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120 Cards in this Set

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  • Back
What characteriistics of lymph nodes are considered normal?
solf, flat, submandibular nodes, <1dm in children and adults
inguinal nodes up to 2cm in health adults.
What is the most common causes of lymphadenopathy?
>2/3 nonspecific causes or URI
What percentage of lymphadenopathy are malignant?
<1%
What constitutes localized lymphadenopathy? What constitutes generalized?
localized: involvement of s single anatomic area
generalized: 3 or more noncontiguous areas
If you find a benign lymph node <1cm, what do you want to exclude initially?
mono and toxoplasmosis
What are the characteristics of lymphoma?
large, discrete, symmetric, rubbery, mobile, firm, nontender
What are the characteristics of metastatic cancer in the lymph nodes?
hard, nontender, nonmovable
What are the causes of tender lymph nodes?
from rapid enlargement:
- inflammatory process
- acute leukemia
What can cause splenomegaly?
Mono, sarcoidosis, toxoplasmosis, cat-scratch disease
lymphoma
acute or chronic leukemia
SLE
other hematological disorders
You are doing an exam on a patient when you find large, tender lymph nodes n the occipital region. What might you suspect (generally)?
An infection of the scalp
If you have preauricular lymph nodes, what might be the origin?
conjunctivitis
cat-scratch disease
URI, oral and dental lesions, mononucleosis, and other viral illness might cause what lymphadenopathy?
cervical
URI, oral and dental lesions, mononucleosis, and other viral illness might cause what lymphadenopathy?
cervical
Where is metastatic cancer primarily from?
head and neck, breast, lung, and thyroid
True or False: Supraclavicular and scalene lymphadenopathy is ALWAYS abnormal.
True
Supraclavicular and scalene lymph nodes drain what regions?
regions of the lung and retroperitoneal space
What might supraclavicular and scalene lymphadenopathy imply?
lymphomas, other cancers, infectious processes
Specifically, supraclavicular nodes get metastasis from what cancers?
lung, breast, testis, or ovarian cancers
What infectious processes might cause supraclavicular lymphadenopathy?
tuberculosis, sarcoidosis, toxoplasmosis
Virchow's node primarily gets metastasis from what area?
from a GI primary
What causes axillary lymphadenopathy?
injuries or infections of upper extremity
melanoma, lymphoma, breast cancer
What causes inguinal lymphadenopathy?
infections or trauma of lower extremity
STD's - LV (from chlamydia), primary syphilis, herpes, chancroid
lymphomas, metastatic cancer from rectum, genitalia, LE (melanoma)
In a young patient, what would cause mediastinal lymphadenopathy?
mononucleosis, sarcoidosis, tuberculosis
In an older individual, what would you suspect with mediastinal lymphadenopathy?
primary lung cancer, lymphomas, metastatic cancer (lung usually), tuberculosis, fungal infection, sarcoidosis
What are some important findings if you detect mediastinal lymph nodes?
cough or wheezing from airway compression
hoarseness from recurrent laryngeal nerve involvement
dysphagia from esophageal compression
swelling of neck, face, or arms due to compression of superior vena cava or subclavian vein
What is the most common cause of intraabdominal or retroperitoneal lymphadenopathy?
usually malignancy
What labs are important in with lymphadenopathy
CBC - leukemias, EBV, CMV, lymphoma
Serological studies
CXR
CT, MRI, US - differentiate from malignant lymph nodes
Lymph node biopsy
When doing a lymph node biopsy, what do you do first?
biopsy any mucosal legion
then excisional biopsy of the LARGEST node first
What are the symptoms of splenomegaly?
pain and heaviness in LUQ
early satiety
If you suspect splenomegaly, what imaging do you do?
US
CT, MRI
What is the differential for massive splenomegaly?
Non-Hodgkin's lymphoma
Chronic lymphocytic leukemia (CLL)
Hairy cell leukemia
Chronic myelogenous leukemia (CML)
Myelofibrosis with myeloid metaplasia
Polycythemia vera
What is the most significant risk factor for cancer?
Age
What methods are used to diagnose cancer?
invasive tissue biopsy
fine-needle aspiration (thyroid nodules)
histology, tumor markers, history (if there is no apparent primary site)
What is used to clinically stage cancer?
PE
radiographs
isotopic scans
CT and other imaging
What classification is used for colorectal cancers? Hodgkin's disease?
Duke's classification
Ann Arbor classification
What are the most common side effects of cancer treatment?
Nausea and vomiting
Febrile neutropenia
Myelosuppression
What drugs can be used to treat the nausea and vomiting associated with cancer treatment?
Prochlorperazine (Compazine)
Dexamethasone
Ondansetron (Zofran)
Reglan
True or False: Cancer therapy is more toxic and less effective with malnutrition.
True
What drug can be used to increase nutrition in cancer patients?
Megestrol acetate (Megace)
What are the most common causes in death in cancer patients?
Infection --> circulatory failure
Respiratory failure
Hepatic failure
Renal failure
What age(s) does Hodgkin's Disease peak?
peak in 20s, peak in 60s
What are the risk factors for Hodgkin's Lymphoma?
HIV
EBV
In Hodgkin's Lymphoma, what are the clinical findings?
one or more enlarged lymph nodes in neck, armpit, or groin
fever
night sweats
weight loss
generalized pruritis
When should you suspect Hodgkin's lymphoma?
persistent and painless enlargement of lymph nodes without an apparent infection
enlarge lymph nodes in chest and abdomen found on CXR or CT
How do you diagnose Hodgkin's lymphoma?
Biopsy of affected lymph node: Reed Sternberg cells (large cancer cells with >1 nucleus)
What are the stages of Hodgkin's lymphoma?
Anne Arbor:
Stage I - one lymph node region involved
Stage II - involvement of two lymph node areas on one side of the diaphragm
Stage III - lymph node regions involved on both sides of the diaphragm
Stage IV - disseminated disease with bone marrow or liver involvement
A - lacks constitutional symptoms
B - 10% weight loss over 6 months, fever, or night sweats
If Hodgkin's Lymphoma is suspected, what tests would you do?
CBC
Sed rate
Liver and kidney function
CT or chest, abdomen, and pelvis
PET scan
What is th emost sensitive test for determining the stage and evaluating response to treatment in Hodgkin's Lymphoma?
PET scan
Radiation and limited chemotherapy is used to treat what stage(s) of Hodgkin's lymphoma?
Stage IA and IIA
How do you treat Stage IIIB and IV Hodgkin's Lymphoma?
combined chemotherapy
What is the 10-year survival rate of IA and IIA Hodgkin's lymphoma? 5-year survival for Stage IIIB and IV?
>80%
50-60%
What are the side effects of chemotherapy?
Temporary or permanent sterility
Increased risk of infection
Reversible hair-loss
Potential damage to other organs (heart and lungs)
Risk of developing leukemia
Risk of non-Hodgkin's lymphoma or other cancers
Non-Hodgkin's lymphoma develops from what cells? What is the most common cell?
B or T lymphocytes
B lymphocytes most common
What are the risk factors for non-Hodgkin's lymphoma?
organ transplant patients
HIV
other immunodeficiency states
What is the etiology of non-Hodgkin's lymphoma?
Infectious agents (H. pylori, gastric MALT lympoma)
Chemical exposure
What are the clinical findings of non-Hodgkin's lymphoma?
Painless lymphadenopathy, isolated or widespread
Cough and SOB (nodes in the chest)
Anorexia, constipation, abdominal pain, swelling in legs (lymph nodes in abdomen)
lymphomas in bloodstream and bone marrow
- anemia
- neutropenia
- thrombocytopenia
- FUO
Constitutional symptoms
What are the clincal findings in children with non-Hodgkin's lymphoma?
anemia, rashes, neurological symptoms (weakness and abnormal sensation)
How do you diagnose non-Hodgkin's lymphoma?
Biopsy of enlarged lymph node
How do you stage non-Hodgkin's lymphoma?
Ann Arbor (same as Hodgkin's)
How do you treat non-Hodgkin's lymphoma stage I and II indolent?
radiation limited to site of lymphoma and adjacent areas
How do you treat non-Hodgkin's lymphoma stage I and II aggressive?
combination chemotherapy with localized radiation
allogeneic transplantation
How do you treat non-Hodgkin's lymphoma stage III and IV indolent?
combination or single chemotherapy
Rituximab
How do you treat non-Hodgkin's lymphoma stage III and IV aggressive?
combination chemotherapy
- CHOP
- cyclophophamide
- hydroxydoxorubicin
- vincristine
- prednisone
What is multiple myeloma?
malignancy of plasma cells characterized by replacement of the bone marrow, bone destruction, and paraprotein formation
What is the etiology of multiple myeloma?
unknown
What are the clinical findings of multiple myeloma?
Bone pain (back and ribs)
Bone lesions
Pathologic fractures
Susceptibility to bacterial infections
Renal failure
Hyperviscosity
Neurologic symptoms
In patients with multiple myeloma, what's the most common cause of their renal failure?
hypercalcemia
What infections are multiple myeloma patients particularly susceptible to?
pneumonias and pyelonephritis
The hyperviscosity in multiple myeloma patients can cause what?
impaired circulation
Raynaud's phenomenon
The neurological symptoms of multiple myeloma are caused by what?
hypercalcemia (lethargy, weakness, depression, confusion)
hyperviscosity (headaches, fatigue, visual disturbances, retinopathy)
bony damage and collapse (cord compression, radicular pain, loss of bowel and bladder control)
How do you diagnose multiple myeloma?
marrow plasmocytosis
lytic bone lesions
serum and/or urine M component
What is the differential for multiple myeloma?
monoclonal gammopathy of undetermined significance (MGUS)
metastatic carcinoma
lymphoma
bone neoplasms (sarcoma)
What are the characteristic lab findings associated with multiple myeloma?
normochromic, normocytic anemia
Rouleaux formation on peripheral smear
What lab findings do you see with multiple myeloma?
normochromic, normocytic anemia
Rouleaux formation on peripheral smear
hypercalcemia (bone lysis)
high BUN/Cr
high uric acid
high sed rate
high total protein
proteinuria
high LDH
hyperviscosity
low sodium
low ion gap
abnormal serum protein electrophoresis
normal serum alk phos
True or False: Since multiple myeloma has bone lesions, a bone scan can be helpful in diagnosis.
False: They are not helpful since lesions are not blastic.
On imaging, what do you expect to see in multiple myeloma?
punched out lytic lesions or osteoporosis
How do you treat multiple myeloma?
systemic chemotherapy
symptomatic supportive care
hydration
bisphosphonates
control hypercalcemia and hyperuricemia
treat anemia with epoetin alfa
What drugs do you want to avoid in patients with multiple myeloma?
nephrotoxic drugs
In younger patients with multiple myeloma, what might you consider as a treatment?
autologous bone marrow transplantation
How do you treat the anemia associated with multiple myeloma?
epoetin alfa
What is the prognosis for multiple myeloma?
median survival - 3 years
What is chronic myelogenous leukemia?
a myeloproliferative disorder that results in overproduction of myeloid cells
What is the characteristc chromosomal abnormality associated with chronic myelogenous leukemia (CML)?
Philadelphia chromosome
What age group gets CML?
middle age (median age 42)
What do CML patients present with?
fatigue
night sweats
low-grade fever
abdominal fullness related to splenomegaly
elevated WBC found incidentally
What are the CML symptoms related to leukostasis?
blurred vision
respiratory distress
priapism
WBC sometimes >500,000
On examination, what do you see in CML patients?
splenomegaly
sternal tenderness
fever without infection
bone pain
blast crisis - bleeding and infection
What lab values would you expect to see in a patient with chronic myelogenous leukemia?
left shift myeloid series
mature forms dominating
blasts <5%
basophilia and eosinophilia
platelet count normal or elevated
elevated B12
elevated uric acid
Philadelphia chromosome
What signs/symptoms do you see as a patient progesses to accelerated and blast phases?
progressive anemia
thrombocytopenia
blasts increase in blood and marrow >30%
What is the differential for CML?
leukocytosis secondary to infection
other myeloproliferative diseases
How do you treat CML?
Emergent leukopheresis with myelosuppressive therapy (for extreme leukocytosis)
Imatinib mesylate (chronic disease)
allogeneic bone marrow transplant
What is the curative treatment for CML?
allogeneic bone marrow transplant
What is acute leukemia?
malignancy of the hematopoietic cells
malignant cell loses it's ability to mature and differentiate
cells proliferate in an uncontrolled fashion and replace normal bone marrow elements
What causes acute leukemia?
often no clear cause
radiation
toxins (benzene)
chemotherapeutic agents
What is the most common cancer in children?
acute lymphoblastic leukemia (ALL)
What are the most common infections with acute leukemia patients?
Gram negative bacteria (E. coli, klebsiella, pseudomonas) or fungi (candida, aspergillus)
Cellulitis, pneumonia, perirectal infections
What is hyperleukocytosis? What symptoms does it have?
elevated blast count usually >200,000
impaired circulation - headache, confusion, dyspnea
What do you do for hyperleukocytosis?
emergent leukapheresis and chemotherapy
In acute leukemia, what might you see on examination?
pale
purpura and petechiae
stomatitis and gum hypertrophy
variable enlargement of liver, spleen, and lymph nodes
bony tenderness over sternum, tibia, and femur
What labs do you expect with acute leukemia?
pancytopenia with circulating blasts >20%
hyperuricemia
DIC
What marker do you see with ALL?
surface markers characteristic of primitive lymphoid cells
What characteristic cell do you see with AML?
Auer rod - eosinophilic needle-like inclusion in cytoplasm
How is ALL classified?
by immunologic phenotype:
- common
- early B lineage
- T cell
What's the differential for AML?
other myeloproliferative syndromes (ex. CML, MDS)
What is the differential for ALL?
CML, lymphoma, hairy cell leukemia, mononucleosis, pertussis
What is the criteria for remission in acute leukemia?
Normal peripheral blood
Normal bone marrow
Normal clinical status
What are the treatments for acute leukemias?
chemotherapy
autologous and allogeneic transplantation
What is chronic lymphocytic leukemia (CLL)?
clonal malignancy of B lymphocytes
usually indolent, with slowly progressive accumulation of long lived small lymphocytes
immunoincompetent cells
What are the clinical manifestations of CLL?
immunosuppression
bone marrow failure
organ infiltration with lymphocytes
Who usually gets CLL?
people over the age of 50 (90%)
What are the symptoms of CLL?
fatigue
lymphadenopathy
enlargement of spleen and liver
most are incidentally discovered to have lymphocytosis
How do you stage CLL?
Stage 0 - lymphocytosis only
Stage 1 - lymphocytosis + lymphadenopathy
Stage 2 - organomegaly
Stage 3 - Anemia
Stage 4 - Thrombocytopenia
What is prolymphocytic leukemia?
a more aggressive variant of CLL
What is Richter's syndrome?
a large cell lymphoma that can occur with CLL
What labs would you expect to see with CLL?
WBC >20,000
75-98% circulating cells are lymphs
normal hematocrit and platelet count at presentation
bone marrow variable infiltrated with small lymphs
What is the differential for CLL?
Viral infections
pertussis
How do you treat early CLL?
no specific treatment
What are the indications for treatment of CLL?
progressive fatigue
symptomatic lymphadenopathy
anemia
thrombocytopenia
If a patient with CLL also has an autoimmune hemolytic anemia or immune thrombocytopenia, how do you treat it?
prednisone or splenectomy
avoid fludarabine (a treatment for standard CLL)
In CLL patients, who gets allogeneic transplants?
patients whose disease is not controlled by standard therapies