Signs & Symptoms of Hematologic/Oncologic Disease Flashcards
Is Venipuncture a Clean or Sterile procedure?
Clean.
Is a Blood Culture a Clean or Sterile procedure?
Sterile.
Blood cultures look for infection in the blood (bacteria or fungi).
In venipuncture, where would you obtain blood from an adult? A child?
Adult - Cubital fossa
Child - Heel, or Scalp
When would you obtain an Arterial Sample?
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.
What symptom(s) is/are shared among anemias?
Fatigue & Pallor.
- Pallor on conjunctiva, nails, and lips.
- Oxygen is not getting to body tissues.
What is the minimal laboratory work-up you need to determine anemia?
CBC w/ diff Peripheral Blood Smear (usually)
Where is Multiple Myeloma located?
In the bones, specifically plasma cells
What is in a CBC w/ Differential?
- 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
Normal Peripheral Blood Smear
“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)
Iron Deficiency Anemia - CBC example
- Decreased MCV
- Decreased Hgb
- Decreased Hct
Anemic - Hemoglobin Level
-
Men:
- Hgb >13.5g/dL
- (or) Hct <41%
-
Women
- Hgb <12.0g/dL
- Hct <36%
Falsely Anemic, or normal “H+H” levels in:
- 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)
Microcytic RBC
- Mean corpuscular volume (MCV)
- Iron deficiency
- Talassemia
- Lead poisoning
Mean corpuscular volume = avg. volume of RBCs
Macrocytic RBCs
- MCV >100
- Larger RBCs
- Vit. B12 deficiency
- Folate deficiency
Just like this image for reference sake…
Normocytic RBC
- MCV btwn 80-100
- Anemia of chronic disease
Anemia - Low RBC Count
- Fatigue
- Pallor
- Exertional dyspena (compensatory)
- Dyspnea at rest
- Palpitations
- Roaring pulse heard in ears
- Rare: Lethary, confusion, CHF, angina, arrhythmia, AMI
Anemia - Low RBC Count
Other signs of anemia
- Bounding pulses (3+)
- Lymphadenopathy
- Hepatosplenomegaly
- Bone tenderness, esp over the Sternum
- Lots of blood cells made in sternum
Iron Deficiency Anemia
- Most common medical disorder WORLDWIDE
- Children = poor diet
- Adults = blood loss (Melena, Menses)
Iron Deficiency Anemia
Signs & Symptoms
- Fatigue
- Cheilitis & glossitis
- Pica & pagophagia
- Koilonychia
Iron Deficiency Anemia
Labs
- Serum Ferritin <15mcg/L
- Increased Total Iron Binding Capacity (TIBC)
- Elevated b/c transferritin not binding to iron
Vitamin B12 & Folate Deficiency
- Megoblastic anemias
- High risk for Development:
- Older Adults
- Alcoholics
- Pure Vegans
- Malnourished
- Pts. w/ gastric bypass & GI Diseases
How long does it take Vit. B12 deficiency to develop? Folate?
- Vit B12: Takes years to develop
- Folate: 4-5 months
Work-up for Vit. B12 & Folate Deficiency
- 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
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!!
Treatment of Vitamin B12 Deficiency
- Parenteral B12
Pernicious Anemia
- B12 Deficiency caused by lack of Intrinsic Factors
- Associated with other autoimmune d/o (thyroid & T1DM)
Pernicious Anemia
Signs and Symptoms
- Skin tingling/burning
- Glossitis
- Fatigue, dyspnea
- Leg weakness or spasms
- Imbalance while standing (especially at night)
- Dementia
Pernicious Anemia
Lab Finding
- Antibodies to Intrinsic Factor (IF)
Pernicious Anemia
Treatment
B12 (intramuscular; shots or pills)
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
Thalassemia
Beta Major
- Profound hypochromic, microcytic anemia w/ bizzare RBC Morphology
- Target Cells
- Heterozygotes - Much more mild symptoms
- Homozygotes - More severe; life-long transfusions
Thalassemia
Beta Major
- Signs/Symptoms of Beta Major:
- Pallor
- Growth retardation
- HSM, Jaundice
- Abnormal skeletal development
- “Chipmunk” face
Thalassemia
Beta Major
- Treatment:
- Life-long transfusions
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
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
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
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
Sickle Cell Anemia
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
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
Sickle Cell Anemia
Acute Chest Syndrome
Treatment
Broad Spectrum Abx
ICU Admission
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
G6PD Deficiency
- G6PD protects RBCs against oxidant injury
- Hemolysis occurs
- Triggers: Infection, Drugs, Chemicals, Fava Beans
G6PD Deficiency
Signs & Symptoms
- Asymptomatic
- Jaundice (neonatal, hyperbilirubinemia)
- Pallor
- Dark Urine
- +/- Abdominal Pain
G6PD Deficiency
Tests
- Peripheral Blood Smear:
- Heinz Bodies
- Bite cells
- Screening Tests:
- Fluorescent Spot Test
- Detects:
- Generation of NADPH from NADP
- Detects:
- Fluorescent Spot Test
G6PD Deficiency
Treatment
- Avoid Triggers- Drugs, chemicals, fava beans
- Transfusions
Aplastic Anemia
- Types:
- Inherited congenital bone-failure syndromes:
- “Fanconi’s”
- Inherited congenital bone-failure syndromes:
- Potential Causes of Acquired:
- Viral Infection
- Drugs
- Toxic Chemicals
- Autoimmune
Aplastic Anemia
Aplastic Anemia
Inherited Bone-Failure Syndromes
- Signs & Symptoms:
- Abnormal Skin Pigmentation
- Short Stature
- Renal, Cardiac, GI Abnormalities
- Microcephaly
- Hypogonadism
- Skeletal anomalies
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
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!
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
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
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…
Lead Poisoning
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
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
Coagulopathies
Coagulopathies
Factor V Leiden
- Most common
- Inherited hypercoagulability
- Caucasian
- Inherited hypercoagulability
- 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
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
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
Coagulopathies
Hemophilia
Signs and Symptoms
- Easy bruising
- Hemarthrosis
- 80% of hemorrhage occurs in joints
*Late complications: Intracranial hemorrhage, Joint destruction
Coagulopathies
Hemophilia
Labs & Treatment
- Lab Test: Prolonged PTT
- Treatment: Prothrombin complex concentrates (PCC) & Human Factor VIIa
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
Coagulopathies
Von Willebrand Disease
3 Types
3 Types:
- Mild to Moderate Decrease in vWF
- Dysfunction of vWF
- Absolute lock of vWF
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?
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
- Desmopression
- Von Willebrand factor replacement therapy
- Antifibrinolytic medications
- Some contraceptives
- DDAVP for mild mucosal bleeding
Oncology
Multiple Myeloma
Multiple Myeloma
Complaints, signs, symptoms
- Common complaints:
- atraumatic back pain
- Signs/Symptoms:
- Bone pain
- Fatigue/generalized weakness
- Weight loss (unexplained)
- Compression fractures
Multiple Myeloma
XR, Tests, Biopsy, PE
- XR:
- “punched-out” lesions
- See through the skeleton
- Radiolucent - air instead of bone
- “punched-out” lesions
- Lab:
- Hypercalcemia
- Renal Insufficiency
- Anemia
- Bone Marrow Biopsy (sup/inf iliac crest)
- PE:
- Decreased reflexes
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
Leukemia
- Cause - unknown
- Common in children
- 90% in adults
Leukemia
Risk Factors
- Risk Factors:
- Smoking
- Ionizing Radiation
- Chemicals (eg Benzene)
- Prior Chemo
- Down Syndrome
- Family Hx of Leukemia
Leukemia
Signs & Symptoms
Leukemia
Diagnostic Studies
- CBC w/ diff
- Leukocytosis
- Increase in WBCs
- A hallmark
- Increase in WBCs
- Anemia: Low H+H
- Thrombocytopenia
- Leukocytosis
- Peripheral Blood Smear & Bone Marrow Biopsy Abnormalities
- Gene Testing
- Philadelphia Chromosome
- in CML
- Philadelphia Chromosome
Leukemia
Treatment
- Combination of:
- Chemo
- Radiation
- Bone Marrow Transplant
- and/or watchful waiting!
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
Lymphoma
Hodgkin’s
vs.
Non-Hodgkin’s
- Hodgkin’s =
- Reed-Sternberg Cell
- Non-Hodgkin’s
- Reed-Sternberg Cell NOT Present!
Diagnosis: Lymph node biopsy
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
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
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
Neutropenic Fever
- Neutropenia defined as:
- Absolute Neutrophil count
- <500 cells/microL
- Absolute Neutrophil count
- Fever >38.3°C
- Onocologic Emergency!!!
- ANC = total WBC count x percentage of polymorphonuclear cells (PMNs) and bands
- Chemo kills all WBCs
