6030 Exam 4 mod 10 hematology.pdf

Hematology Evaluation and management of hematologic disorders • Definition and Epidemiology o Definition § Reduction in the # of RBCs, hemoglobin concentration, or hematocrit § Anemia diminishes the capacity of blood to carry oxygen § Diagnosis is often based on laboratory data alone • Epidemiology...

Hematology Evaluation and management of hematologic disorders • Definition and Epidemiology o Definition § Reduction in the # of RBCs, hemoglobin concentration, or hematocrit § Anemia diminishes the capacity of blood to carry oxygen § Diagnosis is often based on laboratory data alone • Epidemiology o Women 85 most at risk o Iron Deficiency Anemia – most common among children and women § ***Menstrual Bleeding o Anemia of Chronic Disease – most common among elderly • Pathophysiology o Increased bodily requirements due to: § RBC production disorders § RBC destruction disorders • Sickle Cell, Thalassemia § RBC Blood loss • Acute Blood Loss, Chronic Blood Loss o Decreased circulation/oxygen to tissues § Low RBC mass, Low RBC count § Low Hemoglobin and/or Hematocrit o Hemodilution expands plasma volume § Occurs within 3 days of acute blood loss § Renin-angiotensin system activation o Classification of categories § Size (cystic), Color (chromic), Shape of RBCs • Diagnosis and Treatment of Anemia o Review assessment & labs § Hgb/Hct § MCV/MCH ~ most useful § RDW § Peripheral smear § Ferritin • Measure iron storage o <12 = decreased iron o Determine Anemia type § Microcytic Anemia § Macrocytic Anemia § Hemolytic Anemia § Normocytic Anemia• o Determine cause § RBC production failure § RBC destruction § Blood loss o Initiate empiric treatment § Diet modifications § Lifestyle changes § OTC supplements § Prescription medication • MICROCYTIC ANEMIAS (MCV<80fl) o Microcytic Anemias - small, often hypochromic, red blood cells § Low MCV (less than 80 fL) o Causes § Increased Requirements § Loss of Iron d/t Bleeding § Inadequate Intake/Storage § Loss of Iron d/t GI Dysfunction • Iron def = Most common cause o Women of reproductive age o Older Adults o Acute Blood Loss à most common cause o Clinical Presentation § Incidental finding on CBC Fatigue, weakness Dyspnea on exertion Angina GI distress Headache Leg cramps Peripheral edema Tinnitus Dysfunctional Uterine Bleeding Tachycardia, Orthostatic BP changes Systolic Murmur Glossitis, cheilitis Jaundice, pallor Bleeding, melena o Subjective HX § Physiologic blood loss § Medications • NSAID, Steroids, ASA § Recent trauma § Alcohol abuse • Leads to Esophageal Varices § Family Hx § Past Medical • Bleeding DO • Lead Exposure • Gastritis • Autoimmune § History § Change in bowel habits § Diet • Low intake o Physical Exam § General ROS: Fatigue, weight loss, irritability § CV: Systolic Murmur, Tachycardia § Respiratory: Shortness of breath § HEENT: Conjunctiva pale, Glossitis, Cheilitis § Integumentary: Pallor, koilonychia (spooning) § Lymph: Lymphadenopathy § GI: Liver/spleen enlargement, FOBT, mass, neoplasia § GU: Pelvic mass, Neoplasia o DX: § CBC w Diff + Anemia Profile • Start with the MCV = Low MCV • Low Hgb <14g/dl (M) and <12g/dl (F) • Low Ferritin <12 g/dl § GI Studies à FOBT, Colonoscopy § Hgb Electrophoresis § US to identify a mass o Differential DX § ***Microcytic Anemias (MCV <80fL) *** • Iron Def • Thalassemia • Anemia of chronic disease • Sideroblastic anemia • Hemoglobin E disease o Interprofessional Collaboration § Consider • Nutritional Referral o If nutritional def • Hematology Referral o If not adherent o No response o Hematology = Blood Trans • Other Referrals to GI/GYN, etc. o Chronic: PCP only o Acute: Refer o Urgent: **emerg o Management § Nonpharmacologic Management • Iron-rich foods o Prune Juice o Olives o Mulberries Other: • Oyster, Spinach, Dark Chocolate, Organ, Lentils Pharmacological Management • Start daily oral iron preparation 150 to 200mg dose – 30 minutes before meals x 4-6 months o Other options: 325 mg ferrous sulfate TID/65mg slow release iron, ferrous gluconate, enteric coated Fe • Hemoglobin should be greater than 10 to move closer to normal • Daily prenatal use of iron to improvement in maternal hemoglobin concentration and reduction in risk of having low-birth-weight babies. • SE: o N/V, Constipation, heart burn, upper GI discomfort, black stools, diarrhea o GI Distress à Long Acting Indications for Referral or Hospitialization • Urgent o Symptomatic: Dyspnea, fatigue, chest pain, dizziness o Transfusion: Hgb 8.0= symptoms, Hct<30% o Chronic patients w acute exacerbations o Immediate referral to Hematologist o Acute Bleeds = Send to ER • Emergent o Symptomatic: Hypotension, pallor, cold clammy skin, adminal bruising, thread pulse, tachycardia, dyspnea, altered mental status o Acute severe hemorrhage o Immedidate ED referral § § § § § Patient and Family Education • Common Side Effects of Oral Iron o N/ Constipation, UP o Hypotension, Pallor, Tready pulse, altered mental status • Dietary Implication o Inhibit absorption § Calcium = block absoption • Dairy, antacid (2hr) § Coffee, Soy, Tea o Enhance absorption § Vitamin C/ meat/ poultry/ fish Healthy Promo • • • Vegetarians may need to with iron rich foods Screen at risk groups o Immunocompromised & Chronically ill o Homeless o Young Children § Universal screening at 1 year § Other screening based on hx à lead exposure o Pregnant Women ~ universal in early pregnancy § Antepartum § Post-partum MACROCYTIC ANEMIA o Macrocytic Anemias – overly large red blood cells § High MCV (greater than 100 fL) o Causes § Deficient Intake of B12 or Folate à Most common • B12/Folate o Alcohol o Bariatric o Preg/Lac o Low Protein Diet § Depletion or Increased Requirements § Malabsorption d/t GI Disease § Medications § Other conditions § Hemolytic Anemia o Clinical Presentation § Fatigue, weakness § Early Infection § GI Malabsorption § GI distress § Leg cramps § Neuropathy § Kidney disease § Glossitis o Subjective History –Macrocytic Amenia § B12 or Folate Deficiency § Increased Nutritional Requirements § Depleted Nutritional Requirements • Alcholism low veg decrease diet § GI Malabsorption • Surgery • Gastritis • Pancreatic Insufficiency § § § o DX: • Decrease Medications • Decrease stomach acid Other conditions • Autoimmune due to inflammation of gastric parietal cells Hemolytic Anemia Priority • Assess clinical presentation* • CBC w Diff • B12, Folate* § Other Diagnostic Studies • FOBT x 3 • Urinalysis • PT/INR/LFTs/CMP • US Imaging of Pelvic/Abdomen • Endoscopy/Colonoscopy § R/O other chronic disease based on Hx • RF, ANA, TSH, Creatinine o Diff DX: § ***Macrocytic Anemias (MCV >100 fL)*** • Pernicious Anemia • Folate & Vitamin b12 Deficiency Anemia o Folate Def: § Dysphagia, Diarrhea, Diarrhea, Ulceration, Flatulence, Neuro changes NOT evident unless with other vitamin def • Hemolytic Anemia o Extravascular – Liver & spleen o Intravascular – Infections, transfusion reactions • Drug Induced – Diuretics, chemo, anticonvulsants, more • Myelodysplastic syndrome (MDS) • Other Conditions with a Normal MCV • Aplastic/Malignancy • Chronic renal failure (order Creat) • Hypothyroidism (order TSH) § • OTHER ANEMIAS o Normocytic Anemia of Chronic Disease § Common among Elderly § Autoimmune Disorders o o o o o • Pernicious Anemia § Chronic Kidney Disease Hemolytic Anemia § Red blood cells are destroyed faster than they can be made. § Thalassemia & Hb S d/t hemoglobin defect d/t Sickle Cell or thalassemia, bone marrow disorders, G6PD deficiency, infections, autoimmune disorders § Sickle Cell/Thalassemia • Most common breakdown • Symptom management • Monitor CBC • Manage Chronic Disease • Thalassemia NOT helped with iron sups à Contraindicated Intraprofessional Collab § Refer, refer, refer! • Hematology/Oncology • Nutritionist Management § Do not treat if asymptomatic. Hospitalization may be required. § Nonpharmacologic Management • Folate-rich foods § Pharmacological Management • Monthly B12 injections o Example: Cyanocobalamin IM (1000 ug weekly x 3-4 weeks, then monthly) • Folate replacement with supplementation o Example: Folate 1-2 mg PO QD x 5 weeks Patient and Family Education § Screening can prevent complications § Neurological damage may become irreversible Health Promo § Screening not recommended in asymptomatic, nonpregnant persons § Screening is recommended for all females of childbearing ahe • 0.4 mg folic acid daily § Newborns screened for Sickle Cell and hemoglobinopathies § Alcoholic