Clinical Medicine
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| IDA (causes) | -chronic blood loss --> GI tract most common
-Chronic NSAID/ASA use
-Pregnancy
-menstrual blood loss
-low iron intake (women, children)
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| IDA (ssx) | -pallor, fatigue, DOE, tachycardia
-*pica*
-esophageal webs (plummer-vinson syndrome)
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| IDA (dx) | -hypochromic, microcytic anemia
-elevated TIBC
-low Fe, ferritin, and transferritin
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| IDA (tx) | -tx underlying cause
-iron supplementation with ferrous sulfate x 6-12 months
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| Lead Poisoning (ssx) | -difficulty concentrating, fatigue, muscle weakness, paralytic ileus
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| Lead Poisoning (dx) | -mild microcytic anemia
-basophilic stippling of RBC
-elevated lead lvl
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| Lead Poisoning (tx) | -remove lead source
-chelating agents if symptomatic or severe toxicity
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| Thalassemia | -inherited disorder of alpha or beta globulin synthesis
-typically family hx
-genetic counseling in sever forms
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| Thalassemia (dx) | -microcytic anemai that does not respond to iron therapy
-normal iron and ferritin levels
-confirm w/ hbg electrophoresis
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| alpha thal (dx) | -peripheral smear: target cells
-Hgb H on electrophoresis
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| alpha thal (tx) | -Avoid iron
-avoid oxidative drugs
-folic acid supplements
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| beta thal major | -Cooley anemia
-onset 4-6 months of age, seveer anemia, growth retardation, osteopenia, deformities, hepatosplenomegaly
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| beta thal minor | -moderate anemia
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| beta thal (dx) | -peripheral smear: basophilic stippling, target cells
-microcytic
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| beta thal major (tx) | -transfusion with deferoxamine to prevent hemosiderosis
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| beta thal minor (tx) | -avoid iron
-monitor
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| B12 deficiency | -vegans, pancreatic insufficiency, gastric bypass surgery, crohn's
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| B12 deficiency (exam) | -glossitis, pale icterus
-neuro: stocking-glove paresthesias, loss of tast and vibratory sensation, ataxia
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| B12 deficiency (Dx) | -macrocytic anemia, poikilocytosis, anisocytosis
-low retic count and serum B12
-high LDH and bilirubin
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| B12 deficiency (tx) | -high dose oral B12, nasal spray or IM
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| B12 deficiency (neuro ssx) | -will resolve if tx is initiated within 6 months of onset
-if not corrected damage is irreversible
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| pernicious anemia | -autoimmune destruction of gastric parietal cells causing lack of intrinsic factor
-most common cause of B12 deficiency
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| pernicious anemia (dx) | -macrocytic anemia
-low serum B12
-shilling test positive
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| pernicious anemai (tx) | -lifelong IM B12 supplement
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| folic acid deficiency | -poor intake, EtOH abuse, pregnancy, bactrim, suflasalazine
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| folic acid deficiency (dx) | -macrocytic
-hypersegmented PMNCs
-folate level <150 ng/mL
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| folic acid deficiency (tx) | -folic acid 1 mg/day by mouth
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| hemolytic anemias (cuases) | -TTP, ITP, DIC
-medication/transfusion reactions
-sickle cell
-G6PD deficiency
-ifxns (malaria, parvo b19)
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| hemolytic anemias (exam) | -splenomegaly
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| hemolytic anemias (dx) | -elevated retic; falling hct
-elevated indirect bilirubin
-elevated LDH
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| sickle cell anemia | -autosomal recessive hemolytic anemia; african americans
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| sickle cell anemia (aggravators) | -sickling of RBCs increased by hypoxemia, high altitudes
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| sickle cell anemia (prognosis) | -life expectancy = 40-50 yrs
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| sickle cell anemia (ssx) | -painful crises, cholelithiasis, poor wound healing, priaprism, splenomegaly, AVN of femoral head
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| sickle cell anemia (dx) | -Hgb electrophoresis shows Hgb S in RBCs
-sickled cells, target cells, howell-jolly bodies
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| sickle cell anemia (tx: symptomatic) | -analgesics, fluids, O2
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| sickle cell anemia (tx: crises) | -possible transfusion
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| sickle cell anemia (tx: asx) | -pneumococcal vaccine/folate supplements
-genetic counseling
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| G6PD deficiency | -X linked recessive; mediterranean populations and african american males
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| G6PD deficiency (path) | -leads to episodic hemolysis or chonic hemolysis if severe
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| G6PD deficiency (risks) | -oxidative drugs; infxn
-fava beans
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| G6PD deficiency (dx) | -bite cells, heinz bodies
-G6PD low after hemolytic episode
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| G6PD deficiency (tx) | -most cases are self-limited
-avoid oxidative meds (ASA, dapsone, sulfonamides, nitrofurantoin)
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| ACD (anemia of chronic dz) | -associated w/ kidney, liver, endocrine dz, or malignancy
-renal dz leads to decreased EPO
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| ACD (dx) | -mild normochromic, normocytic anemia
-normal cell morphology
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| ACD (tx) | -treat underlying dz and anemia will resolve
-give EPO
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| aplastic anemia (ssx) | -weakness, bleeding, bacterial and fungal infections, purpura, petichiae, hepatosplenomagaly
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| aplastic anemia (causes) | -most common: T cell mediated autoimmune suppression
-radiation, chemotherapy, medications, SLE
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| aplastic anemia (dx) | -pancytopenia w/ normocytic anemia
-hypocellular marrow
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| aplastic anemia (tx: mild) | -supportive; EPO/transfusions
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| aplastic anemai (tx: severe) | -bone marrow transplant
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| polycythemia vera (primary) | -JAK 2 mutation
-splenomegaly, normal O2 sat, increased red cell mass
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| polycythemia vera (secondary) | -chronic hypoxia, smoking, renal tumors
-splenomegaly absent
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| polycythemia vera (who?) | -males>females
-age>60
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| polycythemia vera (complications) | -bleeding (PUD/epistaxis), thrombosis, progression to leukemia
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| polycythemia vera (ssx) | -tinnitus, HA, dizziness, blurred vision, plethora
-pruritis after bathing
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| polycythemia vera (dx) | -elevated Hct
-leukocytosis, increased large/bizarre platelets
-hypercellular bone marrow
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| polycythemia vera (tx) | -phlebotomy
-hydroxyurea
-low dose ASA
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| thrombocytopenia | -decrease in the number of platelets
-most common cause of abnormal bleeding
-associated w/ SLE and CLL
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| thrombocytopenia (ssx) | -gingival bleeding, epistaxis, menorrhagia, petichiae
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| thrombocytopenia (causal drugs) | -heparin, sulfonamides, thiazides, cimetidine
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| ITP | -autoimmune, IgG mediated
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| acute ITP (ssx) | -petechia, purpura, hemorrhagic bullae on skin
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| acute ITP (tx) | -most are self-limiting
-steroids
-splenectomy if severe
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| acute ITP (who?) | -children, following a viral infection
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| chronic ITP (who?) | -women>men; ages 20-50 yrs
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| chronic ITP (ssx) | -petechiae on skin and mucous membranes
-associated w/ autoimmine conditions (SLE)
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| chronic ITP (tx) | -high dose steroids; IVIG; SCT
-splenectomy
-avoid ASA
-platelet transfusion for severe bleeding
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| TTP (who?) | -women>men; age 20-50; previously healthy
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| TTP | -associated w/ HIV, pregnancy, estrogen, quinine, ticlopidine
-rare but can be fatal
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| TTP (ssx) | -severe thrombocytopenia, anemia (schistocytes), elevated LDH, thrombosis
-pallor, petechiae, purpura, pancreatitis, fever
-neurologic signs that come and go
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| TTP (tx) | -emergent plasmapheresis (NO PLATELETS)
-prednisone
-antiplatelet agents
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| DIC | -SAS
-occurs pts w/ sever systemic illnesses; sepsis, cancer, transfution reactions, trauma
-high mortality (30-80%)
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| DIC (ssx) | -shock, hemorrhage from skin and mucous membranes, digital ischemia, gangrene
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| DIC (labs) | -coagulopathy: elevated D-dimer, prolonged PT
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| DIC (tx) | -urgently treat underlying cause
-component blood transfusions
-cyroprecipitate
-+/- heparin
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| vW dz | -most common congenital coagulopathy
-deficiency of facter VIII antigen and defective vWF
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| vW dz (gentics) | -autosomal dominant bleeding disorder
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| vW dz (ssx) | -bleeding of nasal passages, vagina, GI tract
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| vW dz (labs) | -prolonged bleeding time
-decreased vWF
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| vW dz (tx) | -desmopressin acetate
-factor VIII concentrates
-avoid ASA and exogenous estrogen
-pregnancy may exacerbate symptoms
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| hemophilia A | -most common hemophilia; factor VIII deficiancy
-most severe bleeding disorder: 2nd most common congenital coagulopathy
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| hemophilia (genetics) | -x-linked recessive
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| hemophilia A (ssx) | -range from severe hemarthrosis, intracranial bleeding to milder prolonged post op bleeding
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| hemophilia A (labs) | -prolonged PTT
-low factor VIII:C levels
-normal vWF
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| hemophilia A (tx) | -heat treated factor VIII concentrates
-mild dz can be treated w/ desopressin
-avoid ASA
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| hemophilia B | -factor IX deficiency or Christmas dz
-x-linked recessive; males
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| hemophilia B (tx) | -factor IX concentrates
-FFP (fresh frozen plasma)
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| Vit K deficiency | -most common acquired coagulopathy
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| Vit K deficiency (causes) | -chronic liver dz (most common), dietary, meds
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| Vit K deficiency (ssx) | -post surgical pts; soft tissue bleeding
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| Vit K deficiency (labs) | -PT/PTT are prolonged
-elevated LFTs
-decreased Factors VII, IX, X, II (SNOT)
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| Vit K deficiency (tx) | -oral or IV vit K
-treat acute bleeds with FFP
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| thrombotic disorders | -pts: >40, family history, recurrent thrombosis
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| aquired thrombotic disorders | -malignancy, estrogen use, immobilization, nephrotic syndrome, ulcerativ colitis, crohn's, heparin
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| congenital thrombotic disorders | -antithrombin III deficiency, factor V leiden, protein C&S deficiencies, lupus anticoagulant
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| thrombotic disorders (tx) | -anticoagulation w/ LMWH or coumadin
-predinsone for lupus anticoagulant
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| hodgkin's dz (who?) | -men>women; ages 15-45
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| hodgkin's dz | -enlargement of lymphoid tissue, liver/spleen
-associated w/ EBV
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| hodgkin's dz (ssx) | -painless LAD, fever, night sweats, pruritis, fatigue
-pain w/ EtOH
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| hodgkin's dz (dx) | -ann arbor creteria -staging
-staging tests: CT neck, chest, abdomen, pelvis, BM bx
-*reed-sternberg cells*
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| hodgkin's dz (tx) | -combinations chemotherapy or radiation depending of stage at diagnosis
-majority of pts are cured
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| non-hodgkin's lymphoma | -malignancy of lymphocytes (MC B lymphocytes)
-age 20-40; more common with HIV/immune compromise
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| non-hodgkin's lymphoma (ssx) | -painless persistent LAD
-abdominal fullness in Burkitt's lymphoma
-spread to bone, bone marrow, GI, skin
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| non-hodgkin's lymphoma (labs) | -biopsy enlarged nodes
-stage w/ CXR, CT abdomen and pelvis
-BM bx
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| non-hodgkin's lymphoma (tx) | -radiation for single node
-rituximab +/- chemotherapy
-high grade: sct
-spontaneous remission may occur
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| multiple myeloma | -malignancy of the plasma cells
-more common in AA
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| multiple myeloma (ssx) | -osteolytic lesions, LAD, recurrent infections
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| multiple myeloma (labs) | -hypercalcemia
-*rouleaux formation* of RBCs
-monoclonal spike on electrophoresis (M spike on SPEP)
-bence-jones proteins in urine
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| multiple myeloma (tx) | -dexamethason, doxorubicin, lenalidomide
-bisphosphonates for osteoporosis
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| acute leukemia (ssx) | -epistaxis, gingival bleeding, gram-negatic bacterial infxns
-anemai, DIC, elevated uric acid
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| acute leukemia (dx) | -pancytopenia w/ circulating blasts
-elevated WBCs
-confirm w/ BM bx
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| acute leukemia (tx) | -induction chemotherapy followed by consolidation therapy
-allopurinol/diuretcs to prevent uric acid stones
-sct
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| ALL | -most common childhood leukemia
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| ALL (ssx) | -rapid onset of fever, fatigue, joint pain, bone pain (sternum, femor), frank bleeding
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| ALL (cxr) | -mediastinal mass
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| ALL (labs) | -leukocytosis w/ lymphocytosis
-philadelphia chromosome (poor prognosis)
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| ALL (tx) | - >50% cure rate for children undergoing chemotheraphy
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| AML (who?) | -adults: median onset of age 60
-MC acute leukemia
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| AML (ssx) | -gradual onset of fatigue, decreased appetite, weight loss, and dyspnea
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| AML (dx) | -*auer rods*
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| AML (tx) | -high remission rate in pts < 60
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| CLL (who?) | -MC of all leukemias
-men>women
-median age of onset 65 years
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| CLL | -malignancy of B lymphocytes, median survival 6 years
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| CLL (ssx) | -recurrent infections, LAD, Richter's syndrome
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| CLL (staging) | -Rai system
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| CLL (dx) | -lymphocytosis
-peripheral smear: *smudge cells*
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| CLL (tx) | -palliative w/ advanced dz
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| CML | -myeloproliferative disorder seeen in middle aged adults
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| CML (ssx) | -gradual onset of weight loss, low grade fever, fatigue, sweating, splenomegaly, early satiety
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| CML (triphasic) | -progression from chronic to accelerated to acute phase (blast crisis/decreased survival
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| CML (dx) | -leukocytosis
-*philadelphia chromosome*
-bcr-abl gene identification
-hypercellular bone marrow
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| CML (tx) | -imantinib mesylate(Gleevec), dasatinib, nilotinib
-allogenic sct only curativ therapy (reserved for progressive disease)
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