Exam 2 (Some Renal and Anemia)
24. Which of the following conditions is unlikely to result in anemia of chronic disease? A. rheumatoid arthritis B. peripheral vascular disease C. chronic renal insufficiency D. osteomyelitis
B. peripheral vascular disease
2. Most of the body's iron is obtained from: A. animal-based food sources. B. recycled iron content from aged red blood cells (RBCs). C. endoplasmic reticulum production. D. vegetable-based food sources.
B. recycled iron content from aged red blood cells (RBCs).
15. Common physical examination findings in patients with pernicious anemia include: A. hypoactive bowel sounds. B. stocking-glove neuropathy. C. thin, spoon-shaped nails. D. retinal hemorrhages.
B. stocking-glove neuropathy.
22. When prescribing erythropoietin supplementation, the nurse practitioner (NP) considers that: A. the adrenal glands are its endogenous source. B. the addition of micronutrient supplementation needed for erythropoiesis is advisable. C. its use is as an adjunct in treating thrombocytopenia. D. with its use, the RBC life span is prolonged.
B. the addition of micronutrient supplementation needed for erythropoiesis is advisable.
28. Intervention in anemia of chronic disease most often includes: A. oral vitamin B12. B. treatment of the underlying cause. C. transfusion. D. parenteral iron.
B. treatment of the underlying cause.
4. One of the earliest laboratory markers in evolving macrocytic or microcytic anemia is: A. an increase in RBC distribution width (RDW). B. a reduction in measurable hemoglobin. C. a low MCH level. D. an increased platelet count.
A. an increase in RBC distribution width (RDW).
47. Which of the following plays an essential role in type 1 hypersensitivity? A. immunoglobulin E B. immunoglobulin A C. immunoglobulin G D. immunoglobulin F
A. immunoglobulin E
49. The time to highest blood concentration (Cmax) of epinephrine is shorter when the medication is given: A. intramuscularly in the vastus lateralis. B. subcutaneously in the abdominal wall. C. intramuscularly in the deltoid. D. intramuscularly into the gluteus.
A. intramuscularly in the vastus lateralis.
44. Second-line drug intervention in the presence of anaphylaxis should be: A. oral diphenhydramine. B. nebulized pentamidine. C. nebulized epinephrine. D. oral prednisone.
A. oral diphenhydramine.
40. Your priority in caring for Tom, the aforementioned patient, is to: A. administer a rapidly acting oral antihistamine. B. administer parenteral epinephrine. C. initiate vasopressor therapy. D. administer a parenteral systemic corticosteroid.
B. administer parenteral epinephrine.
16. You examine a 47-year-old man who presents with difficulty initiating and maintaining sleep and chronic pharyngeal erythema with the following results on hemogram: Hemoglobin (Hgb) = 15 g (normal 14 to 16 g)Hct = 45% (normal 42% to 48%)RBC = 4.8 million mm3 (normal 4.7 to 6.1 million mm3)MCV = 108 fL (normal 81 to 96 fL)MCHC = 33.2 g/dL (normal 31 to 37 g/dL)These values are most consistent with: A. pernicious anemia. B. alcohol abuse. C. thalassemia minor. D. Fanconi disease.
B. alcohol abuse.
33. When the cause of a macrocytic anemia is uncertain, the most commonly recommended additional testing includes which of the following? A. haptoglobin and reticulocyte count. B. Schilling test and gastric biopsy. C. methylmalonic acid and homocysteine. D. transferrin and prealbumin.
C. methylmalonic acid and homocysteine.
21. Results of hemogram in a person with anemia of chronic disease include: A. microcytosis. B. anisocytosis. C. reticulocytopenia. D. macrocytosis.
C. reticulocytopenia.
5. A 48-year-old woman developed iron-deficiency anemia after excessive perimenopausal bleeding, successfully treated by endometrial ablation. Her hematocrit (Hct) level is 25%, and she is taking iron therapy. At 5 days into therapy, one possible observed change in laboratory parameters would include: A. a correction of mean cell volume. B. an 8% increase in Hct level. C. reticulocytosis. D. a correction in ferritin level.
C. reticulocytosis.
29. Poikilocytosis refers to alterations in a red blood cell's: A. thickness. B. color. C. shape. D. size.
C. shape.
43. The most common clinical manifestation of systemic anaphylaxis typically is: A. dizziness. B. airway obstruction. C. urticaria. D. gastrointestinal upset.
C. urticaria.
6. A healthy 34-year-old man asks whether he should take an iron supplement. You respond that: A. this is a prudent measure to ensure health. B. iron-deficiency anemia is a common problem in men of his age. C. use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload. D. excess iron is easily excreted.
C. use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload.
General DX for Anemia
CBC- MCV tells us macro, micro, or normo Platelet count WBC with diff reticulocyte count peripheral blood smear hgb electrophoresis you have to order to differentiate thalassemia's ferritin, serum iron, and TIBC
Pre-renal (40-80% of cases) *Decrease in intravascular volume *Changes in vascular resistance *Decrease in cardiac output ***Wide BUN/creatinine ratio*** Intra-renal (40-50% of cases) *Renal ischemia *Nephrotoxic injury ***intra-renal failure can lead to ischemic injury when MAP <60 mm Hg or circulation interrupted for >30 minutes***
Causes, Acute renal failure
* Diabetic nephropathy * Hypertensive nephroscleropathy * Polycystic kidney disease * Glomerulonephritis
Causes, Chronic renal failure
Decrease in renal function/glomerular filtration usually as the result of a chronic or destructive renal disease
Chronic renal failure
14. Pernicious anemia causes which of the following changes in the RBC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic
D. macrocytic, normochromic
20. You examine a 27-year-old woman with menorrhagia who is otherwise well and note the following results on hemogram: Hgb = 10.1 gHct = 32%RBC = 2.9 million mm 3MCV = 72 fLMCHC = 28.2 g/dLRDW = 18.9%Physical examination is likely to include: A. conjunctiva pallor. B. hemic murmur. C. tachycardia. D. no specific anemia-related findings.
D. no specific anemia-related findings.
41. Which of the following food-based allergies is likely to be found in adults and children? A. milk B. egg C. soy D. peanut
D. peanut
27. Erythropoietin is a glycoprotein that influences a stem cell to become a: A. lymphocyte. B. platelet. C. neutrophil. D. red blood cell.
D. red blood cell.
42. A person with latex allergy also often has a cross-allergy to all of the following except: A. banana. B. avocado. C. kiwi. D. romaine lettuce.
D. romaine lettuce.
iron deficiency anemia management
Ferrous Sulfate 150-200 mg PO 1-2 hours after meals in divided doses for 4-6 months
Hemolytic anemia - G6PD corticosteroid therapy
Hemolytic anemia - G6PD corticosteroid therapy
Low B12 (<100 pg/mL [73.8 pmol/L]) Increased MMA Increased factor antibodies Neuro symptoms
Lab findings/symptomns, Pernicious anemia
Normal lab studies expected for Hb and Hct Fatigue
Lab findings/symptoms, Anemia of chronic disease
Low iron stores Low serum iron Low serum ferritin (first indicator) Elevated total iron binding capacity (TIBS) and RDW Fatigue
Lab findings/symptoms, Iron deficiency anemia (microcytic = MCV low)
Normal iron RDW normal Hb electrophoresis
Lab findings/symptoms, Thalassemias
•Clinical presentation/Exam: (Microcytic Anemia)
•Mild to moderate anemia no s/s. •Severe IDA s/s same as severe anemia: fatigue, decreased exercise tolerance, weakness, palpitations, irritability, HA. •Complaints specific to iron store depletion: parenthesis, sore tongue, brittle nails, pica, craving for ice (pagophagia). •Exam: forceful apical pulse, tachycardia w/exertion, systolic flow murmur. •Pallor of conjunctiva, mucous membranes, nail beds, and palmar creases.
Microcytic Anemia presentatation
•Mostly affects women of reproductive age and older adults. •Most common cause is chronic blood loss. •Inadequate nutrition & incr requirements for iron are causes of IDA in children & prego women.
• Chronic Leukemia
•Myelogenous leukemia (CML) • Chronic lymphocytic leukemia (CLL)
Macrocytic Anemia: Megaloblastic Anemia, •Life Span Considerations:
•Neural tube defects related to folate deficiency •Women should begin folic acid supplements before prego to reduce incidence of neural tube defects- o.4mg/day
•Most prevalent types: Lymphomas (pg. 1315 staging)
•Non-Hodgkin's Lymphoma (NHL)- more common in older adults and males •Hodgkin's Lymphoma (HL)
Complications: Anemia of Chronic Disease (ACD)
•None if underlying disease is managed appropriately.
Blood Coagulation Disorders, Diagnostics and Differential Dxs
•Obtain a careful, comprehensive bleeding history - pt's and family's •Platelet count •PT or aPTT clotting time
Clinical Presentation/Exam: Anemia of Chronic Disease
•Often mild and asymptomatic. •Progression of anemia has s/s of fatigue and poor activity tolerance.
•Patient Education: Iron Deficiency Anemia (IDA)= most common type of anemia (Microcytic Anemia)
•Optimum absorption if taken 30 min before meals. •Calcium significantly inhibits iron absorption. •Ascorbic acid may enhance absorption, take PO iron dose with OJ.
Management: Iron Deficiency Anemia (IDA)= most common type of anemia (Microcytic Anemia)
•PO iron 150-200mg per day in divided doses until anemia is corrected. •Typically 4-6 months. •SE nausea, constipation, heartburn, upper GI discomfort, black stools, diarrhea. •Severe anemia, malabsoprtion problems, or PO iron not tolerated IM or IV iron needed.
Management Acute Leukemia (PROMPT!)
•Prompt evaluation and intervention $$$$Require aggressive chemotherapy •Hematopoietic stem cell transplantation (HSCT)$$$$ •Induction therapy in hospital •Chemotherapy usually takes about 2 years •Multidisciplinary care •Close monitoring - Infection prevention
•Referral/Hospitalization: Sickle Cell Anemia
•Pts can be cared for in a primary care setting but generally require care by specialists or a hospital w/ a sickle cell center that is familiar w/ the disease. •Many complications require hospitalizations. •Also, consult w/ a social worker is recommended for school, employment, transportation, and medical billing issues.
Blood Coagulation Disorders, P.E.
•Pts may be asymptomatic or show signs of bruises, petechiae, gingival bleeding, epistaxis, and hematomas, may be evident
Clinical Presentation: Aplastic Anemia
•Pts may be seen w/ abnormal bleeding, infection, and anemia (from pancytopenia). •Onset is usually sudden w/o any other apparent illness.
Management: Aplastic Anemia
•Refer to hematologist for mang. •Difinitive tx is either BMT or immunosuppressive therapy. •Do not transfuse unless ok'd by hematologist.
Macrocytic Anemia: Megaloblastic Anemia, •Referral:
•Refer to hematologist if severe macrocytic anemia, neuro complications
•Referral: Iron Deficiency Anemia (IDA)= most common type of anemia (Microcytic Anemia)
•Refer to hematologist: intolerance of PO iron, persistent IFDA, persistent microcytic anemia despite iron replacements .
Referral: Hemolytic Anemias
•Referral to hematologist is prudent when an acute hemolysis does not appear to be resolving or when the anemia is severe or does not respond to tx.
Microcytic Anemia: Thalassemia, •Life Span Considerations:
•Reproductive issues are major concern. •Well-chelated and well transfused women may be fertile.
•Severe B12 deficiency includes S/S of marked anemia and neurologic deficits.
•Severe B12 deficiency includes S/S of marked anemia and neurologic deficits.
•Severe B12 deficiency- smooth, red, shiny tongue and neuro changes.
•Severe B12 deficiency- smooth, red, shiny tongue and neuro changes.
Sickle Cell Anemia
•Sickle Cell Disease is most common inherited hemoglobinopathies. •Mild to moderate hemolytic anemia . •Hallmark is acute vaso-occlusive crisis that causes unpredictable sever pain & organ damage. •8% of African Americans carry the gene, and 1 in 400 are affected by the disease.
Clinical Presentation, Lymphomas
•Signs and Sxs vary depending on type of lymphoma •Dependent on the type of lymphoma and the area of involvement •Lymphadenopathy is common •Fever (>38° C) •Unintentional weight loss
•The CBC will usually reveal a normocytic anemia, but the anemia can occasionally be microcytic.
•The CBC will usually reveal a normocytic anemia, but the anemia can occasionally be microcytic.
Diagnostics: Anemia of Chronic Disease (ACD)
•The CBC will usually reveal a normocytic anemia, but the anemia can occasionally be microcytic. •Hgb levels are generally 10-11 g/dL. Iron studies reveal a low serum iron level, a normal or incr ferritin level, & a normal or elevated TIBC. •Retic count is normal. •The only way to distinguish ACT from IDA is by assessment of iron stores (which are absent in IDA and normal or incr in ACD).
Diagnostics, Lymphomas
•The Hasenclever Index (prognostic screening to guide clinical management)
Referral/Hospitalization: Anemia of Chronic Disease (ACD)
•The anemia should be monitored w/ periodic CBCs and iron studies and referral if anemia worsens and requires therapy.
•The only remarkable evidence of hemolysis may be sclera icterus (especially in sickle cell dz)
•The only remarkable evidence of hemolysis may be sclera icterus (especially in sickle cell dz)
Management Chronic Leukemia
•Treated initially with imatinib mesylate (Gleevec) •If intolerant to chemotherapy or refractory - Allogeneic stem cell transplantation and clinical trials •IVIG infusions •Close monitoring - Infection prevention
Management, Lymphomas
•Treatment is based on the staging of HL (Ann Arbor staging system) •Combination chemotherapy is the cornerstone of HL treatment •Radiation therapy in select pts •Non-Hodgkin's lymphoma •First radiation; followed by chemotherapy
Macrocytic Anemia: Megaloblastic Anemia, •Complications:
•Undiagnosed or mistreated vit B12 can cause irreversible neuro damage. •Weakness, ataxia, poor coordination, forgetfulness, dementia, psychosis.
Management: Hemolytic Anemias
•Varies according to disease state. •If Hgb fall well below pt's baseline, an occasional transfusion of packed RBCs may be necessary. •All pts require 1mg/day folic acid supplement to maintain adequate erythropoiesis.
Macrocytic Anemia: Megaloblastic Anemia
•Vitamin B12 & Folate Deficiency are primary causes $$$$Folate (Folic Acid) deficiency$$$$ found with decreased dietary intake, diseases associated with malabsorption, or increased requirements such as pregnant women; alcoholics $$$$Pernicious anemia (lack of intrinsic factor) is common cause of B12 deficiency$$$$ (malabsorption) •Onset of pernicious anemia usually occurs after age 50
Blood Coagulation Disorders, •Inherited D/O
•e.g., Von Willebrand disease, hemophilia A, and hemophilia B
Anemia of Chronic Disease (ACD), Pathophysiology:
•is an anemia of underproduction, usually normocytic, normochromic, with a hemoglobin level above 10g/L but can be severe with MCV reduced in approx 30% of pts. •ACD is marked by low serum iron levels, but total iron stores are normal or elevated.
Differential Dxs Chronic Leukemia
•non-Hodgkin's lymphoma, hairy cell leukemia, and a variety of other lymphoproliferative disorders
MCV=80-99 fL, (Mechanism unclear)
Normocytic anemias
Caused by large amounts of traumatized tissue simulating the release of thromboplastin and stimulating extrinsic clotting (i.e., trauma, sepsis, infection, malignancy, pregnancy complications). Clotting factors are used up and depleted, causing lethal bleeding.
Pathophysiology, Disseminated intravascular coagulation (DIC), Disorders of Platelet Function, Uremia-induced coagulopathy and disseminated intravascular coagulation
Type I reaction - A direct effect of the heparin (onset 1-4 days after therapy begins) Type II reaction - An immune-mediated response where heparin-induced antibodies bind to platelets and activate them -> thrombocytopenia (onset 4-10 days after therapy begins, can be <24 hours if prior exposure)
Pathophysiology, Heparin-induced thrombocytopenia (HIT)
Autoimmune process of platelet destruction and deceased production Typically a diagnosis of exclusion
Pathophysiology, Primary immune thrombocytopenia purpura (ITP)
Occurs as the result of abnormal hemoglobin synthesis due to a DNA point mutation. Sickled red blood cells cannot flex as they pass through capillaries. Microinfarcts occur predisposing to infection and anoxia. Sicle cell crisis is an acute pain syndrome.
Pathophysiology, Sickle Cell Anemia
Uremic plasma causes platelet dysfunction with decreased aggregation and impaired adhesiveness.
Pathophysiology, Uremia-induced coagulopathy (uremic bleeding), Disorders of Platelet Function, Uremia-induced coagulopathy and disseminated intravascular coagulation
Inflammation of the pericardium. Usually due to viral infection; wide variety of other causes include other infection, post-MI, autoimmune, uremia. Characterized by non-radiating, sharp, stabbing, knife-like chest pain over the PMI. Friction rub may be present. 12-lead ECG may reveal global concave ST elevations. Pain may be relieved by positioning to relieve pressure from pericardium. Symptomatic treatment with NSAID for mild forms; corticosteroids for more severe cases.
Pericarditis, Infectious Cardiac Disease
Anemia: generalized
Physician consultation is recommended for hemoglobin values of less than 10 g/dL Pharmacotherapy Iron deficiency anemia - ferrous sulfate, B12, and folate - megaloblastic anemia Hydroxyurea, analgesics - sickle cell anemia RBC transfusions to maintain adequate hemoglobin levels and iron chelation (B thalassemia) Hemolytic anemia - G6PD corticosteroid therapy
RBC transfusions to maintain adequate hemoglobin levels and iron chelation (B thalassemia)
RBC transfusions to maintain adequate hemoglobin levels and iron chelation (B thalassemia)
Tests for iron deficiency anemia (most common)
Serum ferritin (first to change) Serum iron (iron bound to transferrin) TIBC Transferrin saturation percentage = Serum Iron/TBIC X 100
Sickle Cell Anemia, •Strokes in
children than in adults.
iron deficiency anemia is the most
common type of anemia
Sickle Cell Anemia, •Skin ulcerations of the lower legs are the most common
cutaneous complication, causing pain and physical disfigurement, the medial or lateral malleoli are more freq. involved ** Some lesions are resistant to therapy and often exist for years.
Iron deficiency anemia (microcytic = MCV low) symptoms
paresthesia, sore tongue, pica in preg, craving ice, tacky with exertion, pallor, nail beds, palmer creases. Usually discovered on regular exam.
Sickle Cell Anemia, Priapism
persistent, painful erection lasting more than 3-4 hours is a medical emergency b/c it can cause impotence
Microcytic Anemia: Thalassemia •Clinical Presentation/Exam:
•A or B-Thalassemia minor have little or no hematologic effects. •A or B- Thalassemia intermedia have moderate microcytic and hypochromic anemia that is NOT transfusion dependent. •B-Thalassemia Major (Cooley's anemia) develop severe, life threatening anemia during 1st year of life- Transfusion dependent. •PE only remarkable in thalassemia intermedia and B-thalassemia major. •Short stature, abnormal facies, cranial marrow expansion, enlarged spleen, heart, or liver, pallor.
•Diagnostics: Sickle Cell Anemia
•Accurate diagnosis of any sickle cell anemia syndrome requires hemoglobin electrophoresis for accurate DX Start here: Pts have evidence of hemolytic anemia: low Hgb, chronic reticulocytosis, chronic hyperbilirubinemia, & chronically elevated LDH levels. •Unfortunately there is no lab tests that predict or diagnose sickle cell crisis.
•Four different types of leukemia:
•Acute •Acute myelogenous leukemia (AML) •Acute lymphocytic leukemia (ALL) • Chronic •Myelogenous leukemia (CML) • Chronic lymphocytic leukemia (CLL)
•Acute leukemia
•Acute myelogenous leukemia (AML) •Acute lymphocytic leukemia (ALL)
Management: Anemia of Chronic Disease (ACD)
•After IDA has been excluded, a mild anemia need not be tx unless it is symptomatic. •The standard tx for ACD of renal insufficiency is recombinant human erythropoietin (rHuEPO) or darbepoetin alfa . • Intermittent transfusions may be required w/ more severe anemias. • As always, the underlying condition should be tx or optimally controlled.
Aplastic Anemia, Pathophysiology: (Rare)
•Aplastic anemia is a life-threatening condition resulting from bone marrow stem cell failure. •It is characterized by pancytopenia and can affect all ages and both genders and is very rare. •It is usually r/t exposure to specific toxins or meds than can cause bone marrow damage or can be immunologic.
Microcytic Anemia: Thalassemia, Pathophysiology/Genetics
•Autosomal dominant pattern •A (alpha)-Thalassemia: four genes (2 from each parent on chromosome 16) •1 gene affected= silent carrier and no S/S •2 genes affected= a-thalassemia trait or a-thalassemia minor •Considered carrier and mild anemia •3 genes affected= a-thalassemia intermedia •Moderate to severe anemia •4 genes affected= a-thalassemia major •Most affected fetuses are born prematurely and are stillborn or die shortly after birth
•Clinical Presentation/Exam: Sickle Cell Anemia
•Jaundice, a physiologic systolic flow murmur (grade I or II pansystolic murmur heard best along L sternal border), and sclera icterus may be present. •Cardiomegaly is also routinely noted.
Differential Dxs, Lymphomas
•Lymphadenopathy may suggest numerous other malignancies
•Diff Dxs: Acute Leukemia
•Lymphoma, solid tumors, Infection - Mononucleosis, tuberculosis, systemic lupus erythematosus, megaloblastic anemia, or aplastic anemia, myelodysplastic syndrome or a myeloproliferative disorder
Blood Coagulation Disorders, •Acquired D/O
•Medications (e.g., aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], or anticoagulants) or organ dysfunction re/to medical injury
Anemia differential approach
•Microcytic anemia •Iron deficiency anemia •Anemia of chronic disease •Sickle cell anemia •Thalassemia •Aplastic anemia •Hemolytic anemia
Macrocytic Anemia: Megoblastic Anemia, •Clinical Presentation/Exam:
•Mild megaloblastic anemia produces few S/S. •Severe B12 deficiency includes S/S of marked anemia and neurologic deficits. •Folic acid deficiency is rarely associated with S/S even in severe state. •NO neuro S/S •PE of severe megaloblastic anemia may reveal classic changes associated with any severe anemia. •Severe B12 deficiency- smooth, red, shiny tongue and neuro changes.
•Like other people w/ hemolytic anemias, pts w/sickle cell disease require
daily folic acid replacement. •Folate is necessary for normal erythropoiesis. Supplemental 1mg/day Folic acid is enough to maintain the higher rate of erythropoesis that occurs in chronic hemolysis. •Bone marrow transplant, which is considered curative, and gene therapy are available but not widely used d/t poor availability of suitable donors.
Anemia of production and anemia of
destruction
Iron deficiency anemia - ferrous sulfate, B12, and folate - megaloblastic anemia
ferrous sulfate, B12, and folate - megaloblastic anemia
Sickle Cell Anemia, Retinopathy
is a significant problem for pts. It is more common in pts w/ SC disease than in those w/ homozygous SS disease.
Sickle Cell Anemia, •Chronic pain
is a substantial problem and most patients require frequent doses of oral narcotic analgesics. •Physical tolerance to narcotics should not be confused with psychological addiction and drug-seeking behaviors, which are uncommon in this population.
•Hallmark Sickle Cell Anemia
is acute vaso-occlusive crisis that causes unpredictable sever pain & organ damage.
•e.g., Von Willebrand disease, hemophilia A, and hemophilia B
know basics of these for test
•In a mild acute hemolytic event,
labs reveal slight decrease in Hgb and RBC count, elevated LDH and slight hyperbilirubinemia.
iron deficiency anemia is associated with
low birth weights
Physician Exam: Aplastic Anemia
may reveal petechiae, ecchymoses, purpura, pallor of the skin and mucous membranes, and mild lymphadenopathy in the late stages.
•Most hemolytic anemias are
mild, well compensated, and associated w/ few signs and symptoms •If anemia is severe, then symptoms of fatigue and exercise intolerance •The only remarkable evidence of hemolysis may be sclera icterus (especially in sickle cell dz)
(Microcytic Anemia) 70% of total body iron content is in hemoglobin •When iron requirement increased or intake decreased,
the small intestine increases absorption of iron to meet the demand If no additional supply is available the body's iron store begin to be depleted
Sickle Cell Anemia, •There is a high risk of renal dysfunction or failure in adults
w/ sickle cell disease. Renal failure results from the sickled cell-induced damage to renal microvasculature; generally dx in 3rd or 4th decade of life and progresses to renal failure.
Low serum and RBC folate
Lab finding/symptoms, Folic acid deficiency anemia
Macrocytic Anemia: Megaloblastic Anemia, •Patient Education:
$$$$Early recognition of alcohol abuse can reduce the incidence of folate deficiency anemia$$$$ •Daily folic acid supplementation may be required for pt's receiving sulfasalazine and methotrexate. •Magaloblastic anemia r/t vit B12 require monthly B12 injections.
Management: Sickle Cell Anemia
$$$$Moderate to severe crises require tx in an ED or hospital-based outpatient tx center w/ parenteral narcotic analgesics and hydration as well as the same local measures$$$$ $$$$Hydroxyurea is becoming standard therapy for pts who experience 3 or more crises per year. Pts must be monitored every 2 weeks for signs of toxicity and once stable checked monthly$$$$ •The freq and severity of crises vary among pts and even in the same pt over time. •Most crisis are mild to moderate and can be managed at home w/ oral analgesics, adequate hydration, rest, and local measures such as heat and gentle massage. •Aggressive, early management of a crisis can prevent hospital admission. Hospitalizations for crises can last days to several weeks.
Hemolytic Anemias, Pathophysiology:
$$$$The most common chronic hemolytic anemia is sickle cell disease$$$$ - most of the others are rare. •Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited erythrocyte enzyme deficiency that can result in an acute hemolytic anemia and is usually precipitated by an infection or by ingestion of an oxidant drug ($$$$ASA, phenacetin, SULFONAMIDES, NITROFURANTOIN, and primaquine$$$$).
•B (beta)-Thalassemia:
(each parent provides one to an offspring, chromosome 11) •1 gene affected= B-thalassemia train or minor •Carrier
Consequence of chronic illness
Cause, Anemia of chronic disease
Diet deficiency or medication
Cause, Folic acid deficiency anemia
Slow chronic blood loss
Cause, Iron deficiency anemia
Impaired Vitamin B12 absorption
Cause, Pernicious anemia
Genetic variation
Cause, Thalassemias
____ 38. The body's normative response to anemia is reticulocytopenia.
False, reticulocytes go up
Sudden drop in kidney function resulting in an inability to maintain acid-base, fluid and electrolyte balance, and to excrete nitrogenous wastes.
Acute renal failure
Microcytic Anemia: Thalassemia, •Patient Education:
Adherence to chelation therapy schedule is essential No S/S of iron overload until advanced stage
Anemia Physical Exam
Angular cheilitis, tachycardia, tachypnea, weakness, lethargy, exercise intolerance, fever, pale or icteric mucous membranes, eye, skin, petechia ecchymoses if also thrombocytopenic, signs of underlying disease, external wounds-HBC, bullet wounds, etc.
•2 genes affected= B-thalassemia intermedia OR
B-thalassemia major (Cooley's anemia) •Intermedia= moderate anemia •Major= severe anemia
8. A 40-year-old woman with pyelonephritis is taking two medications: ciprofloxacin and ferrous sulfate (for iron-deficiency anemia). She asks about taking both medications. You advise that: A. she should take the medications with a large glass of water. B. an inactive drug compound is potentially formed if the two medications are taken together. C. she can take the medications together to enhance adherence to therapy. D. the ferrous sulfate potentially slows gastrointestinal motility and results in enhanced ciprofloxacin absorption.
B. an inactive drug compound is potentially formed if the two medications are taken together.
19. You examine a 57-year-old woman with rheumatoid arthritis who is on a disease-modifying antirheumatic drug (DMARD) but continues to have poor disease control and find the following results on hemogram: Hgb = 10.5 gHct = 33%RBC = 3.1 million mm 3MCV = 88 fLMCHC = 32.8 g/dLRDW = 12.2%Reticulocytes = 0.8%The laboratory findings are most consistent with: A. pernicious anemia. B. anemia of chronic disease. C. beta thalassemia minor. D. folate-deficiency anemia.
B. anemia of chronic disease.
11. Risk factors for folate-deficiency anemia include: A. menorrhagia. B. chronic ingestion of overcooked foods. C. use of nonsteroidal anti-inflammatory drugs. D. gastric atrophy.
B. chronic ingestion of overcooked foods.
9. Two months into therapy for pernicious anemia, you wish to check the efficacy of the intervention. The best laboratory test to order at this point is a: A. Schilling test. B. hemoglobin measurement. C. reticulocyte count. D. serum cobalamin.
B. hemoglobin measurement.
32. When counseling a patient about the neurological alterations often associated with vitamin B12 deficiency, the NP advises that: A. these usually resolve within days with appropriate therapy. B. if present for longer than 6 months, these changes are occasionally permanent. C. the use of parenteral vitamin B12 therapy is needed to ensure symptom resolution. D. cognitive changes associated with vitamin B12 deficiency are seldom reversible even with appropriate therapy.
B. if present for longer than 6 months, these changes are occasionally permanent.
13. Pernicious anemia is usually caused by: A. dietary deficiency of vitamin B12. B. lack of production of intrinsic factor by the gastric mucosa. C. RBC enzyme deficiency. D. a combination of micronutrient deficiencies caused by malabsorption.
B. lack of production of intrinsic factor by the gastric mucosa.
3. Which of the following is most consistent with iron-deficiency anemia? A. low mean corpuscular volume (MCV), normal mean corpuscular hemoglobin (MCH) B. low MCV, low MCH C. low MCV, elevated MCH D. normal MCV, normal MCH
B. low MCV, low MCH
50. The use of a systemic corticosteroid in the treatment of anaphylaxis is primarily helpful for: A. treatment of the most acute symptoms. B. minimization of a protracted allergic response. C. prevention of future episodes. D. reducing the risk of fatality associated with the event.
B. minimization of a protracted allergic response.
18. A 68-year-old man who is usually healthy presents with new onset of "huffing and puffing" with exercise for the past 3 weeks. Physical examination reveals conjunctiva pallor and a hemic murmur. Hemogram results are as follows: Hgb = 7.6 gHct = 20.5%RBC = 2.1 million mm3MCV = 76 fLMCHC = 28 g/dLRDW = 18.4%Reticulocytes = 1.8%The most likely cause of these finding is: A. poor nutrition. B. occult blood loss. C. malabsorption. D. chronic inflammation.
B. occult blood loss.
48. Of the following medications, which is least likely to be implicated as a trigger for anaphylaxis? A. ibuprofen B. amoxicillin C. acetaminophen D. aspirin
C. acetaminophen
7. Which of the following is the best advice on taking ferrous sulfate to enhance iron absorption? A. "Take with other medications." B. "Take on a full stomach." C. "Take on an empty stomach." D. "Do not take with vitamin C."
C. "Take on an empty stomach."
17. You examine a 22-year-old woman of Asian ancestry. She has no presenting complaint. Hemogram results are as follows: Hgb = 9.1 g (normal 12 to 14 g)Hct = 28% (normal 36% to 43%)RBC = 5.6 million mm3 (normal 4.2 to 5.4 million mm3)MCV = 68 fL (normal 81 to 96 fL)MCHC = 33.2 g/dL (normal 31 to 37 g/dL)RBC distribution width (RDW) = 13% (normal ≤15%).Reticulocytes = 1.5% (normal 1% to 2%)This is most consistent with the laboratory assessment of: A. iron-deficiency anemia. B. Cooley anemia. C. alpha-thalassemia minor. D. hemoglobin Barts.
C. (a) alpha-thalassemia minor.
25. In health, the ratio of hemoglobin to hematocrit is usually: A. 1:1. B. 1:2. C. 1:3. D. 1:4.
C. 1:3.
30. Which of the following is not consistent with anemia of chronic disease (ACD)? A. NL RDW B. NL MCHC C. Hct less than 24% D. NL to slightly elevated serum ferritin
C. Hct less than 24%
39. Tom is a 19-year-old man who presents with sudden onset of edema of the lips and face and a sensation of "throat tightness and shortness of breath" after a bee sting. Physical examination reveals inspiratory and expiratory wheezing as well as pruritic wheals on his face and arms. Blood pressure is 78/44 mm Hg, heart rate is 102 bpm, and respiratory rate is 24/min. His clinical presentation is most consistent with the diagnosis of: A. vasculitis. B. angioedema. C. anaphylaxis. D. reactive airway disease.
C. anaphylaxis.
26. An increase in the normal variation of RBC size is known as: A. poikilocytosis. B. granulation. C. anisocytosis. D. basophilic stippling.
C. anisocytosis.
10. A woman who is planning a pregnancy should increase her intake of which of the following to minimize the risk of neural tube defect in the fetus? A. iron B. niacin C. folic acid D. vitamin C
C. folic acid
23. In the first weeks of anemia therapy with parenteral vitamin B12 in a 68-year-old woman with hypertension who is taking a thiazide diuretic, the patient should be carefully monitored for: A. hypernatremia. B. dehydration. C. hypokalemia. D. acidemia.
C. hypokalemia.
Acute bleeding
Cause, Acute blood loss
45. Which of the following is the best answer regarding anaphylaxis? A. Adults usually do not develop new anaphylaxis triggers such as food allergies. B. Peanuts are the primary food that can cause a severe allergic reaction. C. Future anaphylactic reactions will become increasingly more severe. D. Trace amounts of an allergen in a food can cause a severe anaphylactic reaction.
D. Trace amounts of an allergen in a food can cause a severe anaphylactic reaction.
31. In children younger than age 6 years, accidental overdose of iron-containing products is: A. easily treated. B. a source of significant gastrointestinal (GI) upset. C. worrisome but rarely causes significant harm. D. a leading cause of fatal poisoning in the age-group.
D. a leading cause of fatal poisoning in the age-group.
46. Increased risks for fatal reactions from anaphylaxis include all of the following except: A. personal history of asthma. B. delay in administering epinephrine. C. age in the teen years. D. delay in administering antihistamines.
D. delay in administering antihistamines.
1. Worldwide, which of the following is the most common type of anemia? A. pernicious anemia B. folate-deficiency anemia C. anemia of chronic disease D. iron-deficiency anemia
D. iron-deficiency anemia
12. Folate-deficiency anemia causes which of the following changes in the RBC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic
D. macrocytic, normochromic
Infection of the endocardium. Caused by bacteria or fungi. Highest risk patients include those withe valvular disease and increased risk of pathogen introduction. Changing cardiac murmur is diagnostically significant but the exception rather than the rule. Physical exam typically reveals acutely septic patient*. Additional findings may include Osler's nodes, Janeway lesions, splinter hemorrhages. Treatment must include coverage of Gram-positive organisms**
Endocarditis, Infectious Cardiac Disease
Symptoms may not be noticeable until
Hgb is below 8
Hydroxyurea, analgesics - sickle cell anemia
Hydroxyurea, analgesics - sickle cell anemia
Microcytic Anemia:
Iron Deficiency Anemia (IDA)= most common type of anemia
vitamin c will increase
Iron absorbtion
Low nutrition in children in pregnant women, chronic blood loss in older adults, menses in women of childbearing age
Iron deficiency anemia (microcytic = MCV low)
Drop in hgb on cbc, order a
Iron pannel
MCV>100 fL, (Abnormal RBC synthesis)
Macrocytic anemias
•B- thalassemia common in
Mediterranean, Middle Eastern, African, or Asian descent.
MCV<80 fL, (Abnormal Hb synthesis)
Microcytic anemias
Persistent albuminuria with normal or increased GFR. GFR >90 mL/min/1.73 m2
Stage 1, Stages of chronic renal failure (Staging is based on GFR not BUN/creatinine)
Persistent albuminuria with mild decrease in GFR. GFR 60-89 mL/min/1.73 m2
Stage 2, Stages of chronic renal failure (Staging is based on GFR not BUN/creatinine)
Moderate decrease in GFR, start preparing patient for dialysis. GFR 30-59 mL/min/1.73 m2
Stage 3, Stages of chronic renal failure (Staging is based on GFR not BUN/creatinine)
Severe decrease in GFR. 15-29 mL/min.1.73 m2
Stage 4, Stages of chronic renal failure (Staging is based on GFR not BUN/creatinine)
Kidney failure requiring dialysis or transplantation. GFR <15mL/min/1.73 m2
Stage 5, Stages of chronic renal failure (Staging is based on GFR not BUN/creatinine)
____ 34. Anemia in children is potentially associated with poorer school performance.
TRUE
____ 35. During pregnancy, folic acid requirements increase twofold to fourfold.
TRUE
____ 36. The red blood cell content is approximately 90% hemoglobin.
TRUE
____ 37. Approximately 90% of the body's erythropoietin is produced by the kidney.
TRUE
Treat cause of loss Transfuse
Treatment, Acute blood loss
Pre-renal *Typically no parenchymal damage *Increase renal blood flow Intra-renal *R/O pre and post-renal causes first *Remove offending agent/cause of ischemia Post-renal *Relieve obstruction
Treatment, Acute renal failure
Transfuse PRN
Treatment, Anemia of chronic disease
May need to adjust renally-excreted drugs Review medication list for offending agents Prevent progression Dialysis treatment depends on stage
Treatment, Chronic renal failure
Treat the underlying process Supportive treatment while underlying process resolves *FFP *Cryoprecipitate *Platelets Therapeutic heparin in some scenarios
Treatment, Disseminated intravascular coagulation (DIC), Disorders of Platelet Function, Uremia-induced coagulopathy and disseminated intravascular coagulation
Correct underlying problem Folate supplements
Treatment, Folic acid deficiency anemia
Type I - Can consider to discontinue and observe Type II - Always stop heparin therapy and use alternative anticoagulation (thrombin inhibitors)
Treatment, Heparin-induced thrombocytopenia (HIT)
Correct underlying problem Replace iron
Treatment, Iron deficiency anemia
Supplement vitamin B12
Treatment, Pernicious anemia
First-line *Steroids: Prednisone 0.5-2 mg/kg/day PO tapered over 4 weeks or dexamethasone 40 mg PO daily x 4 days *IVIg: 1g/kg/day IV for 2-3 days (consider if a rapid incease in platelets is needed) *Anti-Rh(D) Ig: 75 mcg/kg/day IV Platelet transfusion if actively bleeding with IVIg or anti-Rh(D) Ig
Treatment, Primary immune thrombocytopenia purpura (ITP)
Centers around prevention of crisis Acute crisis treatment is supportive. *oxygen *IV antibiotics or infection *Aggressive pain management *Hydrea for extreme cases *Supplemental folate
Treatment, Sicle Cell Anemia
Genetic counseling Transfuse PRN
Treatment, Thalassemias
Desmopressin (dDAVP) Cryoprecipitate Consider holding antiplatelet agents
Treatment, Uremia-induced coagulopathy (uremic bleeding), Disorders of Platelet Function, Uremia-induced coagulopathy and disseminated intravascular coagulation
First change in CBC its self for anemia would be
a decrease in hgb
$$$$Referral to a hematologist is indicated for
all suspected cases of leukemia$$$$
Anemia is a symptom of
an underlying disease
(Microcytic Anemia) Once iron stores are depleted and no iron is available for erythropoiesis a microcytic, hypochromic
anemia is present Iron studies show LOW ferritin level & HIGH TIBC.
Take iron and calcium
apart
•All the hemolytic anemias are
assoc w/ an increased rate of RBC destruction.
•A-thalassemia common in people
from Southeast Asia, India, China, or Philippines.
Sickle Cell Anemia, Acute pulmonary disease
has become the most common cause of death and 2nd most common cause for hospitalization
•Pts w/ chronic hemolytic anemias
have persistent reticulocytosis, Assays for G6PD are useful and detect most deficient pts.
Sickle Cell Anemia, •The bony skeleton is a common target of the consequences of
sickling: Bone marrow necrosis, bone infarcts, avascular necrosis (AVN), and osteomyelitis are common complications. •The heads of the femur and humerus are common sites for marrow infarction and necrosis but can also occur in the spine, ribs, and sternum. •AVN commonly affects the hip and shoulder joints and is a more chronic condition than an acute bone infarct.
Physician consultation is recommended for hemoglobin
values of less than 10 g/dL Pharmacotherapy
Microcytic Anemia: Thalassemia, •Management:
•B-thalassemia minor- no medical management needed. •B-thalassemia intermedia- treat in office with attention to changes in anemia, refer to hematologist if clinical problems present. •B-thalassemia major - regular transfusion to maintain adequate Hgb to allow normal growth and development AND iron chelation therapy to prevent complications of transfusion-dependent iron overload. •Transfusion of RBC every 3-6 wks. •Deferoxamine sub-q through slow infusion 5-7 days a week for life for chelation therapy. •Goal of chelation therapy is ferritin level <1000 ug/L. •Bone marrow transplant only cure for B-thalassemia
Diagnostics Acute Leukemia
•CBC •Bone marrow aspirate with biopsy •Peripheral blood smear •Immunophenotyping and cytogenetic analysis •Blood Smear (Blasts-Auer rods) •Metabolic and Electrolyte levels •Clinical exam: bruising, fatigue
Anemia Diagnostic Testing
•CBC (MCV is an important diagnostic value) •Platelet count •White cell differential •RBC morphology •Reticulocyte count •Peripheral blood smear •Hemoglobin electrophoresis •Serum ferritin, serum iron, total iron-binding capacity (TIBC), and transferrin saturation percentage
Macrocytic Anemia: Megaloblastic Anemia, •Diagnostics:
•CBC that suggests macrocytic anemia- low Hgb & MCV >100 fL. •Severe anemia may also show leukopenia or thrombocytopenia. •Retic count will be low.
Diagnostics: Aplastic Anemia
•CBC will show pancytopenia with normocytic and normochromic RBC indexes and morphology. •The retic count is also below normal, reflecting the lack of bone marrow activity. Gold Standard - A bone marrow biopsy is essential for diagnosis and reveals severe hypoplasia.
Diagnostics Chronic Leukemia
•CBC with Differentials •Bone marrow aspirate with biopsy •Peripheral blood smear •Serum uric acid •Urinalysis - uric acid •Leukocyte alkaline phosphatase screen •Philadelphia chromosome (Ph1) test •Clinical exam: Nontender adenopathy or splenomegaly. Patients may report fatigue, night sweats, occasional fever, or malaise
Blood Coagulation Disorders, •Management
•Case-dependent •Von Willebrandt's Disease •Hemophilia •Thrombophilia •Venous Thromboembolism
•Chronic leukemia
•Chronic Myelogenous leukemia (CML) •Chronic lymphocytic leukemia (CLL)
Lymphomas
•Clonal disorders that arise from lymphocytes (B or T cells, rarely NK cells)
Blood Coagulation Disorders
•Coagulant or anticoagulant triggers contribute to coagulopathy or thrombosis
P.E. & Diagnostics, Lymphomas
•Complete Hx and P.E. •Functional status screen •CBC •Electrolytes •Liver, renal •Lactate dehydrogenase •Infectious disease panel •Peripheral smear •Bone marrow biopsy and aspirate •PET, CT scan with IV contrast
Microcytic Anemia: Thalassemia, •Complications:
•Complications associated with regular transfusion regimen and chelation therapy. •Iron overload primary complication of chronic transfusions. •Excess iron leads to cirrhosis, HF, & endo problems (DM, hypothyroidism, growth failures, and delayed sexual development).
Sickle Cell Anemia, •Pathophysiology:
•Deoxygenated hemoglobin S tends to undergo irreversible polymerization, deforming the erythrocytes and giving them the sickle shape •Sickled cells are rigid and can be trapped and cause obstruction, ischemia, & infarction •Common pain crises occur in joints, extremities, back chest, abdomen, & lungs
Macrocytic Anemia: Megaloblastic Anemia• Management:
•Depends on severity. •Life threatening anemia need treatment with packed RBC. •Treatment with both B12 and folate can be started until definitive diagnosis is made. •Vit B12 deficiency- PO Vit B12 supplements, if related to IF then IM injections every week for 8 weeks then monthly for life. •Folic acid deficiency anemia- 1mg folic acid PO daily and correction of the underlying cause of the deficiency.
Macrocytic Anemia: Megoblastic Anemia, Pathophysiology
•Dietary sources of B12 are meat and meat byproducts •B12 is bound to IF in the stomach •Those with normal diet and normal absorption have no problem getting daily requirement •Dietary sources of folic acid are green leafy vegetables •Body stores limited to 3 months •Many foods now supplemented with folic acid
•Folic acid deficiency is rarely associated with S/S even in severe state.
•Folic acid deficiency is rarely associated with S/S even in severe state.
Microcytic Anemia: Thalassemia
•Group of inherited blood disorders caused by variant or missing genes that affect how the body makes hemoglobin.
•Complications: Iron Deficiency Anemia (IDA)= most common type of anemia (Microcytic Anemia)
•IDA associated with preterm delivery, low birth weight, and learning deficits.
Iron Deficiency Anemia (IDA)= most common type of anemia (Microcytic Anemia) DX
•IDA commonly discovered during routine CBC •Iron studies reveal LOW serum iron levels, decr serum ferritin, incr TIBC, & decr % of transferrin saturation. •First change in CBC is drop in hemoglobin.
Complications: Aplastic Anemia
•If untreated, can result in sepsis and death from pancytopenia. •Complications of BMT include graft failure, graft-versus-host disease, and a risk of secondary malignant neoplasms.
•Triggers Lymphomas
•Infectious agents (e.g., EBV) •Chemicals (e.g., dioxin) •Medical Tx - Chemotherapy, Radiation •Genetic Diseases •(e.g., Klinefelter's Syndrome) •Autoimmune Diseases •(e.g., Rheumatoid Arthritis)
•Patient Education/Health Promotion: Sickle Cell Anemia
•Initially pts and parents are taught how to manage pain crises, to recognize signs of infection, and to administer daily medications. •Pain mang. education is important. Also preventive care (ophthalmologic, gynecologic, dental, immunizations, sickle cell clinic visits, and folic acid supplementation.
Sickle Cell Anemia things you might find
•Jaundice, a physiologic systolic flow murmur (grade I or II pan-systolic murmur heard best along L sternal border), and sclera icterus may be present. •Cardiomegaly is also routinely noted.