AGACNP - Hematology and Oncology Questions and Answer

AGACNP - Hematology and Oncology Questions and Answer Anemia in chronic conditions will be ___chromic. Normo - Why is hgb higher in males? Hgb is increased in males because testosterone stimulates erythropoiesis The higher the binding capacity the ___ the need for iron. Greater Cytic = ____ Size Mean Corpuscular Hemoglobin Concentration (MCHC) Average concentration of hemoglobin per RBC; 32-36% Anemias associated with low MCV (AKA small size / microcytic) Iron deficiency and Thalassemia Anemias associated with high MCV (AKA large size / macrocytic) B12 or folate deficiency, alcoholism, liver failure and drug effects Anemias that are normocytic (AKA normal size) Those associated with chronic disease, sickle cell disease, renal failure, blood loss and hemolysis Most common anemia? Iron deficiency anemia What the most common cause of anemia in the elderly? Chronic disease Causes of iron deficiency anemia Blood loss Inadequate iron intake Impaired iron absorption Symptoms of iron deficiency anemia Slow onset often and few symptoms with hematocrit 30 -- As HCT falls we see: *PICA (clay and ice) Dyspnea Mild fatigue with exercise Headaches Treatment for iron deficiency anemia? Ferrous Sulfate (PO 300-325mg) What things affect iron absorption? (HINT: 2 interfere with and 1 increases absorption) 1) Antacids - interfere with absorption 2) Vitamin C - increases absorption 3) Take 1-2 hours after meals - food SLOWS absorption What causes Thalassemia? Genetically inherited disorders -- Decreased hgb production and microcytic, hyopchromic anemia Common populations with thalassemia? Mediterranean, African, Middle Eastern, Indian and Asian populations Symptoms of thalassemia Unremarkable unless severe -- Beta thalassemia is most severe How many types of Thalassemia are there? How do they differ? - 2 types: - Minor: Only 1 copy of beta gene and normal beta-chain -- mild anemia; may mimic iron-def anemia - Major (Cooleys): 2 genes for beta and no normal beta-chain gene; normal @ birth but anemia develops within first few months of life and gets progressively severe -- Failure to thrive Bouts of feeding difficulty Fever Diarrhea Liver signs Maxillary enlargement Treatment for thalassemia None for mild to moderate forms; RBCs for more severe forms Folic acid deficiency cause and especially who is at risk? Inadequate intake; Alcoholics or those with an eating disorder Folic acid deficiency S&S Fatigue Dyspnea on exertion Pallor HA Tachycardia Anorexia *Glossitis *Aphthous ulcers What differentiates B12 from folic acid deficiency? (HINT: what symptom do we see with B12 but not folic acid deficiency? In B12 deficiency we see NEUROLOGICAL signs (B think Brain) Treatment for folic acid deficiency? Folate (1mg PO daily) Foods high in ____: Bananas, PB, fish Folic acid Foods high in ____: Raisins, red meat, citrus Iron Pernicious (B12) anemia cause Due to deficiency of intrinsic factor -- malabsorption of B12 Signs and symptoms of pernicious anemia Paresthesia, Loss of vibratory sense and/or fine motor control (+) Romberg and Babinski Treatment for pernicious anemia B12 (Cyanocobalamin) 100 mcg IM daily x 1 week -- then once monthly for LIFE Anemia of chronic disease cause & effect Chronic inflammation, infection, renal failure or malignancy - Decreased erythrocyte lifespan Second most common anemia? (HINT: #1 in elderly and in the hospital setting) Anemia of chronic disease S&S of anemia of chronic disease Fatigue, weakness, dyspnea on exertion and anorexia Treatment for anemia of chronic disease Epoetin alpha and nutritional support Sickle Cell Cascade after a trigger occurs - What happens? Acute exacerbation in which the RBC becomes sickled, causing vessel obstruction and clogged circulation -- cellular hypoxia, acidosis, tissue ischemia and blood hyperviscosity -- PAIN What triggers sickle cell? Hypoxia Infection High altitude Dehydration Physical or emotional stress Surgery Blood loss Acidosis Early S&S of sickle cell anemia Occur in childhood / developmental phases: delayed growth and development, increased susceptibility to infection What occurs in sickle cell crisis? Sudden onset of severe pain in extremities, back, chest and abdomen Aching joint pain Weakness Dyspnea What lab test shows sickle cells? Peripheral smear Acute treatment for sickle cell Fluids for dehydration, pain medication and oxygen for hypoxemia Von Willebrand Disease A genetic deficiency in the Von Willebrand factors and clotting factor and factor VIII -- reduced ability to create blood clots Treatment for Von Willebrand Disease Desmopressin, recombinant Von Willebrand Factor/Factor VIII concentrate You CAN treat Leukemia with which of the following? Surgery, Chemo, Bone Marrow Txp. or Radiation? Chemo and bone marrow transplant Acute Lymphocytic Leukemia (ALL) - More easily cured in kids or adults? Kids The most common leukemia in adults and has a median survival of 10 years Chronic Lymphocytic Leukemia (CLL) Hallmark of ALL Pancytopenia with circulation blasts Hallmark of CLL Lymphocytosis This leukemia occurs mostly in those 40+ years old and has ~65% 5 year survival rate Chronic myelogenous leukemia (CML) Hallmark of CML Philadelphia Chromosome Symptoms of leukemia Fatigue / weakness Anorexia Generalized Lymphadenopathy Weight loss MAY be asymptomatic Leukemia: Elevated or Decreased ESR? Elevated How is acute and chronic leukemia differentiated? How is it confirmed? -Peripheral smear DIFFERENTIATES -Bone marrow aspiration CONFIRMS What medication reduces the risk of Tumor Lysis Syndrome in high-risk patients? Allopurinol Causes of Tumor Lysis Syndrome Electrolyte imbalances, renal failure, etc. How do we diagnose lymphoma? Biopsy of enlarged lymph nodes Stage I Lymphoma Disease localized to single lymph node or group Stage II Lymphoma More than one lymph node group involved: confined to ONE SIDE of the diaphragm (TOP VS. BOTTOM) Stage III Lymphoma Lymph nodes or the spleen involved; occurs on BOTH SIDES of the diaphragm Stage IV Lymphoma Liver or bone marrow involvement What is the most common neoplasm between ages 20-40? Non-Hodgkins Lymphoma How does Non-Hodgkins usually present? With lymphadenopathy Hodgkin's disease is more common in ___ and the average age is ___ y.o. Males; 32 How does Hodgkin's lymphoma present? Cervical adenopathy and spreads along lymph node groups What differentiates Non-Hodgkins and Hodgkins lymphoma? Reed-Sternberg cells are present with Hodgkins lymphoma Treatment options for lymphoma Radiation, chemo and bone marrow transplant Microcytic, Normocytic and Macrocytic refer to what? The size of the erythrocyte Hypochromic, normochromic and hyperchromic refer to what? The color of the erythrocyte TIBC 250-450 ug/dL Serum Iron 50-150 ug/dl MCV (mean corpuscular volume) 80-100 fL Hematocrit Male = 40-54 Female = 37-47 Idiopathic Thombocytopenia Purpurea (ITP) Autoimmune destruction of platelets with or without suppression of thrombopoiesis In adults ITP is usually ___, causing thrombocytopenia that me be ____ for long intervals Chronic; asymptompatic ITP Diagnosis Bone marrow analysis and/or low PLT r/o by other causes What areas may you first see bleeding in patients with ITP? Kidneys and gums Treatment for ITP High dose corticosteroids or IV Gamma Globulin to elevate the platelet count within 2-3 days; PLT transfusion may be of benefit If HIV-related ITP, do we prefer high dose corticosteroids or IV Gamma Globulin? IV Gamma Globulin Precautions for the thrombocytopenic patient Avoid constipation, no flossing or shaving, and hold pressure for any incision or cuts for 5 minutes HIT treatment Argatroban (Argatroban) and Lepirudin (Refludan) In Lupus and ITP we se thrombocytopenia - how do we differentiate the 2? Bone marrow analysis Disseminated Intravascular Coagulation (DIC) Acquired coagulation disorder resulting from intravascular activation of coagulation and fibrinolytic systems (thrombin and plasmin) causing thrombosis and hemorrhage simultaneously; mortality = 50-85% Conditions associated with DIC Malignancy Infections Liver disease Massive Trauma Extensive burns Shock Obstetrical comp. Acute leukemia Pathophysiology of DIC Thrombin causes conversion of fibrinogen to fibrin -- fibrin clots produced in microcirculation -- coagulation factors (fibrinogen, prothrombin, platelets, factors V and VIII) reduced -- circulating plasmin activate fibrinolytic systems -- lyses fibrin clots into fibrin degradation products -- hemorrhage (due to anticoag properties of FDPs and depleted coag factors) DIC diagnosis and labs Thrombocytopenia (PLT 150,000) Hypofibrinogenemia (fibrinogen 170) Increased fibrin degradation products (FDPs 45) Increased PT (19 seconds) and PTT (42 seconds) D-dimer + at 1:8 dilution (if seen with increased FDP, 96% accuracy in diagnosis)