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Royal College Exam > Hematology > Flashcards

Hematology Flashcards

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1
Q

What are risk factors for lymphoma?

A
  1. Infection: HIV, HBV, HCV, HTLV1, EBV, H. pylori.
  2. Immune: RA, Crohn’s celiac, sjogren’s, HIV, post-solid organ transplant.
  3. Family history.
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2
Q

What are the Ann-Arbor staging criteria for lymphoma?

A

I - one region of nodal involvement.
II - multiple areas of nodes on one side of diaphragm.
III - both sides of diaphragm.
IV - extranodal (including bone marrow) involvement.

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3
Q

When do you not use DOAC for VTE?

A
  1. GI, GU or intracranial malignancy
  2. BMI>40 or wt>120 kg
  3. Renal failure CrCl < 15
  4. APLA syndrome
  5. Pregnancy/breastfeeding
  6. High clot burden (extensive PE, post thrombolysis, iliofemoral DVT, submassive PE).
  7. Drug interactions
  8. Plt < 50
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4
Q

What are indications for warfarin for VTE?

A

Mechanical valvse (INR 2.5-3.5 mitral, 2-3 aortic)
APLA (INR 2-3)
ESRD
Breastfeeding (INR 2-3)

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5
Q

When should you treat distal DVT?

A 
Severe symptoms
Multiple deep veins involved
Active cancer
>= 5cm long
Close to popliteal vein
Progression
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6
Q

When should you treat superficial vein thrombosis?

A
  1. <= 3cm from saphenofemoral junction (treat for 3 months full dose)
  2. > 3cm from saphenofemoral junction and >= 5cm long (prophylaxis for 45 days)
  3. > 3cm from saphenofemoral junction + <5cm long - NSAIDs and monitor on serial U/S
    * Consider treating all pregnant, past clots, severe symptoms.
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7
Q

How do you manage with recurrent VTE on anticoagulation?

A

Verify compliance, INR, consider malignancy
If on DOAC/VKA -> switch to LMWH x 1 mo.
If on LMWH -> increase dose by 25-33%

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8
Q

What are diagnostic tests for von willebrand disease?

A
  1. VWF Ag quantity
  2. Ristocetin cofactor (VWF activity)
  3. Factor VIII level (VWF protects FVIII)

aPTT can be normal, hence not a good screening test

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9
Q

What are the 3 types of VWF disease?

A

Type 1 - mild to mod. Quantitative deficiency (Low VWF Ag = Low VWF activity)

Type 2: Qualitative def (low to normal VWF Ag, VERY LOW VWF activity)

Type 3: NO VWF produced (very low factor VIII) - behaves like hemophilia A

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10
Q

When do you avoid DOACs in cancer-associated VTE?

A
  1. GI, GU, intracranial malignancy
  2. Nephrostomy tubes or mucosal abnormalities
  3. Concomitant antiplatelet therapy
  4. High clot burden - extensive PE, sub-massive PE, post-thrombolysis, iliofemoral DVT
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11
Q

When should you consider outpatient DVT prophylaxis in cancer patients?

A

Khorana score >1 (i.e. high risk ambulatory cancer patients) can be offered apixaban 2.5 mg bid or rivaroxaban 10 mg daily (ASCO)

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12
Q

How do you reverse warfarin?

A

INR>9 = hold and give vitK 2.5-5 mg po
INR 4.5-9 = hold and lower warfarin dose
Minor bleed = vit K and support
Major bleed = IV vit K and PCC 2000 units x 1

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13
Q

Which patients with PE can be discharged home

A

Stable, no bleeding, no liver/kidney disease, platelets>70, no RV strain (STD and TWI in V1-3) or elevated troponin, compliant and access to healthcare.

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14
Q

How do you treat VWF disease?

A

Acute bleeding/periop:

  • can give DDAVP to increase VWF level (does not work in type 2 and 3)
  • VWF and FVIII concentrate
  • Cryoprecipitate (type 2 and 3)
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15
Q

What are treatment options for ITP?

A

Dex 40 x4 days or Pred 0.5-2mg/kg (pred>dex for preg) + IVIG

2nd line splenectomy, ritux, TPO-R agonist

Admit if new ITP and platelets<20

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16
Q

How do you treat TTP while awaiting PLEX?

A
  1. FFP 3-4 units then 1 unit q2h.
  2. Plt if life threatening bleed
  3. Prednisone 1mg/kg/d or Solumedrol IV 1g/day
  4. Folic acid 5mg OD
  5. ASA if trop rise
  6. DVT proph when Plt >50
17
Q

How do you manage HIT?

A
  1. IV argatroban or SC fonda, danaparoid if pregnant.
  2. Add warfarin when plt>150 and stop initial tx when INR 2-3 for >5d
  3. Bilateral leg dopplers
  4. Treat for 1 month if no VTE, 3 months if VTE.
18
Q

What is the indication of rasburicase over allopurinol?

A

AKI
Uric acid > 535 umol/L
No response to allopurinol

*Must not have G6PD Def

19
Q

What are indications for irradiated blood products?

A

Prevent transfusion related GVHD:

T cell deficiency
Hodgkin’s lymphoma
Chemotherapy with purine antagonists
HSC transplant recipient (allogenic = life, autologous = 3 months)

20
Q

What are indications for treatment for CLL?

A 
Lyphadenopathy > 10cm or symptomatic
Splenomegaly > 6cm below costomargin or symptomatic
Progressive cytopenia/BM failure
AIHA/ITP with poor steroid response
Extranodal involvement
21
Q

What is the diagnostic criteria for MGUS?

A

M spike < 30g/L AND
BM plasma cell < 10% AND
No end organ dmg or CRAB symptoms

22
Q

What is the diagnostic criteria for smoldering myeloma?

A

M spike >= 30g/L or UPEP-spke >= 500mg/24hr AND/OR
BM plasma cell 10-60% AND
No end organ dmg or CRAB symptoms

23
Q

What is the diagnostic criteria for multiple myeloma?

A

BM plasma cell >=10% or plasmacytoma AND either

End organ dmg (CRAB) OR one of
BM clonal plasma >=60%, focal lesions that are >=5mm on MRI, FLC raio >=100

24
Q

What are risk factors in MGUS progression and how do they affect subsequent mgt?

A
  1. M protein >= 15g/L
  2. Non igG M protein
  3. FLC ratio <0.26 or >1.65

0/3 RF -> low risk MGUS, SPEP in 6 months then q2yr (no BM bx or bone imaging)

> =1/3 RF -> high risk MGUS: BM bx, skeletal survey, CT abdo if IgM

25
Q

What are treatment options for MDS?

A

Low cytogenic risk: supportive, lenalidomide

High cytogenic risk: supportive, HSC txt, azacitadine

26
Q

How do you treat polycythemia vera?

A

Low risk age <60 and no thrombosis
High risk age >=60 or thrombosis h

Everyone ASA 81mg, HCT <45% with phlebotomy

High risk add hydroxyurea or ruxolitinib if unable to tolerate

27
Q

What are primary causes of TMA?

A
  1. TTP (low ADAMTS13)
  2. aHUS - complement-mediated
  3. HUS (Shiga)
  4. Drugs
28
Q

What are secondary causes of TMA?

A
  1. Pre-eclampsia/HELLP
  2. Malignancy
  3. Infection
  4. Autoimmune - SRC, APLA, SLE, vasculitis
  5. Transplant
  6. Hypertensive emergency
  7. DIC

Royal College Exam (15 decks)

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