Signs & Symptoms of Hematologic/Oncologic Disease Flashcards
1
Q
Is Venipuncture a Clean or Sterile procedure?
A
Clean.
2
Q
Is a Blood Culture a Clean or Sterile procedure?
A
Sterile.
Blood cultures look for infection in the blood (bacteria or fungi).
3
Q
In venipuncture, where would you obtain blood from an adult? A child?
A
Adult - Cubital fossa
Child - Heel, or Scalp
4
Q
When would you obtain an Arterial Sample?
A
When you need fresh blood - for coma & critically ill patients.
Determines gas exchange levels in the blood in relation to respiratory, metabolic, and renal function.
5
Q
What symptom(s) is/are shared among anemias?
A
Fatigue & Pallor.
- Pallor on conjunctiva, nails, and lips.
- Oxygen is not getting to body tissues.
6
Q
What is the minimal laboratory work-up you need to determine anemia?
A
CBC w/ diff Peripheral Blood Smear (usually)
7
Q
Where is Multiple Myeloma located?
A
In the bones, specifically plasma cells
8
Q
What is in a CBC w/ Differential?
A
- Hemoglobin (Hgb) - oxygen carrying protein in RBCs
- Hematocrit (Hct) - % of RBCs in blood
- Red blood cell count
- White blood cell count
- Platelet count
- Reticulocyte count - Bone Marrow function assessment
- RDW
- MCV - measures RBC volume
- MCH
- MCHC - measures Hgb concentration
- Neutrophils; Neutrophils, Absolute
- Lymphocytes; Lymphocytes Absolute
- Monocytes; Monocytes Absolute
- Eosinophils; Eosinophils Absolute
- Basophils; Basophils Absolute
9
Q
Normal Peripheral Blood Smear
A
“A normal peripheral blood smear indicates the appropriate appearance of red blood cells, with a zone of central pallor (of the RBC) occupying about 1/3 of the size of the RBC.” - Utah School of Medicine (see image below)
10
Q
Iron Deficiency Anemia - CBC example
A
- Decreased MCV
- Decreased Hgb
- Decreased Hct
11
Q
Anemic - Hemoglobin Level
A
-
Men:
- Hgb >13.5g/dL
- (or) Hct <41%
-
Women
- Hgb <12.0g/dL
- Hct <36%
12
Q
Falsely Anemic, or normal “H+H” levels in:
A
- Acute Active Bleeding
- H+H levels may appear normal, but…
- ~36-48 hours after blood loss, you will see the levels decrease due to compensattion
- H+H levels may appear normal, but…
- Pregnancy
- “physiologic” or dilutional anemia
- Volume depletion
- (hemo-concentrated)
13
Q
Microcytic RBC
A
- Mean corpuscular volume (MCV)
- Iron deficiency
- Talassemia
- Lead poisoning
Mean corpuscular volume = avg. volume of RBCs
14
Q
Macrocytic RBCs
A
- MCV >100
- Larger RBCs
- Vit. B12 deficiency
- Folate deficiency
15
Q
Just like this image for reference sake…
A
16
Q
Normocytic RBC
A
- MCV btwn 80-100
- Anemia of chronic disease
17
Q
Anemia - Low RBC Count
A
- Fatigue
- Pallor
- Exertional dyspena (compensatory)
- Dyspnea at rest
- Palpitations
- Roaring pulse heard in ears
- Rare: Lethary, confusion, CHF, angina, arrhythmia, AMI
18
Q
Anemia - Low RBC Count
Other signs of anemia
A
- Bounding pulses (3+)
- Lymphadenopathy
- Hepatosplenomegaly
- Bone tenderness, esp over the Sternum
- Lots of blood cells made in sternum
19
Q
Iron Deficiency Anemia
A
- Most common medical disorder WORLDWIDE
- Children = poor diet
- Adults = blood loss (Melena, Menses)
20
Q
Iron Deficiency Anemia
Signs & Symptoms
A
- Fatigue
- Cheilitis & glossitis
- Pica & pagophagia
- Koilonychia
21
Q
Iron Deficiency Anemia
Labs
A
- Serum Ferritin <15mcg/L
- Increased Total Iron Binding Capacity (TIBC)
- Elevated b/c transferritin not binding to iron
22
Q
Vitamin B12 & Folate Deficiency
A
- Megoblastic anemias
- High risk for Development:
- Older Adults
- Alcoholics
- Pure Vegans
- Malnourished
- Pts. w/ gastric bypass & GI Diseases
23
Q
How long does it take Vit. B12 deficiency to develop? Folate?
A
- Vit B12: Takes years to develop
- Folate: 4-5 months
24
Q
Work-up for Vit. B12 & Folate Deficiency
A
- Check Vit. B12 & Folate levels
- If low B12 - not good b/c neurologic issues
- Check Methylmalonate (MMA) & Total Homocysteine levels
- If Vit. B12 Deficiency: Both are elevated
- If Folate Deficiency: Only Total Homocysteine is elevated
25
**Vit. B12 Deficiency**
***Signs/Symptoms***
* **Paresthesias:**
* ****Decreased proprioception/postion & vibratory sense
* Gait disturbance
* Glossitis
* Anorexia/Diarrhea
* Late Finding: Alerted Mental Status
\*\*Irreversible Neurological Damage can occur if not diagnosed correctly!!
26
**Treatment of Vitamin B12 Deficiency**
* Parenteral B12
27
**Pernicious Anemia**
- B12 Deficiency caused by lack of Intrinsic Factors
- Associated with other autoimmune d/o (thyroid & T1DM)
28
**Pernicious Anemia**
*Signs and Symptoms*
* Skin tingling/burning
* Glossitis
* Fatigue, dyspnea
* Leg weakness or spasms
* Imbalance while standing (especially at night)
* Dementia
29
**Pernicious Anemia**
*Lab Finding*
* Antibodies to Intrinsic Factor (IF)
30
**Pernicious Anemia**
*Treatment*
B12 (intramuscular; shots or pills)
31
**Thalassemia**
* Genetic Defect
* Impaired production of globin chains
* Beta and Alpha Minor are **Asymptomatic**
* Beta Major - not good...
* Alpha Major - Incompatible with extra-uterine life
32
**Thalassemia**
***Beta Major***
* Profound hypochromic, microcytic anemia w/ bizzare RBC Morphology
* Target Cells
* Heterozygotes - Much more mild symptoms
* Homozygotes - More severe; life-long transfusions
33
**Thalassemia**
***Beta Major***
* Signs/Symptoms of Beta Major:
* Pallor
* Growth retardation
* HSM, Jaundice
* Abnormal skeletal development
* "Chipmunk" face
34
**Thalassemia**
***Beta Major***
* Treatment:
* Life-long transfusions
35
**Sickle Cell Anemia**
* Production of Abnormally-Shaped RBCs
* Subtype causing anemia
* Homozygous Hemoglobin S
* Will present by age
* RBCs lose function
* Vaso-occulsion
* Hemolysis
* Autosomal Recessive Diease
* Must inherit gene from _both parents_
36
**Sickle Cell Anemia**
***Signs & Symptoms***
* Dactylitis
* Acute pain in hands and/or feet
* Joint Pain
* Splenic Sequestration: Pooling of blood in Spleen
* Splenomegaly - b/c spleen is trying to clean this up!
* Multiorgan/Multisystem Dysfunction or Failure
* Infections, Pain, Fatigue
37
**Sickle Cell Anemia**
***Tests***
* Peripheral Blood Smear
* Blood test screens for hemoglobin S — the defective form of hemoglobin that underlies sickle cell anemia
* *"Every state in the United States, the District of Columbia, and the U.S. territories require that every baby is tested for SCD as part of a newborn screening program." -NIH*
38
**Sickle Cell Anemia**
***Painful Episode***
*(previously known as "Sickle Cell Crisis")*
* No identifiable cause
* Lasts 2-7 days
* Can affect any area of body
* Pain is Trivial to Excruciating!!
* 1/2 of episodes accompained by:
* Fever
* Swelling
* Tenderness
* Tachypnea
* HTN
* N/V
39
**Sickle Cell Anemia**
## Footnote
***Acute Chest Syndrome***
* **Leading cause of Death in Patients w/ SCD**
* Unclear etiology
* Vaso-occulsive crisis
* "Radiodensity (consolidation) on chest XR *plus* Fever and/or Respiratory Symptoms
40
**Sickle Cell Anemia**
***Acute Chest Syndrome***
*Signs & Symptoms*
* Temperature \>38.5ºC
* Tachypnea
* Intercostal retractions, nasal flaring, accessory muscle use
* Chest Pain
* Cough, wheezing, rales
* **Do not miss this Dx -- Progresses Rapidly!!!**
* **Can see on XR**
41
**Sickle Cell Anemia**
***Acute Chest Syndrome***
Treatment
Broad Spectrum Abx
ICU Admission
42
**Glucose-6-phosphate deydrogenase (G6PD) Deficiency**
Most common enzymatic disorder of RBCs in the world!
* Found most often in those w/:
* African
* Middle-Eastern
* Mediterranean
* or Asian descent
43
**G6PD Deficiency**
* G6PD protects RBCs against oxidant injury
* Hemolysis occurs
* Triggers: Infection, Drugs, Chemicals, Fava Beans
44
**G6PD Deficiency**
***Signs & Symptoms***
* Asymptomatic
* Jaundice (neonatal, hyperbilirubinemia)
* Pallor
* Dark Urine
* +/- Abdominal Pain
45
**G6PD Deficiency**
***Tests***
* Peripheral Blood Smear:
* Heinz Bodies
* Bite cells
* Screening Tests:
* Fluorescent Spot Test
* Detects:
* Generation of NADPH from NADP
46
**G6PD Deficiency**
***Treatment***
* Avoid Triggers- Drugs, chemicals, fava beans
* Transfusions
47
**Aplastic Anemia**
* Types:
* Inherited congenital bone-failure syndromes:
* "Fanconi's"
* Potential Causes of Acquired:
* Viral Infection
* Drugs
* Toxic Chemicals
* Autoimmune
48
**Aplastic Anemia**
49
**Aplastic Anemia**
***Inherited Bone-Failure Syndromes***
* Signs & Symptoms:
* Abnormal Skin Pigmentation
* Short Stature
* Renal, Cardiac, GI Abnormalities
* Microcephaly
* Hypogonadism
* Skeletal anomalies
50
**Aplastic Anemia**
***Acquired Aplastic Anemia***
* Signs & Symptoms (insidious onset):
* Pallor
* Petechiae
* Purpura
* Ecchymosis
* Mucosal & Gingival Bleeding
* Vaginal Bleeding
* Active Bacterial Infections
\*Lots of associations w/ different things; have not found exact cause
\*Unable to clot, lots of bleeding
51
**Anemia of Chronic Disease**
* Associatedd with infectious, inflammatory, or neoplastic disease
* CKD, RA, leukemia, HIV, Hep B/C, etc...
* Typically, normochromic, normocytic, hypoproliferative & mild in degree
* Treat the cause!
52
**Anemia of Chronic Disease**
***Pathogenesis***
* Reduction in RBC production by bone marrow
* Mild shortening of RBC survival
* Inability to increase erthyropoesis in response to anemia
53
**Lead Poisoning**
* Often caused by:
* Lead Exposure at Work
* Look at Pt. Hx and occupation during exam
* Painters, construction workers, etc...
* Those who live in older houses
* Dx: Blood Lead Level \>80mcg/dL
* Tx: Chelation
54
**Lead Poisoning**
***Signs & Symptoms***
* "Lead colic"
* Abdominal Pain
* Anemia - Microcytic
* Headache, Irritability
* Confusion
\*Don't miss this Dx!!! -- Irreverisible damage to the Nervous sys, kidneys, other organs...
55
**Lead Poisoning**
56
**Polycythemia Vera**
* Myeloproliferative Disorder
* Bone Marrow can Overstimulate
* Often incidental finding on CBC
* Hemoglobin \>18.5 in men or 16.5 women
* Persistent Leukocytosis & thrombocytosis
* Elevated Platlets & WBCs
57
**Polycythemia Vera**
***Signs & Symptoms***
***+***
***Treatment***
* Signs/Symptoms
* Splenomegaly
* Headache
* Generalized puritis (post-bath)
* Unusual thrombosis
* Erthromelalgia
* Hands change colors!
* Normal pulse
* Treatment: Phlebotomy
* Try to get rid of the RBCs
58
**Coagulopathies**
59
**Coagulopathies**
***Factor V Leiden***
* Most common
* Inherited hypercoagulability
* Caucasian
* Risk of venous thromboemolism
* DVT
* Ask patient about Hx of clotting
* PMH and FH
* Tx: Anticoagulation if clot, decrease clotting risk via lifestyle
* Do NOT go on estrogen
60
**Coagulopathies**
***Immune Thrombocytopenia***
* Acquired
* Caused by autoantibodies against platelet antigens
* Viral infections, autoimmune
* Triggers: Viral infections & systemic conditions (ex: SLE)
* Disrupt immume homeostasis
* Exam: Petechaie, purpura, epistaxis
* TX – glucocorticoids, IVIG
61
**Coaglopathies**
***Hemophilia***
Lacks clotting factors
* X-linked recessive
* Hemophilia A - lacks Factor VIII
* Hemophilia B - lacks Factor IX
Usually presents around age 1-1.5yo
62
**Coagulopathies**
***Hemophilia***
*Signs and Symptoms*
* Easy bruising
* Hemarthrosis
* 80% of hemorrhage occurs in joints
\*Late complications: Intracranial hemorrhage, Joint destruction
63
**Coagulopathies**
***Hemophilia***
*Labs & Treatment*
* Lab Test: Prolonged PTT
* Treatment: Prothrombin complex concentrates (PCC) & Human Factor VIIa
64
**Coagulopathies**
***Von Willebrand Disease***
* Most common inherited bleeding disorder
* Platelets have normal morphology, but lack Factor VIII/vWF complex
* Adherance issues
* Platelet count is **normal,** just CANT adhere
65
**Coagulopathies**
***Von Willebrand Disease***
*3 Types*
**3 Types:**
1. Mild to Moderate Decrease in vWF
2. Dysfunction of vWF
3. Absolute lock of vWF
66
**Coagulopathies**
***Von Willebrand Disease***
*Signs & Symptoms*
* Easy bruising w/ hematoma
* Skin bleeding
* Prolonged bleeding from mucosal surfaces
* Epistaxis, Dental/Surgery, GI, menorrhagia
Ask:
* Do you bleed a lot after the dentist?
* Do you have a very heavy period?
67
**Coagulopathies**
***Von Willebrand Disease***
*Diagnosis & Treatment*
* Diagnosis:
* Increased Bleeding time
* Normal Platelet Count
* Treatment:
* DDAVP for mild mucosal bleeding
* Desmopression
* Acts by increasing circulation levels of Factor VII and vWF
* Von Willebrand factor replacement therapy
* Antifibrinolytic medications
* Some contraceptives
68
**Oncology**
Multiple Myeloma
69
**Multiple Myeloma**
*Complaints, signs, symptoms*
* Common complaints:
* atraumatic back pain
* Signs/Symptoms:
* Bone pain
* Fatigue/generalized weakness
* Weight loss (unexplained)
* Compression fractures
70
**Multiple Myeloma**
*XR, Tests, Biopsy, PE*
* XR:
* "punched-out" lesions
* See through the skeleton
* Radiolucent - air instead of bone
* Lab:
* Hypercalcemia
* Renal Insufficiency
* Anemia
* Bone Marrow Biopsy (sup/inf iliac crest)
* PE:
* Decreased reflexes
71
**Leukemia**
*Types*
* Acute lymphoblastic leukemia (ALL)
* Chronic lymphocytic leukemia (CLL)
* Acute myeloid leukemia (AML)
* Chronic Myeloid Leukemia (CML)
\*Acute - Rapid increase in immature WBCs; "Blast Cells"
\*\*Chronic - Excessive buildup of mature, but still abnormal WBCs
72
**Leukemia**
* Cause - unknown
* Common in children
* 90% in adults
73
**Leukemia**
*Risk Factors*
* Risk Factors:
* Smoking
* Ionizing Radiation
* Chemicals (eg Benzene)
* Prior Chemo
* Down Syndrome
* Family Hx of Leukemia
74
**Leukemia**
*Signs & Symptoms*
75
**Leukemia**
*Diagnostic Studies*
* CBC w/ diff
* Leukocytosis
* Increase in WBCs
* A hallmark
* Anemia: Low H+H
* Thrombocytopenia
* Peripheral Blood Smear & Bone Marrow Biopsy Abnormalities
* Gene Testing
* Philadelphia Chromosome
* in CML
76
**Leukemia**
*Treatment*
* Combination of:
* Chemo
* Radiation
* Bone Marrow Transplant
* and/or watchful waiting!
77
**Lymphoma**
*Signs and Symptoms*
* Painless Lymphadenopathy
* "B" Symptoms (in agressive lymphoma)
* Fever \>38C
* Weight Loss \>10% over past 6 months
* Night Sweats (drenched)
* Pruritis (generalized)
* Anorexia
* SOB (if nodes become restrictive)
* Mediastinal Mass
78
**Lymphoma**
Hodgkin's
vs.
Non-Hodgkin's
* Hodgkin's =
* Reed-Sternberg Cell
* Non-Hodgkin's
* Reed-Sternberg Cell NOT Present!
Diagnosis: Lymph node biopsy
79
**Lymphoma**
***Hodgkin's Lymphoma***
* Most common malignancy of head & neck in children (mostly teens)
* Ages:
* 15-35, \>55
* Exam:
* Non-tender, firm, rubbery consistency cervical and/or supraclavicular node(s
* Mediastinal mass on routine chest x-ray
80
**Lymphoma**
***Non-Hodgkin's Lymphoma***
* Most common type
* 60,000/yr in U.S.
* Can die quickly
* Group of 20+ types
* eg. Burkitt lymphoma - fastest growing tumor, most common in abdomen
* Exam findings:
* Lymphadenopathy below clavicles, multiple peripheral nodes
81
**Neutropenic Fever**
* Cancer patients receiving chemotherapy - at risk for invasive infection due to colonizing bateria and/or fungi that translocate across GI muscosal surfaces
* Bacteria can translocate
* Fever may be earliest and *only* sign of infection
* Recognize it early!
* Initiate broad-spectrum abx to avoid sepsis/possible death
82
**Neutropenic Fever**
* Neutropenia defined as:
* Absolute Neutrophil count
* \<500 cells/microL
* Fever \>38.3°C
* Onocologic Emergency!!!
* ANC = total WBC count x percentage of polymorphonuclear cells (PMNs) and bands
* Chemo kills all WBCs
