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)
