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NM 703 Primary Care > Module 2 Anemia and HIV > Flashcards

Module 2 Anemia and HIV Flashcards

1
Q

What is the definition of anemia?

A

Reduction in RBCs, hemoglobin concentration, or hematocrit

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2
Q

What level of hemoglobin in women defines anemia?

A

Hbg <12

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3
Q

What is the pathophysiology of anemia?

A

Hgb transports oxygen to tissues. In anemia, there is a decrease in the amount of hgb, which results in inadequate oxygen being carried to tissues.

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4
Q

What are the three causes of anemia?

A

Decrease in RBCs production (proliferative disorder)
Destruction of RBCs
Blood loss

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5
Q

What is proliferative disorder?

A

Also known as a decrease in RBC production.

Happens when the bone marrow is not producing properly. Can be caused by hormone imbalances (thyroid), low iron, inflammation, etc.

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6
Q

What is the most common cause of proliferative disorder in women?

A

Iron deficiency

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7
Q

What is MCV (mean corpuscular volume? What is normal volume? What is normal volume called?

A

MCV is the size (volume) of a red blood cell.

Normal (normocytic) is 80-100%

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8
Q

What MCV is Macrocytic?

A

MCV greater than 100

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9
Q

What MCV is Microcytic?

A

MCV is less than 80

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10
Q

Define hypochromic. Give two examples of hypochromic anemias.

A

Reduction in red blood cell hemoglobin (pale in color)

Thalassemia and sickle-cell anemia

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11
Q

Define normochromic. Give example of normochromic anemia.

A

Normal amount of hemoglobin

Anemias from blood loss

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12
Q

What is an erythrocyte and reticulocyte?

A

Erythrocyte-RBC

Reticulocyte-immature RBC

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13
Q

What are some risk factors for anemia?

A

Women of African/Mediterranean, middle east, southeast Asia, Indian, and Pakistan descent.
Older women, pregnancy, acute blood loss, CKD, G6PD Deficiency, Autoimmune disorders, chronic disease

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14
Q

What are the differential diagnosis for anemia?

A

Blood loss
Malignancy
Renal Failure

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15
Q

What subjective data may we see with anemia?

A

Some may be symptomatic. Specific symptoms depend on the cause.

May see fatigue, racing heart rate, dizziness, peripheral neuropathy, fainting

Severe symptoms: breathlessness, headache, memory loss, angina

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16
Q

What objective data may we see with anemia?

A

Exam may be normal

May see pallor or tachycardia

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17
Q

What diagnostics may be performed for suspected anemia?

A

H&H, CBC with indices (MCV, peripheral smear, reticulocytes), iron stores (ferritin, iron, total iron-binding capacity, transferrin saturation percentage)

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18
Q

What type of anemia do these labs indicate? (micro, normo, macro)

Hgb 9.8; MCV 74; TIBC 465ug/dL; Serum ferritin 10ug/dL

A

microcytic anemia

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19
Q

What type of anemia do these labs indicate? (micro, normo, macro)

Hgb 10.0; MCV 110; TIBC 426; Serum ferritin 50ug/dL

A

macrocytic anemia

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20
Q

What type of anemia do these labs indicate? (micro, normo, macro)

Hgb 10.8; MCV 92; TIBC 360; Serum ferritin 80ug/dL

A

normocytic anemia

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21
Q

What type of anemia do these labs indicate?

Hgb 10.6; MCV 76; TIBC 283; Serum ferritin 30ug/dl

A

thalassemia

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22
Q

Which type of anemia is the most common anemia in elderly populations, and due to hypo-proliferation and reduced response to erythropoietin?

A

Anemia of chronic disease

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23
Q 
A 66-year-old's recent blood tests reveal the following results:
Hemoglobin - 11.1
Hematocrit - 33.3
MCV - 92
Serum iron low
Serum ferritin is slightly elevated
TIBC slightly elevated
What type of anemia does she have?
A

Anemia of chronic disease

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24
Q

What are some types of normocytic anemia?

A

Acute blood loss, anemia of chronic disease, and early iron deficiency

Chronic diseases examples: Autoimmune diseases, renal failure, liver disease, cancer, IBD

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25
Q

What subjective and objectice data may we see with normocytic anemia?

A

Subjective: May be asymptomatic, Fatigue, feeling cold, dyspnea with activity

Objective: pallor, fatigue, sallow colored skin (brown/yellow), pale conjunctiva, glossitis (shiny tongue), angular stomatitis (cracked corners of mouth)

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26
Q

What should be included in the exam for normocytic anemia? Why/What might you find?

A

Cardio-pulmonary (tachycardia, tachypnea, pulmonary edema) abdomen (hepatomegaly/splenomegaly), extremities (poor cap refill, spoon-nails, pale palmar creases, brittle nails, cold hands and feet

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27
Q

What labs/diagnostic results do we expect with normocytic anemia from acute blood loss?

A

MCV: 80-100,
ferritin normal
reticulocyte high
TIBC normal

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28
Q

How can normocytic anemia be treated?

A

Early iron deficiency anemia: diet change-increase iron-rich foods
Chronic Disease: referral for disease

Follow up with CBCs and iron studies collab with specialist

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29
Q

What are the two most common Microytic anemias?

A

Iron deficiency anemia and thalassemia

Note: these are the ones we will see most often in women

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30
Q

What subjective data may we see with microcrytic anemia? What should be sure to ask about?

A

Fatigue, weakness, tachycardia/palpitations, lightheaded, dyspnea on exertion

Medications- antacids, H2 blockers, PPIs, NSAIDs, ASA, Zinc
Menstrual hx
PICA
Melena in stool

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31
Q

What objective data may we see in microcytic anemia?

A

Pallor, sallow skin, fatigue, pale conjunctiva, angular stomatitis, atrophic glossitis

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32
Q

What should be included in the exam for microlytic anemia? Why/What might you find?

A

Cardio-pulmonary (tachycardia, tachypnea, pulmonary edema) abdomen (hepatomegaly/splenomegaly), extremities (poor cap refill, spoon-nails, pale palmar creases, brittle nails, cold hands and feet

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33
Q

What labs/diagnostic results do we expect with microlytic iron deficiency anemia?

A 
MCV: <80
H/H: Low
Serum Iron: low
Ferritin low
Retic low
TIBC high
MCHC <27
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34
Q

How can microcytic anemia be treated?

A

Facilitate absorption-increase diet of animal protein, avoid tannins, iron overload, antacids

Supplemental iron (ferrous sulfate 325 po 1-3 times a day (slow Fe, Feratab)

Recheck H&H in 2 months

In pregnancy: treat with elemental iron 60-120 mg daily then decrease to 30 mg once normalized

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35
Q

What is the inherited form of hemolytic anemia? What patient are highest risk?

A

Thalassemia (microcytic)

Women of African/Mediterranean, middle east, southeast Asia, Indian, and Pakistan descent.

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36
Q

When do I need to order electrophoresis?

A

When a patient has relatives with thalassemia or suspected thalassemia

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37
Q

What subjective and objective data do we see with thalassemia?

A

Subjective: may be asymptomatic or have mild-severe anemic symptoms
Objective: Pallor, sallow skin, fatigue, pale conjunctiva, angular stomatitis, atrophic glossitis

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38
Q

What lab results do we expect to find in alpha thalassemia?

A 
Ferritin: normal
Reticulocyte: normal
TIBC: normal
MCV: <80
H/H: low
RBC: Normal-elevates
4 genes-one or all four are damaged or missing
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39
Q

What lab results do we expect to find in beta thalassemia?

A 
Ferritin: normal to high
Reticulocyte: low
TIBC: normal
MCV: <80
RBC: normal or elevated
2 genes
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40
Q

How do we manage Thalassemia?

A

DO NOT treat with iron, may cause severe organ damage
Refer to hematologist
Blood transfusions
Genetic counseling

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41
Q

What are the most common causes of macrocytic anemia?

A

Nutritional deficiency (B12 or Folate)
Pernicious Anemia
Alcohol abuse
Hypothyroidism

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42
Q

What can cause vitamin B12 deficiency? Why is it important?

A

B12 is needed to make red blood cells and to keep nerve cells healthy

Can be caused by inadequate intake, intrinsic factor deficiency (pernicious anemia or gastrectomy, chron’s, malabsorption)

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43
Q

What subjective data do we see in vitamin B12 deficiency?

A

Memory issues, fatigue, SOB, diarrhea, pain/tingling, peripheral neuropathy, depression, irritability, difficulty walking

Medications: antacids, H2, PPIs, metformin
Medical sx history: thyroid disorder
alcohol use

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44
Q

What patients we most often see pernicious anemia in?

A

The elderly and chronic disease

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45
Q

What objective data may we see with vitamin B12 deficiency?

A

Jaundice, glossitis, unstable gait, neuro symptoms (positive Romberg, cognitive impairment if severe)

46
Q

What diagnostics would we use for macrocytic anemia?

A 
CBC with diff
RBC indices
Folate
Vitamin B12 (Serum Cobalamin)
Serum Homocysteine
Methylmalonic Acid
Anti-intrisic factor antibodies
47
Q

What lab results may we find with vitamin B12 deficiency?

A 
Ferritin: normal
Reticulocyte: low
TIBC: normal
MCV: >100
B12: low
Folate: normal
H/H: low
WBCs and platelets: low
peripheral smear: abnormal
Anti intrinsic factor antibodies
Methylmalonic acid: elevated
homocysteine: elevated
48
Q

What lab results may we find with Folate deficiency?

A 
Ferritin: Normal
Reticulocyte: Low
TIBC: Norma
MCV: >100
B12: Normal
Folate: Low
Methylmalonic acid: normal
Homocysteine: elevated
49
Q

What are some management options for B12 deficiency?

A

Packed RBCs, oral Vitamin B12, injected B12, referral

50
Q

What is the schedule for Vitamin B12 medications (both injections and oral)?

A

Injections:
Week 1:daily injections
week 2:twice weekly
weeks 3-6: once weekly followed by monthly for life

Oral: 1-2 mg by mouth daily

51
Q

What are some of the causes of folate deficiency?

A 
Decreased dietary intake
malabsorption
pregnancy
alcoholism
cancer
medications
52
Q

Which is the most common macrocytic anemia?

A

Folate Deficiency

53
Q

What subjective and objetive data may we see for folate deficiency?

A

Subjective:
Rarely symptomatic
Medications: methotrexate, metformin, sulfa, anticonvulsants
Review Alcohol consumption

Objective: nearly none-depends on labs

54
Q

How do we differentiate folate vs B12 deficiency?

A

Methylmalonic acid. Normal with elevated cyctine indicated folate deficiency

55
Q

What is the management of folate deficiency?

A

Folic acid- 1 mg per day for 6 months (400 mg daily for pregnant or childbearing age)
High folic acid diet (cheese, eggs, greens, meats, and some breads-cooking can destroy folic acid). Vitamin C also needed for absorption
Periodic testing

56
Q

What is the important teaching for iron supplementation?

A

Iron should be taken between meals with vitamin C
Cooking may destroy folic acid
Stools may be black or tarry
GI discomfort may occur

57
Q

What are some of the complications seen with Iron deficiency anemia during pregnancy?

A

preterm birth, low birth weight, learning deficits

58
Q

What are some complications seen with anemia?

A

Fatigue, falls, cardiovascular compromise

59
Q

What are some complications seen with vitamin B12 deficiency?

A

Irreversible neurological damage (if untreated for >3 months) and mental status changes

60
Q

What is a complication seen with folate deficiency?

A

Neural tube defects

61
Q

Who may we refer anemic patients to?

A

Nutritionist
Hematologist
Genetic counselor

62
Q

What is most important during an exam of a patient presenting with anemia?

A

a thorough history and head to toe exam

63
Q

What labs/diagnostic results do we expect with normocytic anemia from chronic disease?

A 
MCV: 80-100
Hgb 10-11
Serum iron low
Ferritin normal or high
Retic low
TIBC low or normal
64
Q

What labs/diagnostic results do we expect with normocytic anemia from early iron deficiency?

A 
MCV: 80-100
Hgb 10-11
Serum iron low
Ferritin low
Retic low
TIBC high
65
Q

What are the common types of normocytic anemia?

A 
Early iron deficiency anemia
Acute blood loss
Anemia of Chronic Disease
Aplastic Anemia
Sickle Cell Anemia
66
Q

What are the CBC and iron indices? What do they mean?

A

MCV- size of the red blood cell
Peripheral smear- looks at the shape of the red blood cell
Reticulocytes- decreased production of RBCs or increased loss

Serum Ferritin-tells us how much-stored iron there is
Serum Iron- the plasma iron concentration
total iron binding capacity- how much iron the blood can carry if the transferrin is totally saturated

67
Q

Explain the pathophysiology of HIV

A

Human immunodeficiency virus is a retrovirus.
The virus infects the CD4 T lymphocytes
decreasing the amount of CD4 T lymphocytes
resulting in a decreased immune system

68
Q

What are the risk factors for HIV?

A

Vaginal or anal sex
Sharing needles/syringes
Blood products-this is a low risk due to testing
Occupation- ex. first responders/healthcare workers
Pregnancy – to child
Breastfeeding – to child

69
Q

What testing/lab monitoring is required for PrEP?

A

Patient must be HIV negative.

Renal function should be monitored
Over 50 y/o and creat >30 monitor every creat every 6 months
All other monitor every 6-12 months

70
Q

What are the medication options for PrEP?

A

•Transgender women and men - Emtricitabine (F) 200mg in
combination with tenofovir alafenamide (TAF) 25mg (also
know as Descovy) – 90 Day supply
•Women and men - Emtricitabine (F) 200mg in combination
with tenofovir disoproxil fumarate (TDF) 300mg (also know
as Truvada) – 90 Day supply
•cabotegravir (CAB) injections approved for those at substantial risk

71
Q

What patient education should be reviewed with patient on PrEP?

A

Educated on the importance of daily medication, STI counseling, and condom use.
Educate on risk to kindey and liver
Educate on need to be HIV negative and no prior Hep B treatment (increased risk of resistant HIV if not) [black box warning]

72
Q

What are our differential diagnosis for HIV?

A

Mono
Flu
Yeast infection
Lymphoma

73
Q

What subjective data may we see with HIV?

A
  • Varies by stage of disease
  • May be asymptomatic
  • Fever
  • Night sweats
  • Fatigue
  • Chronic yeast infections
74
Q

What objective data may we see with HIV?

A
  • Lymphadenopathy
  • Vaginal yeast or lesions
  • Oral lesions
75
Q

When should patients be screened for HIV?

A

USPSTF: 15-65, pregnant. Those outside ranges that are high risk should be screened
CDC: 13-64 with an opt-out option, yearly for high-risk, pregnancy with opt-out

76
Q

What diagnostics should be performed to screen for HIV?

A

Nucleic acid Test (NAT)- is extremely expensive and used less. Can detect earlier after exposer (10-33 days)
HIV 1,2-has less false positives

77
Q

How is HIV managed? What consults if any?

A
  • Referral for immediate treatment of HIV
  • GYN care-NP and CNM can perform. All contraceptives ok. At risk of pap abnormalities and lesions
  • Dermatology issues-CNM can manage fungal infections and skin conditions
  • Prenatal care-CNM may provide in collaboration with HIV specialist
78
Q

What labs should be monitored on a patient with HIV?

A

CD4 count and viral load

79
Q

What education is important for patient with and without HIV?

A
  • STI prevention
  • Disclosure is recommended
  • Continued care – team approach
  • PrEP is available
  • Early and consistent treatment is crucial
80
Q

What are some complications associated with HIV?

A
  • Lymphoma
  • TB
  • Coinfection with Hep C or Hep B
  • Cardiovascular disease
  • Drug to drug interactions
81
Q

What can be given to a patient exposed to HIV?

A

Postexposure Prophylaxis

Medication given after exposure to prevent HIV (Occupational and Nonoccupational)

82
Q

What are the CDC guidelines for Postexposure Prophylaxis (PEP)

A
  • Use of rapid antigen/antibody (Ag/Ab) combination HIV tests
  • 3-drug antiretroviral nPEP regimens
  • Follow up labs
  • Take within 72 hours after exposure – the sooner the better. Treat without delay.
  • Take for 28 days
  • Can be used in pregnancy
  • Baseline and follow up labs – serum creatinine and creatinine clearance, LFTs
  • Transitioning from nPEP to PrEP
83
Q

What are our medication choices for PEP?

A

A 3-drug regimen consisting of tenofovir DF 300 mg and fixed dose combination emtricitabine 200 mg (Truvadac) once daily with
raltegravir 400 mg twice daily or dolutegravir 50 mg once daily

84
Q

What education should be reviewed with a patient starting PEP?

A

•advise patients of need to begin PEP within 72
hours of exposure and continue PEP for full 28-day
course
•review possible side effects from PEP, including
–fatigue
–nausea
–diarrhea
–rash
•review possible toxicities, including liver and kidney
dysfunction, and lab monitoring schedule to detect
these and prevent lasting complications

85
Q

What follow up monitoring should be performed on a patient exposed to HIV on PEP?

A

•monitor complete blood count (CBC), electrolytes, renal function, and liver function tests during treatment to ensure no toxicities are developing (typically around 2 weeks after starting therapy)
•repeat testing for HIV–perform HIV serology at 6 weeks, 3 months, and 6 months after exposure (although 6-month testing not recommended by some agencies as 99% of infected
patients have antibodies at 3 months)
–testing may be done only at 6 weeks and 4 months if combination HIV antibody/p24 antigen (Ab/Ag) testing is used and is negative at both time points

86
Q

Which type of anemia affects 10-15% of premenopausal women, represents 25% of all anemia cases, and is often due to slow, persistent blood loss?

A

Iron deficiency anemia

87
Q

How soon should the CBC be rechecked after starting treatment with ferrous sulfate and dietary education for a patient with iron deficiency anemia?

A

7-8 weeks

88
Q

Nonpharmacologic management of a patient with a hemoglobin of 8.0, MCV of 68, low serum ferritin, and a high TIBC includes:

A

Diet with increased iron content

89
Q

A 22-year-old patient presents to review labs.
Laboratory Results:
Hgb - 9.8
MCV - 68
TIBC - 502
Serum ferritin - 9ug/dL
What is the most important data to obtain from the patient?

A

Menstrual history

90
Q

Which of the following are causes for macrocytic anemia?

  • Chronic inflammation, hemolysis, renal failure
  • Gastritis, thalassemia, inadequate diet
  • Pernicious anemia, sideroblastic anemia, hyperthyroidism
  • Folate deficiency, liver disease, hypothyroidism
A

Folate deficiency, liver disease, hypothyroidism

91
Q

A patient has normocytic, normochromic anemia with a slightly elevated ferritin level. Which of the following choices will best treat the cause of this patients anemia?

A

Optimal management of their rheumatoid arthritis

92
Q

It is important to discern thalassemia minor from iron deficiency anemia because…

A

Iron overload has dangerous complications

93
Q

Macrocytic normochromic anemia can be caused by

A

Folic acid deficiency

94
Q

A 55-year-old with a history of chronic gastritis is concerned about numbness in their fingers and toes. They have also been having difficulty with balance.
Physical findings include decreased vibratory sense, loss of proprioception, and positive Romberg.
Which of the following is the most appropriate treatment?

A

Vitamin B12 and folate supplementation

95
Q 
A 55-year-old patient with anemia has labs rechecked. 
Follow-up lab results are:
H/H-10.6/31.8
MCV-68
MCHC-30
RDW-14.5
Serum iron-36
Serum ferritin-7
TIBC-480
Transferrin saturation-6
Reticulocyte count-120,000 u/L
Fecal occult blood-Positive
Hemoglobin electrophoresis-99% Hgb A1
Peripheral smear-Positive microcytosis, Positive hypochromic
Platelets-341
Which of the above results would help distinguish the cause of the anemia?
A

Fecal occult blood test

96
Q

What Is the first lab value we should look at when a patient is anemic?

A

MCV

97
Q

What are the diagnostics for Thalassemia?

A

Hemoglobin electophoresis

98
Q

How is thalassemia managed?

A

DO NOT give iron

Some patients need blood transfusions

99
Q 
Which of the following is normocytic?
Iron deficiency anemia
Vitamin B12
Thalassemia
Anemia of chronic disease
A

Anemia of chronic disease

100
Q 
What type of anemia do the following labs indicate?
Ferritin-low
Retic-low
TIBC-high
MCV- <80
Serum Iron-low
A

Microcytic–»iron deficiency anemia

TIBC shows us this is not thalassemia-if it was it would be normal

101
Q

Why is ferritin so important when it comes to iron deficiency anemia?

A

It measures the stored iron and is the first lab value to change. A low H/H is a late indicator of anemia

102
Q

What are some of the objectives we may find with a patient with Vitamin B12 deficiency?

A 
Jaundice
Neuropathy
Angular stomatitis
Glossitis
Unstable Gait
Cognitive Impairment
Positive Romberg

Neuro will not resolve if not treated early

103
Q

What are some causes of VB12 deficiency?

A 
Intrinsic factor deficiency
Malabsorption issues (I.e. chrons, IBs, stomach sx)
104
Q

What other labs should be reviewed with VB12 deficiency?

A

Serum coballum
Folate
Homocystine
Methylmalonic acid

105
Q 
A 76-year-old patient with Lupus (managed by another provider) and no complications presents with a normal exam and the following labs:
H/H: 11.3/33
MCV: 94
Serum iron-low
Ferritin-slightly elevated
TIBC-normal

What does she have and how should we educate her?

A

iron deficiency of chronic disease

Education: diet-green leafy veggies, vaccine review

106
Q 
A 76-year-old patient presents with these labs:
H/H: 11.3/33
MCV: 72
Retic: low
Serum iron: low
Ferritin- low
TIBC: high
What anemia does she have? What may be causing it (I.e. most common cause)?
A

Iron deficiency anemia

Most commonly: Bleeding-possibly GI due to age

107
Q

What education should we give patients taking iron?

A

Iron supplements should be taken with orange juice to assist with absorption
May cause GI upset-should be taken on an empty stomach but can be taken with meal if needed
May cause stomach cramps and nausea
Avoid calcium and dairy within a few hours
Will take 1 month to improve

108
Q

What is the leading cause of iron deficiency anemia in elderly women?

A

GI bleed

109
Q

What are the types of microcytic anemia?

A

Iron deficiency - most common

Thalassemia

110
Q

When would we treat for iron deficiency anemia versus not treat?

A 
When to treat:
acute blood loss 
impaired absorption 
pregnancy 
heavy mensural bleeding 
GI blood loss 
Chronic kidney disease 
Gastric bypass 
inflammatory bowel disease 
dietary deficiency

When not to treat:
early iron deficiency anemia, especially if asymptomatic

NM 703 Primary Care (8 decks)

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