Sasha: Clinical Assessment Heme/Onc Flashcards
Blood Draw:
Adult site
Infant site
Adult sites: Cubital fossa, medial vein
Infant sites: Heel, Scalp
Is a venipuncture clean or sterile?
well… it depends -usually? CLEAN so what does this mean? use alcohol prep…start on the inside making circular motions and work your way out cleaning the site. when would we do sterile blood draw? transfusions/blood culture so that way you don’t introduce bacteria into the sample
When would you want an arterial sample?
BLOOD GAS you order these when your patient has an altered mental state you want to know how much oxygen is in the brain
What is anemia?
Disorder of RBC there are numerous types and etiologies
what symptoms do all anemia’s share?
All share fatigue and pallor as symptoms
why do you have these symp? Lack of oxygen to body tissues
what is pallor? and where do you look for it on the body?
Pallor= pale Look for this in conjunctiva mucosa and on skin of hands and nails—can mean low anemia
what (at minimum) lab work do you do for anemia
CBC with differential
Peripheral blood smear (usually), shows morphology of RBC
What does CBC stand for?
Complete blood count
I know you got this one….good job!!!!!
what is the difference between a CBC w/ differential and a CBC without differential and what does a CBC include?
Differential- gives more information…more to interpret..
all the different types of WBC (neutrophils, Lymphocytes, Monocytes, Eosinophils, Basophils)
Gives the percentages of WBC
what does a CBC include:
- Hemoglobin (Hgb)
- Hematocrit (Hct)
- Red blood cell (RBC) count
- RBC indices
- White blood cell (WBC) count
- Platelet count
- Reticulocyte count (√ bone marrow)
what is hemoglobin ? (Hgb)
oxygen carrying protein in RBC
what is hematocrit? (Hct)
percentage of RBC in blood
What are RBC indices?
MCV – measures RBC volume (macro/normo/microcytic)
MCHC – measures Hgb concentration in single RBC (hypo/hyperchromic)
what is reticulocyte count?
assessment of bone marrow function
describe this pictureand the arrows :)
to understand abnormal we have to be able to describe normal first
red arrow: center should be 1.3 diameter of whole RBC
Black arow- platlets- not a lot of platlets on blood smears
blue arrow- WBC not a whole lot of WBC on normal blood smears
What is anemic referring to?
What is an H&H?
what is hematocrit?
What are the normal values for Women and Men?
Referring to hemoglobin level when they say “I’m anemic”
H&H- hemaglobin and hemoatocrit
Hematorcrit=number of RBC in a sample=H&H
Low hemoglobin=low hematocrit (directly proportional)
If someone has a low hemoglobin level, they are going to have a low hematocrit.
- Hgb <13.5 g/dL or Hct <41% in men
- Hgb <12.0 g/dL or Hct <36% in women
why do men have higher values to be reached in their H+H?
Muscle mass for men, higher= men need more oxygen to muscles to function so there number is higher
what happens to your hemoglobin when you are bleeding ?
what about acute bleeding ? aka trauma
stays normal ….because its just a portion…
In trauma Hemoglobin is normal but you know its not normal because half of the blood has come out and is on the floor in the ER
36-48ish hours later you will see the drop in hemoglobin after acute bleeding and more plasma…H&H will be low
SO what are the 3 things that can cause falsely anemic or normal H+H levels…
- *–Acute bleeding**
- *–Pregnancy** (“physiologic”=increased blood volume so RBCs diluted but ok! aka dilutional anemia)
- *–Volume depletion** (hemo-concentrated) “dehydration makes it look like higher [hemoglobin]
how does pregnancy show on an H+H
during pregnancy you can increase your blood volume by 50% !!!!!!!! but does not rise the hemoglobin level….they will have more plasma in blood sample…. Appears she has less hemoglobin but she does not
isnt this CRAZY
what about volume depletion how does that affect our H+H
let’s say you’re really dehydrated…. You will have less volume in the blood which makes the [hemoglobin] look higher since all of the cells are closer together
Ruth’s Explanation: regarding the dehydration= higher H+H - She misspoke if she said that you will have more plasma if you are dehydrated. If you are dehydrated your blood will have a lower percentage of serum, or plasma, to RBC/WBC/PLT, thus increasing the percentage of your blood that is made up of those cells. Like when you cook down tomatoes to make tomato sauce - as the water cooks off, the sauce gets thicker. It still has the same amount of sugar and fiber etc, they just make up a larger percent of it.
Morphology of RBC
Define:
Microcytic
Macrocytic
Normocytic
give me there MCV numbers and what deficencies you see in each
Macrocytic (larger cells)
Microcytic (abnormally small cells)
•Microcytic (MCV < 80)
–Iron deficiency
–Thalassemia
–Lead poisoning
•Macrocytic (MCV > 100)
–Vitamin B12 deficiency
–Folate deficiency
•Normocytic
–Anemia of chronic disease
what does MCV stand for
mean corpuscular volume
So what other symptoms do we see with Anemia -low hemaglobin (5)…
and then
what other other signs do we see depending on underlying pathology for anemia? (4)
OTher symptoms
•Exertional dyspnea- shortness of breath during exercise
•Dyspnea at rest- SOB
•Palpitations
•Roaring pulsatile (pulsating) sound in the ears
•Rarely, lethargy, confusion, CHF, angina (not getting enough O2), arrhythmia, and/or AMI with severe anemia
Other signs- depends on underlying pathology
•Bounding pulses
•Lymphadenopathy (disease of lymph nodes)
•Hepatosplenomegaly (enlargement to liver and spleen)
•Bone tenderness, especially over the sternum
my sternum is killing me? how come?
a lot of bone marrow and RBC are made in sternum…..so could have pain there if anemic
what is the number 1 cause of anemia
IRON DEFICIENCY ANEMIA!
GREAT JOB :)
what is it typically cause by in infants?
why is it typically caused by in children?
why is it typically caused by in adults?
it is referring to Iron deficiency Anemia…. sorry :)
infants-who love breast milk and have hard time transitioning to food
•Children – typically due to poor diet
•Adults – typically due to blood loss (eg, GI bleed, menses)
signs and symptoms of Iron deficiency Anemia (6)
•Signs/Symptoms
–Fatigue
–Cheilitis, glossitis
–Pica and pagophagia (want to eat paint/rocks)
–Koilonychia “spoon nails”
cards on what these wierd words mean later… no worries :)
what Labs for Iron deficieny am i going to order and what am i going to see for results (3 labs tests)
•Lab – low serum ferritin <15mcg/L, ↑ TIBC
TIBC= total iron binding capacity
•Peripheral blood smear – hypochromic, microcytic (these definitions will come up in a card a little later )
the RBC will look small
hypochromic?
RBC look pale due to lack of hemoglobin
microcytic
look small and then middle part smaller etc.
think back to the picture of normal blood smar
melena
black tarry stool….. yum
hematochezia
bright red stool from distal GI bleed
Pica
eating non food product
ie. dirt, rocks, and paint!
Pagophagia
eating ice!
Koilonychia
spooning of nails
what is this?
Cheilitis=lesions on corner of mouth
annnd… what is this?
Glossitis=smooth sore tongue
Key for “nuitritonal deficient anemia” (B12, folate, and iron)
so if iron deficient anemia happens from my diet then what foods have iron in them?
Red meat, pork, poultry, seafood, beans, leafy greens, dried fruit (raisins), iron fortified cereals, breads, pasta
Mother presents wth her 12 month old babe they do labs and find out she has iron deficiency anemia… why is it so common in a 12 month old?
weaning from breast milk starts to occur and they can start to get iron deficiency… if they are having a hard time weaning then it can be a problem they just want mom’s milk… they need real food to not get iron deficient .
CBC will show anemia
what are the three things in your work up for someone with iron def. anemia
- CBC-abnormal
- History
- Iron level/ iron panel / total iron binging capacity (TIBC)
if you don’t have a lot of iron you will have a lot of TIBC because its waiting to bind to iron.
So we are still talking about nutritional deficiencies if you were wondering….
what are two types of megaloblastic anemias
Vitamin B12 & Folate Deficiency
who is at higher risk of devloping Vitamin B12 & Folate Deficiency (4)
–Older adults (maybe not getting a good diet)
–Alcoholics (spending money on other things)
–Pure vegans (in animal products)
–Those with malnutrition
how long do i have to have nutirional deficiency to get these anemia’s?
–Vitamin B12: takes years
–Folate: takes 4-5 months
WHAT ARE THE TWO STEPS FOR
Vitamin B12 & Folate Deficiency Workup
•Step 1 – check vitamin B12 and folate levels… DUH
•If results are borderline or discordant with other clinical features…
•Step 2 – check methylmalonate (MMA) and total homocysteine
–If vitamin B12 deficiency: both elevated
–If folate deficiency: only total homocysteine elevated
MMA AND TOTAL HOMOCYSTEINE WILL ALWAYS LEAD YOU TO THE ANSWER OF EXACTLY WHICH DEFICENCY IT IS!
what do i NEED to rule out when doing a workup of vit B12 and folate defic.? WHY?
HAVE TO RULE OUT B12
Have to evaluate for b12 because it can cause irreversible neurologic damage
ALRIGHT…. let’s talk about
Vitamin B12 Deficiency
who do we see it in?
Watch for especially in patients with gastric bypass, GI disease (Crohn’s, etc)
again DONT MISS THIS! can cause irreversible neurological damage!
Vitamin B12 Deficiency
SIGNS AND SYMPTOMS (4…well kinda 5)
what are some S/S with late findings (1)
–Gait disturbance
–Glossitis
–Anorexia/diarrhea
–Paresthesias (damage to peripheral nerves, pins and needles, tingly), decreased sensory of position (is it up is it down..remember that test?) and vibratory sense
•Late finding – altered mental status
and you know why? because if you miss this it causes IRREVERSIBLE NEUROLOGICAL DAMAGE
Treatment of
Vitamin B12 Deficiency
in PERNICIOUS ANEMIA
TX – parenteral B12
FACT: B12 is absorbed in ileum with intrinsic factor, so want to get it parenteral (injection) because if they have pernicious anemia then they don’t have intrinsic factor and can’t absorb it if you take it as a pill. you will have issues…so PARENTERAL IT IS!
(intrinsic factor is too expsensive to give instead of parentral B12!)
What is Pernicious Anemia? and what does it cause?
What is it? lack of intrinsic factor
stomach does not make Intrinsic factor in Pernicious anemia
why is this bad aka what does this cause…… so due to a lack of intrinsic factor we get B12 deficiency
so: Pernicious leads to B12 deficency since intrinsic factor absorbs B12
or
B12 Deficency happens BECAUSE you lack intrinsic factor (pernicious anemia)
sorry to say this so many different ways! she just kept stressing this so i wanted to say it as many ways as possible so everyone understands :)
Pernicious Anemia Signs and symptoms (6)
–Skin tingling/burning
–Glossitis
–Fatigue, dyspnea
–Leg weakness or spasms
–Imbalance while standing (especially at night)
–Dementia
is Pernicious Anemia associated with other autoimmune disorders?
YES!
•Associated with other autoimmune d/o (thyroid & T1DM)
PERNICIOUS ANEMIA
LAB FINDINGS
TREATMENT
LABS: antibodies to intrinsic factor (IF)
TX: IM B12
Thalassemia PATHO
Impaired production of globin chains (genetic defect)
4 TYPES of Thalassemia? and their symptoms/signs
1) Beta minor - asymptomatic
2) alpha minor – asymptomatic
3) Beta Major- (present ~6 months old) –
–Pallor
–Growth retardation
–Hepatosplenomegaly(HSM), jaundice
–Abnormal skeletal development, “chipmunk” facies
4) Alpha major – incompatible with extra-uterine life
Beta Thalassemia Major (BTM)
what ar the characteristics on the blood smear? what specific cell do you see characteristic of this?
treatment for BTM?
name two types in thalassemia that require different treatments?
- BTM – profound (KEY!) hypochromic, microcytic anemia with bizarre RBC morphology (“Target cells”)
- BTM TX – life-long transfusions
2 types: heterozygote’s (minor)– much more mild symptoms
homozygote’s (major) – life-long transfusions (BTM)
what type of anemia is Thalassemia?
INHERITED ANEMIA (not nutritional)
People may have minors (remember the four types there were two types of minors that were asymptomatic) and never know it
Around 6 months the infant now produces its own hemoglobin but there is a defect and it now causes a defect in the child.
again blood smear apperance : Hypochromic, microytic, profoundly low
Tell me about the apperance and symptoms that happen in a child with Beta Thalassemia Major?
Child will fall off the growth cord!
Facial and skull features will be deformed
hoffman described this as a: Chipmunk face
what is unique in the Beta Thalassemia Major peripheral blood smear?
It will have target cells!
what will children with Beta Thalassemia Major need for life?
Will need life long transfusions
What is sickle cell anemia?
HEMOLYTIC ANEMIA
•Production of abnormally-shaped RBCs
–Subtype causing anemia: homozygous hemoglobin S
•Diminished ability to function as RBCs
–Vasoocclusion
–Hemolysis
Signs and Symp. of Sickle Cell Anemia (4)
–Dactylitis (acute pain in the hands and/or feet) [the vessels more easily occulde causing issues]
–Joint pain
–Splenic sequestration
–Multiorgan/multisystem dysfunction or failure
what age does sickle cell show up at?
AGE 2
tell me all about this picture and whats the problem with it?
Crescent or “Sickle” shaped
They look sharp…. They get stuck in blood stream— spleen gets big because its trying to clean up the messed up RBC
painful episode? what is that? how long can it last?
Previously referred to as SICKLE CELL CRISIS
•No identifiable cause; lasts 2-7 days
•Can affect any area of the body….. it is basal occulding
•Pain trivial to excruciating
•½ of episodes accompanied by:
–Fever
–Swelling
–Tenderness
–Tachypnea
–Hypertension
–Nausea/vomiting
Acute Chest Syndrome (ACS)
signs/symptoms
–Temperature ≥38.5°C
–Tachypnea
–Intercostal retractions, nasal flaring, or use of accessory muscles
–Chest pain
–Cough, wheezing, rales
*******Always look for it; progresses rapidly
what is going on here?
Acute Chest Syndrome
Left side- radioopaque…. Probably fluid collection
how does a blood smear look with G6PD Deficiency
what is the important cells only seen in this disease?
•Peripheral blood smear:
–Heinz bodies
–Bite cells
Inherited Bone-Failure Syndromes (Fanconi’s)
signs and symptoms
–Abnormal skin pigmentation
–Short stature
–Renal, cardiac, GI abnormalities
–Microcephaly
–Hypogonadism
–Skeletal anomalies
Petechiae
what is it? what is it caused by?
little pinpoint dots on the skin that come from microhemmoraging
caused by decreased platelets, thrombocytopenia
whats this?
petechiae
what this?
purpura
they are bigger!
what’s this?
ecchymosis
biggest
AHHH, WHAT IS WRONG WITH ME?
lead collects on the gum line… so check it out!
what is so unique to the lead poisoning blood smear? if you see this word you 100% KNOW ITS LEAD POSIONING?
BASOPHILIC STIPPLING ON PERIPHERAL BLOOD SMEAR! = LEAD POISONING
signs and symptoms of Polycythemia Vera (5)
–Splenomegaly
–Headache
–Generalized pruritus (post-bath)-severe ithching
–Unusual thrombosis (clotting)
–Erythromelalgia (hands turn colors)
Erythromelalgia
hands change colors
normal pulse but change in color of hands
**specific to polycynthemia vera**
How do patients present with Immune Thrombocytopenia
aka what do you see on your exam?
petechiae, purpura, epistaxis
show up complaining of bleeding
What is this?
purpura
signs and symptoms of Hemophilia
Late complications?
–Easy bruising
–Hemarthrosis (80% of hemorrhage occurs in joints)
•Late complications – ICH (intracranial hemorrhage), joint destruction
what are spontaneous hemarthrosis
large joints in hemophilia
Alright guys almost there…. lets start Oncology
and just remember this is the only lecture for CA for the exam so by doing these flashcards you are almost done with studying for CA
:)
What do x-rays look like in Multiple Myeloma
•X-ray shows “punched out” lesions
Get an x ray
Plasma cells are proliferating in bone and causes this punched out thing on x-ray
Then bone scan to see where lesions are
Raadiolucent air where the holes are
What will Multiple myeloma x ray show
punched out
What is going to be your diagnostic workup for multiple myeloma?
•Diagnostic workup: bone marrow biopsy
In the hip…. Posterior superior iliac crest
Multiple Myeloma blood smear
see a lot of B cells
symptoms of leukemia
(hint: it’s a whole diagram of symptoms)
NONSPECIFIC
comes into your office is “Soooo run down, extremely tired, can’t get rid of the cough”
you say alright lets give it another week or two
Symptoms failed to resolve and he went back
Extremely high WBC count—he had leukemia
Hoffman told us this story… who knows if she’ll take questions from experiences she’s had. so here it is :)
LeuKemia Cutis
Rash primarily on face and chest
what is this?
splenomegaly in leukemia
How does patint present with lymphoma?
Non tender palpable lymph node
Descirbe X-ray findings for lymphoma
Could pick it up on chest x-ray and having a large mediastinal mass
What does the Reed Sternberg cell look like on a blood smear
OWL’S EYES
NICE JOB GUYS!
hope these helped!
only thing not on here is that little paper packet she gave us with normal lab values on it that we have to know..
I may add those in later this weekend :)
other then that… enjoy and happy studying!
