IM Flashcards
What are the three things an attending expects you to know about a patient you’ve seen with DM?
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
What is the diagnostic criteria for DM based on fasting plasma glucose?
FPG > 7 (8 hr fast)
What are the diagnostic criteria for DM based on the 2 hour glucose challenge?
2 hr plasma glucose > 11.1
What are the diagnostic criteria for DM based on the HBA1c?
HbA1c > 6.5% (48 mmol/mol)
What are the diagnostic criteria for DM based on the random plasma glucose?
Classic Sx/signs\nAND\nA random plasma glucose > 11.1
What 6 questions about the patient’s DM history can help differentiate type 1 from type 2?
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
What 3 questions can clarify the patient’s current treatment?
1) Which activity, diet and drugs are used?\n2) What is the timing of their insulin use?\n3) How do they monitor their glucose?
What 3 ACUTE consequences of DM should patients be asked about?
1) Hypoglycemia\n2) Hyperglycemia (e.g., dehydration, HHS, HHS)\n3) Infection (e.g., UTI, yeast)
What CHRONIC consequences of DM should patients be asked about? (6 organ systems)
Eyes \nHeart \nBrain \nLegs/vessels \nFeet \nNerves
What should you examine on physical exam (6 things)
Weight\nBP\nEyes\nThyroid\nInjection sites\nFeet
What are the three causes of low levels of a blood component?
Low production\nClearance\nSequestration
How does sepsis cause thrombocytopenia?
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
Which drugs are most frequently the cause of Drug Induced Thrombocytopenia
Penicillin based antibiotics (E.g. Pip–Tazo)
What is the TTP Pentad?\n(Mnemonic: FAT RN)
Fever\nAnemia\nThrombocytopenia\nRenal Failure\nNeurologic symptoms (e.g., headache)\n\nClassically presents in a young woman
What would be found in the blood work of a person with TTP?
New thromboycytopenia \nMAHA (anemia and schistocytes)\nhelmet cells\nnormal coags, \nelevated WBC
What non heme lab findings would arise in TTP?
Elevated LDH (common in TTP)\nElevated Cr (less common, later stage)
What causes TTP
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
How is TTP treated?
Plasmaphoresis against plasma (remove Ab against ADAMTS–13)\nOnly available at large hospitals (if at a smaller centre temporize for transfer with plasma infusion)
Other than TTP, what is the Ddx for MAHA (microangiopathic hemolytic anemia)?
hypertensive disorders of pregnancy, \nscleroderma renal crisis, \nsystemic lupus, \nintravascularhemolysis
What are the indications for Heparin use. That is, list four conditions that would cue to think about Heparin use and HIT.
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
4T score – what are the 4Ts?
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
How long does HIT take to develop?
5–14 days after administration of Heparin
Is HIT create a pro or anti coaguable state? How is HIT treated?
Pro–coagulant state\nTreat with HIT safe antithrombotic \nArgatroban in ICU\nFondaparinux once stable
RIsk of DVT in untreated HIT?
50%
HIT lab testing
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
What is the thrombocyte range generally seen in HIT?
50–70
Are coags normal in HIT?
Yes
What is the normal upper limit of INR? PTT?
INR: 1.3\nPTT: 35
What do reticulocytes look like
Larger\nBluer (RNA)
How is DIC treated? What is used to replace clotting factors? fibrinogen? When are platelets given?
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
Why can’t you use prothrombin complex concentrate – in DIC?
PCC contains factors 2,7,9,10 and can cause thrombosis. It also fails to replace factors 5,10, 8
Thrombin clotting time (TCT) tests the levels of what?
Fibrinogen levels
Increased INR in isolation suggests what etiologies?
Warfarin, \nvitamin K deficiency, \nrivaroxaban
• Increased PTT in isolation suggests what etiologies?
Heparin, \nvitamin K in recovery, \nhemophilia, \ninhibitor to coag factors, \ndabigatran
Increased PTT and INR together suggest what etiologies?
Heparin, \nvitamin K deficiency, \nreductions inmultiple coagulation factors (DIC), \ndabigatran
Causes of chronic DIC
Prostate cancer \nPersistent weak or intermittent activating stimulus
Fetal demise + falling fibrinogen =
DIC (even in the presence of near normal blood work) \nNeed to remove fetus asap
How does febrile neutropenia present?
Fever and neutropenia, frequently in the context of myelosuppressive chemotherapy
Name the three hematological emergencies
Febrile Neutropenia\nTTP\nDIC
Is fibrinogen decreased, normal or elevated in pregnancy?
It should be elevated
