Hem_Rheum_Oncology

Question 1

“<span>Complications post chemoRx</span>”

Answer 1

-Chemotherapy side effects<br></br>-Tumour lysis syndrome<br></br>-Gastroenteritis (viral or bacterial)<br></br>-Typhlitis<br></br>-Urinary tract infection<br></br>-Bowel obstruction (small or large)

Question 2

Electrolytes disturbances of Tumor lysis syndrome:

Answer 2

HyperK<div>HypoCa</div><div>HyperPO4</div><div>Hyperuricemia</div>

Question 3

DDx of monoarthritis

Answer 3

Septic joint<div>Gout</div><div>Pseudo gout</div><div>Reactive arthritis</div><div>RA</div><div>Spont hemoarthrosis</div><div>OA</div>

Question 4

Gout vs Pseudogout

Answer 4

“<img></img>”

Question 5

Therapies for SVC syndrome

Answer 5

Corticisteroids<div>Diuretics</div><div>Anticoagulation</div><div>Thrombolysis</div>

Question 6

What are some specific treatments for SVC synd

Answer 6

Radiation<div>Chemotherapy</div><div>Surgery</div><div>Endovascular stent</div>

Question 7

Risk factors for ALL

Answer 7

Chromosomal and (Philadelphia translocation)<div>Radiation exposure</div><div>ChemoRx for prior malignancy</div>

Question 8

List 5 causes of fever in the cancer patient

Answer 8

1. Infection (only identified in ⅓ of patients) <br></br>2. DVT / Pulmonary embolus <br></br>3. Chemotherapy or medication effect <br></br>4. Direct tumor burden effect <br></br>5. Transfusion reaction

Question 9

List 4 causes of pericardial effusion in the cancer patient:

Answer 9

• Malignancy (lung, breast, hematologic, melanoma) <br></br>• Hypoalbuminemia <br></br>• Radiation <br></br>• Chemotherapy

Question 10

Causes of hyperviscosity syndrome

Answer 10

<ol> <li>Elevation of cellular contents of blood (leukostasis, polycythemia)</li> <li>Cryoglobulinemic Hyperviscosity (e.g., Multiple Myeloma)</li> <li>Polyclonal or monoclonal immunoglobulins that are not cryoglobulins (e.g.,Waldenstrom’s macroglobulinemia)</li> <li>Partial obstruction by sickled RBCs</li> <li>Partial obstructed by parasitized cells (malaria, Babeiosis)</li> </ol>

Question 11

How cancer patient get hypercalcemia?

Answer 11

PTHrP synthesis<div>Active vit D overproduction</div><div>Bone osteolysis (direct spread)</div><div>Ectopic PTH production</div>

Question 12

Common Ca that mets to bone:

Answer 12

Breast<div>Lung</div><div><br></br></div><div>Kidney</div><div>Prostate</div><div>Testes</div><div><br></br></div><div>Myeloma</div>

Question 13

Causes of SVC syndrome

Answer 13

Malignancy (lung,lymphoma)<div>Thrombosis (pacemaker)</div><div>Infections (endocarditid, mediastinitis, TB, syphilis)</div><div>Post radiation fibrosis</div>

Question 14

CVS complications of SVC Malignancy:

Answer 14

SVC synd<div>DVT/PE</div><div>Dysrhythmias due to electr dist (hyperK)</div><div>Malignant pericrdial dis/temponade</div><div>Carotid blowout synd/carotid rupture</div>

Question 15

Neurological complications of malignancy

Answer 15

<div><b>Infections: </b><br></br><i>Brain abscess<br></br>Meningitis<br></br>encephalitis</i><br></br></div>

<div><br></br><b>Vascular: </b><br></br><i>Leukostasis<br></br>Hyperviscosity syndrome</i></div>

<div><br></br><b>Electrolyte disturbances: </b><br></br><i>Hypercalcemia; <br></br>Hyponatriemia<br></br>SIADH</i><br></br></div>

<div><br></br><b>Mechanical :</b><br></br><i>brain mets, <br></br>spinal cord compression/cauda equina, <br></br>hydrocephalus</i></div>

Question 16

Mx of Acute chest syndrome due to Sickle cell crisis

Answer 16

<p>Needs IV Antibiotics to cover CAP - Ceftriaxone and Azithromycin or Resp. Fluroquinolone (Chlamydia most common in sputum/Strep most common in Blood)</p>

<p>O2</p>

<p>IV Narcotics</p>

<p>Exchange Transfusion or Simple Transfusion</p>

<p>CT Chest - Infiltrate no PE</p>

<p>Hematology Consultation and ICU Admission</p>

Question 17

“<h2><span>Classic Clinical Presentation for TTP</span></h2>”

Answer 17

“Never say “FAT RN” out loud in the ED or you might suffer bodily harm!<div><br></br></div><div>Fever</div><div>Anemia: microangiopathic H A, schistocytes</div><div>Thrombocytopenia</div><div>Renal insuff</div><div>Neuro abn <b>(the wholemark of TTP, HA, confusion, CN palsies, seizure, coma)</b></div>”

Question 18

Mx of TTP in ER:

Answer 18

FFP (15 ml/kg)<div>Steroids (methylprednisolone)</div><div>Plasma exchange</div><div>Plt transfusion</div><div>Nephrology/hematology consult</div>

Question 19

Minimum requirements to Dx TTP

Answer 19

MAHA<div>TCP</div>

Question 20

Causative agent of HUS

Answer 20

E.Coli 0157:H7—Shiga toxin

Question 21

3 abnormalities of HUS in blood work:

Answer 21

Low plt<div>Low Hb</div><div>Elevated creat</div><div>Schistocytes</div><div>Elevated LDH</div><div>Elevated Bilirubin<br></br><div><br></br></div></div>

Question 22

Drugs should not be given in HUS:

Answer 22

AB<div>Antimotility agents</div>

Question 23

<p>Name 3 clinical or lab criteria of TLS:</p>

Answer 23

<p><b>Clinical:</b> <br></br><i>renal failure, <br></br>renal stones, <br></br>gout, <br></br>tetany, <br></br>cardiac dysrhythmias.</i></p>

<p><b>Lab:</b><br></br><i>Increased uric acid, potassium, phosphate<br></br>Decreased calcium</i></p>

Question 24

<p>What characteristics of cancer put a patient at high risk for TLS?</p>

Answer 24

<ul> <li>Rapid cell turnover</li> <li>Fast growth rate</li> <li>Large tumor burden</li> <li>Highly sensitive to chemo drugs</li> </ul>

Question 25

Bleeding sites that would suggest a coagulation pathway defect over a platelet pathway defect?

Answer 25

Coagulation pathway defect:

     ICH

     Joint bleeding

     Bleeding into muscle

Plt pathway defect:

     Mucocutaneous bleeding

     GIB

     GUB

     Heavey menses

     Petechiae

     Epistaxis

Question 26

Causes of Micro and Macro cytic anemia:

Answer 26

–Microcytic – iron-deficiency, thalassemia, anemia of chronic disease, sideroblastic (lead).

–Macrocytic – low B12, low folate, alcohol, liver disease, hypoT4, myelodysplastic

Question 27

Name indications of transfusion in anemia pt:

Answer 27

–Symptomatic

–Evidence of tissue hypoxia

–Hemodynamically unstable

–Acute, ongoing bleeding

–Limited cardiopulmonary reserve

Question 28

What prothrombin comples concentrate (PCC) contain?

Answer 28

Vit K-dependent factors

Protein C

Protein S

Question 29

What is the major selling point of PCC over FFP?

Answer 29

1. Rapidity of onset (reversal in 10 minutes)
2. low volume. 
3. Less infectious risk. 
4. Less TRALI. 
5. Less allergic/transfusion reactions

Question 30

Complications of Blood transfusion:

Answer 30

Transfusion reaction:

     Major ABO incompatibility

     Febrile reaction

     Allergic reaction

     Delayed hemolytic reaction

Transfusion related acute lung inj (TRALI)

Infections (Viral, Bacterial)

Hypervolemia

Hypothermia

Question 31

What is the most common cause of bacterial sepsis from pRBC transfusion?

Answer 31

–Yersinia enterocolitica

Question 32

• Name 5 triggers of DIC?

Answer 32

"

–ILLNESS

–Sepsis/infection: Bonus – what bacteria class is usually the culprit? (G -ve bacteria)

–Trauma

–Transfusion reactions

–ALI/ARDS

–Pregnancy (abruption, HELLP, embolus etc)

–Acute leukemia

–Liver disease

–Pancreatitis

–Vasculitits

–Envenomation: Bonus – which snakes? (Rattlesnake and vipers)

"

Question 33

Name 5 lab tests you would like to order that you expect to be abnormal in DIC. For each test, state how the test will be abnormal.

Answer 33

 

CBC:

Low Hb
Low Plt
Schistocytes in peripheral smear

Coagulation profile:
Increased PT
Increased PTT
Increased D-Dimer
Low fibrinogen

LFT:
High bilirubin
High LDH
Low haptoglobin

Question 34

Patient is oozing blood from everywhere. Fibrinogen is 60. How will you treat?  What is your target fibrinogen level?

Answer 34

–Cryoprecipitate

–Target >100 (100-150)

Question 35

In DIC, when would you consider plt transfusion?

Answer 35

–Bleeding + platelet level <50

–Any platelet level <10-20

Question 36

How much one unit of plt increase the plt count?

Answer 36

by = 50 in an adult

Question 37

Indications of FFP:

Answer 37

–Reversal of warfarin/vit K deficiency

–Massive transfusion

–Bleeding in a patient with multiple coagulation deficiencies – liver failure, DIC etc

–Bleeding in a patient with a factor deficiency that is not available – ex hemophilia

–FFP treatment generally monitored by PT/INR

Question 38

Indications of Cryoppt:

Answer 38

–Bleeding with a low fibrinogen level (<100)

• DIC, liver disease, massive transfusion/dilution

–Bleeding in vWD

–If desperate in Hemophilia A (should use recombinant factor VIII)

Question 39

What does Cryoppt contain?

Answer 39

VIII

Fibrinogen

vWF

Question 40

Doses of FFP and Cryoppt:

Answer 40

Plasma: 15-20 ml/kg

CryoPPt: 2-4 bags/10 kg

Question 41

Flowchart for consumptive thrombocytopenia

Answer 41

"

"

Question 42

DDX of polyarthritis:

Answer 42

Infection:

     Lyme dis

     Viral (parvovirus, hepatitis, rubella)

     Gonococcal

     Rheumatic fever

RA

Seronegative arthropathy (AS)

Reactive arthritis

SLE

Question 43

Features of reactive arthritis:

Answer 43

"Recent bact infection (venereal/diarrheal)

     Salmonella, chlamydia, mycoplasma

     campylobacter

Conjunctivits

Urethritis

Can't pee, Can't see, Can't climb a tree

"

Question 44

PPT factors for Sickle cell crisis

Answer 44

Cold

Dehydration

Infection

Stress

High altitude

Exercise

Question 45

C/F and complications of SCD:

Answer 45

• Acute chest syndrome
• Pain crisis
• Splenic infarction/sequestration
• Aplastic crisis
• CVA
• Bone pathology – infarction, osteomyelitis
• Hepatic infarction
• Priapism
• Hemolytic anemia
• Infection

Question 46

What type of bacteria are SCD patients most susceptible and why?

Answer 46

–Encapsulated organisms (H.flu, S. pneumo)

–Functional asplenia from recurrent infarction

Question 47

What bacteria must you think of in a SCD with osteomyelitis?

Answer 47

Salmonella typhimurium

Question 48

Name 2 indications where exchange transfusion is considered.

Answer 48

–Acute chest syndrome

–CVA (especially in kids)

–Priapsim

Question 49

Define febrile neutropenia

Answer 49

Either: Temp > 38.3 once or > 38 for > 1 hr

ANC <500 (or <1000 and predict <500)

Question 50

Tests for febrile neutropenia:

Answer 50

Blood cultures x 2 sets

Urine culture

CXR

Sputum culture

Catheter culture (PICC line...etc)

Question 51

Micro-organisms for febrile neutropenia

Answer 51

Most common: staph/strept

Others:

     Candida albicans

     HSV

     VZV

     CMV

Question 52

What 2 characteristics are you looking for when you choose your antibiotic regimen in febrile neutropenia?

Answer 52

Broad spectrum

Bacteriocidal

Synergistic

Good SE profile

Low toxicity

Question 53

What AB would you choose in Feb neutropenia

Answer 53

Vancomycin

Meropenem

4th gen cephalo: cefipime/ceftazidime

PIP-TAZ

Question 54

Criteria for Dx of Acute chest synd of SCD

Answer 54

1. Consolidation or infiltrate on CXR
2. At least 1 of the following:           
     fever >38.5°C, 

     chest pain, 

     tachypnea, 

     cough, 

     wheezing, or 

     PaO2 <60mmHg

Question 55

Rx of bleeding due to vWD

Answer 55

Desmopressin (DDAVP)

Factor VIII

Cryoppt

TXA

Topical agents:

Fibrin glue

Thrombine spray

Question 56

Transfusion graft-vs-host disease

Answer 56

Serious adverse reaction which is usually fatal. It is rare, and it most commonly occurs in patients with: 

immune defects, 

lymphoproliferative disorders, or 

those being treated with immunosuppressive agent of chemotherapy.

Question 57

Leukemias

Answer 57

""

Question 58

Which type of leukemia causes gingival lesions

Answer 58

AML (acute myelogenous leuk)

Question 59

Which drug can induce gingival hyperplasia

Answer 59

Phenytoin

Question 60

Triad of HUS

Answer 60

MAHA

TCP

Renal failure

Question 61

vWD

Answer 61

More common in young females

Usual presentations are:

Heavey menses

PPH

Bleeding post dental procedures

Question 62

Transfusion Related Acute Lung Injury (TRALI)

Answer 62

is a rapid onset non-cardiogenic pulmonary edema that is not secondary to fluid overload and thus nitroglycerin and lasix should be avoided. 

     Respiratory support, 

     supportive care, 

     IV fluids and 

     vasopressors if needed 

are the mainstay of treatment. 

Bronchodilation has no pathophysiological role in TRALI and thus albuterol would not be indicated.

Question 63

"

If the patient has SCD, what complication he could have?

"

Answer 63

"The child appears to be suffering from Fifth's disease, an exanthem caused by Parvovirus B19. This virus can commonly cause transient aplastic anemia or crises in sickle cell disease patients."

Question 64

Most common cancers for TLS

Answer 64

"ALL

Non-Hodgkin's lymphoma

less common for solid cancers

"

Question 65

Acute potentially life-threatening SCD crises

Answer 65

Acute stroke

Acute chest syndrome

Aplastic crisis

Acute bacterial infection

Symptomatic anemia

Question 66

Poly arteritis Nodosa

Answer 66

Features:

Livedo reticularis

Intra-renal aneurysms

30% are ass w HBV

Rx: steroids

Question 67

Classic tetrad of HSP

Answer 67

Abd pain

Arthralgia

Purpuric rash

Renal impairment

Question 68

Compl of HSP

Answer 68

Intussusception

Question 69

CREST synd

Answer 69

Calcinosis

Raynauds

Esophageal dysmotility

Scleroductyly

Telangiectasia

Question 70

Key features of Sarcoidosis

Answer 70

Bilateral Hilar LAP

Erythema nodosum

Increase in ACE levels 

Question 71

Lab findings of sarcoidosis

Answer 71

Leukopenia

Eosinophilia

Elevated ESR

HyperCa

Elevated ACE levels

Question 72

Features of PCP pneumonia

Answer 72

elevated LDH, 

hypoxia, 

non-productive cough and 

diffuse, bilateral alveolar infiltrates on x-ray

Question 73

What are the oncologic emergencies?

Answer 73

Febrile neutropenia
SVC syndrome
TLS
Hyperviscosity syndrome
Hyperuricemia
HyperK
HyperCa
Neoplastic cardiac temponade
Spinal cord compression
Raised ICP

Question 74

Classical presentation of hyperviscosity syndrome

Answer 74

Bleeding
Visual dist
Neurological manifestations

Question 75

Common primaries for cerebral mets

Answer 75

Lung
Breast 
followed by:
Malignant melanoma
Kidney
GI