Heme

Question 1

What is the differential for isolated thrombocytopenia?

Answer 1

ITP, HIT, drug-induced, tick-borne, H.pylori, gestational

Question 2

What physical exam signs should you focus on in the patient with thrombocytopenia

Answer 2

Signs of bleeding (mucocutaneous bleeding, petechiae, purpura, rectal / vaginal / uro bleeding)
CV strain
Liver failure
Thrombus (PE, DVT etc.)

Question 3

How do you differentiate between pseudothrombocytopenia, DIC, ITP, TTP, HUS?

Answer 3

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

Question 4

What investigations do you want to order in the patient with thrombocytopenia?

Answer 4

CBC, blood smear, TSH, B12, hemolytic workup, INR, aPTT, fibrinogen, HIV/HCV/HBV serology
Blood, urine Cx, CXR
ANA/RF
Abdo U/S

Question 5

How do you manage ITP?

Answer 5

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

Question 6

What do giant platelets indicate?

Answer 6

Increased BM production of platelets -> thus likely to be peripheral.

Question 7

If You have thrombocytopenia in the setting in the setting of hemolysis, what is the differential?

Answer 7

Schistocytes -> DIC, TTP, HUS, Scheroderma renal crisis, drug-induced, HELLP, Valvulopathy, B12 deficeiency.
No schistocytes -> paroxysmal nocturnal hemoglobinuria or Evan’s

Question 8

What is the SLiM CRAB criteria for diagnosis of multiple myeloma

Answer 8

> 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

Question 9

What is the route of clearance for warfarin

Answer 9

Liver

Question 10

What is the route of clearance for DOACs

Answer 10

Renal

Question 11

What is the difference between clopidogrel/prasugrel and ticagrelor

Answer 11

Ticagrelor is a reversible P2Y_12 inhibitor (the others are irreversible)

Question 12

What are the biggest risk factors for recurrent VTE

Answer 12

Cancer, male sex, unprovoked PE, positive D-Dimer post anticoagulation

Question 13

What is the criteria for massive PE

Answer 13

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)

Question 14

What is the cutoff for anemia in women

Answer 14

<120 in non-pregnant women, <110 in pregnant women

Question 15

What is the cutoff for anemia in men

Answer 15

<130

Question 16

What is the first question to think about when you see anemia?

Answer 16

Is the anemia acute or chronic?

Question 17

What are the 2 causes of acute anemia?

Answer 17

Acute blood loss or hemolysis

Question 18

What is a spherocyte? How do you get them?

Answer 18

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

Question 19

What evidence would you see in someone who is hemolyzing

Answer 19

Increased unconjugated bili and LDH, decreased haptoglobin +/-hemoglobinuria.

Question 20

What are the intrinsic red cell problems that lead to hemolysis

Answer 20

Membrane disorders (hereditary spherocytosis), hemoglobinopathies and enzyme problems (G6PD deficiency)

Question 21

What are the extrinsic causes of hemolysis

Answer 21

Immune-mediated (auto/allo-immune, drug mediated, cold-agglutinated), mechanical (e.g. mech heart valve)

Question 22

What workup do you order when you suspect hemolysis

Answer 22

Direct anti-globulin test

Question 23

What is the difference between a DAT vs an anti-glob test

Answer 23

DAT is anti IgG -> causing RBCs clump
Indirect -> test for serum antibodies that react against red cells (more like alloantibody testing for transfusion)

Question 24

What is the difference between warm vs cold autoimmune hemolytic anemia

Answer 24

Warm -> DAT +ve IgG; no temperature difference
Cold -> complement-mediated antibody (only causes agglutination at cold temperature)

Question 25

When do you give irradiated RBCs?

Answer 25

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

Question 26

What is the differential for chronic, microcytic anemia

Answer 26

Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoining
Sideroblastic anemia

Question 27

How do you differentiate between iron deficiency vs thal on a CBC

Answer 27

IDA = low RBC#, high RDW
Beta thal trait is high RBC# normal RDW

Question 28

What causes basophilic stippling

Answer 28

Lead, MDS (coarse), thal (fine), alcohol

Question 29

Does HbA (eg alpha thal trait) show up on hemoglobin electrophoresis?

Answer 29

No!

Question 30

What is the differential (5) for chronic normocytic anemia?

Answer 30

Pregnancy, early IDA, hemolysis, anemia of chronic disease, aplastic anemia

Question 31

What is the management of acute leukemia?

Answer 31

Watch out for hyperleukostasis (renal, liver function), DIC markers (PT, aPTT, fibirinogen), hemolysis (uric, bili, LDH), consider hydroxyurea, Wtransfusion support as needed, call heme.

Question 32

What is the differential for chronic macrocytic anemia?

Answer 32

Megaloblastic (B12, folate), drugs, MDS, Liver disease, hypothyroid. >120 MCV is B12/folate.

Question 33

What are the symptoms of B12 deficiency?

Answer 33

Neuro (combined cord degeneration with peripheral neuropathy, peripheral neuropathy, CNS demetia, personality change)