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Houseman (break your leg) > Hematology > Flashcards

Hematology Flashcards

1
Q

DVT

A 
Ward complain
 - Bed rest + elevation
 - ECG
 - Warfarin diet
 - Avoid IMi injection
 - SC enoxaparin 0.4mL q12H (if 40kg), stop when INR >1.8
 - Start warfarin with 3mg for D1, then PO 2mg daily aim INR 2-3
 - Other option
 >>>> SC Innohep 10000 AXA IU q24H
  • IVC filter if CI with anticoagulant
  • Consult med x DVT

Admission
Pretest possibility of DVT (well’s score)
- CA (receiving treatment for CA previous 6mo/current palliative)
- Paralysis/ paresis/ plaster immobilization of lower extremity
- Bedridden 3D+, major surg 4W
- Localized tenderness along deep venous system
- Entire leg swollen
- Calf circumference 3cm larger than asymptomatic side (measure 10cm below tibial tuberosity)
- Pitting edema unilat
- Collateral superficial vein (non-varicose)
- other diagnosis less likely

  • bed rest
  • DAT/ warfarin diet
  • Obs q4H
  • Calf circumference x1 then daily
  • Bld x CBC LRFT clotting bone INR RG D-dimer
  • Thrombophilia investigation: antithrombin, protein C/S, antiphospholipid antibody, lupus anticoagulant, anticardiolipin, genetics testing, flow cytometry
  • CXR
  • ECG
  • Urgent doppler USG LL
  • SC enoxaparin 40mL q12H
  • USG abdomen early for pelvic obstruction if DVT confirmed
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2
Q

Leukemia

A

Admission

  • Reverse isolation
  • DAT (low purine diet)
  • Obs q4H
  • Chart IO
  • Bld x CBC d/c LRFT clotting bone RG
  • Bld x urate, LDH, T&S, Coombs’, D-dimer, fibrinogen
  • HBsAg, anti-HCV, anti-HIV, CMV serology, G6PDH
  • Bld C/S if fever >38
  • Bld x cytoflowmetry
  • Sputum x C/S
  • MSU x stix, C/S
  • CXR
  • Resume usual meds
    • PO panadol 500mg q4H prn
    • PO allopurinol 300mg daily
  • +- IVF if need
  • +- Abx if infection

Bone marrow exam

  • Memo x blood bank for CMV- blood product
  • Consult hematology
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3
Q

MM

A

Admission

  • If hyperCa, reverse AG ratio, osteolytic lesion
  • DAT (low purine diet)
  • Obs q4H
  • Chart IO
  • Bld x CBC d/c LRFT clotting bone RG
  • Bld x urate, LDH, T&S, Coombs’, D-dimer, fibrinogen
  • HBsAg, anti-HCV, anti-HIV, CMV serology, G6PDH
  • SPE, Ig pattern
  • Urine x bence jones protein
  • +- bld x cytoflowmetry (askCMO)
  • Sputum x C/S
  • MSU x stix, C/S
  • CXR
  • Skeletal survey
  • Resume usual meds
    • PO panadol 500mg q4H prn
    • PO allopurinol 300mg daily
  • +- IVF if need
  • +- Abx if infection

Bone marrow exam

  • +- early bone scan
  • consult hematology
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4
Q

Pulmonary embolism

A

Ward complain

  • HD stable
  • Warfarin diet
  • Avoid IMi injection
  • SC enoxaparin 0.4mL q12H (if 40kg), stop if INR >1.8
  • Warfarin with D1 3mg, then PO 2mg daily
  • HD not stable +- massive PE
  • Warfarin diet
  • Avoid IMi injection
  • IV heparin 70U/kg stat x1 (~5000U), then 500U/H aim APTT 60-80
  • Check APTT q6H
  • Consult med x PE
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5
Q

Thrombocytopenia

A

Admission

  • DAT
  • Obs q4H
  • Chart IO
  • Bld x CBC d/c LRFT bone clotting RG
  • Bld x urate, LDH, T&S
  • PLT in citrate bottle
  • BM exam
  • Resume usual meds
  • Transfuse prn
    &raquo_space;» PLT <10 afebrile/ PLT <20 febrile/ symptomatic e.g. bleeding tendency/epistaxis/hemoptysis/hematuria
    &raquo_space;» Transfuse __ U of PLT FR
  • Consult hematology
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6
Q

Warfarin and heparin bridging

A

Uncomplicated AF

  • no need bridge before procedure
  • W/H warfarin 4/7 before
  • INR <1.8
  • restart warfarin post procedure

Complicated AF/ stroke/ DVT/ valve replacement
- Admit + W/H warfarin 4/7 before
- Monitor INR
- Enoxaparin/ heparin when INR <1.8
&raquo_space;» SC enoxaparin 0.4mL q12H (40kg) for DVT/AF (INR aim 2-3)
&raquo_space;» IV heparin infusion 70U/kg stat x1 (~5000U), then infuse as 500U/H for valve replacement (INR aim 2.5-3.5, APTT aim 60-80)
- Check APTT q6H
&raquo_space;» APTT <40: repeat IV heparin stat 5000U, increase 100U/H
&raquo_space;» APTT 40-60: increase 100U/H
&raquo_space;» APTT 60-80: no action
&raquo_space;» APTT 80-100: decrease 100U/H
&raquo_space;» APTT >100: stop infusion x30mins, decrease 100U/H
- Restart warfarin with original dosage (or 3mg D1, 2mg daily PO)
- Aim INR 2-3 if DVT, stoke, AF; 2.5-3.5 if valvular replacement done

Warfarin titration see break your leg

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7
Q

Anemia

A 
HPI
Tiredness
Lightheadedness
SOB
Development/worsning of ischemia (angina/ claudication)
GI bleed
Menstrual history
Chronic ds/ previous surg
FHx
Drug history
(hemolytic: jaundice; B12: peripheral neuropathy/ dementia/subacute combined degeneration of cord; sickle cell: leg ulcer, stroke, pul HTN)
PE
Pallor
Tachypnea
JVP
Tachycardia
Flow murmur
edema
postural hypotension

Workup and interpretation
- CBC: Hb low
- Retic count high: bleeding/ hemolysis
- Retic count low + MCV:
&raquo_space;> MCV low: Fe def/ thal
- Ferritin: N/ high in anemia of chronic ds, Low in Fe def
- Target cell/ basophilic stippling: Thal
&raquo_space;> MCV normal: blood loss/ anemia of chronic ds
&raquo_space;> MCV high: B12/folate, myelodysplastic
- Hypersegmented: folate/B12, drugs
- Target/stomatocyte: liver function
- Dysplasia: marrow (myelodysplasia)
- Polychromasia: bleeding/ hemolysis

Hemolysis blood pic

  • bili, LDH, H
  • spherocyte, fragment
  • Coomb’s
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8
Q

Lymphadenopathy

A

Onset
Rate of enlargement
Pain
Weightloss, night sweat, itch

Localized/ generalized
Size
Character: hard, soft, rubbery
Fixed, mobile
Other general exam (clubbing, joint, rash)
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9
Q

Bleeding

A

Site （ms/joint, retroperitoneal, intracranial vs purpura, prolonged bleed from cut, GI, menorrhagia)
Duration
Precipitating cause (spontaneous/surg/ trauma)
FHx (consanguinous marriage)
Drug history (quinine, vancomycin, TCM, cytotoxic)
Age at presentation
Other med condition (e.g. liver ds)

Mucosal v Deep tissue

  • mucosal (PLT def/ vWD): petechiae/ bruises, gum/mucosal bleed, fundal h’age, post-surg
  • hemarthrosis/ hematoma in ms (coag factor): soft tissue, regroperitoneal, intracranial, post-surg

PE
Retinal, ICH
Lips + tongue
Petechiae purpura (dermis bleed, flat + non blanching)
Ecchymosis (deep skin, purple/red/yellow)

Retroperitoneal
Joints
Splenomegaly
Liver
Malignancy

DDx
Decrease production
1. marrow hypoplasia (aplastic anemia, drug e.g. cytotoxic/ antimetabolite, transfusion)
2. marrow infiltration (leukemia, myeloma, carcinoma, myelofibrosis, osteoporosis)
3. hematinic def (B12/ folate)
4. familial (alport, bernard soulier, wiskott aldrich)
Increase consumption
1. immune (ITP, post-trans, drug associated e.g. vanco/quinine)
2. coag activation (DIC)
3. mechanical pooling (hypersplenism)
4. thrmobotic microangiopathies (HUS, TTP, liver)

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10
Q

Thrombosis

A

Indication for thrombophilia testing

  • venous thrombosis <45
  • FHX of unprovoked thrombosis
  • Arterial+venous thrombosis
  • Unusual thrombosis (cerebral venous thrombosis, hepatic vein, portal vein, mesenteric vein)

Component of thrombophilia testing

  • antithrombin
  • protein C/S
  • Antiphosphoilpid antibody, lupus anticoagulant, anticardiolipin
  • Genetic test: Factor V leiden, prothrombin G20210A, JaAK2 utation
  • Flow cytometry: glycerol phosphatidyl inositol linked ell surface protein def in PNH
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11
Q

Erythrocytosis

A

Investigate if persistent >2mo

  • relative (low vol) erythrocytosis: diuretics, smoking, obesity, alcohol, Gaisbock
  • absolute erythrocytosis: myeloproliferative, hypoxia (cardiopul, high alt), inappropriately high EPO (renal cyst/hydronephrosis/CA, tumor e.g. hepatoma, bronchogenic, fibroid, pheo)

Polycythemia vera: aquagenic pruritis (hot bath), hepatosplenomegaly, gout + JAK2 V614F mut

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Houseman (break your leg) (23 decks)

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