Hematology Flashcards
Virchows triad
stasis, hypercoagulability, endothelial injury
What is the D Dimer cutoff?
500 mcg/L
Consider Age x 10 for > 50 years old
Very sensitive, not specific
What do you do if clinical suspicion for DVT is high but US is negative?
Repeat US in 5-7 days
If someone is diagnosed with VTE, what general workup should be done to evaluate for cancer?
- complete H and P with rectal and pelvic exam
- CBC, LFT, CXR, stool guaiac
Extensive workup not necessary or effective as cancer usually makes its presence known prior to VTE
If someone is diagnosed with VTE, when should you consider workup for thrombophilia?
- Initial thrombosis prior to 50
- family history of VTE
- recurrent VTE
- unusual vascular beds (not extremities)
- Warfarin-induced skin necrosis
What testing should be obtained in thrombophilia workup?
- Protein C and S
- Fibrinogen
- antithrombin III
- Factor V leiden
- lupus anticoagulant
- anticardiolipin Ab
- prothrombin 20210 gene mutation
Test of choice for diagnosis of PE
CT angiogram
Test of choice to diagnose PE in pregnancy
VQ scan
or low dose CTA
Preferred treatment modality for VTE according to ACCP 2016 guidelines
- DOAC when cancer not present
- cancer associated VTE use LMWH (lovanox)
Management of distal DVT according to 2016 ACCP guidelines
- if no severe symptoms and low risk for extension, then serial imaging x 2 weeks rather than anticoagulation
- risk factors for extension: high D dimer, > 5 cm thrombus, close to proximal veins, no reversible provoking factors, active cancer, hx of VTE, inpatient status
What criteria should be met for patient to be treated outpatient for VTE
- ambulatory and stable - no O2, IV Abx, IV pain control
- low risk of bleed
- no renal insufficiency
- reliable patient and system
Duration of treatment of VTE according to 2016 ACCP guidelines
- 3 months for provoked DVT/PE
- 3+ months if unprovoked DVT/PE
- indefinite if recurrent DVT/PE
According to 2016 ACCP guidelines, what is the role of the following in management of DVT/PE?
- movement
- compression stockings
- movement recommended over bedrest
- compression stockings non-beneficial
Management of subsegmental PE according to according to 2016 ACCP guidelines
Clinical surveillance recommended over anticoagulation if the following
- no proximal pulm artery involvement
- no proximal DVT in legs
- low risk for recurrent VTW
- fairly healthy patient
Treatment of choice for VTE in pregnancy
LMWH (lovenox)
- this is due to more data than DOACs. Warfarin strictly contraindicated
- doesn’t cross placenta and safe SOR B
- epidural anesthesia 12 hours after last dose of LMWH SOR C
- Convert from LMWH to unfractionated heparin for last month of pregnancy
When should anti coagulation be restarted in postpartum?
- 4-6 hours after vaginal delivery
- 6-12 hours after C section delivery
What are the recommendations for contraception in history of VTE
- avoid estrogen
- Use of progesterone controversial. Per NIH it is OK with first DVT but not if recurrent
Major causes of normocytic, normochromic anemia
- acute blood loss
- acute hemolysis
- hypersplenism
- anemia of chronic disease (most common cause)
How do you monitor response to iron therapy?
- Reticulocyte count should normalize in 5-7 days
- Hct 4-6 weeks
- iron stores 4-6 months
**should stay on iron for at least 4-6 months
Management of penicillin in children with sickle cell - who should be on it and for how long?
- all types of SSD
- Pen V 125 mg BID from 3 mo to 3 years (fetal Hb stays 3-6 months)
- Pen V 250 BID from 3-5 years
- after age 5 its controversial
Who should be on hydroxyurea for sickle cell disease?
- Age 9-42 months (3.5 years)
- Adults who have had 3 or more crisis in 12 months (decrease vasocclusive effects and risk of acute chest syndrome)
When re-initiaing hydroxyurea in sickle cell disease, what counseling or monitoring needs to take place?
- contraceptive counseling: teratogen and present in breast milk
- monitor CBC and reticulocyte xount Q4Weeks
- disease modifying therapy that increases levels of HbF
What are the most common signs and symptoms of multiple myeloma?
Sx:
- Anemia (73%)
- bone pain
- elevated creatinine
- hypercalcemia
- N/V, weakness, recurrent infections, weight loss
DX:
- abnormal plasma cells in marrow
- monoclonal protein in serum/urine
- bone lesions
When suspecting multiple myeloma, what is the workup?
CBC with Diff Creatinine LDH Beta-2 macroglobulin immunoglobulin studies skeletal survey BM biopsy
After diagnosis of multiple myeloma, what is the management?
primary care:
- Bisphosphonate tx upon diagnosis (inhibit osteoclasts)
- DVT prevention
- prophylactic Abx
- referral to oncology for chemo and stem cell transplant
In hemophilia, what action can be taken to help improve joints from destruction?
early initiation of factor concentrate treatments
Pentad of thrombotic Thrombocytopenic purpura (ttp)
- thrombocytopenia with purpura
- fever
- microangiopathic hemolytic anemia (MAHA)
- acute renal insufficiency (HUS)
- neurological symptoms (TTP)
rare for all 5 to be present
Causes of thrombotic Thrombocytopenic purpura (ttp)
- idiopathic
- ADAMTS13 deficiency: protease of VWF, long polymers of VWF attract platelets
- shiga toxin from E coli (0157 H7)
- collagen vascular disease
- meds: Plavix
Treatment of thrombotic Thrombocytopenic purpura (ttp)
plasma exchange therapy is curative
Acute lymphoblastic leukemia (ALL)
- age group
- findings
- children
- fever, bleeding***
- MSK sxs
- hepatosplenomegaly (75%), lymphadenopathy (60%)
Acute Myelogenous leukemia (AML)
- age group
- findings
- adults
- fever, bleeding***
- fatigue, weight loss
- anemia
- thrombocytopenia
Chronic Myelogenous leukemia (CML)
- age group
- findings
- adults
- asymptomatic
- discovered with leukocytosis on CBC
- splenomegaly
Chronic Lymphocytic leukemia (CLL)
- age group
- findings
- adults
- asymptomatic
- discovered with leukocytosis on CBC
- Hepatosplenomegaly and lymphadenopathy
Workup in adults with elevated WBC on CBC while asymptomatic
- repeat CBC
- peripheral smear
- flow cytometry
- oncology referral
A child with sickle cell disease is on your panel. What screening image do they need yearly?
Annual screening with transcranial doppler ultrasound to eval risk of stroke age 2-16 years
