Normal Iron studies
14
Q
Iron-Deficiency Anemia
-Diagnostics
A
- GI studies — FOBT, Colonoscopy
- Hgb electrophoresis
- US to ID a mass
15
Q
Iron-Deficiency Anemia
-Differential’s for Microcytic Anemia’s <80fL
A
- Iron deficiency
- Thalassemia — Most have normal RDW and Iron studies — varying degrees of anemia
- Anemia of chronic dz
- Sideroblastic anemia
- Hemoglobin E disease
16
Q
Iron Rich Foods?
A
Highest Iron
- Prune Juice
- Olives
- mulberries
Other Iron rich foods
- Fortified cereals
- Cooked oysters, organ meets (liver), soy beans. Lentils and spinach
17
Q
Iron-Deficiency Anemia
-Management
A
- Non-Pharm — Iron rich foods
- Pharm
—Daily Iron 30 minutes before meals x4-6 months or serum ferritin levels >50
—Hgb rises w/2 weeks.
—MCV will correct in 1-2 months - Follow-up
—6 wks to 3 months
18
Q
Oral Iron S/E’s
A
- Nausea
- Constipation
- Heart burn
- Upper GI discomfort
- Black stools and Diarrhea
- Take Iron 30 minutes before meals
- Slow release for those who do not tolerate GI symptoms
19
Q
Indications for Referral or Hospitalization
A
- URGENT
- Symptomatic — Dyspnea, fatigue, chest pain
- Transfusion: Hgb 8=symptoms; Hct <30%
- Immediate referral to Hematologist
- Acute bleeds — ER - EMERGENT
- Symptomatic — hypotension, pallor, cold clammy skin bruising, tachy and thready pulse
- Acute severe hemorrhage
- Immediate ER Referral
20
Q
Patient Education with Iron Supplementation
A
- Metal based foods (supplements with calcium or magnesium — Chelates iron and BLOCKS Iron absorption
- Dairy or Antacids should NOT be taken 2 hours before or after Iron therapy
- Coffee, Tea, Bran, and soy products can also interfere w/ absorption
- Vitamin C increases absorption —Meat, poultry and fish also increase absorption
21
Q
Iron Deficiency
-Health Promotion and Risk Groups?
A
- Strict Vegetarians should supplement diet with Iron fortified vitamins or iron fortified foods
- Screening recommended in:
- All children 1 year of age
- All “AT-RISK” Groups
- Screen ALL PREGNANT women in pregnancy
22
Q
Macrocytic Anemia
-Definition & Causes
A
- Overly large red blood cells — HIGH MCV (Greater than 100fL)
- Vitamin B12 and Folate Deficiency is MOST COMMON cause of macrocytic anemias
—Ex: Alcoholism, bariatric surgery, low protein diets, pregnancy or lactation
23
Q
Macrocytic Anemia
-Clinical Presentation
A
- Develops VERY slowly in chronic diseases over 20-30 years
- Early Stages of Dz — Infections, mood swings, weakness/fatigue GI dz’s, & Kidney Dz
- Severe Stages of Folate deficiency — Abdominal pain, Glossitis, stomatitis, ulceration, Dysphagia & GI
- Severe B12 Macrocytic Anemia — Neuropathy, memory loss Parasthesias of feet and fingers & difficulty walking
- Macrocytic anemia in nutritional deficiency — Normal MCV in elderly patients, those w/ Chronic Infections, or lack ability to produce stomach acids to aid in digestion
- Folate Deficiency may cause HIGH MCV
24
Q
Macrocytic Anemia
-Subjective Hx
A
- B12 or Folate Deficiency — Alcoholism, dietary fat, malabsorption, & low veggie diet
- GI Malabsorption — s/p removal of parts of the stomach (Gastritis), infections, or pancreatic insufficiency
—This can decrease the secretion of INTRINSIC factor or ability to produce IF - Liver Involvement — Causes jaundice and enlarged liver — Leads to Right HF
- Autoimmune Conditions — Production of antibodies against gastric parietal cells — leads to macrocytic anemia
25
Macrocytic Anemia
| -Diagnostics
1. Signs of Macrocytic Anemia — Low Hgb, Elevated MCV >100, Elevated RDW
2. If macrocytic anemia is considered, evaluate B12 and FOLATE
REFER to Hematology/Oncology**
Other Diagnostics:
- FOBT X3
- UA
- PT/INR/LFT’s/CMP
- US Pelvic/Abdo
- Endoscopy/colonoscopy
26
Macrocytic Anemia
| -Differential Dx’s (Macrocytic Anemia’s
1. Pernicious Anemia — B12 deficiency d/t lack of intrinsic factor —MVC increases >100. Parasthesias, difficulty walking when severe
2. Folate Deficiency Anemia — Vit needed for RBC production/maturation —absorbed in upper intestine and stored in liver
—GI symptoms and a BEEFY RED TONGUE when folate deficiency is severe
—Pregnant or lactating women require HIGHER folate level to prevent Neural tube defects
—Symptoms of folate deficiency are similar to pernicious anemia — EXCEPT NO Neurologic changes In Folate Deficiency**
27
Macrocytic Anemia
| -Other important info?
1. Damage to the posterior and lateral columns of the spinal chord cause neurologic symptoms
—Ex: loss of position, loss of vibration sense, ataxia, spasticity, loss of appetite, memory loss
2. G6PD Deficiency — Sickle cell dz & thalassemia
—MCV is typically normal with hemolysis or destruction of RBC’s
3. Normal MCV is found with
- Aplastic anemia/malignancy
- Chronic Renal Failure (Order Creat)
- Hypothyroidism (Order TSH)
28
Normocytic Anemia’s
| -Anemia of Chronic Disease
1. Normal size RBC but fewer in number — Total Iron stores are normal or elevated
2. Anemia of Chronic Disease
-Mild to moderate and a results of — Inflammatory disorders, infection, or malignancy
-AKA anemia of inflammation
-Occurs in:
—Elderly men and women >85 yrs
—Autoimmune disorders (Ex: Lupus, RA)
—Chronic illness contributing to CKD (Ex: DM HTN) — symptoms associated w/ underlining disease, not anemia
3. Anemia of Chronic Disease WILL NOT respond to iron supplementation
29
Hemolytic Anemia
1. RBC’s are destroyed faster than they can be made
S/S Include:
-abdominal pain, palpitations, jaundice, dark urine, fever, weakness, confusion, dizziness, inability to handle physical activity, Paleness
Treatment:
-Blood transfusions, meds, plasmaphoresis, surgery, blood and bone marrow stem cell transplants, lifestyle changes
30
Anemia
| -Management
1. DO NOT treat if asymptomatic
2. Hospitalization may be required if severe
PHARM
- Monthly B-12 injections for pernicious anemia
- Folate replacement w/ supplementation
Non-Pharm
-Folate-rich foods — beef liver, Green leafy veggies, peas, beans, avocados, eggs & milk
31
B12 Deficiency
| -Complications?
1. Complication of undiagnosed or mistreated Vit B12 deficiency — Irreversible neurological damage
—mental status change, weakness, ataxia and poor coordination may not resolve
32
Anemia
| -Health Promotion
1. Screening recommended for all women of childbearing age
| 2. Newborns should also be screened for sickle cell and hemoglobinopathies
