family medicine heme

folate vs. B12 deficiency anemia

* B12: macrocytic, neuro sx * folate macrocytic, no nuero sx, glossitis; more associated with ETOH

alpha vs. beta thalassemia presentation

1. alpha: HCT 28-40; MCV 60-75; blood smear: micocytes, hypochromia, target cells, acanthocytes; no tx 2. b thal major; - From birth to 6 months, everything is normal; but at 6 months, when Hgb F turns to Hgb A, severe anemia req. transfusion - Clinical problems like growth failure, body deformaties, hepatosplenomegaly, and jaundice - Unpaired α-globin precipitates ==> RBC cell destruction - Will have: hypochromia, anisocytodid, target cells, microcytosis, poikilocytosis, nucleated RBCs, BONE DEFORMITIES, SPLENOMEGALY, JAUNDICE, basophilic stippling * require transfusion

1. normal MCV, low hmg/hct, elevated ferritin, decreased serum iron, low TIBC 2. microcytic, low ferritin, serum iron and increased TIBC 3. micocytic and normal iron studies

1. anemia of chronic dz; adequate iron stores and inability to properly use them 2. iron deficiency anmia 3. thalassemia

1. JAK2 mutation, high platelet count, high hematocrit 2. tx

1. polycythemia vera 2. phebotomy and ASA

1. sx of iron deficiency anemia in infants 2. characteristic of alpha thalassemia minor and beta thalassemia major 3. how is sideroblastic anemia dx

1. sx of iron deficiency anemia in infants: * low birth weight * hemoglobin about 8.0mg/dL *developmental delay 2. characteristic of alpha thalassemia minor and beta thalassemia major: * mild anemia * marked micocytic 3. how is sideroblastic anemia dx: is far less common than iron deficiency anemia and typically diagnosed based on the finding of ringed sideroblasts visible on peripheral smear.

1. what is acute chest syndrome; what disorder causes it 2. what is tx, what are the parameters for tx 3. what is prophylactic tx for above

1. what is acute chest syndrome; what disorder causes it: oPatients with sickle cell disease are prone to acute chest syndrome resulting from sickling of cells within the lung that typically presents with chest pain, tachypnea, cough, fever, and oxygen desaturation. 2. what is tx, what are the parameters for tx: Transfusion is indicated when the hematocrit drops below 30% or oxygen saturation drops below 90%. 3. what is prophylactic tx for above: Hydroxyurea (D) is used prophylactically to reduce the frequency of sickle cell crises and/or acute chest syndrome.

• A 32 year-old obese woman presents to the clinic complaining of swelling, warmth, and redness of her left lower extremity. Doppler ultrasound confirms a deep venous thrombosis is the greater saphenous vein. Which of the following best describes the most likely pathophysiology underlying her thrombophilia?

Factor V Leiden is a common genetic mutation that results in resistance to activated protein C.

• A 48-year-old man presents to the clinic for a routine employment physical. The patient is asymptomatic. A pre-employment CBC reveals hemoglobin of 13.2g/dl, hematocrit of 39.5%, and MCV of 60.6 fL. Subsequent iron studies, hemoglobin electrophoresis, and sickle cell screening are "normal." After the labs are reviewed, the patient states "they are always normal." What is the most likely diagnosis?

The patient has a mild anemia with pronounced microcytosis consistent with alpha thalassemia minor. Alpha thalassemia minor hemoglobin electrophoresis reveals normal results.

labs for 1. alpha thalassemia minor 2. iron deficiency 3. beta thalassemia major 4. sickle cells

The patient has a mild anemia with pronounced microcytosis consistent with alpha thalassemia minor. Alpha thalassemia minor hemoglobin electrophoresis reveals normal results. Patients with anemia of chronic disease (A) and iron deficiency anemia (D) have abnormal iron studies; while patients with beta thalassemia major (C) and sickle cell disease (E) have abnormal hemoglobin electrophoresis results

What tests are used to confirm the following: 1. pernicious anemia 2. hemolytic anemia 3. serum folate levels 4. what is schilling test associated with

What tests are used to confirm the following: 1. pernicious anemia: anti-intrinsic antibodies factor 2. hemolytic anemia: Coomb test 3. serum folate levels: macrocytic anemia, but not dx PA 4. what is schilling test associated with: was once used to dx PA, but no used b/c no reliable radiolabled human intrinsic factor

A 59-year-old female patient with no complaints is undergoing routine physical examination in your family practice office and has a hypochromic, microcytic anemia that was not present on her physical examination last year. Which of the following is the most important cause to rule out in this patient?

While there are many causes of hypochromic, microcytic anemia, high on the differential is blood loss, commonly occult and long standing in nature. This can be from heavy menstruation or gastrointestinal loss. This later is commonly caused by an occult colon cancer. This patient should initially receive a sensitive screen such as an immunochemical fecal occult blood test (IFOBT) and, given her age, a colonoscopy should be strongly considered.

etiology/pathophys of each 1. schizocytes 2. Howell-Jolly bodies 3. basophilic stippling 4. Burr cells

etiology/pathophys of each 1. schizocytes * look like small cell fragments; intravascular hemoysis, hemolytic anemia 2. Howell-Jolly bodies * nucleus seen inside cell; lack of removal of nuclear material b/c spleen not work well or absent; seen in sickle cell, hemolytic anemia, megalobastic anemia, 3. basophilic stippling * numerous ribosomes seen in cells; seen in sideroblastic anemia, beta and alpha thalassemia, TTP 4. Burr cells RBC that not have smooth round circumference; look like waves; due to change in pH

A 48-year-old female presents with a gradual progression of fatigue, pallor, and dyspnea on exertion over the last few months. Initial CBC results show a hemoglobin of 10.2 mg/dL, hematocrit of 31%, an MCV of 74 fL, and a reticulocyte count of 0.1%. Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?

o : The patient most likely has an underlying iron deficiency anemia (IDA), which requires confirmation and then evaluation for sources of chronic blood loss. IDA results from defective hemoglobin production. o Acute blood loss (A) would present more acutely and with normal hemoglobin, hematocrit, and MCV until hemodilution occurs and lowers the hemoglobin concentration and hematocrit. Defective bone marrow/stem cell function (B) tends to produce normocytic red blood cells. Defective DNA production (C) results in failure of RBC maturation and macrocytosis (elevated MCV). Hemolysis (E) is less likely than IDA, but can be confirmed or ruled out through the assessment of iron studies, the reticulocyte count and further hematologic labs as necessary.

• A 63 year-old woman complains of fatigue, loss of appetite, a sore-red tongue, paresthesias of her feet and hands, and unsteadiness of her gait. Which of the following tests is be used to confirm the patient's suspected diagnosis?

o A diagnosis of pernicious anemia (PA) can be supported through the presence of anti-intrinsic factor antibodies. o Antiparietal (B) cell antibodies aren't associated with the development of PA. The Coomb's test (C) is used in the evaluation of hemolytic anemias. Serum folate (D) levels are beneficial in evaluating macrocytic anemias, but will not establish a diagnosis of PA. The Schilling test (D) was once commonly used to diagnosis PA, but is no longer available due to lack of available radiolabeled human intrinsic factor.

• A 73 year-old woman with a past medical history of diabetes and hypertension presents to the clinic complaining of progressive fatigue. An initial CBC reveals a hemoglobin 10.1 mg/dL and MCV of 91 fL. Which of the following best describes the cause of the abnormality pictured in the patient's peripheral smear? looks like flowers

o Burr cells are present on the peripheral smear and are associated with uremia; look like flowers, o Howell-Jolly bodies result from the lack of removal of nuclear material due to an absent or non-functioning spleen (A). Macrocytosis results from failure of nuclear maturation (B) commonly secondary to vitamin B12 or folate deficiency. Intravascular hemolysis (C) creates schizocytes, and lead intoxication (D) or thalassemia cause basophilic stippling.

A 52-year-old female with a past medical history of dyslipidemia, GERD, hypothyroidism, and osteoarthritis presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.7 mg/dL, hematocrit of 33%, an MCV of 117 fL, and a reticulocyte count of 0.0%. Which of the following medications should be considered as a potential cause of her anemia?

o Cholestyramine is associated with folate malabsorption and may rarely be a medication cause for macrocytic anemia. o Celecoxib (A), levothyroxine (C), omeprazole (D), and ranitidine (E) are not strongly associated with vitamin B12 or folate deficiency leading to macrocytic anemia

• A 22-year-old non-obese female presents to the clinic with sign and symptoms of deep vein thrombosis (DVT). She denies recent trauma, prolonged immobilization, smoking, use of oral contraceptives, or changes in her health. Her last menstrual period was one week ago. Which of the following is the most likely diagnosis that contributed to the development of her DVT?

o Factor V Leiden mutation is one of the most common genetically inherited prothrombotic states.

MCC of inherited prothrombotic states that leads to DVT in young females; what is underlying pathophys

o Factor V Leiden mutation is one of the most common genetically inherited prothrombotic states. o Factor V Leiden is a common genetic mutation that results in resistance to activated protein C.

• A 41-year-old alcoholic male, who lives primarily on the streets, appears pale, cachectic, and mildly icteric. He is complaining of several weeks of increasing fatigue. Laboratory findings note an elevated MCV of 128. What other physical finding would most support the diagnosis for megaloblastic anemia?

o Features of folate deficiency are similar to vitamin B12 deficiency. However, there are none of the neurologic abnormalities associated with vitamin B12. Glossitis is the only non-neurologic finding in the PE that would support folate deficiency. Alcoholism and poor dietary intake also support the diagnosis of folate deficiency.

• A 12 year-old African-American male with a history of sickle cell disease presents to the clinic for routine follow up. A peripheral smear is performed. Which of the following best describes the cause of the abnormality pictured in the patient's peripheral smear?

o Howell-Jolly bodies are noted in the peripheral smear and result from the lack of removal of nuclear material due to an absent or non-functioning spleen. o Failure of nuclear maturation (B) produces macrocytosis, intravascular hemolysis (C) leads to the creation of schizocytes, lead intoxication (D) and thalassemia cause basophilic stippling, and uremia (E) is associated with Burr cells.

• An 11-month-old African-American male presents to the pediatric office with lethargy, jaundice and splenomegaly. A CBC reveals hemoglobin of 8.0 mg/dl and a hematocrit of 25%. Peripheral smear appearance is available below. Which of the following treatments will reduce hemolysis and increase hemoglobin levels for this patient?

o Hydroxyurea directly reduces hemolysis and increases levels of fetal hemoglobin and reduces complications and transfusion frequency. o Sickle cell disease can be cured in 80% of individuals who receive a suitable transplant (A), but this procedure carries great risk and donors are difficult to identify.

An 8-month-old male presents to the clinic due to irritability, fatigue and parental concerns about developmental delays. He is fifth percentile for weight and 33rd percentile for height. An office based hemoglobin level is 8.4 mg/dL. Which of the following is the most likely diagnosis?

o Infants with poor nutrition are at greatest risk of iron deficiency anemia between the ages of 6 and 24 months. o Alpha thalassemia minor (A) and beta thalassemia minor (B) present with a markedly microcytic, but mild anemia. Folate deficiency (C) due to inadequate nutrition in the absence of co-morbid disease is rare. Sideroblastic anemia (E) is far less common than iron deficiency anemia and typically diagnosed based on the finding of ringed sideroblasts visible on peripheral smear.

•A 23 year-old vegan presents to the clinic complaining of fatigue. Initial CBC reveals a hemoglobin of 11.1 mg/dL and an MCV of 113 fL. Which of the following best describes the cause of the abnormality pictured in the patient's peripheral smear? (note photo taken from figure 57-5- in Harrison's)

o Macrocytes are present on the peripheral smear and result from failure of nuclear maturation commonly secondary to vitamin B12 or folate deficiency. o Howell-Jolly bodies result from the lack of removal of nuclear material due to an absent or non-functioning spleen (A). Intravascular hemolysis (C) creates schizocytes, lead intoxication (D) and thalassemia cause basophilic stippling, and uremia (E) is associated with Burr cells.

A 68-year-old female with a past medical history of diabetes, dyslipidemia, hypertension, and gout presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 112 fL, and a reticulocyte count of 0.1%. Which of the following medications should be considered as a potential cause of her anemia?

o Metformin is associated with vitamin B12 deficiency and may rarely be a medication cause for macrocytic anemia. o Nicotinic acid (E) administration may help reduce the risk of vitamin B12 deficiency secondary to nicotinic acid deficiency. Allopurinol (A), atorvastatin (B), and lisinopril (C) are not strongly associated with vitamin B12 or folate deficiency.

•A 63 year-old woman developed severe thrombocytopenia after undergoing her first treatment of a cisplatin-based chemotherapy regimen. Which of the following agents may be administered to prevent thrombocytopenia if the patient continues her cisplatin-based regimen?

o Oprelvekin, or recombinant interleukin-11, is a megakaryocyte growth factor that promotes platelet production. o Erythropoietin (B) and darbepoetin alfa (A) are both stimulators of red blood cell production, while filgrastim (C) and sargramostim (E) stimulate granulocyte production.

What is used to stimulate 1. platelet production 2. RBC 3. granulocytes

o Oprelvekin, or recombinant interleukin-11, is a megakaryocyte growth factor that promotes platelet production. o Erythropoietin (B) and darbepoetin alfa (A) are both stimulators of red blood cell production, while filgrastim (C) and sargramostim (E) stimulate granulocyte production. •

A 23-year-old male with a recent diagnosis of Non-Hodgkin's lymphoma presents complaining of swelling of the neck and face, cough, and dyspnea on exertion. On exam you note dilated neck veins. Which of the following is the most likely diagnosis?

o The classic presentation signs and symptoms of superior vena cava syndrome (SVCS) are present in this patient. Although the most common cancer associated with SVCS is lung cancer, it also occurs in Non-Hodgkin's lymphoma. o Angioedema (A), carotid artery dissection (B), Cushing's syndrome (C) and myxedema (D) can result in facial swelling, but should not lead to the presence of dilated neck veins.

• A 64-year-old, nonsmoking male presents to the clinic with complaints of headache and dizziness. Initial labs reveal hemoglobin of 20.1 g/dl, hematocrit of 60%, and platelet count of 567,000. Which of the following laboratory finding confirms the suspected diagnosis?

o The clinical presentation is most consistent with polycythemia vera (PCV), which, in the presence of a markedly elevated red blood cell mass, is confirmed by the presence of the JAK2 mutation. o The patient's erythropoietin (C) and ferritin (B) are most likely decreased as a result of bone marrow overproduction of RBCs and use of iron stores to produce these RBCs. The bone marrow of patients with PCV is typically hypercellular (A) across all cell lines.

• A 48-year-old man presents to the clinic for a routine employment physical. The patient is asymptomatic. A pre-employment CBC reveals hemoglobin of 13.2g/dl, hematocrit of 39.5%, and MCV of 60.6 fL. Subsequent iron studies, hemoglobin electrophoresis, and sickle cell screening are "normal." After the labs are reviewed, the patient states "they are always normal." Which of the following is the most appropriate management for this patient?

o The patient has a mild anemia with pronounced microcytosis consistent with alpha thalassemia minor and requires reassurance. o Alpha thalassemia minor hemoglobin electrophoresis reveals normal results. Patients with alpha thalassemia are often inappropriately advised to take iron supplements (B) and don't require iron, folic acid (C) or vitamin B12 supplements unless a coexisting deficiency is confirmed. Referral to an oncologist (E) and a bone marrow aspirate (A) aren't necessary for this patient.

A 18 year-old man presents to the clinic with a lifelong history of transfusion dependent anemia and iron chelation therapy. Which of the following hemoglobin electrophoresis findings is most likely present?

o The patient history is most consistent with beta thalassemia major that presents with increased HbA2 and/or HbF levels.

• A 78-year-old obese male smoker presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 74 fL, and a reticulocyte count of 0.1%. Iron studies reveal an elevated ferritin, decreased serum iron and TIBC. Which of the following is the most likely cause of this patient's anemia?

o The patient most likely has an underlying chronic disease resulting in anemia, as evidenced by his adequate iron stores and inability to properly use that iron for RBC production. o Iron studies in patients with thalassemia (A and B) are typically normal. Iron deficiency anemia (E) is confirmed with low ferritin, serum iron, and increased TIBC.

A 48-year-old female presents with a gradual progression of fatigue, pallor, and dyspnea on exertion over the last few months. Initial CBC results show a hemoglobin of 10.2 mg/dL, hematocrit of 31%, an MCV of 74 fL, and a reticulocyte count of 0.1%. After treatment for her anemia begins, which of the following diagnostic studies can be ordered first (earliest) to demonstrate a response to therapy?

o The patient most likely has an underlying iron deficiency anemia (IDA) which requires confirmation and then evaluation for sources of chronic blood loss. IDA is treated with iron replacement (e.g., ferrous sulfate) and response to therapy can be assessed in 7-10 days via a reticulocyte count.

A 28-year-old female presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 112 fL, and a reticulocyte count of 0.1%. Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?

o The patient most likely has an underlying vitamin B12 or folate deficiency resulting in macrocytosis (MCV of 112 fL). o Defective DNA production (C) results in failure of RBC maturation and macrocytosis (elevated MCV). Acute blood loss (A) would present more acutely and with normal hemoglobin, hematocrit, and MCV until hemodilution occurs and lowers the hemoglobin concentration and hematocrit. Defective bone marrow/stem cell function (B) tends to produce normocytic red blood cells. Microcytic, hypochromic anemia results from defective hemoglobin production (D). Hemolysis (E) is less likely than vitamin B12 and folate deficiency, but can be confirmed or ruled out through the assessment of the reticulocyte count (increased reticulocyte will increase the MCV and be inconsistent with a nutritional deficiency) and further hematologic labs as necessary.

• A 73-year-old, male with a 30 pack-year smoking history presents to the clinic with complaints of headache and dizziness. Labs reveal a hemoglobin of 21.3 g/dl, hematocrit of 63%, and platelet count of 498,000. He tests positive for the JAK2 mutation. Which of the following should be recommended to this patient to prevent secondary complications from his diagnosis?

o The patient most likely has polycythemia vera and is at risk for thrombotic events that can be reduced through the use of daily aspirin. In addition, he should be counseled on smoking cessation if he is still currently smoking. o The patient should not take iron supplements (B) as they compete with phlebotomy therapy that seeks to reduce iron stores.

1. s/sx of B12 deficiency 2. s/sx of anemia d/2 chronic kidney dz 3. iron deficiency 4. folate deficiency

o The patient most likely has vitamin B12 deficiency, as evidenced by the macrocytic anemia and neurological signs and symptoms. The patient should be treated with vitamin B12. o Anemia secondary to chronic kidney disease (A) typically presents as a normocytic, normochromic anemia. Iron deficiency anemia (B) presents as a microcytic, hypochromic anemia. Folate deficiency (C) typically presents as a macrocytic anemia, but without the classic neurological symptoms consistent with vitamin B12 deficiency.

• A 65-year-old man presents to the clinic complaining of fatigue, weakness, paresthesias, and an unsteady gait. Physical exam reveals decreased vibratory sensation and lack of proprioceptive feedback, noted on Romberg testing. CBC reveals hemoglobin of 10.7 g/dl, hematocrit of 32.1% and MCV 117.6 fL. Which of the following is the most appropriate treatment?

o The patient most likely has vitamin B12 deficiency, as evidenced by the macrocytic anemia and neurological signs and symptoms. The patient should be treated with vitamin B12. o Anemia secondary to chronic kidney disease (A) typically presents as a normocytic, normochromic anemia. Iron deficiency anemia (B) presents as a microcytic, hypochromic anemia. Folate deficiency (C) typically presents as a macrocytic anemia, but without the classic neurological symptoms consistent with vitamin B12 deficiency.

• A 28-year-old female presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 112 fL, and a reticulocyte count of 0.1%. Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?

o The time course of the patient's presentation is consistent with multiple episodes of acute hemolysis. o Defects in bone marrow (B) or red blood cell precursors (C and D) are refuted by the elevated reticulocyte count. Chronic blood loss (A) would have a more insidious, gradual onset and likely result in a decreased MCV.

A 33 year-old man with long-standing, recurrent, abdominal pain is diagnosed with anemia secondary to vitamin B12 deficiency. Which of the following gastrointestinal disorders most likely explains his diagnoses?

o Vitamin B12 complexed with intrinsic factor produced by gastric parietal cells is absorbed in the ileum, which is commonly affected by Crohn's disease (B). Achalasia (A) can lead to malnutrition and anemia secondary to vitamin B12, folate, and iron, but presents as difficulty swallowing, chest pain, and heartburn. Duodenal ulcer (C) and ulcerative colitis (E) may result in chronic blood loss and the development of iron deficiency anemia. Pancreatitis (D) causes malabsorption of fat soluble vitamins and may also lead to vitamin B12 deficiency in rarer instances.

A 5 year-old girl presents to the clinic with her mother who is concerned about her daughter's energy level since starting full day kindergarten. CBC reveals a hemoglobin of 12.3 g/dl, hematocrit of 36%, MCV of 62 fL, and an MCHC of 34 g/dL. Serum ferritin levels are normal. What is the most likely hemoglobin electrophoresis results for this patient?

oAlpha thalassemia presents with a normal hemoglobin electrophoresis, since all adult hemoglobin are alpha-containing and affected equally. oBeta thalassemia major may present with increased HbA2 and/or HbF levels (C and D). Beta thalassemia minor typically presents with increased HbA2 (C).

electrophoresis for: 1. Alpha thalassemia 2. beta thalassemia major 3. beta thalassemia minor

oAlpha thalassemia presents with a normal hemoglobin electrophoresis, since all adult hemoglobin are alpha-containing and affected equally. oBeta thalassemia major may present with increased HbA2 and/or HbF levels (C and D). Beta thalassemia minor typically presents with increased HbA2 (C).

•A 22-year-old patient with sickle cell disease presents to the emergency department complaining of chest pain, fever, and non-productive cough. On physical exam his temperature is 100.6°F, BP is 144/88, pulse is 110, respiratory rate is 24, and pulse oximetry is 84%. CBC shows a WBC of 11,500, hemoglobin of 8.3%, and hematocrit of 28%. What is the most critical/emergent treatment for this patient?

oPatients with sickle cell disease are prone to acute chest syndrome resulting from sickling of cells within the lung that typically presents with chest pain, tachypnea, cough, fever, and oxygen desaturation. Transfusion is indicated when the hematocrit drops below 30% or oxygen saturation drops below 90%. oBone marrow transplant is only an option in children (B) and not indicated for emergent therapy. Furosemide (C) would promote dehydration and further exacerbation of cell sickling. Hydroxyurea (D) is used prophylactically to reduce the frequency of sickle cell crises and/or acute chest syndrome. Acetaminophen (A) may be used for symptomatic treatment, but is less critical than transfusion and may not provide adequate pain management.

•A 6-week-old male with sickle cell disease presents to the pediatric office for his well-child visit. When should this child begin taking daily prophylactic penicillin?

oPatients with sickle cell disease develop functional asplenia as early as 3 months of age and should begin treatment with prophylactic penicillin at 2 months of age to prevent infection by encapsulated organisms (i.e., pneumococcus).

• A 64-year-old, nonsmoking male presents to the clinic with complaints of headache and dizziness. Initial labs reveal hemoglobin of 20.1 g/dl, hematocrit of 60%, and platelet count of 567,000. Which of the following is the most likely physical exam finding in this patient?

oSplenomegaly is the most common physical exam finding in patients with polycythemia vera (PCV) and may be accompanied by hepatomegaly (B). oErythromelalgia (A) also occurs in patients with PCV due to increased red blood cell mass, but occurs less commonly than splenomegaly. Patients with PCV often have thrombocytosis, which most commonly contributes to thrombotic events, but less commonly may result in abnormal platelet function and petechiae (D) and increased bleeding risk. PCV is associated with elevated B12 levels and not likely to result in the classic neurologic findings of B12 deficiency including peripheral neuropathy assessed by vibratory sensation (C), ataxia and dementia.

A 23-year-old male with a recent diagnosis of Non-Hodgkin's lymphoma presents complaining of swelling of the neck and face, cough, and dyspnea on exertion. On exam you note dilated neck veins. • Which of the following is the most appropriate initial treatment for this patient?

oThe classic presentation signs and symptoms of superior vena cava syndrome (SVCS) are present in this patient. Patients with lymphoma often respond with a decrease in tumor mass and improvement in SVCS with glucocorticoid therapy. oBeta-blockers (A) and vena cava stenting (E) aren't routinely used in the management of SVCS. Other initial symptomatic therapies include low salt diet, diuretics, head elevation, and diuretics. IV fluids (C) and Trendelenburg position (D) are contraindicated.

what conditions cause the following? 1. hypersegmented neutrophils 2. aur rods 3. left shift and basophilia 4. hodgkin's lymphoma 5. multiple myeloma

what conditions cause the following? 1. hypersegmented neutrophils: B12 or folate deficiency 2. aur rods: AML 3. left shift and basophilia: PCV 4. hodgkin's lymphoma: no neutrophils 5. multiple myeloma no specific neutrophil on peripheral smear

what is H/H, MCV, and retic of: 1. anemia of chronic blood loss 2. acute blood loss 3. defective bone marrow/stem cell function 4. defective DNA production 5. hemolysis

what is H/H, MCV, and retic of: 1. anemia of chronic blood loss: * low H/H, low MCV, retic of 0.1% 2. acute blood loss: * normal H/H 3. defective bone marrow/stem cell function: * normocytic RBC 4. defective DNA production: * failure of RBC maturation; macrocytosis 5. hemolysis: * need to look at iron stores and retic count

what increases the absorption of iron in the ileum?

• An acidic achieved through presence of additional acids (C) (e.g., ascorbic acid) increases absorption of iron. Food (E), other heavy metals (A), and basic stomach environments (B, D) negatively affect the absorption of iron.

what confirms the presence of IDA and the efficacy of therapy? what time frame?

• An elevated reticulocyte count 1 week after initiation of iron supplementation confirms the presence of IDA and efficacy of therapy. • The hemoglobin (B), hematocrit (C), serum iron (E) and ferritin (A) will improve subsequently to the increase in the reticulocyte count. After one month of iron supplementation the patient's hemoglobin should increase by 1-2 mg/dL and the hematocrit should increase by 3-6%.