Approach to the Hematological Patient PDF

Approach to the Hematological Patient Lee Scott, M.D. Vocabulary Objectives 1. Describe the clinical evaluation of a patient with a hematologic disorder. 2. Take an appropriate History (including ROS) for a given hematologic complaint. 3. Conduct an appropriate Physical E...

Approach to the Hematological Patient Lee Scott, M.D. Vocabulary Objectives 1. Describe the clinical evaluation of a patient with a hematologic disorder. 2. Take an appropriate History (including ROS) for a given hematologic complaint. 3. Conduct an appropriate Physical Exam for a given hematologic complaint. 4. Offer a patient a basic Assessment and Plan at the end of your evaluation of a patient with a hematologic complaint. We will focus specifically on anemia and bleeding disorders today. Patient Cases- Case 1 A 66-year-old postmenopausal woman presents to her physician with complaints of fatigue, dyspnea on exertion, and mild dizziness with standing. She says she craves chewing on ice cubes. Physical examination reveals mild tachycardia as well as pallor of the conjunctiva and the mucous membranes of her mouth. Patient Cases- Case 2 A 2-year-old boy is brought to his family physician by his parents who are concerned about the multiple bruises on the boy’s shins and hands. They report that the child seems to get large bruises with minimal injury and bleeds profusely when his teeth are brushed. They also report that a month ago he fell and hit his head on a coffee table, and they could not stop the bleeding for hours. Patient Cases- Case 3 A 32-year-old woman presents with a 1-day history of left lower leg swelling and discomfort after a cross country flight. Key Components of Blood Plasma Red Blood Cells (RBCs) White Blood Cells (WBCs) Platelets Clotting factors  Functions? What do RBCs do? Deliver oxygen to tissues What do WBCs do? Primarily involved in immune response What do platelets do? Involved in clotting (along with clotting factors) Anemia Anemia- Reduction below normal of RBCs Symptoms: Fatigue Heart racing Shortness of breath, especially with exertion Dizziness Trouble concentrating Headaches Pallor Cold hands/feet Restless Legs (iron deficiency) Craving ice (iron deficiency) Anemia- Etiology There are, essentially, three ways to be anemic: 1. Not making enough RBCs Necessary components missing Ø Iron, Vit B12, Folate Bone marrow not working Decreased erythropoietin 2. Losing them Bleeding somewhere 3. Destroying them Hemolysis History of Present Illness (HPI) -OPPQRST You may have to take history from someone other than the Onset patient: Provocation/Palliation -parent -grandparent Quality -spouse -child Region and Radiation -social worker Severity -neighbor -co-worker Time Associated Symptoms HPI Was Onset abrupt or gradual? Abrupt onset may indicate acute bleeding or hemolytic crisis. Gradual may be more consistent with dietary deficiencies, gradual blood loss or chronic disease. Provocation/Palliation Is fatigue, heart racing, or shortness of breath worse with exertion? (increased oxygen demand) Quality Is the way they describe the symptoms consistent with anemia? Shortness of breath with wheezing after trigger exposure more likely asthma. Fatigue described as muscle weakness may be a neuromuscular issue. HPI Region and Radiation Symptoms with anemia are typically generalized Severity Is the patient just a little tired? Can be worked up as an outpatient. Severity doesn’t have to be pain scale. Do they black out upon standing? Likely need admission and transfusion Time Rapidly worsening? May need to look for an acute GI bleed. Have they had this before? Ask multiple questions! “I was iron deficient during my last pregnancy.” HPI Associated Symptoms Does the patient mention other symptoms consistent with anemia? Fatigue is associated with pallor, dyspnea with exertion, lightheadedness on standing. Sounds like anemia Does the patient mention other symptoms consistent with another disease process? Fatigue is associated with hair loss, dry skin and constipation Sounds more like hypothyroidism Fatigue associated with loss of interest in usual activities, feeling down, and having thoughts of being better off dead Sounds more like depression Past Medical History (PMH) -SMASH Medications Chronic diseases Chronic Renal Disease especially significant erythropoietin Cancer/Cancer treatment Infections Prosthetic Heart Valves Family History (FH) Thalassemia? Sickle Cell? Early gallstones? More common in hemolytic disease  Social History (SH) Diet Vegans can develop B12 deficiency Alcohol Heavy alcohol use can cause folate deficiency Work Exposures (e.g. hemolytic anemia associated with: arsenic, methyl chloride, naphthalene, lead, cadmium, mercury) Review of Systems (ROS) Ask other symptoms of anemia that didn’t come up in HPI: Fatigue? Heart racing? Shortness of breath, especially with exertion? Dizziness? Trouble concentrating? Headaches? Pallor? Cold hands/feet? Restless Legs? Craving ice? Review of Systems (ROS) Ask questions that may identify the cause of an anemia: Heavy periods? Blood in urine? Blood in stool? Dark stools? Fever? Weight loss? Abdominal pain? Swollen “glands”? Review of Systems (ROS) Ask questions that may identify non anemia causes of the chief complaint: Depression? Sleep problems? Joint pain? Muscle weakness? Constipation? Weight gain? Physical Exam (PE) Vital signs Hypotension and tachycardia with acute blood loss General appearance Nutritional status Skin/eyes Pallor Petechiae Jaundice Petechiae or purpura Jaundice Physical Exam (PE) Mouth Glossitis Glossitis Heart Murmurs Prosthetic valve Abdomen Splenomegaly Rectal Gross or occult blood Lymph Nodes enlarged Enlarged lymph nodes Plan Plan- what you are going to do to further evaluate and/or treat the patient. Examples: Plan Labs CBC, Ferritin, B12/Folate 1. CBC, B12 level Meds/treatments 2. Dietary counseling Oral iron, IM B12, transfusion 3. Will call patient with lab results Imaging Abdominal US and start B12 supplementation if Procedures indicated. Reassess here in 1 Colonoscopy, node biopsy, bone marrow biopsy month. OMT Soft tissue, MFR Counseling/Education Alcohol cessation, exercise. Plan Referrals/Consults 1. Admit to hospital Follow-up (always include) 2. CBC, ferritin, hemoccult stool Return to clinic in 2 weeks to assess response to meds. We will call tomorrow with lab results. 3. Type and cross Patient to call if not feeling better in 48 hours 4. Start IVFs 5. Consult GI for endoscopy Patient Cases- Case 1 A 66-year-old postmenopausal woman presents to her physician with complaints of fatigue, dyspnea on exertion, and mild dizziness with standing. She says she craves chewing on ice cubes. Physical examination reveals mild tachycardia as well as pallor of the conjunctiva and the mucous membranes of her mouth. What are the key features? Patient Cases- Case 1 A 66-year-old postmenopausal woman presents to her physician with complaints of fatigue, dyspnea on exertion, and mild dizziness with standing. She says she craves chewing on ice cubes. Physical examination reveals mild tachycardia as well as pallor of the conjunctiva and the mucous membranes of her mouth. What is her most likely diagnosis? What is the most likely cause? What do you need to ask? What do you do? Bleeding and Clotting Disorders Coagulation Cascade What happens if this cascade goes wrong? Too much Too much Bleeding Clotting Bleeding Disorders Symptoms: Excessive Ecchymoses Bruising Petechiae Small red or purple spots Ecchymosis Petechiae Purpura Larger red or purple spots Extended bleeding after minor cuts, blood draws Purpura Bleeding Disorders Symptoms: Menorrhagia Heavy menses GI bleeding Upper and/or lower Unexplained Epistaxis Nosebleeds Bleeding gums Hematuria Blood in urine It can be helpful to think of bleeding disorders as being either: Platelet related OR Clotting factor related Bleeding due to platelet disorders Disorders of platelet number (thrombocytopenia) 1. Decreased production of platelets Medications (examples include valproic acid, linezolid, thiazide diuretics, gold compounds, antineoplastic chemotherapy drugs) Bone marrow replacement by malignancy, fibrosis, granulomas Bone marrow aplasia Alcohol What history B12 deficiency should you ask?? Bleeding due to platelet disorders Disorders of platelet number (thrombocytopenia) 2. Disorders of platelet function 1. Congenital von Willebrand disease What history Other rare genetic abnormalities should you ask?? 2. Acquired Medications, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) Myeloproliferative disorders, such as essential thrombocythemia, polycythemia vera Coating of platelets by abnormal proteins, such as in multiple myeloma and, occasionally, immune thrombocytopenia Uremia Bleeding due to clotting factor abnormalities 1. Congenital Hemophilia A (the most common) Other clotting factor deficiencies What history should you ask?? 2. Acquired Deficiency of a factor or factors Liver disease Vitamin K deficiency (nutritional or due to warfarin therapy) Abnormal adsorption of a factor, e.g., factor X adsorption to amyloid fibrils Consumption of factors, eg, DIC Dilution of factors, e.g., massive transfusion Acquired inhibitor to clotting factor or factors Recognize key factors such as: Age at onset Severity Gender Patient Cases- Case 2 A 2-year-old boy is brought to his family physician by his parents who are concerned about the multiple bruises on the boy’s shins and hands. They report that the child seems to get large bruises with minimal injury and bleeds profusely when his teeth are brushed. They also report that a month ago he fell and hit his head on a coffee table, and they could not stop the bleeding for hours. Patient Cases- Case 3 A 32-year-old woman presents with a 1-day history of left lower leg swelling and discomfort after a cross country flight. Questions? [email protected] Rm. 215