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Microsoft PowerPoint - Heme101.ppt [Read-Only]
 

Microsoft PowerPoint - Heme101.ppt [Read-Only]

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    Microsoft PowerPoint - Heme101.ppt [Read-Only] Microsoft PowerPoint - Heme101.ppt [Read-Only] Document Transcript

    • Heme 101 Allan Platt PA-C Emory PA Program Atlanta GA aplatt@emory.edu Emory University Physician Assistant Program Emory University Physician Assistant Program Blood Blood Components Blood has red cells(erythrocyctes) White cells (leukocytes) Plasma 54% Platelets (thrombocytes) White cells and platelets 1% Red Cells 45% Emory University Physician Assistant Program Emory University Physician Assistant Program White Blood Cells White Blood Cells WBC - White Blood Cells 4.5 - 11.0 K/uL Fight infections Low = Leukopenia High = Leukocytosis WBC Differential Are increased in infections Neutrophils - Segs 54 -62% Move inside and outside of blood Neutrophils - Bands 3 -5 % vessels Lymphocytes - Lymphs 25 - 33% Are made in the bone marrow Monocytes - Monos 3 - 7% Eosinophils - Eos 1 - 3% Basophils - Basos 0 - 0.75% Atypical Lymphs 0 Emory University Physician Assistant Program Emory University Physician Assistant Program 1
    • Platelets Red Blood Cells Plug holes in the body to stop bleeding Carry oxygen from the lungs Can help cause blood to clot Carry carbon dioxide back to the lungs Made in the bone marrow Normally live 120 days Contains the protein hemoglobin Made from iron, folic acid, vitamin B12 Fibrin Made in the bone marrow Emory University Physician Assistant Program Emory University Physician Assistant Program Red Blood Cells Microscope View Red cells look like doughnuts that are very flexible Emory University Physician Assistant Program Emory University Physician Assistant Program Red Blood Cells - Shape Red Blood Cells Red Cell Flow Red cells travel through very narrow blood vessels Blood Vessel Emory University Physician Assistant Program Emory University Physician Assistant Program 2
    • Red Blood Cells - Hemoglobin Red Blood Cells - Hemoglobin Oxygen Hemoglobin, the main protein in red cells holds four oxygen molecules Emory University Physician Assistant Program Emory University Physician Assistant Program Red Blood Cells - Retics Red Blood Cells - Marrow Red cells, white Reticulocytes, or Retics are young red cells cells and platelets just released from the bone marrow. The Retic count is the best indicator about how are made in the the marrow factory is doing. bone marrow Emory University Physician Assistant Program Emory University Physician Assistant Program Red Blood Cells Red cells are Red Blood Cells - Recycled made in the Red cells are recycled in the spleen and liver. bone marrow The iron and protein are stored and bilirubin is released. Liver Food with iron Red cells live Spleen and vitamins is 120 days in digested the circulation Emory University Physician Assistant Program Emory University Physician Assistant Program 3
    • Red Blood Cells - The Kidney Erythropoietin is made by The History the kidney as a signal to the bone marrow to make more Weakness red cells Tiredness - Fatigue Dyspnea Dizzy – non vertigo Palpitations New angina Emory University Physician Assistant Program Emory University Physician Assistant Program The History -2 The History -3 - History of melena, abdominal pain, Aspirin or non-steroidal anti- - Family history of blood cell or bleeding disorder: consider Sickle inflammatory agents (NSAIDs) use, past peptic ulcer disease , then Cell disease, G6PD,Thalassemia, Hemophilia, von Willebrand consider GI bleeding, platelet dysfunction. - History of jaundice, transfusion, new medication, infection - - In females the menstrual history quantifying the amount of consider hemolytic process bloodloss ,or possible pregnancy should be obtained. - History of weight loss, Cancer, HIV, rheumatoid arthritis, thyroid - History of pica or abnormal craving for ice, clay, starch...; disease, renal disease -then consider secondary cause dysphagia then consider iron deficiency. - History of fever and chills, cough, dyspnea, then consider - Poor diet, then consider iron or folate deficiency, and general Infection. malnutrition - History of gastric surgery, distal paresthesias, gait problems - consider B12 deficiency - History of alcohol abuse - consider folate deficiency or liver disease. If moonshine use or lead paint/pipe exposure, consider lead toxicity. Emory University Physician Assistant Program Emory University Physician Assistant Program Physical Exam Sclera Emory University Physician Assistant Program Emory University Physician Assistant Program 4
    • Glossitis and Chelosis – Spoon Nails – Fe Def. Fe and B12 Emory University Physician Assistant Program Emory University Physician Assistant Program LAB- INITIAL SCREENING Physical Exam TESTS GENERAL INSPECTION- clubbing in TB or lung cancer Skin- Hypothyroid, SLE, Bruises, lesions, petechiae or purpura. Weight - Loss in Cancer, HIV, Chronic disease, gain in hypothyroid VITAL SIGNS- Pulse: Tachycardia from increased cardiac output Urinalysis- Hematuria/proteinuria in renal Respirations: Tachypnea from decreased oxygen transport disease ,hemoglobinuria in hemolysis. BP: Orthostatic if volume depleted CBC, red cell morphology and white Temp: Fever in infections and drug or transfusion reactions, blood cell differential, Reticulocyte count, HEENT- Eye: Jaundice if hemolysis, pallor in palpebral conjunctiva Mouth: Glossitis and angular stomatitis in iron or B12 deficiency Chemistry profile (LDH, Bilirubin- Direct NECK- Thyroid enlargement or nodules, lymph nodes and Indirect, BUN, Creatinine, GOT), HEART- Increased output/murmur- consider high output failure Hemoglobin Electrophoresis if hereditary LUNG- consider infection, lesion hemoglobinopathy is suspected ABDOMINAL- Liver/spleen size, masses, tenderness, surgical scars RECTAL- Stool guaiac, prostate exam in men IF BLEEDING - Platelet Count, PT, aPTT PELVIC/BREAST- Uterine abnormality, Pap smear, Breast nodule LYMPHNODES- consider lymphoma,leukemia,infection,connective tissue Disease NEUROLOGIC- Decreased vibratory and position sense in B12 deficiency Emory University Physician Assistant Program Emory University Physician Assistant Program CBC- Red Cell Measures Red Cell Indices MCH, MCHC PARAMETER NORMAL ADULT COMMENTS MCH - Mean Corpuscular 27 -32 pg Low = Hypochromic Hemoglobin High = Hyperchromic HB - Hemoglobin Male= 15.5 +/- 2 mg/dl Low = Anemia MCHC - Mean Corpuscular 30 - 36 gm/dl Low = R/O Fe def. Female = 13.5 +/- 2 High = polycythemia Hemoglobin Concentration High = Spherocytosis HCT - Hematocrit Male= 46.0 +/- 6% " Female= 41.0 +/- 6% " RBC - Red Blood Male = 4.3 - 5.9 Million/uL " Cell Count Female = 4.0 - 5.2 " " Emory University Physician Assistant Program Emory University Physician Assistant Program 5
    • Red Cell Indices MCV - RDW Platelets MCV - Mean Corpuscular Volume 80 - 94 fl Low = Microcytosis High = Macrocytosis Platelet Count 150 - 400 K cell/uL RDW - Red Cell Distribution Width 11.5 - 14.5 Low = Thrombocytopenia Variation in RBC size High = Thrombocytosis Emory University Physician Assistant Program Emory University Physician Assistant Program Retics or Reticulocyte count Corrected Retic Count Corrected Retic Raw Retic Pt's Hematocrit Retic - Reticulocyte Count 0.5 -1.5 % Percentage = Percentage X 45 Low in anemia = low marrow output High = RBC loss Corrected Retic Raw Retic Pt's Hemoglobin Percentage = Percentage X 14 An example would be if the raw retic percentage reported on the CBC was 6% and the patient's hematocrit is 23 then: The corrected retic percentage = 6% x 23/45 or 3%. The normal corrected reticulocyte percentage is 1 - 2%. With severe anemia and marked marrow response, other corrections may be necessary. Emory University Physician Assistant Program Emory University Physician Assistant Program RBC Morphology Red Cell Morphology SIGNIFICANCE Diagnostic Pathway Reticulocyte Production Index Burr Cells Uremia, Low K, artifact, Ca stomach, PUD Spur Cell Post-splenectomy, Alcoholic liver <2 Decreased Production >2 Increased Loss disease Stomatocyte Hereditary, Alcoholic liver disease, Spherocyte Hereditary, Immune hemolytic anemia, Red Cell Indicies MCV Hemolysis Bleeding water dilution, post-transfusion Shistocyte - helmet TTP, DIC, vasculitis, glomerulonephritis, heart valve, burns >94 80-94 <80 Macro Normo Micro Extrinsic Intrinsic Eliptocyte - Ovalocyte Hereditary, Thalassemia, Fe Def., Myelophthistic, megaloblastic anemias Sickle Cells Sickle cell disease Coombs Coombs Membrane Hb Enzyme Target Cells Thalassemias, hemoglobinopathies Positive Negative Microcytes Thalassemia, Iron Def., Lead Toxic, Macrocytes B12 of Folate Def. Drug Warm Cold Parasites Malaria, Babesiosis Antibody Antibody Emory University Physician Assistant Program Emory University Physician Assistant Program 6
    • Microcytic Microcytic Tests MICROCYTIC = "TICS" TESTS TO ORDER: Serum Iron T-Thalassemias TIBC = Transferrin binding sites I-Iron Deficiency % Saturation = Transferrin saturation with Iron C-Chronic Inflammation S-Sideroblastic - lead, Ferritin = Storage Iron drug, or hereditary HBELP = Hemoglobin Electrophoresis Lead level if exposed Emory University Physician Assistant Program Emory University Physician Assistant Program Thalassemia Syndromes. Iron deficiency Hereditary – Alpha or Low Serum iron, Beta chain Low Ferritin, High Decrease Hemoglobin A TIBC Hemoglobin ELP and Find out why –GI normal Iron are diagnostic bleed, menses, diet Supportive therapy or Treat FeSO4 300mg BMT tid Target Cells Emory University Physician Assistant Program Emory University Physician Assistant Program Chronic Inflammation Sideroblastic Block of normal iron stores transport to Ring sideroblasts in bone marrow bone marrow factory Serum iron is increased Normal Ferritin, serum iron and TIBC and TIBC normal are low with a low saturation resulting in a high saturation. Serum High Sed rate or c-reactive protein ferritin is increased Treat inflammation – RA, SLE, HIV…. Basophillic stippling Lead toxicity is suspect Emory University Physician Assistant Program Emory University Physician Assistant Program 7
    • Normocytic Anemia Normocytic Tests NORMOCYTIC = "NORMAL SIZE" Blood Urea Nitrogen (BUN), Creatinine, N-Normal Pregnancy O-Over hydration SGOT, Alkaline Phosphatase, Bilirubin, R-Renal Disease Erythrocyte Sedimentation Rate (ESR), M-Myelophthistic A-Acute Blood Loss Urinalysis, and Thyroid profile L-Liver Disease Bone Marrow Biopsy SI-Systemic Infection Z-Zero Production- Aplastic anemia E-Endocrine:Hypothyroid, hypoadrenal, hypoandrogen Emory University Physician Assistant Program Emory University Physician Assistant Program Macrocytic Anemia Macrocytic Tests MACROCYTIC = "BIG FAT RED CELLS" The peripheral blood changes include: B-B12 Malabsorbtion I-Inherited -Anemia with decreased reticulocyte count, - G-Gastrointestinal disease or surgery Increased MCV F-Folic Acid Deficiency A-Alcoholism -Neutropenia with hypersegmented T-Thiamine responsive Neutrophils R-Reticulocytes miscounted as large RBCs -Thrombocytopenia with large platelets. E- Endocrine - hypothyroid D-Dietary C-Chemotherapeutic Drugs LABS to order: E-Erythro Leukemia L- Liver Disease B12, Serum Folate, RBC Folate L- Lesch-Nyhan Syndrome S-Splenectomy if all normal, consider TSH, and a Bone Marrow Bx. Emory University Physician Assistant Program Emory University Physician Assistant Program B12 Cobalamin Deficiency Folate Deficiency . Physical signs include Causes - liver disease, diet edema, pallor, jaundice, smooth tongue, decreased vitamin B12 deficiency, and drugs vibratory and position sensation such as methotrexate, ethanol, Hypersegmented polys and dilantin. Low B12 Lab – low serum and RBC Folate pernicious anemia - anti- intrinsic factor antibodies Rx – Folate 1mg po qD Schilling's test Rx - cobalamin 1000 mg I.M. Emory University Physician Assistant Program Emory University Physician Assistant Program 8
    • Hemolytic Anemia HEMOLYTIC = "HEMATOLOGIST" Hemolytic Signs H-Hemoglobinopathy: sickle cell disease 1. Elevated reticulocyte count, with stable or falling - Hemoglobinuria: Paroxysmal Nocturnal Hemoglobinuria hemoglobin. E-Enzyme Deficiency 2. Elevated indirect bilirubin - M-Medication - drug induced: aldomet, INH A-Antibodies - Immune attack 3. Eevated serum lactate dehydrogenase (LDH)- T-Trauma to the red cells: D.I.C , artificial heart valves 4. Decreased Haptoglobin levels - Haptoglobin binds O-Ovalocytosis hemoglobin released in the plasma from red cell L-Liver disease breakdown. O-Osmotic fragility in Hereditary spherocytosis 5. Hemoglobinemia and hemoglobinuria and in Hereditary Eliptocytosis G-G6PD Glucose-6-Phosphate Dehydrogenase Deficiency 6. Erythroid hyperplasia in bone marrow I-Infection: malaria, babesiosis 7 Abnormal Hemoglobin Electrophoresis S-Splenic destruction in hypersplenism T-Transfusion - Thalassemias Emory University Physician Assistant Program Emory University Physician Assistant Program Hemolytic Tests Hemoglobinopathy 1. The direct antiglobulin (Coombs') test Direct Sickle Cell Disease – SS, SC, Coombs test looks for antibody on the red cells. The Indirect Coombs looks for antibody in the serum. SD, SE, SOarab, S beta Thal 2. Hemoglobin electrophoresis Newborn Screening or HbELP 3. Heinz body stain 4. Osmotic fragility Daily Penicillin –birth -6yo 5. Blood smear Hydroxyurea Hydration, Oxygen, Temperature, and Folate Emory University Physician Assistant Program Emory University Physician Assistant Program G6PD - Glucose - 6 - Phosphate Parasites – Malaria - Dehydrogenase Deficiency Babesiosis X linked genetic Precipitated by oxidant drugs Heinz body stain show denatured Hb Avoid medications such as antimalarials, aspirin, sulfa drugs, and avoid eating fava beans. Emory University Physician Assistant Program Emory University Physician Assistant Program 9
    • Spherocytosis and Ovalocytosis To Clot or Not Coagulopathies Allan Platt, PA-C Faculty, Physician Assistant Program Emory University School of Medicine Atlanta, GA aplatt@emory.edu Emory University Physician Assistant Program Emory University Physician Assistant Program Clotting Needs Clotting Steps Emory University Physician Assistant Program Emory University Physician Assistant Program Clotting system activated Clot Normal Blood Flow Clot Emory University Physician Assistant Program Emory University Physician Assistant Program 10
    • Platelet Activation Clotting Cascade Emory University Physician Assistant Program Emory University Physician Assistant Program Inhibitors of Clotting Vitamin K Factors Emory University Physician Assistant Program Emory University Physician Assistant Program Increased Bleeding Presentation Increased Clotting Presentation Bleeding gums Easy Bruising Deep Vein Thromboplebitis (DVT) Prolonged Post-op Bleeding Calf swelling, pain Prolonged Bleeding post dental work Pulmonary Embolus (PE) Petechiae or Purpura Myocardial Infarction, Angina Increased Menstrual Bleeding Stroke, or Transient Ischemic Attacks (TIAs) Lab Finding of Low Platelets or Abnormal High Risk – post operative, pregnancy, atrial PT, aPTT fibrilation, congestive heart failure G.I. Bleeding Elevated platelets Emory University Physician Assistant Program Emory University Physician Assistant Program 11
    • Bleeding History Bleeding History 1. Abnormal bleeding from the mucus HX - History of melena, abdominal pain, Aspirin or non- membranes such as the mouth, nose or vagina steroidal anti-inflammatory agents (NSAIDs) use, past peptic ulcer disease , then consider GI bleeding, platelet suggests platelet defects or von Willebrand’s dysfunction. disease (vWD). - In females the menstrual history quantifying the amount of bloodloss ,or possible pregnancy should be 2. Abnormal bleeding into joint spaces and soft obtained. tissues implies a defect in the clotting factors. - History of alcohol abuse - consider liver disease. 3. Purpuric lesions are usually caused by - Family history of blood cell or bleeding disorder: consider Hemophilia, von Willebrand Disease vascular wall defects. Emory University Physician Assistant Program Emory University Physician Assistant Program Bleeding History Increased Clotting History - History of weight loss, Cancer, HIV, rheumatoid arthritis, thyroid disease, renal disease -then consider History of recurrent clots, PEs... consider secondary cause protein S,C, or Antithrombin III deficient - History of fever and chills, cough, dyspnea, then consider Infection. Pregnancy - Increased blood viscosity, - History of prolonged bleeding after dental extractions, fibrinogen and factor VIII. Post Partum - epistaxis, gum bleeding, easy bruising, then consider low or dysfuctional platelets. Hypercoaguable state - History of bleeding into joints, then consider Polycythemia vera - increased viscosity hemophilia. - History of Lupus - Lupus anticoagulant Emory University Physician Assistant Program Emory University Physician Assistant Program Increased Clotting History Physical Exam PHYSICAL EXAM Smoking, Resent Surgery, Diabetes, GENERAL INSPECTION- clubbing in TB or lung cancer Congestive Heart Failure, Cancer, Atrial Skin- Hypothyroid, SLE, Bruises, lesions, petechiae or purpura. Fibrillation are all high risk Weight - Loss in Cancer, HIV, Chronic disease Autoimmune diseases such as systemic lupus VITAL SIGNS- Pulse: Tachycardia from increased cardiac output erythematosis, and medications such as Respirations: Tachypnea from decreased oxygen transport procainamide, chlorpromazine, and quinidine. BP: Orthostatic if volume depleted Temp: Fever in infections and drug or transfusion reactions, Oral contraceptives - Estrogen HEENT- Eye: Jaundice if hemolysis, pallor in palpebral conjunctiva Emory University Physician Assistant Program Emory University Physician Assistant Program 12
    • Platelet Problems or Von Physical Exam 2 Willebrand Disease (vWD) HEENT- Eye: Jaundice if hemolysis, pallor in palpebral conjunctiva LUNG- consider infection, lesion, rub CV - new murmer or CHF , Listen for Bruits ABDOMINAL- Liver/spleen size, masses, tenderness, surgical scars RECTAL- Stool guaiac, PELVIC/BREAST- Uterine abnormality, Pap smear, Breast nodule LYMPHNODES- consider lymphoma, leukemia, infection, connective tissue disease EXTR- Homan’s or calf tenderness/swelling Emory University Physician Assistant Program Emory University Physician Assistant Program Clotting Factor Disorders Vascular Wall Defects Hemarthrosis Purpura Emory University Physician Assistant Program Emory University Physician Assistant Program Tests to Order Bleeding Time The bleeding time: To check -CBC, Differential, Cell Morphology -Platelet Count - 150,000 - 350,000 cu/mm Bleeding can occur if < 50,000 if > platelet function 500,000 Clotting too much Check platelet count -Chem 18 (Hepatic profile, Indirect Bili in hemolysis, Renal) -Bleeding Time - (normal 3-8 minutes) is a measure of platelet function and an No aspirin X 7 days intact coagulation cascade. 1. BP cuff inflated to 40 mm. -PT -Prothrombin Time - +/- 2 of control = 11 - 16 sec. Extrinsic system monitor for coumadin therapy. INR is International Normalization Ratio, 1 is normal, 2- 3 for 2. Two cuts on volar arm Coumadin Therapy, 2.5 - 3.5 if heart valve -aPTT - activated Partial Thromboplastin Time- 25 - 38 sec. Intrinsic system. Used 9mm long 1 mm deep. to monitor Heparin therapy - Fibrinogen level (normal 100-300 mg/dl). Causes of an abnormally low fibrinogen 3. Blot excess blood do not level include DIC, hereditary dysfibrinogenemia, and hepatic failure. touch cut. - Fibrin degradation products. Abnormal elevations occur in DIC, primary fibrinolytic states, and hepatic failure. 4. Normal time until stops is 9 minutes For Clotting too much: Protein S, C and antithrombin III assay Emory University Physician Assistant Program Emory University Physician Assistant Program 13
    • Differential Diagnosis Clotting too much Clotting Too much - Pulmonary Embolus, Deep C - Cirrhosis/Liver Disease and Coumadin Vein Thrombophlebitis, Stroke, Myocardial A - Aspirin and other drugs NSAIDs Infarction L - Leukemia, Lupus anticoagulant F - Factor Deficiency - Hemophilia D - Disseminated Intravascular Coagulation I - Idiopathic Thrombocytopenic Purpura P - Platelet Deficiency (TTP, HUS, DIC, Heparin) or Platelet Dysfunction (vWD) S - Scurvy: Vitamin C Deficiency Emory University Physician Assistant Program Emory University Physician Assistant Program Differential Diagnosis Differential Diagnosis Hypercoagulation The mnemonic is: 5 Ps CLOT Hypercoagulation The mnemonic is: 5 Ps CLOT C - Congestive Heart Failure (CHF), Cholesterol elevation, P - Pregnancy - Increased blood viscosity, fibrinogen Cancer - procoagulant effects and factor VIII. L - Lipids - Antiphospholipid antibodies - infection, P - Post Partum - Hypercoaguable state autoimmune diseases such as systemic lupus P - Protien S, C, or Antithrombin III deficient – Inherited erythematosis, cancer, and medications such as procainamide, chlorpromazine, and quinidine. P - Polycythemia vera - increased viscosity O - Oral contraceptives - Estrogen is the main culprit P - Platlets - Thrombocytosis - too many platelets T - Trauma, Travel (immobility) - Stasis of blood flow and S- Smoking, Surgery, Sugar - Diabetes release of tissue throboplastin in trauma Emory University Physician Assistant Program Emory University Physician Assistant Program Who ya gonna Call? Therapy To block Clotting- Clot Busters Antiplatelet: Aspirin, NSAIDS, Ticlopidine, Clopidogrel Stop Clotting and clot prevention- Heparin tPA, Streptokinase, and LMW Heparin Coumadin (Reversed with vitamin K) Urokinase Thrombin inhibitor - bivalirudin - Angiomax, Argatroban lepirudin - Refludan, Thrombate III Antithrombin III - Atnativ To Bust Clots - tPA - alteplase, enecteplase streptokinase urokinase Emory University Physician Assistant Program Emory University Physician Assistant Program 14
    • Resources Lymphadenopathy L- Lymphoma, Leukemia Aventis http://www.thrombosis- Y-Yersinia Pestis (Plague) M-Mononucleosis or CMV consult.com/home.htm P-Parasite - Toxoplasmosis H-Hodgkins Disease or HIV infection American Heart Association N-Neoplasm or metastisis O-Obvious local infection or inflamation http://www.americanheart.org -Other systemic infections: Hep B, Rubella, Tularemia, Cat scratch D-Drug- Procainamide (Pronestyl), Phenytoin (Dilantin) E-Endocrine - Addisons, Hypothyroid S- Syphilis -SLE/Rheumatoid arthritis -Serum sickness -Sarcoid Emory University Physician Assistant Program Emory University Physician Assistant Program Mononucleosis Mono - continued Emory University Physician Assistant Program Emory University Physician Assistant Program Hodgkins – Reed Sternberg Hodgkins Disease cells Emory University Physician Assistant Program Emory University Physician Assistant Program 15
    • Multiple Myeloma Primary - Polycythemia vera Symptoms and Signs - Itching, Bone pain, weakness, anemia, lytic bone lesions, Sx: Pruritis HA, Dizziness, vertigo, increased protein, M - Spike, Bence Jones visual disturbance, tinnitus protein in urine PE: Rubor, BP increased, splenomegaly or hepatomegally Lab: HCT >55 lncreased platelets and WBC count RX: Phlebotomy, Hydroxyurea Emory University Physician Assistant Program Emory University Physician Assistant Program Secondary Polycythemia Leukemia and Lymphoma ALL: Acute Lymphocytic Leukemia (Usually in Children) Increase erythropoietin due to hypoxia AML: Acute Myelogenous Leukemia CLL: Chronic Lymphocytic Leukemia (COPD, smokers, high altitude), tumors CML: Chronic Myelogenous Leukemia Lymphomas, Hodgkins of kidney, ovary, liver, brain, drugs: HX: Fatigue, anorexia, wt loss, fever, bone pain, headaches, lymphadenopathy, steroids, androgen, dehydration, burns non healing infections, thrush, bleeding PE: Pallor, gingival hyperplasia, Candida infections, lymphadenopathy, hepatosplenomegaly, lung infiltrates, bleeding, bruising PE: No hepatospenomegaly unless LAB: CBC, WBC Differential, Chem 18, Bone Marrow Biopsy Philadelphia Chromosome seen in CML tumor Auer bodies or rods in AML Lymph node BX: Reed -Sternberg cells in Hodgkins Disease CT - MRI chest and abdomen CXR - Chest infiltation, pneumonias RX: Chemotherapy, Bone Marrow Transplant Emory University Physician Assistant Program Emory University Physician Assistant Program ALL - Blasts CLL - Blasts Emory University Physician Assistant Program Emory University Physician Assistant Program 16
    • AML Auer Rod CML Emory University Physician Assistant Program Emory University Physician Assistant Program 17