Hematology

Question 1

What are the key criteria in modified Well’s for PE assessment with d-dimer?

Answer 1

• Symptoms of DVT
• Other dx less likely
• HR > 100
• Immobilization in prior 4 weeks
• Prior DVT / PE
• Hemopytysis
• Malignancy with tx within 6 months or palliative

Question 2

What is the preferred AC for cancer patients?

Answer 2

LMWH

Question 3

What is standard of care for low-risk acute isolated distal DVT?

Answer 3

per 2016 ACCP guidlines, serial imaging x2 weeks (rather than AC)

Question 4

what acute isolated distal DVTs should get AC?

Answer 4

at high risk of extension - cancer pt, prior DVT, unprovoked, > 5 cm, inpatient, strongly positive d-dimer

Question 5

What is the standard treatment length for DVT?

Answer 5

3 months for provoked DVT/PE, > 3 months if unprovoked (could go 6-12 months or longer, consult specialist), Indefinite if recurrent

Question 6

Who gets worked up for underlying causes of thrombosis? (up to 5 criteria)

Answer 6

• Initial thrombosis prior to age 50
• Family hx of VTE
• Recurrent venous thrombosis
• Unusual vascular beds
• Warfarin induced skin necrosis - protein c/s could be low?

Question 7

What is the preferred AC for proximal DVT?

Answer 7

DOACs!

Question 8

If suspecting PE in pregnancy, what is the best imaging modality?

Answer 8

• Low dose chest CTPA safe in pregnancy
• If no low dose, then do CXR, do V/Q scan if normal CXR
  If abnormal CXR, do full dose CT

Question 9

What is preferred AC type in pregnancy?

Answer 9

LMWH

Question 10

What kind of PE does NOT need AC?

Answer 10

sub-segmental PE

Question 11

What is contained in the sPESI score for PE? (5 criteria)

Answer 11

sPESI: age >80; h/o cancer, CHF, chronic lung disease; HR >110 bpm; systolic BP <100 mmHg; SaO2 <90%. Zero = low risk. One or above = high risk.

Question 12

What are two imaging tests about the PE work-up beyond CTPA?

Answer 12

lower extremity ultrasound (if thinking pt higher risk, may have higher clot burden), TTE (esp if intermediate or high risk)

Question 13

What are the treatments for int-high risk PE?

Answer 13

heparin gtt, because may need to go to procedure to easy to turn off heparin

Question 14

What is the treatment for massive PE?

Answer 14

systemic thrombolytics or catheter directed thrombolysis (IR or cardiology suite)

Question 15

How is b12 absorbed? and how do RBCs look on microscopy with b12 def?

Answer 15

Vitamin B12 deficiency is most commonly related to a deficiency of intrinsic factor that is produced by the gastric mucosa and is necessary for absorption of vitamin B12 in the terminal ileum. Hematologically, it is manifested as a megaloblastic macrocytic anemia. In addition to an elevated mean corpuscular volume, the classic finding on microscopy of the peripheral smear is the presence of multiple (usually five or more) segments in the WBC nuclei.