MED COMP PTS > hematologic dx > Flashcards

hematologic dx Flashcards

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1
Q

anemia

A

Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood

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2
Q

anemia classifeid by:

A

cause and morphology

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3
Q

anemia causes

A
  • Blood Loss
  • Inadequate production
  • Excess destruction
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4
Q

anemia morph

A
  • Normocytic
  • Microcytic
  • Macrocytic
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5
Q

anemia lab test

shorthand?

A

** CBC (Complete Blood Count): **
* Hb
* Hematocrit*
* WBC
* Platelet
* RBC indices*

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6
Q

anemic Hb values

A

<13.5 g/dL (men) or <12.0 g/dL (women)

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7
Q

anemic hematocrit values

A

<41.0% (men) or <36.0% (women)

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8
Q

RBC indices*

A
  • MCV (mean corpuscular volume)= size
  • MCH (mean cell hemoglobin)= color
  • RDW (red cell distribution width)= sixe distribution
  • MCHC (mean cell hemoglobin concentratio
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9
Q
  • Microcytic anemias
A

– Iron Deficiency Anemia
– Thalassemias

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10
Q

macrocytic anemias

A

– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency

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11
Q

normocytic anemias

A

– Hemolytic Anemia
– Sickle Cell Anemia

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12
Q

Iron Deficiency Anemia
* cells app?
* More common in?
* Causes:
* Labs:

A
  • Microcytic anemia
  • More common in women of childbearing age and children
  • Causes: blood loss, poor iron intake, poor iron absorption, or increased demand for iron
  • Labs: Serum iron, ferritin, TIBC, transferrin
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13
Q
  • Folate Deficiency, cell size?
    – stored in the body?
    – Deficiency during pregnancy?
    – Labs:
A

Macrocytic
– Not stored in the body in large amounts; continual
dietary supply is needed
– Deficiency during pregnancy causes neural tube
defects in the child
– Labs: Serum folate level

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14
Q

Cobalamin (B12) Deficiency
* Deficiency of?
* dental office agent of etiology? effects?
– Labs:

A

– AKA Pernicious Anemia, macrocytic
* Deficiency of intrinsic factor which is necessary for B12 absorption

– Nitrous Oxide:
* Irreversible inactivation of B12
* Neurologic symptoms
– Labs: Serum B12

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15
Q

systemic presentation of anemia

signs and symptoms

A

– Symptoms: Fatigue, weakness, palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and spooning of fingernails

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16
Q

oral manifestations of anemia

A

– Atrophic glossitis with loss on tongue papillae, redness or cheilosis
– Mucosal pallor

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17
Q

anemia pts and dental tx

A

–Generally tolerate routine dental treatment well unless severe

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18
Q

severe anemia pts

A
  • Severe anemia (cardiopulmonary symptoms)
    –Defer routine dental care
    –Pulse oximeter and supplemental oxygen
    –Avoid strong narcotics
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19
Q

what should be avoidied in pts with b12 def

A

NO

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20
Q

What is important to determine in anemic pts?

A
  • Important to find the cause!
    –GI bleed, chronic inflammation pancytopenia
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21
Q

Sickle Cell Anemia
* inheritance?
* RBC sickling in what environments?
* results on hemodynamics?

A
  • Autosomal recessive inherited disorder
  • RBC sickling in low oxygen or low blood pH environments
  • Erythrostasis, increased blood viscosity, reduced blood flow, vascular occlusion, hypoxia= more sickling
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22
Q

Sickle Cell Anemia
* Systemic Signs and Symptoms:
– Result of?
– skin app?
– ulceration where?
– Cardiac?
– Delays in?
– Pain where/ why?
– crisis?

A

– Result of chronic anemia and small blood vessel occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac: Cardiac failure and Stroke
– Delays in growth and Development
– Pain: Abdominal (splenomegly) and Bone (aseptic necrosis)
– Sickle cell crisis

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23
Q

sickle cell crisis

A
  • Prolonged (hours-days) severe pain which pay require
    hospitalization for pain management
  • Causes: infection, higher altitude (hypoxia), dehydration, trauma
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24
Q

Sickle Cell Anemia
* Oral Manifestations
–Mucosal?
–Papilla?
–Delayed?
–Aseptic bone and pulpal?
– bone?
–Neuro?

A

–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal necrosis
–Osteomyelitis
–Neuropathy

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25
radiogrpahic findings with sickle cell
* Increased widening and decreased number of trabeculations * Generalized osteoporosis (thinning of the inferior border of the mandible) * Trabeculations and lamina dura appear more prominent * “Stepladder” trabeculae * “Hair on end
26
sickle cell pt dental care – non-crisis states – appt length? – Emphasis on? infections?
– Routine care during non-crisis states – Keep appointments short to reduce stress – Emphasis on oral hygiene instructions to reduce risk of infection> If infection occurs, consider IM or IV antibiotics
27
sickle cell anesthetic * Avoid what LA * Epinephrine concentration? * May consider using LA without?
* Avoid prilocaine * Epinephrine 1:100,000-no stronger concentration * May consider using LA without epinephrine
28
sickle cell O2 in appt
– Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than 50% with high flow rates
29
with major surgical operations what should be done with sickle cell pts
Abx prophylaxis
30
pain control with sickle cell
Pain management: consult their primary care or hematologist (opioid contract)
31
Aplastic Anemia * Causes * Treatment
* Bone marrow failure resulting in pancytopenia * Causes: – Chemotherapy and radiation – Autoimmune diseases – Toxic chemicals (benzene) – Viral – Medications (methotrexate) – Inherited (Fanconi anemia) * Treatment– Hematopoietic cell transplant
32
Aplastic Anemia oral manifestationa due to anemia
* Atrophic glossitis with loss on tongue papillae, redness or cheilosis * Mucosal pallor
33
aplastic anemia oral manifestations due to thrombocytopenia
* Petechia, spontaneous or prolonged bleeding
34
aplastic anemia oral manifestations due to neutropenia
* Infection – Viral, fungal, bacterial * Ulceration
35
Aplastic Anemia & Bone Marrow Failure dental management: * Thorough? * Discussion with? * Defer? *setting?
* Thorough medical history * Discussion with oncologist: Current status and goals * Defer routine care * Dental office vs hospital *
36
Aplastic Anemia & Bone Marrow Failure labs
*** CBC** * Platelet: may require platelet transfusion due to thrombocytopenia * ANC-may require antibiotic prophylaxis for neutropenia (<500)
37
Aplastic Anemia & Bone Marrow Failure * Confirm patient is? * Local hemostatic measures when pt is?
* Confirm patient is afebrile * Local hemostatic measures for patients with thrombocytopenia
38
* Thrombocytopenia –Causes –result
–Low platelet levels (CBC) * Normal: 150,000-400,000 * Severe: <50,000 –Causes: decreased production, destruction, medications, blood loss –Prolonged bleeding, petechia
39
* Thrombocytopenia –Oral Manifestations
* Petechia * Spontaneous gingival bleeding * Prolonged bleeding after procedures
40
Thrombocytopenia – Dental Management: * Thorough? * routine dental care? * CBC? * Discussion with? * Avoid? * Local measures?
* Thorough medical history * May defer routine dental care * CBC * Discussion with patient’s MD * Avoid block injections * Local hemostatic measures
41
thrombocytopenia med hx
– Cause of thrombocytopenia (acute cause? chronic cause?) – Bleeding history, transfusion history
42
CBC results with thrombocytopenia
– Recent (<24 hours) – Platelet >50,000 for most dental procedures reduces risk – Higher for invasive surgical procedures (ex. multiple extractions)
43
thrombocytopenia MD discussion
– Platelet transfusions, timing – Dental office vs hospital (<50,000 more appropriate in hospital setting)
44
* Von Willebrand Disease commonality?
– Missing or defective VWF (clotting protein) * Required for platelet adhesion – Most common inherited clotting disorder (1% US population)
45
VWD types
– Type 1 (20-50% normal levels), Type 2 (qualitative), Type 3 (quantitative, severe symptoms)
46
VWD signs and symptoms
– SS: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis
47
VWD tx
Tx: DDAVP (desmopressin)
48
* Von Willebrand Disease –Dental Management
* Thorough medical history/bleeding history and physical exam * Discussion with patient’s MD * Avoid block injections * Local hemostatic measures
49
Von Willebrand Disease Discussion with patient’s MD
– Confirm history and severity of disease – DDAVP, aminocaproic acid – Dental office vs hospital
50
* Hemophilia types/inheritence/severity?
–Hemophilia A (Factor 8 deficiency) and B (Factor 9 deficiency) * X-linked recessive –Severity * Mild 6%-30% (A) or 49% (B), moderate 1%-5%, severe <1%
51
SS of hemophilia
prolonged or spontaneous bleeding, ecchymosis, hemarthrosis
52
hemoplhilia tx
factor infusions, DDAVP (A)
53
* Hemophilia –Dental Management
* Thorough medical history/bleeding history and physical exam * Discussion with patient’s hematologist * Avoid block injections * Local hemostatic measures
54
* Hemophilia discussion with MD
– Confirm history and severity of disease – Dental office vs hospital – Factor infusions, aminocaproic acid
55
Plavix (clopidogrel) –agent for? –Reduce risk of? –Increased risk of?
–Antiplatelet agent –Reduce risk of MI and stroke –Increased risk of bleeding and bruising
56
* Plavix (clopidogrel)–Dental Management
* Medication list to evaluate bleeding risk – Other anticoagulants * Local measures– Low risk of bleeding far outweighs interrupting Plavix treatment
57
* Coumadin (warfarin) – mech? – For patients with? – Common side effect:
– Vitamin K antagonist – For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history... – Common side effect: bleeding
58
warfarin monitoring * PT/INR goals: * Higher in patients with?
* PT/INR goals: 2.0-3.0 * Higher in patients with prosthetic heart valves (3.0-3.5)
59
antidote for warfarin
K
60
* Coumadin (warfarin) –Dental Management
* Dental procedures are generally considered low risk of bleeding * Review INR (within 24 hours) (<3) * Local hemostatic measures * Medications interactions
61
dental tx bleeding with warfarin
* Dental procedures are generally considered low risk of bleeding – Thromboembolic risk vs procedural bleeding risk – Discussion with patients MD for procedures with higher risk of bleeding
62
warfarin med intreactions
– Many medication interactions due to narrow therapeutic range – Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
63
* Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors –Direct inhibitor of? –Class of? * Alternative to? – effective? lab monitoring? –Reversal? –cost?
–Direct inhibitor of factor Xa and thrombin –Class of newer anticoagulants * Alternative to warfarin –Highly effective –No lab monitoring –Reversal agent –More expensive
64
* DOAC and Direct Thrombin Inhibitors –Dental Management
* No lab monitoring * Bleeding risk for dental procedures seems to be low * Local hemostatic measures
65
good local measures for bleeding pts
gauze, gelfoam, cellulose, thrombin, tranexamic acid, amicar
66
Hematologic Malignancies
* Leukemia * Lymphoma * Myeloma
67
Leukemia * Cancer of? * Affects? * Proliferation of WBCs which can be? Or?
* Cancer of WBCs * Affects bone marrow and circulating blood * Proliferation of WBCs which can be non-functional (blasts) or overtime overcrowd/suppress normal marrow production
68
leukemia classes
* Lineage: Myeloid vs Lymphoid * Timing: Acute vs Chronic
69
common leukemias
* Acute Myeloid (AML) * Chronic Myeloid (CML) * Acute Lymphocytic (ALL) * Chronic Lymphocytic (CLL) **acute forms more likely to be symptomatic**
70
Leukemia causes
* Radiation * Chemotherapy * Genetic * Down syndrome
71
leukiemia diagnosis
* CBC * Blood smear * Molecular studies
72
leukemia tx
* Chemotherapy * Radiation * Targeted therapy * Hematopoietic stem cell transplant
73
Leukemia Signs and Symptoms
* Fatigue, malaise, petechiae, ecchymoses, fever * Related to functional or treatment related neutropenia and thrombocytopenia
74
Leukemia oral manifestations
* Leukemia infiltrate * Spontaneous gingival bleeding * Oral ulceration (neutropenic ulcer, mucositis) * Infection: Viral, fungal, bacterial * Lymphadenopathy (chronic)
75
leukemia dental management * dx unknown/suspected? * If Dx known:
* Urgent referral to PCP or emergency room for leukemic infiltrate-CBC, smear, flow cytometry * If Dx known: * Thorough medical history * Discussion with oncologist 1. * Current status and goals (comprehensive vs. palliative) 1. * Dental office vs hospital 1. * Timing of dental care-not on active chemotherapy for routine care
76
important labs of leukemia
*** CBC** * Platelet: may require platelet transfusion due to thrombocytopenia * ANC-may require antibiotic prophylaxis for neutropenia (<500)
77
leukemia * Confirm patient is? * Local hemostatic measures?
* Confirm patient is afebrile * Local hemostatic measures for patients with thrombocytopenia
78
Lymphoma
* Cancer of lymphoid organs and tissues
79
forms of lymphoma
HL and NHL
80
* Hodgkin Lymphoma *cell? * demo? * LAD? * LN feel? * >50% affect where?
* Hodgkin Lymphoma * Reed-Sternberg cell * Young adults * LAD * Non-tender, firm * >50% affect mediastinal or neck nodes
81
* Non Hodgkin Lymphoma (NHL) * Median Age: * B-symptoms? * Over how many types?
* Median Age: 67 * B-symptoms: Fever, night sweats (drenching), weight loss (unintentional >10%) * Over 20 types
82
Lymphoma causes
* Autoimmune diseases * Hepatitis C * EBV * Sjogren syndrome
83
lymphoma diagnosis/staging
* Bone marrow or lymph node biopsy * MRI for staging
84
lymphoma tx
* Chemotherapy * Radiation * Immunotherapy * Stem cell transplant * Watching
85
Lymphoma oral manifestations * LAD? * Extranodal involvement? * radiographic lesions? * Infection?
* LAD (Waldeyers ring, neck) * Extranodal involvement: 1. Oral Ulceration 1. Localized infiltrate 1. Osteolytic radiographic lesions * Infection: Viral, fungal, bacterial
86
lymphoma tc related oral manifestations
* Head and Neck Radiation (lymphomas in head and neck region only): 1. * Hyposalivation 1. * Trismus 1. * Osteonecrosis
87
Lymphoma dental management
– Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and generally treatment related (chemotherapy, radiation) – Thorough medical history – Discussion with oncologist
88
lymphoma discussion with oncologist: * Current? * setting? * Timing of dental care?
* Current status and goals (comprehensive vs. palliative) * Dental office vs hospital * Timing of dental care: not on active chemotherapy for routine care
89
lymphoma labs of interest
*** CBC** – Platelet: may require platelet transfusion due to thrombocytopenia – ANC-may require antibiotic prophylaxis for neutropenia (<500)
90
lymphoma – Confirm patient is? – Local hemostatic measures?
– Confirm patient is afebrile – Local hemostatic measures for patients with thrombocytopenia
91
Multiple Myeloma
* Cancer of plasma cells – Prevents normal production of antibodies
92
MM s/s
– Hypercalcemia – Renal damage – Anemia – Bone pain – Infection
93
MM tx
– Chemotherapy (RVD) – Bisphosphonates – Hematopoietic Stem Cell Transplant
94
Multiple Myeloma * Oral Manifestations
– Plasmacytoma – Lytic bone lesions – Infection: Viral, fungal, bacterial
95
tx related MM oral manifestations nn? bone? radiographic findings?
* Neuropathy * MRONJ (IV Zometa) * Radiographic: 1. – Thick lamina dura 1. – Persistent extraction site 1. – Sclerosis 1. – Sequestra 1. – Fracture
96
Multiple Myeloma * Dental Management, dx related
* Soft tissue swelling, radiographic findings * Infection management * Pre-bisphosphonate exam
97
MM Medication related management what should be provided?
* MRONJ – Bisphosphonate history (number of doses, active) – Chlorhexidine rinses – Oral Hygiene – Antibiotic regimen – Sequestration
98
MM surgical procedures
– Informed consent – As atraumatic as possible – Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis – Re-eval after surgical procedures to ensure healing
99
Hematopoetic Stem Cell Transplant
* Infusion of stem cells to re-establish hematopoietic function in patients whose bone marrow or immune system is damaged or defective * Treatment for solid or hematologic malignancies or other hematologic disorders
100
Indications for Stem Cell Transplant
* Leukemia * Lymphoma * Multiple Myeloma * Aplastic anemia * Fanconi anemia * Sickle Cell
101
Pre-Transplant Evaluation (hematopoetic)
102
Pre-Transplant Evaluation: Dental Screening Goals
* Remove active foci of infection and limit potential foci of infection * Dentition to be** stable for at least 12 months ** – **Urgent care only for 12 months post** transplant – **Risk of salivary GVHD** and **hyposalivation**=caries * Patient education about home care * If planned correctly, pre-transplant evaluation + patient compliance=dental maintenance
103
Dental Screening Pre-HSCT
* Comprehensive hard and soft tissue exam * Full mouth series of radiographs * Treatment – Scaling and prophylaxis – Removal of caries * Restorations * Endodontic therapy * Extractions – Extraction of all hopeless teeth & 3rd molars with hx periocoronitis * Including teeth with questionable or poor prognosis – Caries risk assessment and need for adjuncts (fluoride) – Dental management based on primary disease
104
Oral Manifestations HSCT (hemo stem cell transplant) * Mucus mem? * Bleeding? * Infection? * Medication side effects? * Graft versus host disease? * Increased risk of?
* Mucositis – Acute; resolves after engraftment * Bleeding– Petechiae, ecchymosis, hematoma * Infection– Viral (ex. HSV), Fungal (ex. candidiasis), Bacterial * Medication side effect/toxicities – Gingival hyperplasia (cyclosporine) – Oral ulceration (sirolimus) * Graft versus host disease– Mucosal (lichenoid changes), Salivary-hyposalivation, caries * Increased risk of oral cancer
105
Hematopoietic Cell Transplant * Dental Management After Transplant med hx, clinical exam, consult, CBC, medications
– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD – Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer – Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital – Labs * CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia – Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**
106
Hematopoietic Cell Transplant * Dental Management After Transplant med hx, clinical exam, consult, CBC, medications
– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD – Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer – Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital – Labs * CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia – Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**
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