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Flashcards in Heme/onc Deck (53):
1

Definition of anemia

Hgb <12 g/dL in females
Hgb <14 g/dL in males
Decrease in the oxygen carrying capacity of blood
Underproduction of nl erythrocytes
Loss or destruction of circulating erythocytes
A condition, not a dz. Must ID underlying cause

2

Hx components of iron deficiency anemia

Prior GI surgeries?
Blood loss from GI tract, either BRB or melena
-Ask pt to quantify if possible
-How much blood loss?
Female pts- blood loss
-Are they menstruating?
-If so, quantify the amount of flow on a daily basis and the duration of the cycle
Hematuria
-Ask pts to quantify if possible
-Microscopic: seen on UA
-Gross or macroscopic hematuria

3

PE of iron deficiency anemia

There may be no PE findings
Acute (blood loss)
-Tachycardia
-Orthostatic changes
-Heart murmur
-Extreme pallor (severe)
Chronic- more often asymptomatic
-Pallor
-Fatigue

4

Lab and workup for iron deficiency anemia

CBC and iron panel
-CBC will show a decreased hgb, and MCV of <80, MCH of <27 and an MCHC of <32
-Microcytic, hypochromic anemia
Iron panel
-Ferritin and serum iron will be decreased, TIBC will be increased

5

Tx of iron deficiency anemia- general principles

Can usually be managed by PCP, however, if not improving or requires IV iron therapy, a hematology consult may be necessary.

6

Meds for iron deficiency anemia

Start with oral iron 325 mg TID after meals
-Ferrous gluconate is generally more easily tolerated

7

Side effects of iron

Dark stools
GI upset
Constipation

8

Pts' response to iron

Some pts will not be able to absorb oral iron d/t poor absorption, esp elderly or with a hx of gastric bypass
These pts will require IV iron

9

F/u of iron deficiency anemia

Recheck H/H, Fe, ferritin 6-8 wks after starting oral iron.
If there is no improvement or minimal improvement, pts may need to be treated with IV iron

10

IV meds for iron deficiency anemia

Ferllecit or InFed is given as loading dose weekly to build iron stores. Once anemia is corrected, may treat with maintenance dose

11

How should symptomatic anemia be treated?

With blood transfusion
Females with heavy menstrual periods should be referred to GYN for exam and possible hormonal manipulation to decrease frequency and flow

12

Hx of anemia of chronic dz

Any medical hx including:
Kidney dz
CA
Chronic infection
Inflammatory dz (such as lupus)
Hepatic dz

13

Lab and workup for anemia of chronic dz

CBC: MCV may be nl or microcytic
Serum iron: nl
Ferritin: may be elevated because ferritin is an acute phase reactant
Some pts may have an undiagnosed chronic dz, so check TSH, RF, ANA, hepatitis serologies
CMP: Creatinine will be elevated in CKD, and AST/ALT may be elevated in liver dz

14

How to diagnose anemia of chronic dz

A dx of exclusion, which means that other causes of anemia have been excluded

15

Tx of anemia of chronic dz

Tx of choice is erythropoietin injections
Hgb must be <11.0 in order to receive EPO injections
Procrit 20,000 u SQ given weekly or monthly in order to stimulate the production of RBCs

16

Hx of vit B12 deficiency

Important to ask about diet in hx. If pt is vegan/vegetarian
Previous surgeries? Gastrectomy or ileal resection?

17

S/sx of vit B12 deficiency

Glossitis
Anorexia/diarrhea
Paresthesias
Gait disturbances
Decreased position and vibratory sensation
AMS (in late presentation)

18

Lab and workup for vit B12 deficiency

CBC: hgb decreased; however, this is macrocytic anemia, therefore, the MCV is >100
Vit B12 decreased
If pernicious anemia, + intrinsic factor antibodies

19

Tx of vit B12 deficiency

Vit B12 injections
1,000 mcg weekly x4 and then monthly
Can generally be managed by PCP

20

DDx of anemia with low MCV

Iron deficiency anemia
Thalassemic disorders
Anemia of chronic dz
Sideroblastic anemia
Copper deficiency, zinc poisoning

21

DDx of anemia with nl MCV

Acute blood loss
Iron deficiency anemia (early)
Anemia of chronic dz
Bone marrow suppression
-Bone marrow invasion
-Acquired pure red blood cell aplasia
-Aplastic anemia
Chronic renal insufficiency
Endocrine dysfunction
-Hypothyroidism
-Hypopituitarism

22

DDx of anemia with high MCV

Ethanol abuse
Folic acid deficiency
Vit B12 deficiency
Myelodysplastic syndrome
Acute myeloid leukemias
Reticulocytosis
-Hemolytic anemia
-Response to blood loss
-Response to appropriate hematinic
Drug-induced anemia
Liver dz

23

Hx of thrombophilias

Thrombosis at a young age (age <50 yrs)
FHx of thrombosis
Recurrent thrombosis
Thrombosis in an unusual site (hepatic, mesenteric, or cerebral)
Pregnancies complicated by frequent miscarriage
Idiopathic thrombosis (no known predisposing factors)

24

What is the most common thrombophilia?

Factor V Leiden

25

What are other types of hereditary thrombophilias?

Prothrombin gene mutation
MTHFR
PAI

26

Inheritance pattern of Factor V Leiden

Autosomal dominance
May be heterozygous or homozygous

27

Dx of Factor V Leiden

APC resistance test
Factor V Leiden genetic testing
-When a mutation is identified, we encourage pts to have family members tested

28

Tx of Factor V Leiden

Refer to hematology
If a thrombotic even present: Lovenox 1 mg/kg SQ q12h x 7 days with concurrent Coumadin therapy
Coumadin therapy will be needed for at least 6 mos. If another clot occurs, the pt will require lifelong therapy

29

Hx of thrombocytopenia

FHx?
Hx of liver dz?
Pregnancy?
Alcohol consumption?
Meds?
-Heparin? Sulfonamides? Thiazides? Cimetidine?
Recent illness?

30

PE of thrombocytopenia

Petechiae (< 3 mm)
Purpura (0.3-1.0 cm)
Ecchymoses (>1.0 cm)
Generalized hemorrhage

31

What is the hallmark of thrombocytopenia?

Mucocutaneous bleeding

32

Hallmark numbers of thrombocytopenia

Platelet count < 150K/mm cubed
>80,000/mm cubed- withstand all but most extreme hemostatic challenges (sx, major trauma)
<20,000/mm cubed- spontaneous bleeding

33

Acute ITP- who does it most commonly occur in?

Children, usually preceding a viral URI

34

Acute ITP

Self-limited, autoimmune IgG disorder
Antibodies are formed against the platelet membrane

35

Characteristics of acute ITP

Characterized by an abrupt onset of petechiae, purpura, and hemorrhagic bullae on the skin and mucutaneous membranes
No splenomegaly.
-If splenomegaly and pos thrombocytopenia, look for another underlying cause

36

Chronic ITP

Develops at any age
More common in women
Usually coexists with another autoimmune disease.
Pts develop petechiae on the skin and mucous membranes

37

Lab findings of acute ITP

CBC will reveal a platelet count, which is significantly decreased to usually 10,000-20,000
May also see lymphocytosis
Coagulation studies will be nl

38

Lab findings of chronic ITP

CBC will only reveal platelet count, not as significantly decreased to 25,000-75,000

39

Tx of acute ITP

Usually resolves spontaneously. Rarely requires prednisone or splenectomy

40

Tx of chronic ITP

Rarely resolves, and most of the time requires high-dose prednisone.
If no response to prednisone, pts require IVIG.
If pt is still not responding, then splenectomy may be warranted

41

Characteristics of thrombotic thrombocytopenic purpura

Severe thrombocytopenia
With:
Purpura
Petechiae
Pallor
Abd pain
Microangiopathic hemolytic anemia
Fever
CNS abnormalities (HA, aphasia, and AMS)
Renal failure

42

Who usually gets TTP?

Usually seen in ages 20-50

43

Causes of TTP

Sometimes unknown
Associated with:
Chemo drugs
Possibly shigella toxin
Pregnancy can increase risk

44

Lab evaluation of TTP

CBC will reveal anemia, red cell fragments on peripheral smear (schistocytes) and thrombocytopenia
ADAMTS 13 is decreased
Indirect bilirubin is elevated

45

PE of TTP

Febrile
Skin: petechiae, purpura, jaundice
Neuro: AMS
Abd: splenomegaly

46

Effects of TTP

Blood vessel blockage
-Hemolytic anemia (RBC degradation)
Neuro/cardio problems
Thrombocytopenia: leads to purpura
Kidney failure

47

Tx of TTP

This is a hematological emergency, so early consultation with hematology is imperative
Corticosteroids
Aggressive plasmapheresis
Avoid transfusion unless catastrophic bleeding, such as intracranial hemorrhage

48

Median age of onset of AML

60

49

RFs for AML

Chemical exposures:
-Benzene, previous chemo
Radiation

50

S/sx of AML

Pallor
Fatigue
Joint pain
Fever
Wt loss
SOB
Persistent and frequent infections
Gingival bleeding

51

PE of AML

Petechiae
Pallor
Gingival edema (d/t leukemic infiltration)
Chloroma (mass of leukemic cells outside of the bone marrow)

52

Lab evaluation of AML

CBC may reveal: leukocytosis or leukopenia, anemia, thrombocytopenia
Auer rods present in peripheral smear
Uric acid elevated
Cytogenetic studies reveal different chromosomal abnormalities
Definitive dx is done by bone marrow bx
-Reveals pos leukemic blast cells

53

Tx of AML

Induction (remission inducing chemo) followed by consolidation (destroys the remainder of leukemic cells)
-Cytarabine and idarubicin are generally used
Uric acid levels may become elevated d/t cell breakdown, so allopurinol is taken daily