IM

Question 1

What are the three things an attending expects you to know about a patient you’ve seen with DM?

Answer 1

What type of diabetes does the patient have?\n– What is their diabetes history?\n\n\nIs it being treated appropriately?\n– What interventions are they using?\n\n\nWhat are its consequences?\n– Acute and chronic

Question 2

What is the diagnostic criteria for DM based on fasting plasma glucose?

Answer 2

FPG > 7 (8 hr fast)

Question 3

What are the diagnostic criteria for DM based on the 2 hour glucose challenge?

Answer 3

2 hr plasma glucose > 11.1

Question 4

What are the diagnostic criteria for DM based on the HBA1c?

Answer 4

HbA1c > 6.5% (48 mmol/mol)

Question 5

What are the diagnostic criteria for DM based on the random plasma glucose?

Answer 5

Classic Sx/signs\nAND\nA random plasma glucose > 11.1

Question 6

What 6 questions about the patient’s DM history can help differentiate type 1 from type 2?

Answer 6

1) age of onset\n2) weight at onset\n3) Signs and symptoms at onset\n4) Treatment at onset\n5) Response to treatment in terms of plasma glucose and weight\n6) Time until addition of another therapy

Question 7

What 3 questions can clarify the patient’s current treatment?

Answer 7

1) Which activity, diet and drugs are used?\n2) What is the timing of their insulin use?\n3) How do they monitor their glucose?

Question 8

What 3 ACUTE consequences of DM should patients be asked about?

Answer 8

1) Hypoglycemia\n2) Hyperglycemia (e.g., dehydration, HHS, HHS)\n3) Infection (e.g., UTI, yeast)

Question 9

What CHRONIC consequences of DM should patients be asked about? (6 organ systems)

Answer 9

Eyes \nHeart \nBrain \nLegs/vessels \nFeet \nNerves

Question 10

What should you examine on physical exam (6 things)

Answer 10

Weight\nBP\nEyes\nThyroid\nInjection sites\nFeet

Question 11

What are the three causes of low levels of a blood component?

Answer 11

Low production\nClearance\nSequestration

Question 12

How does sepsis cause thrombocytopenia?

Answer 12

Diffuse endothelial activation due to circulating bacteria ––> platelets adhere to endothelial surface ––> decreasing amount in circulation \n**When clotting factors are also activated then we consider it DIC

Question 13

Which drugs are most frequently the cause of Drug Induced Thrombocytopenia

Answer 13

Penicillin based antibiotics (E.g. Pip–Tazo)

Question 14

What is the TTP Pentad?\n(Mnemonic: FAT RN)

Answer 14

Fever\nAnemia\nThrombocytopenia\nRenal Failure\nNeurologic symptoms (e.g., headache)\n\nClassically presents in a young woman

Question 15

What would be found in the blood work of a person with TTP?

Answer 15

New thromboycytopenia \nMAHA (anemia and schistocytes)\nhelmet cells\nnormal coags, \nelevated WBC

Question 16

What non heme lab findings would arise in TTP?

Answer 16

Elevated LDH (common in TTP)\nElevated Cr (less common, later stage)

Question 17

What causes TTP

Answer 17

Antibody against ADAMTS–13 causes deficiency\nADAMTS–13 cleaves VWF, \ndeficiency of ADAMTS–13 causes excessive platelet adhesion\n36 second video explaining this: https://www.youtube.com/watch?v=qO7Kkm6jf9w&fbclid=IwAR1S1R0Thk28GjaSt1–hqeuJLLbeKKhYKmHDnOdq74FP_YA2GeaaKidnLFo

Question 18

How is TTP treated?

Answer 18

Plasmaphoresis against plasma (remove Ab against ADAMTS–13)\nOnly available at large hospitals (if at a smaller centre temporize for transfer with plasma infusion)

Question 19

Other than TTP, what is the Ddx for MAHA (microangiopathic hemolytic anemia)?

Answer 19

hypertensive disorders of pregnancy, \nscleroderma renal crisis, \nsystemic lupus, \nintravascularhemolysis

Question 20

What are the indications for Heparin use. That is, list four conditions that would cue to think about Heparin use and HIT.

Answer 20

Acute coronary syndrome, e.g., NSTEMI\nAtrial fibrillation\nDeep–vein thrombosis and pulmonary embolism\nCardiopulmonary bypass for heart surgery\nECMO \nDialyses\nIndwelling central or peripheral venous catheters

Question 21

4T score – what are the 4Ts?

Answer 21

Thrombocytopenia severity\nTiming of platelet count fall\nThrombosis or other sequelae\noTher cause of thrombocytopenia possible?\nSee https://www.mdcalc.com/4ts–score–heparin–induced–thrombocytopenia

Question 22

How long does HIT take to develop?

Answer 22

5–14 days after administration of Heparin

Question 23

Is HIT create a pro or anti coaguable state? How is HIT treated?

Answer 23

Pro–coagulant state\nTreat with HIT safe antithrombotic \nArgatroban in ICU\nFondaparinux once stable

Question 24

RIsk of DVT in untreated HIT?

Answer 24

50%

Question 25

HIT lab testing

Answer 25

ELISA testing for Ab (high sensitivity, low specificity) – a couple days to get result\nSerotonin release assay (definitive test) – takes 2 to 5 days for turnaround

Question 26

What is the thrombocyte range generally seen in HIT?

Answer 26

50–70

Question 27

Are coags normal in HIT?

Answer 27

Yes

Question 28

What is the normal upper limit of INR? PTT?

Answer 28

INR: 1.3\nPTT: 35

Question 29

What do reticulocytes look like

Answer 29

Larger\nBluer (RNA)

Question 30

How is DIC treated? What is used to replace clotting factors? fibrinogen? When are platelets given?

Answer 30

Treat underlying cause of diffuse coagulation/activation\nReplace missing clotting factors with plasma (not PCC)\nIf low fibrinogen give cryoprecipetate or fibrinogen concentrate\nGive platelets if moderate or severe thrombocytopenia

Question 31

Why can’t you use prothrombin complex concentrate – in DIC?

Answer 31

PCC contains factors 2,7,9,10 and can cause thrombosis. It also fails to replace factors 5,10, 8

Question 32

Thrombin clotting time (TCT) tests the levels of what?

Answer 32

Fibrinogen levels

Question 33

Increased INR in isolation suggests what etiologies?

Answer 33

Warfarin, \nvitamin K deficiency, \nrivaroxaban

Question 34

• Increased PTT in isolation suggests what etiologies?

Answer 34

Heparin, \nvitamin K in recovery, \nhemophilia, \ninhibitor to coag factors, \ndabigatran

Question 35

Increased PTT and INR together suggest what etiologies?

Answer 35

Heparin, \nvitamin K deficiency, \nreductions inmultiple coagulation factors (DIC), \ndabigatran

Question 36

Causes of chronic DIC

Answer 36

Prostate cancer \nPersistent weak or intermittent activating stimulus

Question 37

Fetal demise + falling fibrinogen =

Answer 37

DIC (even in the presence of near normal blood work) \nNeed to remove fetus asap

Question 38

How does febrile neutropenia present?

Answer 38

Fever and neutropenia, frequently in the context of myelosuppressive chemotherapy

Question 39

Name the three hematological emergencies

Answer 39

Febrile Neutropenia\nTTP\nDIC

Question 40

Is fibrinogen decreased, normal or elevated in pregnancy?

Answer 40

It should be elevated