Heme Flashcards
What is the differential for isolated thrombocytopenia?
ITP, HIT, drug-induced, tick-borne, H.pylori, gestational
What physical exam signs should you focus on in the patient with thrombocytopenia
Signs of bleeding (mucocutaneous bleeding, petechiae, purpura, rectal / vaginal / uro bleeding)
CV strain
Liver failure
Thrombus (PE, DVT etc.)
How do you differentiate between pseudothrombocytopenia, DIC, ITP, TTP, HUS?
DIC - > tends to be septic patients or massive hemorrhage
ITP -> Diagnosis of exclusion
TTP -> associated with MAHA (so will see schistocytes)
HUS -> tends to be associated with e-coli (GI symptoms).
Psudothrombocytopenia -> platelets clumped on screen
What investigations do you want to order in the patient with thrombocytopenia?
CBC, blood smear, TSH, B12, hemolytic workup, INR, aPTT, fibrinogen, HIV/HCV/HBV serology
Blood, urine Cx, CXR
ANA/RF
Abdo U/S
How do you manage ITP?
If bleeding now and hemodynamically unstable-> start platelet transfusion
If platlets <30 steroids +/- IVIG (both if bleeding Hb drop >20 or requiring 2+ transfusion).
If platelets >30 observation
What do giant platelets indicate?
Increased BM production of platelets -> thus likely to be peripheral.
If You have thrombocytopenia in the setting in the setting of hemolysis, what is the differential?
Schistocytes -> DIC, TTP, HUS, Scheroderma renal crisis, drug-induced, HELLP, Valvulopathy, B12 deficeiency.
No schistocytes -> paroxysmal nocturnal hemoglobinuria or Evan’s
What is the SLiM CRAB criteria for diagnosis of multiple myeloma
> 10% of BM clonal proliferation or biopsy proven plasmacytoma
hyperCa, Renal insufficiency, Anemia, Bone lesion
S - clonal bone marrow > 60
Li - light chains
M - MRI showing lesion
What is the route of clearance for warfarin
Liver
What is the route of clearance for DOACs
Renal
What is the difference between clopidogrel/prasugrel and ticagrelor
Ticagrelor is a reversible P2Y_12 inhibitor (the others are irreversible)
What are the biggest risk factors for recurrent VTE
Cancer, male sex, unprovoked PE, positive D-Dimer post anticoagulation
What is the criteria for massive PE
R heart strain + large clot burden
Massive PE is any of the following:
Hypotension sBP<90 >15 minutes
sBP drop >40 from baseline
Arrest
Persistent Brady with shock (HR/sBP>1)
What is the cutoff for anemia in women
<120 in non-pregnant women, <110 in pregnant women
What is the cutoff for anemia in men
<130
What is the first question to think about when you see anemia?
Is the anemia acute or chronic?
What are the 2 causes of acute anemia?
Acute blood loss or hemolysis
What is a spherocyte? How do you get them?
An RBC that has no central pallor; caused by the spleen taking off
a chunk of membrane (often antibody mediated, can be hereditary). It is a cardinal sign of hemolysis
What evidence would you see in someone who is hemolyzing
Increased unconjugated bili and LDH, decreased haptoglobin +/-hemoglobinuria.
What are the intrinsic red cell problems that lead to hemolysis
Membrane disorders (hereditary spherocytosis), hemoglobinopathies and enzyme problems (G6PD deficiency)
What are the extrinsic causes of hemolysis
Immune-mediated (auto/allo-immune, drug mediated, cold-agglutinated), mechanical (e.g. mech heart valve)
What workup do you order when you suspect hemolysis
Direct anti-globulin test
What is the difference between a DAT vs an anti-glob test
DAT is anti IgG -> causing RBCs clump
Indirect -> test for serum antibodies that react against red cells (more like alloantibody testing for transfusion)
What is the difference between warm vs cold autoimmune hemolytic anemia
Warm -> DAT +ve IgG; no temperature difference
Cold -> complement-mediated antibody (only causes agglutination at cold temperature)
When do you give irradiated RBCs?
When you’ve got someone that’s +++immunocompromised (e.g. transplant or hodgkin’s) that you worry about exposing them to even a small population of other WBCs that can set up graft vs host disease
What is the differential for chronic, microcytic anemia
Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoining
Sideroblastic anemia
How do you differentiate between iron deficiency vs thal on a CBC
IDA = low RBC#, high RDW
Beta thal trait is high RBC# normal RDW
What causes basophilic stippling
Lead, MDS (coarse), thal (fine), alcohol
Does HbA (eg alpha thal trait) show up on hemoglobin electrophoresis?
No!
What is the differential (5) for chronic normocytic anemia?
Pregnancy, early IDA, hemolysis, anemia of chronic disease, aplastic anemia
What is the management of acute leukemia?
Watch out for hyperleukostasis (renal, liver function), DIC markers (PT, aPTT, fibirinogen), hemolysis (uric, bili, LDH), consider hydroxyurea, Wtransfusion support as needed, call heme.
What is the differential for chronic macrocytic anemia?
Megaloblastic (B12, folate), drugs, MDS, Liver disease, hypothyroid. >120 MCV is B12/folate.
What are the symptoms of B12 deficiency?
Neuro (combined cord degeneration with peripheral neuropathy, peripheral neuropathy, CNS demetia, personality change)
