differential diagnosis hematologic disorders. primary hematologic diseases are uncommon commonly see...
TRANSCRIPT
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Differential Diagnosis
Hematologic Disorders
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Hematologic Disorders
Primary hematologic diseases are uncommon Commonly see hematologic manifestations
due to other diseases In PT setting, most commonly see symptoms
due to use of NSAIDs, neurologic complications associated with pernicious anemia and complications of chemotherapy or radiation
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Common symptoms of hematologic disorders Changes in the hands and fingernail beds Symptoms of dyspnea, weakness, fatigue
and palpitations Neurologic symptoms
Headache Drowsiness Dizziness Syncope Polyneuropathy
Easy bruising and bleeding
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Complete Blood Count (CBC)
Male Female Hematocrit (%) 39 - 49 33 - 43
Hemoglobin (gm/dl) 14 – 18 12 – 16
RBC Count (cell/mm3) 4.2 – 5.4 3.6 – 5
Diameter 7.3 – 7.5 μ MCV 85 – 100 μm3
MCH 28 – 31 pg
MCHC 30 – 35 gm/dl RDW 11.5 – 14.5 %
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Complete Blood Count (CBC)
Total WBC 4 – 11 x 103 / mm3
Differential PMN (Segs) 45 – 70%
(Bands) 2 – 6% Lymphocytes 15 – 45%
Eosinophils 1 – 6% Basophils 0 – 2% Monocytes 1 – 10%
Platelets 145 – 400 x 103 / mm3
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Erythrocyte Disorders - Anemia
Reduction in the oxygen-carrying capacity of the blood
Results from abnormality in either the quantity or quality of erythrocytes
Most common causes are excessive blood loss, increased destruction of erythrocytes and decreased production of erythrocytes
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Erythrocyte Disorders - Anemia
4 broad categories seen in PT: Iron deficiency associated with GI blood loss
secondary to NSAID use Chronic and inflammatory disorders such as
RA or SLE Neurologic conditions seen with pernicious
anemia. Common complication of chemotherapy and bone marrow metastasis
Infectious diseases such as TB or AIDS and neoplastic disease or cancer
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Erythrocyte Disorders - Anemia
With slow onset, symptoms may not be noticeable until hemoglobin concentration and hematocrit levels are 50% depleted
Symptoms of rapid onset include dyspnea, weakness and fatigue, and palpitations
No change in systolic BP, but diastolic BP may be lower than normal
Increased resting pulse rate
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Erythrocyte Disorders - Anemia
Pale hands Evaluate at heart level Although pale, hands should feel warm
Diminished exercise tolerance With progression of anemia, dyspnea,
tachycardia and palpitations begin to occur at rest
Exercise should be prescribed cautiously and monitored closely in anemic patients
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Erythrocyte Disorders - Polycythemia
AKA erythrocytosis Increase in both the number of RBCs and the
concentration of hemoglobin Increased whole blood volume and increased
blood viscosity Increased tendency and risk of clotting Increased viscosity diminishes blood supply
to the brain and other vital tissues May contribute to formation of thrombi
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Erythrocyte Disorders - Polycythemia
Primary – Relatively rare neoplastic disease of the bone marrow
Secondary – As a result of decreased oxygen supply to the tissues High altitudes Heavy tobacco smoking Chronic heart and lung disorders (especially
congenital heart defects)
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Erythrocyte Disorders - Polycythemia
Symptoms are often vague and unnoticeable Often diagnosed after a sudden complication
(stroke or thrombosis) Occasionally exhibit symptoms of increased
skin coloration and elevated blood pressure Gout is sometimes a complication Patients may develop peripheral neuropathies If untreated, can lead to gangrene and loss of
tissue
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Erythrocyte Disorders – Sickle Cell Anemia Autosomal recessive disorder with an
abnormal form of hemoglobin Genetic defect causes the hemoglobin to
aggregate in long chains and alters the shape of the cell
The sickled or curved shape of the cell causes it to be unable to squeeze through tiny blood vessels
Tissue is therefore deprived of adequate blood supply and oxygen
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Sickle Cell Anemia
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Erythrocyte Disorders – Sickle Cell Anemia Pain is most common acute symptom
Due to formation of clots Ischemic tissue damage may last for 5-6 days
Stress from infection, dehydration, emotional disturbances, fever, strenuous physical exertion or fatigue may increase symptoms
CVA is the most severe manifestation
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White Blood Cells
Neutrophils Increase – infection, glucocorticoids, uremia,
RBC destruction Decrease – chemotherapeutics, viral &
overwhelming bacterial infection, dialysis Increased risk of infection
Lymphocytes Increase – viral infections, TB, leukemia Decrease – HIV (TCD4)
Decreased immunosurveillance
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White Blood Cells
Monocytes Increase – Leukemia, TB, collagen vascular
diseases Decrease – HIV (TCD4)
Eosinophils Increase – allergies, parasite infection, some
neoplasia Decrease – infections, stress, trauma
Basophils Increase – leukemia, some infections
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Leukocyte disorders
Disorders of leukocytes are recognized as the body’s reaction to disease processes and noxious agents
Lymphocytes produce antibodies and initiate the immune response to fight infection
Monocytes form macrophages in response to foreign substances such as bacteria
Granulocytes contain lysing agents capable of digesting foreign materials, bacteria and infectious substances
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Leukocyte disorders - Leukocytosis
Leukocyte count >10,000/mm3 Commonly seen with the body’s response to:
Bacterial infections Inflammation or tissue necrosis Metabolic intoxications Acute hemorrhage Acute appendicitis Pneumonia Acute rheumatic fever
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Leukocyte disorders - Leukopenia
Reduction in number of circulating leukocytes (<5000/microliter)
Never beneficial Seen with bone marrow failure (common
following chemotherapy or radiation), overwhelming infections, dietary deficiencies and in autoimmune diseases
The lowest point the WBC count reaches after chemotherapy occurs 7-14 days after treatment. At this time the client is extremely susceptible to opportunistic infections.
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Platelet disorders
Platelet functions Hemostasis (stopping bleeding) Maintaining capillary integrity
Life cycle is 8-10 days in circulation Affected by anticoagulation drugs, including
aspirin and heparin Affected by diet
Lecithin prevents coagulation Vitamin K promotes coagulation
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Platelet disorders
Exercise boosts the production of chemical activators that destroy unwanted clots
Platelets are easily suppressed by radiation and chemotherapy
Liver disease often causes suppression of production of Vitamin K which will in turn lessen coagulation
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Platelet disorders - Thrombocytosis
Abnormally high platelet count Usually a temporary condition
Compensatory mechanism after severe hemorrhage, surgery and splenectomy
Iron deficiency Occult neoplasm
Blood viscosity is increased resulting in clots and occasionally thrombosis
Symptoms of splenomegaly and easy bruising may not occur until platelet count exceeds 1 million/mm3
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Platelet disorders - Thrombocytopenia
Platelet count is abnormally low Most common causes seen in PT
Bone marrow failure from radiation treatment, leukemia or metastatic cancer
Drug-induced platelet reduction (Sometimes seen with RA patients or with treatment of inflammatory conditions)
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Platelet disorders - Thrombocytopenia
GI bleeding and CNS bleeding may be life threatening
PT should be observant for multiple bruising (without known injury), external hematomas and the presence of multiple petechiae
These symptoms indicate platelet count <100,000/mm3
Strenuous exercise, straining or bearing down could cause hemorrhage of the eyes or brain
Contact MD immediately
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Hemophilia
Hereditary blood clotting disorder Due to abnormality in Factors VIII and IX Common clinical signs
Hemarthrosis – Bleeding into the joint Muscle hemorrhage
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Hemophilia - Hemarthrosis
May result from trauma, stress or spontaneously Most often affects (in order) the knee, elbow, ankle,
hip and shoulder Severity of symptoms vary but include pain, swelling,
tingling, stiffness/decreased ROM, tenderness, heat Treat initial symptoms with Factor replacement and
joint immobilization Repeated hemarthrosis results in progressive loss of
motion, muscle atrophy and flexion contractures
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Hemophilia – Muscle hemorrhage
Most common in the flexor muscle groups Iliopsoas Gastocnemius Flexor surface of the forearm
May result in deformities Hip flexion contracture Equinus position of the foot Volkmann’s deformity of the forearm
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Hemophilia – Muscle hemorrhage
Loss of sensation in the anterior thigh may occur with bleeding into the iliopsoas
Distention of the muscles may also cause lower abdominal pain To reduce the distention and pain, a position
of hip flexion is preferred Sometimes mistaken for appendicitis
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References
Goodman CC, Snyder TE. 2007. Screening for Hematologic Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p261-273.
Milone MC. Sickle Cell Anemia. Retrieved 06/04/07 from the World Wide Web http://www.nlm.nih.gov/medlineplus/ency/imagepages/1223.htm