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1 Emory University Physician Assistant Program Heme 101 Allan Platt PA-C Emory PA Program Atlanta GA [email protected] Emory University Physician Assistant Program Emory University Physician Assistant Program Blood Blood has red cells(erythrocyctes) White cells (leukocytes) Platelets (thrombocytes) Emory University Physician Assistant Program Blood Components Plasma 54% White cells and platelets 1% Red Cells 45% Emory University Physician Assistant Program White Blood Cells White Blood Cells Fight infections Are increased in infections Move inside and outside of blood vessels Are made in the bone marrow Emory University Physician Assistant Program White Blood Cells WBC - White Blood Cells 4.5 - 11.0 K/uL Low = Leukopenia High = Leukocytosis WBC Differential Neutrophils - Segs 54 -62% Neutrophils - Bands 3 -5 % Lymphocytes - Lymphs 25 - 33% Monocytes - Monos 3 - 7% Eosinophils - Eos 1 - 3% Basophils - Basos 0 - 0.75% Atypical Lymphs 0

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Page 1: Microsoft PowerPoint - Heme101.ppt [Read-Only]

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Emory University Physician Assistant Program

Heme 101

Allan Platt PA-CEmory PA Program

Atlanta [email protected]

Emory University Physician Assistant Program

Emory University Physician Assistant Program

BloodBlood has red cells(erythrocyctes)White cells (leukocytes)Platelets (thrombocytes)

Emory University Physician Assistant Program

Blood Components

Plasma 54%

White cells and platelets 1%

Red Cells 45%

Emory University Physician Assistant Program

White Blood CellsWhite Blood CellsFight infectionsAre increased in infectionsMove inside and outside of blood vesselsAre made in the bone marrow

Emory University Physician Assistant Program

White Blood CellsWBC - White Blood Cells 4.5 - 11.0 K/uL

Low = Leukopenia High = Leukocytosis

WBC Differential

Neutrophils - Segs 54 -62%

Neutrophils - Bands 3 -5 %

Lymphocytes - Lymphs 25 - 33%

Monocytes - Monos 3 - 7%

Eosinophils - Eos 1 - 3%

Basophils - Basos 0 - 0.75%

Atypical Lymphs 0

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Emory University Physician Assistant Program

PlateletsPlug holes in the body to stop bleedingCan help cause blood to clotMade in the bone marrow

FibrinFibrin

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Red Blood Cells Carry oxygen from the lungsCarry carbon dioxide back to the lungsNormally live 120 daysContains the protein hemoglobinMade from iron, folic acid, vitamin B12Made in the bone marrow

Emory University Physician Assistant Program

Red Blood Cells

Red cells look like Red cells look like doughnuts that are doughnuts that are very flexiblevery flexible

Emory University Physician Assistant Program

Microscope View

Emory University Physician Assistant Program

Red Blood Cells - Shape

Red cells travel through Red cells travel through very narrow blood vesselsvery narrow blood vessels

Emory University Physician Assistant Program

Red Blood Cells Red Cell Flow

Blood VesselBlood Vessel

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Emory University Physician Assistant Program

Red Blood Cells - Hemoglobin

OxygenOxygen

Hemoglobin, the Hemoglobin, the main protein in main protein in red cells holds red cells holds four oxygen four oxygen moleculesmolecules

Emory University Physician Assistant Program

Red Blood Cells - Hemoglobin

Emory University Physician Assistant Program

Red Blood Cells - Marrow Red cells, white cells and platelets are made in the bone marrow

Emory University Physician Assistant Program

Red Blood Cells - Retics

Reticulocytes, or Retics are young red cells just released from the bone marrow. The Retic count is the best indicator about how the marrow factory is doing.

Emory University Physician Assistant Program

Red Blood CellsRed Blood Cells

Red cells live 120 days in the circulation

Food with iron and vitamins is digested

Red cells are made in the bone marrow

Emory University Physician Assistant Program

Red Blood Cells Red Blood Cells -- RecycledRecycledRed cells are recycled in the spleen and liver. Red cells are recycled in the spleen and liver. The iron and protein are stored and bilirubin The iron and protein are stored and bilirubin is released.is released.

SpleenSpleen

LiverLiver

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Emory University Physician Assistant Program

Red Blood CellsRed Blood Cells - The KidneyErythropoietin is made by Erythropoietin is made by the kidney as a signal to the the kidney as a signal to the bone marrow to make more bone marrow to make more red cellsred cells

Emory University Physician Assistant Program

The History

WeaknessTiredness - FatigueDyspneaDizzy – non vertigoPalpitationsNew angina

Emory University Physician Assistant Program

The History -2- History of melena, abdominal pain, Aspirin or non-steroidal anti-

inflammatory agents (NSAIDs) use, past peptic ulcer disease , then consider GI bleeding, platelet dysfunction.

- In females the menstrual history quantifying the amount of bloodloss ,or possible pregnancy should be obtained.

- History of pica or abnormal craving for ice, clay, starch...; dysphagia then consider iron deficiency.

- Poor diet, then consider iron or folate deficiency, and generalmalnutrition

- 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

The History -3- Family history of blood cell or bleeding disorder: consider Sickle

Cell disease, G6PD,Thalassemia, Hemophilia, von Willebrand- History of jaundice, transfusion, new medication, infection -

consider hemolytic process- History of weight loss, Cancer, HIV, rheumatoid arthritis, thyroid

disease, renal disease -then consider secondary cause- History of fever and chills, cough, dyspnea, then consider

Infection.

Emory University Physician Assistant Program

Physical Exam

Emory University Physician Assistant Program

Sclera

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Emory University Physician Assistant Program

Spoon Nails – Fe Def.

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Glossitis and Chelosis –Fe and B12

Emory University Physician Assistant Program

Physical ExamGENERAL 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 outputRespirations: Tachypnea from decreased oxygen transportBP: Orthostatic if volume depletedTemp: Fever in infections and drug or transfusion reactions,

HEENT- Eye: Jaundice if hemolysis, pallor in palpebral conjunctivaMouth: Glossitis and angular stomatitis in iron or B12 deficiency

NECK- Thyroid enlargement or nodules, lymph nodesHEART- Increased output/murmur- consider high output failureLUNG- consider infection, lesionABDOMINAL- Liver/spleen size, masses, tenderness, surgical scarsRECTAL- Stool guaiac, prostate exam in menPELVIC/BREAST- Uterine abnormality, Pap smear, Breast noduleLYMPHNODES- consider lymphoma,leukemia,infection,connective tissue DiseaseNEUROLOGIC- Decreased vibratory and position sense in B12 deficiency

Emory University Physician Assistant Program

LAB- INITIAL SCREENING TESTS

Urinalysis- Hematuria/proteinuria in renal disease ,hemoglobinuria in hemolysis. CBC, red cell morphology and white

blood cell differential, Reticulocyte count,Chemistry profile (LDH, Bilirubin- Direct and Indirect, BUN, Creatinine, GOT),Hemoglobin Electrophoresis if hereditary hemoglobinopathy is suspectedIF BLEEDING - Platelet Count, PT, aPTT

Emory University Physician Assistant Program

CBC- Red Cell Measures

PARAMETER NORMAL ADULT COMMENTS

HB - Hemoglobin Male= 15.5 +/- 2 mg/dl Low = Anemia

Female = 13.5 +/- 2 High = polycythemia

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

Red Cell Indices MCH, MCHC

MCH - Mean Corpuscular 27 -32 pg Low = Hypochromic

Hemoglobin High = Hyperchromic

MCHC - Mean Corpuscular 30 - 36 gm/dl Low = R/O Fe def.

Hemoglobin Concentration High = Spherocytosis

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Emory University Physician Assistant Program

Red Cell Indices MCV - RDWMCV - Mean Corpuscular Volume 80 - 94 fl

Low = Microcytosis High = Macrocytosis

RDW - Red Cell Distribution Width 11.5 - 14.5Variation in RBC size

Emory University Physician Assistant Program

PlateletsPlatelet Count 150 - 400 K cell/uL Low = ThrombocytopeniaHigh = Thrombocytosis

Emory University Physician Assistant Program

Retics or Reticulocyte countRetic - Reticulocyte Count 0.5 -1.5 %Low in anemia = low marrow output High = RBC loss

Emory University Physician Assistant Program

Corrected Retic CountCorrected Retic Raw Retic Pt's HematocritPercentage = Percentage X 45

Corrected Retic Raw Retic Pt's HemoglobinPercentage = 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

RBC MorphologyRed Cell Morphology SIGNIFICANCE

Burr Cells Uremia, Low K, artifact, Ca stomach, PUD

Spur Cell Post-splenectomy, Alcoholic liver disease

Stomatocyte Hereditary, Alcoholic liver disease,Spherocyte Hereditary, Immune hemolytic anemia,

water dilution, post-transfusionShistocyte - helmet TTP, DIC, vasculitis, glomerulonephritis,

heart valve, burnsEliptocyte - Ovalocyte Hereditary, Thalassemia, Fe Def.,

Myelophthistic, megaloblastic anemiasSickle Cells Sickle cell diseaseTarget Cells Thalassemias, hemoglobinopathiesMicrocytes Thalassemia, Iron Def., Lead Toxic,

Macrocytes B12 of Folate Def.Parasites Malaria, Babesiosis

Emory University Physician Assistant Program

Diagnostic PathwayReticulocyte Production Index

<2 Decreased Production >2 Increased Loss

Red Cell Indicies MCV Hemolysis Bleeding

>94 80-94 <80Macro Normo Micro Extrinsic Intrinsic

Coombs CoombsPositive Negative

Drug Warm ColdAntibody Antibody

Membrane Hb Enzyme

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Emory University Physician Assistant Program

MicrocyticMICROCYTIC = "TICS"

T-Thalassemias I-Iron DeficiencyC-Chronic InflammationS-Sideroblastic - lead, drug, or hereditary

Emory University Physician Assistant Program

Microcytic TestsTESTS TO ORDER:Serum Iron

TIBC = Transferrin binding sites

% Saturation = Transferrin saturation with Iron

Ferritin = Storage Iron

HBELP = Hemoglobin Electrophoresis

Lead level if exposed

Emory University Physician Assistant Program

Thalassemia Syndromes.Hereditary – Alpha or Beta chainDecrease Hemoglobin AHemoglobin ELP and normal Iron are diagnosticSupportive therapy or BMT Target Cells

Emory University Physician Assistant Program

Iron deficiencyLow Serum iron, Low Ferritin, High TIBCFind out why –GI bleed, menses, dietTreat FeSO4 300mg tid

Emory University Physician Assistant Program

Chronic Inflammation

Block of normal iron stores transport to bone marrow factoryNormal Ferritin, serum iron and TIBC are low with a low saturationHigh Sed rate or c-reactive proteinTreat inflammation – RA, SLE, HIV….

Emory University Physician Assistant Program

SideroblasticRing sideroblasts in bone marrowSerum iron is increased and TIBC normal resulting in a high saturation. Serum ferritin is increasedBasophillic stipplingLead toxicity is suspect

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Emory University Physician Assistant Program

Normocytic AnemiaNORMOCYTIC = "NORMAL SIZE"

N-Normal PregnancyO-Over hydrationR-Renal DiseaseM-MyelophthisticA-Acute Blood LossL-Liver Disease

SI-Systemic InfectionZ-Zero Production- Aplastic anemiaE-Endocrine:Hypothyroid, hypoadrenal, hypoandrogen

Emory University Physician Assistant Program

Normocytic Tests

Blood Urea Nitrogen (BUN), Creatinine, SGOT, Alkaline Phosphatase, Bilirubin, Erythrocyte Sedimentation Rate (ESR), Urinalysis, and Thyroid profileBone Marrow Biopsy

Emory University Physician Assistant Program

Macrocytic AnemiaMACROCYTIC = "BIG FAT RED CELLS"

B-B12 MalabsorbtionI-InheritedG-Gastrointestinal disease or surgery

F-Folic Acid DeficiencyA-AlcoholismT-Thiamine responsive

R-Reticulocytes miscounted as large RBCsE- Endocrine - hypothyroidD-Dietary

C-Chemotherapeutic DrugsE-Erythro LeukemiaL- Liver DiseaseL- Lesch-Nyhan SyndromeS-Splenectomy

Emory University Physician Assistant Program

Macrocytic TestsThe peripheral blood changes include: -Anemia with decreased reticulocyte count, -Increased MCV-Neutropenia with hypersegmented

Neutrophils-Thrombocytopenia with large platelets.

LABS to order:B12, Serum Folate, RBC Folateif all normal, consider TSH, and a Bone Marrow Bx.

Emory University Physician Assistant Program

B12 Cobalamin Deficiency. Physical signs include

edema, pallor, jaundice, smooth tongue, decreased vibratory and position sensation

Hypersegmented polysLow B12pernicious anemia - anti-

intrinsic factor antibodies Schilling's testRx - cobalamin 1000 mg I.M.

Emory University Physician Assistant Program

Folate DeficiencyCauses - liver disease, diet vitamin B12 deficiency, and drugs such as methotrexate, ethanol, and dilantin.Lab – low serum and RBC FolateRx – Folate 1mg po qD

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Emory University Physician Assistant Program

Hemolytic AnemiaHEMOLYTIC = "HEMATOLOGIST"

H-Hemoglobinopathy: sickle cell disease- Hemoglobinuria: Paroxysmal Nocturnal Hemoglobinuria

E-Enzyme DeficiencyM-Medication - drug induced: aldomet, INHA-Antibodies - Immune attackT-Trauma to the red cells: D.I.C , artificial heart valvesO-OvalocytosisL-Liver diseaseO-Osmotic fragility in Hereditary spherocytosis

and in Hereditary EliptocytosisG-G6PD Glucose-6-Phosphate Dehydrogenase DeficiencyI-Infection: malaria, babesiosisS-Splenic destruction in hypersplenismT-Transfusion- Thalassemias

Emory University Physician Assistant Program

Hemolytic Signs1. Elevated reticulocyte count, with stable or falling hemoglobin.2. Elevated indirect bilirubin -3. Eevated serum lactate dehydrogenase (LDH)-4. Decreased Haptoglobin levels - Haptoglobin binds hemoglobin released in the plasma from red cell breakdown. 5. Hemoglobinemia and hemoglobinuria6. Erythroid hyperplasia in bone marrow 7 Abnormal Hemoglobin Electrophoresis

Emory University Physician Assistant Program

Hemolytic Tests1. The direct antiglobulin (Coombs') test Direct Coombs test looks for antibody on the red cells. The Indirect Coombs looks for antibody in the serum.2. Hemoglobin electrophoresis3. Heinz body stain4. Osmotic fragility 5. Blood smear

Emory University Physician Assistant Program

HemoglobinopathySickle Cell Disease – SS, SC, SD, SE, SOarab, S beta Thal

Newborn Screening or HbELP

Daily Penicillin –birth -6yo

Hydroxyurea

Hydration, Oxygen, Temperature, and Folate

Emory University Physician Assistant Program

G6PD - Glucose - 6 - Phosphate Dehydrogenase Deficiency

X linked genetic

Precipitated by oxidant drugs

Heinz body stain show denatured Hb

Avoid medications such as antimalarials, aspirin, sulfa drugs, and avoid eating favabeans.

Emory University Physician Assistant Program

Parasites – Malaria -Babesiosis

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Spherocytosis and Ovalocytosis

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To Clot or NotCoagulopathies

Allan Platt, PA-CFaculty, Physician Assistant ProgramEmory University School of Medicine

Atlanta, [email protected]

Emory University Physician Assistant Program

Clotting Needs

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Clotting Steps

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Clotting system activated

Normal Blood FlowNormal Blood FlowClotClot

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Clot

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Platelet Activation

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Clotting Cascade

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Inhibitors of Clotting

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Vitamin K Factors

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Increased Bleeding PresentationBleeding gums

Easy Bruising

Prolonged Post-op Bleeding

Prolonged Bleeding post dental work

Petechiae or Purpura

Increased Menstrual Bleeding

Lab Finding of Low Platelets or Abnormal PT, aPTT

G.I. Bleeding

Emory University Physician Assistant Program

Increased Clotting Presentation

Deep Vein Thromboplebitis (DVT)

Calf swelling, pain

Pulmonary Embolus (PE)

Myocardial Infarction, Angina

Stroke, or Transient Ischemic Attacks (TIAs)

High Risk – post operative, pregnancy, atrialfibrilation, congestive heart failure

Elevated platelets

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Emory University Physician Assistant Program

Bleeding History

1. Abnormal bleeding from the mucus membranes such as the mouth, nose or vagina suggests platelet defects or von Willebrand’sdisease (vWD). 2. Abnormal bleeding into joint spaces and soft tissues implies a defect in the clotting factors.3. Purpuric lesions are usually caused by vascular wall defects.

Emory University Physician Assistant Program

Bleeding History

HX - History of melena, abdominal pain, Aspirin or non-steroidal anti-inflammatory agents (NSAIDs) use, past peptic ulcer disease , then consider GI bleeding, platelet dysfunction.

- In females the menstrual history quantifying the amount of bloodloss ,or possible pregnancy should be obtained.

- History of alcohol abuse - consider liver disease.- Family history of blood cell or bleeding disorder:

consider Hemophilia, von Willebrand Disease

Emory University Physician Assistant Program

Bleeding History- History of weight loss, Cancer, HIV, rheumatoid

arthritis, thyroid disease, renal disease -then consider secondary cause

- History of fever and chills, cough, dyspnea, then consider Infection.

- History of prolonged bleeding after dental extractions, epistaxis, gum bleeding, easy bruising, then consider low or dysfuctional platelets.

- History of bleeding into joints, then consider hemophilia.

- History of Lupus - Lupus anticoagulant

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Increased Clotting History

History of recurrent clots, PEs... consider protein S,C, or Antithrombin III deficient Pregnancy - Increased blood viscosity, fibrinogen and factor VIII. Post Partum -Hypercoaguable statePolycythemia vera - increased viscosity

Emory University Physician Assistant Program

Increased Clotting History

Smoking, Resent Surgery, Diabetes, Congestive Heart Failure, Cancer, AtrialFibrillation are all high riskAutoimmune diseases such as systemic lupus erythematosis, and medications such as procainamide, chlorpromazine, and quinidine. Oral contraceptives - Estrogen

Emory University Physician Assistant Program

Physical ExamPHYSICAL EXAMGENERAL INSPECTION- clubbing in TB or lung cancer

Skin- Hypothyroid, SLE, Bruises, lesions, petechiae or purpura.

Weight - Loss in Cancer, HIV, Chronic diseaseVITAL SIGNS- Pulse: Tachycardia from increased cardiac output

Respirations: Tachypnea from decreased oxygen transportBP: Orthostatic if volume depletedTemp: Fever in infections and drug or transfusion reactions,

HEENT- Eye: Jaundice if hemolysis, pallor in palpebralconjunctiva

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Emory University Physician Assistant Program

Physical Exam 2

HEENT- Eye: Jaundice if hemolysis, pallor in palpebralconjunctivaLUNG- consider infection, lesion, rubCV - new murmer or CHF , Listen for BruitsABDOMINAL- Liver/spleen size, masses, tenderness, surgical scarsRECTAL- Stool guaiac,PELVIC/BREAST- Uterine abnormality, Pap smear, Breast noduleLYMPHNODES- consider lymphoma, leukemia, infection, connective tissue diseaseEXTR- Homan’s or calf tenderness/swelling

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Platelet Problems or Von Willebrand Disease (vWD)

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Clotting Factor Disorders

Hemarthrosis

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Vascular Wall Defects

Purpura

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Tests to Order

-CBC, Differential, Cell Morphology-Platelet Count - 150,000 - 350,000 cu/mm Bleeding can occur if < 50,000 if > 500,000 Clotting too much-Chem 18 (Hepatic profile, Indirect Bili in hemolysis, Renal)-Bleeding Time - (normal 3-8 minutes) is a measure of platelet function and an intact coagulation cascade.-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 Coumadin Therapy, 2.5 - 3.5 if heart valve-aPTT - activated Partial Thromboplastin Time- 25 - 38 sec. Intrinsic system. Used to monitor Heparin therapy- Fibrinogen level (normal 100-300 mg/dl). Causes of an abnormally low fibrinogen level include DIC, hereditary dysfibrinogenemia, and hepatic failure.- Fibrin degradation products. Abnormal elevations occur in DIC, primary fibrinolytic states, and hepatic failure.

For Clotting too much: Protein S, C and antithrombin III assay

Emory University Physician Assistant Program

Bleeding TimeThe bleeding time: To check platelet functionCheck platelet countNo aspirin X 7 days1. BP cuff inflated to 40 mm.2. Two cuts on volar arm 9mm long 1 mm deep.3. Blot excess blood do not touch cut.4. Normal time until stops is 9 minutes

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Differential DiagnosisC - Cirrhosis/Liver Disease and CoumadinA - Aspirin and other drugs NSAIDsL - Leukemia, Lupus anticoagulant F - Factor Deficiency - Hemophilia

D - Disseminated Intravascular Coagulation I - Idiopathic Thrombocytopenic PurpuraP - Platelet Deficiency (TTP, HUS, DIC, Heparin) or Platelet Dysfunction (vWD)S - Scurvy: Vitamin C Deficiency

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Clotting too muchClotting Too much - Pulmonary Embolus, Deep Vein Thrombophlebitis, Stroke, Myocardial Infarction

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Differential DiagnosisHypercoagulation The mnemonic is: 5 Ps CLOT

P - Pregnancy - Increased blood viscosity, fibrinogen and factor VIII.P - Post Partum - Hypercoaguable stateP - Protien S, C, or Antithrombin III deficient – InheritedP - Polycythemia vera - increased viscosityP - Platlets - Thrombocytosis - too many plateletsS- Smoking, Surgery, Sugar - Diabetes

Emory University Physician Assistant Program

Differential DiagnosisHypercoagulation The mnemonic is: 5 Ps CLOT

C - Congestive Heart Failure (CHF), Cholesterol elevation, Cancer - procoagulant effects L - Lipids - Antiphospholipid antibodies - infection, autoimmune diseases such as systemic lupus erythematosis, cancer, and medications such as procainamide, chlorpromazine, and quinidine. O - Oral contraceptives - Estrogen is the main culpritT - Trauma, Travel (immobility) - Stasis of blood flow and release of tissue throboplastin in trauma

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Who ya gonna Call?

Clot Busters

tPA, Streptokinase, Urokinase

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TherapyTo block Clotting-Antiplatelet: Aspirin, NSAIDS, Ticlopidine, ClopidogrelStop Clotting and clot prevention- Heparin and LMW HeparinCoumadin (Reversed with vitamin K)Thrombin inhibitor - bivalirudin - Angiomax, Argatrobanlepirudin - Refludan, Thrombate III

Antithrombin III - AtnativTo Bust Clots - tPA - alteplase, enecteplase

streptokinaseurokinase

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Resources

Aventis http://www.thrombosis-consult.com/home.htmAmerican Heart Association http://www.americanheart.org

Emory University Physician Assistant Program

LymphadenopathyL- Lymphoma, LeukemiaY-Yersinia Pestis (Plague)M-Mononucleosis or CMVP-Parasite - ToxoplasmosisH-Hodgkins Disease or HIV infectionN-Neoplasm or metastisisO-Obvious local infection or inflamation-Other systemic infections: Hep B, Rubella, Tularemia, Cat scratch

D-Drug- Procainamide (Pronestyl), Phenytoin (Dilantin)E-Endocrine - Addisons, HypothyroidS- Syphilis

-SLE/Rheumatoid arthritis-Serum sickness-Sarcoid

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Mononucleosis

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Mono - continued

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Hodgkins Disease

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Hodgkins – Reed Sternberg cells

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Multiple MyelomaSymptoms and Signs - Itching, Bone pain, weakness, anemia, lytic bone lesions, increased protein, M - Spike, Bence Jones protein in urine

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Primary - Polycythemia vera

Sx: Pruritis HA, Dizziness, vertigo, visual disturbance, tinnitusPE: Rubor, BP increased, splenomegalyor hepatomegallyLab: HCT >55 lncreased platelets and WBC countRX: Phlebotomy, Hydroxyurea

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Secondary Polycythemia

Increase erythropoietin due to hypoxia (COPD, smokers, high altitude), tumors of kidney, ovary, liver, brain, drugs: steroids, androgen, dehydration, burnsPE: No hepatospenomegaly unless tumor

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Leukemia and LymphomaALL: Acute Lymphocytic Leukemia (Usually in Children)AML: Acute Myelogenous LeukemiaCLL: Chronic Lymphocytic LeukemiaCML: Chronic Myelogenous LeukemiaLymphomas, Hodgkins

HX: Fatigue, anorexia, wt loss, fever, bone pain, headaches, lymphadenopathy, non healing infections, thrush, bleedingPE: Pallor, gingival hyperplasia, Candida infections, lymphadenopathy, hepatosplenomegaly, lung infiltrates, bleeding, bruisingLAB: CBC, WBC Differential, Chem 18, Bone Marrow BiopsyPhiladelphia Chromosome seen in CMLAuer bodies or rods in AMLLymph node BX: Reed -Sternberg cells in Hodgkins DiseaseCT - MRI chest and abdomenCXR - Chest infiltation, pneumoniasRX: Chemotherapy, Bone Marrow Transplant

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ALL - Blasts

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CLL - Blasts

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AML Auer Rod

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CML