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359 Cards in this Set
- Front
- Back
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What are you thinking if you see a craving for ice or dirt
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Pica
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What is associated with seeing a craving for ice or dirt and CBC?
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Anemia
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If you see fatigue, malasie, and loss of energy maybe SOB what diseases other than anemia should you think of ?
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Hypoxia
CO poisoning Methmaglobinemia Isch. Heart disease |
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what will you find on physical exam in a pt. with anemia?
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pallor, pale conjunctiva, FLOW murmur I or II sYSTOLIC murmur
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What if you suspect a pt. has anemia and you are looking at physical exam what would you find if you thing there might be hemolysis involved?
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Jaundice and sclera icterus---yellow eyes.
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You see a pt. with fatigue, malasie, loss of energy, what intial lab would you order?
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CBC with peripheral smear
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What if you order a CBC and peripheral smear and you suspect anemia...what would you pay close attn. to?
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MCV and MCHC
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What other than the CBC with peripheral smear would you order to diagnose Anemia?
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Retic ct.
Haptoglobin, LDH Total and direct BR TSH and free T4 B12/Folate iron studies U/A with microscopic analysis |
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Why do you look at the MCV for anemia patients?
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To tell if MACRO, Micro, or NORMOcytic
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What does the MCHC tell you ?
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If there is a problem with making Hemoglobin
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What terminology is associated with MCHC?
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HYPOchromic, Hyperchromic, and Normochromic
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What are you thinking if you see this in the history...blood loss?
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Iron Def. Anemia
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What are you thinking if you see this in the history...elevated platelet count
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Iron Def. Anemia
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What are you thinking if you see this in the history...RA?
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Anemia of Chronic Ds.
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What are you thinking if you see this in the history...Arthritis
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Anemia of Chronic DS
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What are you thinking if you see this in the history...ESRD..
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Anemia of chronic ds.
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What are you thinking if you see this in the history...Chronic infection
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Anemia of chronic ds.
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What are you thinking if you see this in the history inflammatory or connective tissue disorder?
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aNEMIa fo chronic disease
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What are you thinking if you see this in the history...very small MCV with few or little symptoms?
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Thalaseemia
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What are you thinking if you see this in the history...Target cells?
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Thalassemia
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What are you thinking if you see this in the history for anemia...Alcoholic?
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Sideroblastic anemia
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What are you thinking if you see this in the history...Isoniazid?
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Sideroblastic Anemia
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What are you thinking if you see this in the history for anemia...lead exposure?
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Sideroblastic anemia
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What is the best intial diagnostic test for iron def anemia?
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Iron studies: ferritin, TIBC, iron, iron sat, RDW
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What will you find in iron studies for iron defic. anemia?
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Low ferritin, High TIBC, low iron, low iron sat. and high RDW
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What is the best initial diag. test for Anemia of chronic disease?
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iRON STUdies: ferritin, iron, iron sat, TIBC
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What will you find in iron studies for anemia of chronic disease
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High ferritin
Low TIBC Low Iron Low Iron sat. |
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What is the best initial diag. test for Thalasemia?
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Iron studies: ferritin, TIBC, iron, iron sat
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What will you find in iron studies for Thalasemia?
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Normal iron studies
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What is the best initial diag. test for sideroblastic anemia?
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Iron studies: ferritin, TIBC, iron, iron sat
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What will you find on iron studies in a pt. with sideroblastic anmeia?
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High IRON
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What is the MOST accurate diagnostic test in iron def. anemia
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Bone marrow biopsy
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What is the MOST accurate diagnostic test in Thalasemia?
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hemoglobin Electrophoresis
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If you do a Hb Electrophoresis in a pt you think has thalasemia what might you find?
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Beta is elevated--High HgA2, HgF
Alpha--normal |
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What is the MOST accurate diagnostic test in Sideroblastic anemia?
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Prussian blue stain
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What is the best inital therapy for iron def. anemia?
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Ferrous sulfate orally
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What if the pt. can't tolerate the ferrous sulfate for iron replacement, what other type of iron can you order?
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Ferrous gluconate
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What is the best inital therapy for Anemia of chronic disease?
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Correct the disorder
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What is the best inital therapy for Thalasemia?
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there is no treatment
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What is the best inital therapy for sideroblastic anemia but its a minor problem?
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Pyridoxine replacement
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What is the best inital therapy for sideroblastic anemia, but it's a Major problem?
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Rmove the toxin exposure
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Why is there a HIGH RDW only found in iron defic anemia?
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B/c newer and newer cells are progressively smaller adn the red cell witdth changes over time
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Why do you use prussian blue as the most accurate diagnostic test in Sideroblastic anmia?
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B/c it stains for IRON
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Where is the accumulation of iron found in a sideroblastic anemia patient?
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inside the mitochondria
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What is the only form of anemia with chronic disease that can be treated with EPO?
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End stage renal disease
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Why don't you see hemolysis that occurs in the liver and spleen on peripheral smear?
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B/c it happens extravascularly
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What is the difference between Vit B12 def and folate defic
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Vit B12 has neurological problems associated with it
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What is the most common neurological finding that Vit B12 def. will show?
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peripheral neuropathy
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What is the LEAST common neurologic problem seen in Vit B12 defic?
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Dementia
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How do you treat the neurological problems found assoc with Vit B12?
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treat the Vit B12 defic
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What if you suspect a pt. with fatigue, malaise, loss o energy and you see a pt. with diarrhea adn smooth tongue (glossitis)...what anemia would you suspect and what is the cause
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Macrocytic anemia d/t VitB12 deficiency
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Does folate defic. present with neurological problems?
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NO
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What is the best initial test when looking at macrocytic anmeia?
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CBC with peripheral blood smear
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What will you find on peripheral blood smear of a pt. with macrocytic anemia?
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hypersegmented neutrophils and oval cells
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What if a pt. has more than 5 hypersegmented neurtrophils, what is this called?
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Megaloblastic anemia
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What does macrocytosis mean?
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Big cells
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What if you see a pt. with Vit B12 def. and hypersegmented neurtrophils, what is this called?
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Megaloblastic and macrocytosis anemia
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What things shoud you order when assessing a pt. for Vit B12 defic?
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CBC with peripheral blood smear
iron studies LDH, Retic count, Bilrubin level |
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What will you find in a pt. with macrocytic anmeia who have Bilirubin and LDH level
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HIGH Bilirubin and high LDH
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What will you find in a pt. with macrocytic anmeia regarding the retic count?
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Retic count will be LOW
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What is the most accurate test to diagnose a pt. with Vit B12 defic?
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Low Vit B12 level
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What is the most accurate test to diagnose a pt with folate defic?
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LOW Folate level
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What should you order if you suspect a pt. has Vit B12 defic and their Vit B12 level comes back normal?
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methylmalonic acid level
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What happens to homocysteine levels in Vit B12 and folate defic?
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Homocysteine levels go up
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What should you do if you find a normal Vit B12 and and elevated methalmalonic acid level (homocysteine) and you want to confirm the cause of the vit B12 defic....what should you order?
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Antiparietal cell antibodies and Anti-intrinsic factor antibodies
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What do anti-parietal cell Ab, and anti-intrinsic factor ab confirm?
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Pernicious anemia as the cause of VIT B12 defic
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Do you have to do a Schilling test if you have positive anti-parietal or anti-intrinsic factor antibodies?
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NO
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what is the treatment of Vit B12 defic and folate defic?
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Replacement
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What should you think of if you see fatigue, malasie, loss of energy that is SUDDEN?
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Think of hemolytic anemia
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What will you order in a pt. that you think has hemolytic anemia?
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CBC with peripheral smear, LDH, retic count, Biliruben, PT/PTT, U/A, haptoglobin
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What will you find in your order results in a pt. you think has hemolytic anemia: LDH, retic ct., Bilirubin, haptoglobin
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High LDH
Low Haptoglobin HIgh INDIRECT bilirubin High Retic Ct. |
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What will you find on peripheral smear if hemolysis is occuring in the liver or spleen?
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Nothing b/c that is considered extravascular hemolysis
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What will you find on peripheral smear in a pt with intravascular hemolysis?
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Schistocyets, Helmet cells, fragmented cells
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What will you find on U/A in a pt with intravascular hemolysis?
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hemoglobinuria
and Hemosiderinuria |
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What is hemosiderinuria?
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oxidized product of Hb in the urine
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What do you suspect if you see a pt. with SEVERe pain in the chest, back and thighs and may have anemia?
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Sickle cell Anemia
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What will you order for a sickle cell pt. in an acute crisis with fever?
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Oxygen, Morphine, IV fluids, and antibiotics if there is fever
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When you assess the Physical exam on a sickle cell pt. what will you find on HEENT, CV, Abd, Ches, Extrem, and neuro?
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Heent: Retinal infarct
CV--flow murmur Abd--splenomegaly in a kid absent spleen in adult Chest--Rasles or consolid Extrem--skin ulcer and aseptic necrosis of hip Neuro--Stroke signs |
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What is the antibiotics would you consider administering in a sickle cell pt. with fever and in crisis?
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Ceftriaxone
Levoquin OR Moxifloxacin |
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Why do you have to administer the antibiotics in a febrile sickle cell pt?
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b.c the pt. has no spleen or has functional asplenia
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In theory, what is the MOST important next step to administer to a pt. that is febrile and sickle cell anemia pt?
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Antibiotics after blood culture
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What will you order after you order Oxygen, IV normal saline, morphine, and right before you give (ceftriaxone, levaquin, or moxiflox) for a sickle cell pt. in CCS>
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blood cultures
U/A urine cultures CBC Retic ct. CXR |
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What do you order in a sickle cell pt. with visual disturbance or retinal infarction?
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Exchange transfusion
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What do you order in a sickle cell pt. with pulm. infarct with and abnormal Xray?
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Exchange transfusion
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What do you order in a sickle cell pt. with priapism form infarct of the prostatic venous plexus?
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Exchg transfusion
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What do you order in a sickle cell pt. with Stroke?
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Exchange transfusion
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What if a sickle cell pt. SUDDENLY gets a drop in Hct. ct. what should you suspect?
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Parvo B19 virus or Folate defic
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What should ALL sickle cell pt. be on universally
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Folate
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How can you suspect if a pt. may be infected with parvo B19 virus vs. folate defic when you see a SUDDEN drop in Hct?
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If the pt. is on folate replacement already....consider a Parvo B19 virus
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How do you confirm that the decrease in Hct. in a sickel cell pt. is due to Parvo B19
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PCR for DNA of the parvovirus
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How do you treat a pt. with sickle cell anemia crisis?
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transfusion and IV IG
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What will you order on discharge for a sickle cell anemia pt?
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Folate,
Pneumovax hydroxyurea |
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Why do we give a sickle cell pt. hydroxyurea?
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To prevent further crisis if they happen >4 times per year
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What is HB SC disease?
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Mild form of sickle cell disease
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Do you see painful crisis in HbSC disease?
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NO
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Do you see visual disturbance in HbSC disease?
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YES
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Do you see renal problems with HbSC disease?
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YES
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What will you find most prominent in HbSC disease?
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Hematuria
Isothenuria (can't concentrate or dilute urine) UTI |
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Is there a specific therapy for HbSC disease?
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NO
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What is the problem in sickle cell trait?
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Concentrating urine and Hemoglobinuria
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Do sickle cell trait pt. go into sickle cell crisis?
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NO
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What manifestations do sickle cell trait pt. manifest with?
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Renal manifestations
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When should you suspect an autoimmune hemolytic anemia based on History?
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If the history has other autoimmune prob...like SLE, RA, CLL, Lymphoma, or meds like alphamethyl-dopa, PCN, quinine, or sulfa drugs
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What will you order if you susupect a pt. has hemolytic anemia and you need to work it up?
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CBC with periph. blood smear
LDH Haptoglobin Bilirubin PT/PTT U/A Retic ct. |
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What will you find in a pt .w/ hemolytic anemia with LDH, Haptogobin, BR, Retic ct. etc?
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LDH, BR, and Retic ct. will be HIGH
Haptoglobin will be low |
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What will all hemolytic anemias have re: Haptoglobin, REtic ct., LDH, and BR?
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High LDH, BR, Retic ct.
Low Haptoglobin |
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What will the haptoglobin level be in intravasc. hemolysis?
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LOW
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What will the haptoglobin level be in extravasc. hemolysis?
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LOw
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What will the peripheral smear show in hemolytic anemia?
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spherocytes
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Waht is the MOST accurate diagnostic test for hemolytic anemia?
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Coomb's test
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What will you give a pt. with a peripheral smear with spherocytes, and lhigh LDH, HIgh BR, high retic ct., and low haptoglobin and a positive Coombs test?
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Steroids (prednisone)
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What is the treatment of choice if a pt. has recurrent episodes of hemolytic anemia
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splenectomy
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What kind of antibodies respond to steroids and splenectomy in autoimmune hemolytic anemia?
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Warm- Antibodies
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What type of immunoglobulins are warm Antibodies?
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IgG
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What do you Rx if a pt. who has severe hemolysis that is not responsive to predinison ro repeated blood transfusions?
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IV immunoglobuilins to stop acut episodes of hemolysis
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What are you thinking if you see cold aggluitnis with a negative Coomb's test?
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Mycoplasma or EBV
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What will you find in complement test in a Mycoplamsa or EBV pt?
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complement test is positive
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What happens in a cold-induced hemolysis for mycoplasma or EBV pt. with regards to steroids, splenectomy, or IVIG?
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No response to steroids, splenectomy or IVIG
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What do you do if you see sudden onset of hemolysis during an infection treated with Abx, and the pt. is a male? What are you thinking?
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Order heinz body test
thinking G6PD |
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Is G6PD what type of genetics?
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X-linked
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What is the MOST common oxidant stress to cause G6PD defic?
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infection
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What drugs are oxidizing in nature to cause G6PD?
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sulfa
primiquine dapsone |
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What are Heinz bodies?
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oxidized, precipitated Hemoglobin embedded in the RBC membrane
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what are bite cells?
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Bite cells appear when pieces of the RBC membrane have been removed by the spleen
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What is the MOST accurate diagnostic test to determine G6PD?
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the G6PD level--
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How long do you have to wait to check the G6PD level after a episode of hemolysis?
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2 months
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what will you find on a G6PD level on the day of hemolysis?
Why/ |
Normal G6PD
B/c only the most deficient G^PD cells have been destroyed |
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WhAT is the definitive treatment of G6PD?
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avoid the stress
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What could present similar to G6PD defic, but is not related to oxidant stress, fava beans, or drugs?
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Pyruvate kindase defic
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What do you suspect if you see a pt. with recuurent hemolytic episodes, splenomegaly, bilrubin gallstones, and a High MCHC?
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hereditary spherocytosis
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What is the most ACCURATE test for hereditary Spherocytosis?
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Osmotic Fragility test
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What is the definitive treatment for Hereditary spherocytosis?
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splenectomy, b/c the rbc are destroyed in the spleen
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What bug do you think of when you think of HUS?
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Ecoli O157:H7
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What med do yu think of when you suspect TTP?
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ticlodipine
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What triad will you find in a HUS pt?
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ART
anemia--autoimmune renal--high bun/creat thrombocytopenia |
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What pentad will you find in a TTP pt?
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F-fever
A-anemia (autoimmune Thrombocytopenia r-enal N-neuro |
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What is the treatment of HUS or TTP?
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they usually resolve on their own
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What can you offer a pt. with Severe TTP or HUS?
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plasmaphereisis
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Do steroids help in TTP or HUS?
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no
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Why should you not treat the HUS with antibiotics ?
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B/c it may make it worse
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Would you suggest platelent transfusion for HUS or TTP?
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NO
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Why no platelet transfusion for HUS or TTP?
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B/c it will make it worse
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What do you suspect if you see low blood line across the board and reccurnt episodes of dark urine in the morning?
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PNH
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What is hte most common cause of death in PNH pt?
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large vessel venous thrombosis
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What is a common venouse thrombosis in PNH pt?
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portal vein thrombosis
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What are some of the complications of PNH/
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aplastic anemia
AML |
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What is the most accurate diagnostic test for PNH?
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CD 55 and CD 59 antibody (decay accelerating factor)
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What were older screening tests which are not used now for diagnosing PNH?
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sugar-water test and Ham's test
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How do sugar water test and Ham's test work?
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they activate complement which leads to hemolysis in PNH
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What is the treatment for PNH?
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glucocorticoids like steroids
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What do you suspect if you see a pt. with hemolysis, abn. LFT, and low platlets?
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HELLP syndrome
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What if you see a pt. that has SOB and was recently treated with nitropursside with a Clear Lung exam and CXR...what are you thinking?
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methemoglobinemia
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What if you see a pt. that has SOB and was recently treated with ntiroglycerin with a Clear Lung exam and CXR...what are you thinking?
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Methemoglobinemia
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What if you see a pt. that has SOB and was recently treated with amyl nitrate with a Clear Lung exam and CXR...what are you thinking?
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Methemaglobinemia
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What if you see a pt. that has SOB and was recently treated with dapsone with a Clear Lung exam and CXR...what are you thinking?
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methemaglobinemia
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What if you see a pt. that has SOB and was recently treated with lidocaine for a dental filling with a Clear Lung exam and CXR...what are you thinking?
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methemaglobinemia
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What if you see a pt. that has SOB and was recently treated with bupivicaine with a Clear Lung exam and CXR...what are you thinking?
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Methemaglobinemia
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What if you see a pt. that has SOB and was recently treated with tetracaine with a Clear Lung exam and CXR...what are you thinking?
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methemaglobinemia
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What if you see a pt. with SOB for no reason, and recently treated with some medication, and clear lung exam and CXR with brown blood, what are you thinking?
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Methemaglobinemia
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What will you treat methemaglobinemia with ?
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methylene blue
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20 min after a transfusion, the pt. becomes SOB, there are transient infilitrates on CXR, all sx resolve spontaneously, what is most likely diagnosis?
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Transfusion related acute lung injury (TRALI)
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What is most likely diagnosis if a pt. as soon as they recieve a transfusion and becomes hypotensive SOB, and tachy?
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IgA defic
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pt. as soon as they recieve a transfusion and becomes hypotensive SOB, and tachy what do you think and how can you prevent it?
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IgA defic....
Give Washed red cells and donor should from IgA deficient donor |
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During a transfusion a pt. becomes hypotnesive, SOB, and there is chest pain with dark urine. The LDH and BR are high and haptoglobin is low, what are you thinking?
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ABO incompat--intravasc hemolysis
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What are you thinking if you see a pt. after a few days of a transfusion and pt. becomes jaundiced, the hematocrit does't rise with transfusion, and ususally he has no symptoms...what is diagnosis?
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Minor blood group incompat to Kell, Duffy, Kill or Rh..
LOOK for delayed jaundice |
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After a few hours of transfusion a pt. becomes febrile with a rise in temp of about 1 degree. No eveidence of hemolysis...what is most likely diagnosis?
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Febrile nonhemolytic reaction
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How do you prevent a febrile nonhemolytic reaction?
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use filtered blood transfusion in the future to remove the white cell antigen
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What do you think of when you see Auer rods?
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AML
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what do you think of when you see fatigue, bleeding, and infections and pt. has a functional immunodefic?
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Acute leukemia
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What is the best initial test when you see an acute leukemia?
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Peripheral smear showing blasts
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What will a peripheral smear show in acute leukemia?
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blasts
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What is the most important prognostic finding in acute leukemia?
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cytogenetic abno---karyotype
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what will cytogenetics tell you in leukemia patients?
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It will tell you who will relapse
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What do you do if the pt. is high risk for replapse based on cytogenitics for leukemia?
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BMT as soon as chemo induces remission
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What is the intial treatment of of AML?
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Idarubicin (Daaunorubin) and cytosine arabinoside
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What do you treat with initially for M3 leukemia?
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Idarubicin (daunorubicin) and
Cytosine arabinoside and ATRA (all trans retinoic acid) |
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What do you treat with initially for ALL?
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Idarubicin (daunorubicin) and
Cytosine arabinoside and ATRA (all trans retinoic acid) and Intrthecal MTX |
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What if a pt. presents with SOB, confusion, and blurry vision. His wbc is over 100,000 what is the best initial therapy
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This is acute leukemia even though it is presenting with high WBC is from the sloughing off of the blood vessels from the eyes and brain and lungs. This would not be a chronic leukemis b/c lymphocytes are much smaller and don't occlude the vessel.
Treat leukostasis with leucopheresis and add hydroxyurea to lower the WBC |
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What do you when you have a leukostasis how do you treat?
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Leucopheresis
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What can you use to treat to lower the wbc in a pt. with sob, confusion, blurry vision and high WBC and you are thinking acute leukemia...what can you givve other tha do leucpherisis?
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Hydroxyurea
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What leukemia is associated with DiC?
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M3--acute promylocytic leukemia
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What if you see a 65 y/o male with pancytopenia, elevated MCV (hyperchromic), low retic ct., and macroovalocytes on smear, with normal Vit B12 level, what are you thinking?
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Myelodysplasia
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what are 2 lobed neutrophils called?
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Pelger-Huet cells
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when are Pelger Huet cells seen?
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seen in myelodysplasia
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What is the difference when you look at the cells btwn myelodysplasia and leukemia?
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there will be a low number of blast cells compared to what is found in leukemia
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What is pre form of acute leukemia?
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myelodysplasia
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what is the most common cause of death in myelodysplasi?
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Infection or bleeding
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Is acute leukemia the most common cause of death in myelodysplasia?
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NO
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what is the treatment of myelodysplasia?
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supportive and may need transfusion
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what is CML and CLL disorders considered other than chronic leukemias?
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Myeloproliferative disorders
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what do you think if you have an elderly pt. with high Wbc and its predominantly neutrophils with splenomegaly?
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CML
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what is the best initial test in diagnosing a pt. with CML?
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LAP score (leuk alkaline phosphatase)
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What will you find in diagnosis for a CML pt.?
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Low LAP and High WBC
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What will you find for LAP score in infection or normal pt?
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High or normal LAP
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What is the MOST accurate test for CML?
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Philadelphia chromosome
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What is teh best treatment for CML?
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Gleevec (Imatinib)
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What is the way to cure CML
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Bone marrow transplant
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Why do you wnat to initiate imatinib (Gleevec) in CML patients?
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B/C it leads to 90% remission
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Would you use Interferon for CML as treatment?
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NO, less efficacy and causes flu-like symptoms
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Would you use Hydroxyurea for CML treatment?
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No, b/c it doesn't make the philadelphia chromosome negative
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Would you use busulfan for CML treatment? What is it's adverse effect?
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NO---pulm fibrosis
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What if you have an older pt. with an elevated WBC that shows normal appearing lymphocytes...what are you thinking...and this pt. doesn't show any symptoms?
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CLL
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What is the best initial test to do to diagnose CLL?
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Peripheral blood smear
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What will you see on your peripheral blood smear in CLL?
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smudge cells
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What are smudge cells that you see on peripheral blood smear?
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ruptured nuclei of lymphocytes
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What stage would you consider a pt. with smudge cells and just elevated wbc?
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stage 0
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What stage would you consider a pt. with smudge cells and enlarged lymph nodes?
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stage 1
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What stage would you consider a pt. with smudge cells and spleen enlargement?
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stage 2
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What stage would you consider a pt. with smudge cells and anemia
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stage 3
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What stage would you consider a pt. with smudge cells and low platelets
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stage 4
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What do you do for treatment if you see a pt. with smuge cells and elevated WBC and has an enlarged LN?
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nothing
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What do you do for treatment in a pt. with elevated Wbc AND smudge cells ?
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Nothing
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What do you do for treatment in a pt. with elevated Wbc AND smudge cells and have a anemia?
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Fludarabine or chlorambucil
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What do you do for treatment in a pt. with elevated Wbc AND smudge cells and have low platelets?
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Fludarabine or Chlorambucil
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Which therapy is likely to extend survival in a CLL patient?
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Fludarabine
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What if you see a 50 y.o. with pancytopenia and massive splenomegaly what are you thinking?
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Hairy cell leukemia
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What are you thinking if you see a 50 y.o. with pancytopenia and massive splenomegaly what would give you the MOST accurate finding
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TRAP--tartrae resistant acid phosphatases smear
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What will a TRAP show you to confirm hairy cell leukemia?
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Hairy cells
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What is the best initial therapy for positive finding on a TRAP smear?
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Cladribine or 2-CDA
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What would you think of if you see a pt. with Pancytopenia who is 50 y/o and has a BIG spleen but has a NORMAL TRA?
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Myelofibrosis
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What will you find on a TRAP smear in a myelofibrosis pt?
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Tear-drop cells
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What are 2 diseases to consider when you see a 50 y/o with pancytopenia and a large spleen?
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Myelofibrosis and
Hairy cell Leukemia |
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What will differentiate Hairy cell leukemia and Myelofibrosis?
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TRAP smear
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What is the findign on a smear for Hairy cell Leuk? vs
Myelofibrosis? |
Hairy cells have Hairy cell
Myelofirbrosis= tear drop |
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Is there a treatment for myelofibrosis?
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NO
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Is there a treatment for Hairy cell leukemia?
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Yes, cladribine or 2-CDA
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What if you see a pt. with HA, dizziness, fatigue, and blurred vision with itchiness when they get out from a HOT shower; what are you thinking?
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Polycythemia vera
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What other physical finding do you find in Polycythemia vera?
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splenomegaly
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Is splenomegaly common in Polycythemia vera?
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YES
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What will you find on diagnosis for a pt. with Polycythemia vera on cbc re: hct and mcv?
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High Hct
LOW MCV |
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What will you find on diagnosis for a pt. with Polycythemia vera on cbc re: EPO level
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EPO will be low
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What is the complication of having a high Hct. count is association with Polycythemia vera?
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Can lead to thrombosis
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What should you order on a pt. that comes with fatigue, HA, blurred vision and c/o of itching after a shower?
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CBC--to see High Hct and
ABG--to r/o hypoxia as the cause of erythrocytosis EPO level--Low |
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What do you want to r/o when considering a case of polycythemia vera?
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Hypoxia to r/o erythrocytosis
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What is the best initial therapy of Polycythemia vera?
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Phlebotomy
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What is also used in conjunction with phlebotomy to treat polycythemia vera?
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Hydroxyurea--to lower cell cout
Aspirin daily |
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What is also used in conjunction with phlebotomy to treat polycythemia vera and thrombocythenia?
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Hydroxyurea
Aspirin Anagrelide |
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What are the 4 plasma cell disorders to consider?
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MM
Monoclonal Gammopathy of Unknown Signif (MGUS) Waldenstrom macroglobulin Aplastic Anemia |
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What should you suspect if you have a 65 y/o man who factures his femur after climbing on a ladder?
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MM
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what is the most common casuse of death in MM?
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Infection--they are immunodefi
and Renal failure |
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What is the best inital test to do is a pt. with MM?
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Skeletal survey--punched out osteolytic lesions
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What if you find osteoblastic lesions on skeletal survey what should you think?
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Mets from Prostate or BReast
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What test other than skeletal survey would you order if a pt. has MM?
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SPEP
UPEP peripheral smear Elevated Calcium B2 microglobulin BUN/Creat |
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What will you find in a MM pt. on their skeletal survey?
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Osteolytic lesions
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What will you find in a MM pt. on their SPEP and UPEP?
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SPEP--High IgG (monoclonal)
UPEP--Bence Jone prote |
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What will you find in a MM pt. on their Periphearl smear?
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Rouleaux formation
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What will you find in a MM pt. on their re: Ca level?
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High calcium level b/c of osteolytic lesion
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What will you find in a MM pt. on their BUN/Creat?
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High level = renal insuff
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What does a B2-microglobulin level suggest in a MM pt?
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Poor prognosis
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What is the prognostic indicator for a MM pt. ?
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B2 microglobulin level
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What is the most specific test for MM? What will you find?
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Bone marrow biopsy
High numbers of plasma cells |
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What if you find a pt. with monoclonal Ab on SPEP and Bence jone proteins on UPEP, what will you treat them with?
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Melphalan and Steroids
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What drug can be added to mephlan and steroids in the treatment of MM that is also a TNF inhibitor?
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Thalidomide
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What is the most effective therapy for MM?
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AUTOlogous BMT
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When would you consider an AUTOlogous BMT?
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when pt. is very young or has advanced disease
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What should you do with a pt. who has MM and hypercalcemia?
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Treat with mephlan and steroids +/- thalidomide and give hydration and diruetics to treat for the hypercalcemia
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What should you do with a pt. with MM and a bone fracture?
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Treat with Melphalan and steroids +/- thalidomide and bisphosphonates
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What should you do with a pt. with MM and renal failure?
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Treat with melphalan and steroids +/- thalidomide adn hydration
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What should you do with a pt. with MM and anemia?
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Treat with melphalan and steroids +/- thalidomide and EPO
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What should you do with a pt. with MM as far as prophylaxis?
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Pneumovax, tetnus, Infulenza
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What if you find an asymptomatic pt. with an elevated IgG level on SPEP; what should you think of?
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Monoclonal Gamopathy of Unknow Signif
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What if you find an elderly pt. with an elevated total protien level and you perform an SPEP that shows asymptomaic high IgG levels....what are you thinking?
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MGUS
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What are you thinking if you see a pt. with blurry vision, confusion, HA, and enlarged nodes adn spleen with no abn. on CBC and high IgM on SPEP?
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Waldrenstrom's Macroglobulinemia
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What is the best initial test to diagnose Waldren Macroglob?
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Serum viscosity
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Is there hyper or hypo viscosity in Waldren Macroglob?
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Hyperviscosity
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Waht is the best initial therapy for Waldrenstrom macroglob?
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Plasmapheresis
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What would you treat Waldrenstrom macroglob with?
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Fludaarabine or Chlorambucil
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What is the Waldrenstrom macroglob treatment similar treatmet to what disease?
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CLL
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What are you thinking if there is no cause to Pancytopenia in a pt.
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Aplastic anemia
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What is the best treatment for a young aplastic anemia pt?
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BMT
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What is the best treatment for a OLDER aplastic anemia pt?
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Anti-thymocye globulin AND
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What is the best treatment for an OLDER aplasic anemia pt.
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Anti-thymocyte Ab AND cyclosporine
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What are the "B" symptoms of lympohoma?
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fever, wt. loss, night sweats
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What are you thinking if a pt. comes with enlarged lymph nodes ususally starting in the neck?
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HOdgkins lymphoma
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What are you thinking if you see a pt. with enlarged lymph nodes but has a more widespread disease course?
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NHL
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waht is the best initial test to diagnose both NHL and Hodgkins?
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Excisional LN biopsy
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Can you do a needle biopsy for NHL?
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NO
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Can you do a needle biopsy for Hodgkins?
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NO
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What is the only acceptable biopsy for NHL or Hodgkins?
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Excisional
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If you find Reed-Sternberg cells on biopsy, what are you thinking?
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Hodgkins
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Why is staging impt. in determining lymphomas?
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Important b/c it guides treatment
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What stage lymphoma is a single node involvement considered?
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Stage I
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What stage lymphoma is a 2 node involvement on same side of diaphram considered?
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Stage II
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What stage lymphoma is a single node on both side involvement considered?
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Stage 3
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What stage lymphoma is a widespread node involvement considered?
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Stage 4
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What should you order if you have a pt. with lymphoma?
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CXR
Ct with contrast Bone Marrow Bx |
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What should you treat Stage I and II lymphomas with no "B" symptoms with?
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Radiation
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What should you treat Stage III and IV lymphomas with?
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Chemo
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What chemo regimen would you give a pt. with HD?
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ABVD
Adrimycin(doxy) Bleomycin Vinblastine Dacarbazine |
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What chemo regimen would you give a pt. with NHL?
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CHOP
Cyclophosphamide Hydroxyadramycn Oncovin(Vincristine) Prednisone |
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What other test should be ordered in a NHL pt?
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Anti CD-20 antigen
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What if a pt. is CD20 + in an NHL pt, what can you treat with?
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Rituxin
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What are the 4 coagulation disorders that you need to know?
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VWD
ITP Uremia-induced platelet dysfx Clotting factor defic (factor 8,9,11, 12) |
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What if you see a platelet dysfx. leading to superficial bleeding from teh skin and mucousal surfaces like gum, vagina, gingiva)
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Think of vWD
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What if you see epitaxis with a normal platelet count and bleedig gets worse with aspirin, what disorder should you think of?
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vWF
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Why might you see an elevated aPTT in pt. with vWF pts?
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B/c vWF destabilizes Factor 8
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What should you order if there is a platelet type bleeding with normal platelet count?
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bleeding time
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What is the most accurate test for vWF diagnosis?
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Ristocetin cofactor assy and
vWF level |
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What does the ristocetin assay tell you in a pt. with vWF pt. if the vWF is normal?
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tells you if it is working properly
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What is the first line treatment in a pt. with VWF disease?
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Desmopressin or DDAVP
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What does desmopressin do in a vWF pt?
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release subendothelial stores of vWF and Factor 8
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What should you expect after you treat a vWF pt. with desmopressin?
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bleeding (epitaxis) should stop
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If DDAVP is not effective in a vWF pt., what is the next best step in management?
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Factor 8 replacement
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Why does Factor 8 replacement help in a pt. with VWF?
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Becasue is has both VWF and Factor 8
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What are platelet type bleeding?
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Petechia
Epitaxis Purpura Gingiva Gums Vagina |
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What are Factor type bleeding?
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Think joints and bones
Hemarthrosis Hematoma |
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What is ITP
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platelet type bleeding (epitaxis, gum, gingiva, vagina, petechia, purpura) with platelets <50,000
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What tests would you order in an ITP patient?
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Anti-platelet Ab
Sonogram--to look for Normal spleen size Bone marrow--see increased number of megakaryocytes Look for Antibodies to GIIb/IIIa Receptor |
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What should you do if a pt. comes with low platelets -34,000 and petechiae?
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start treatment with prednisone
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Is it more impt. to start treatment on a ITP pt. ro diagnose the ITP?
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Start treatment
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What would you order on CCS for a ITP pt?
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Platelet count
anti-platelet Ab Bone marrow biopsy Heme consult Sonogram and treatment with prednisone |
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A pt. comes with ITP and a platelet count of 5,000, and has epitaxis and petechia with an Intracranial Hmmg and melena, what is the best next step?
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IVIG administartion or Rhogam
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When do you give IVIG to a ITP pt?
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when platelets are less than 20,000 and life threatening bleeding like that in the bowel or brain
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Would you transfuse platelets to a pt. with petechiae, and low platelets (10,000)
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NO, b/c could be ITP and it may make situation worse, best thing to start is IVIG
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What if you see a pt. with platelet count of 43,000 and minor bleeding, what would you treat with?
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Prednisone
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What if you see a pt. with platelet count of 53,000 and minor bleeding, what would you treat with?
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No treatment
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What if you see a pt. with platelet count of 19,000 and serious nq bleeding, what would you treat with?
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IVIG or Rhogam
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What if you see a pt. with recurrent episodes of bleeding, what would you treat with?
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splenectomy
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What happens when you have uremia?
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It makes platelets stop working properly
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What happens to the platelets with uremia present?
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It doesnt' degranulate properly
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What shoudl you think of if you have a pt. with elevated BUN/Creat, petechiae, and ginigival bleeding, with normal platelets?
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uremia induced platelet dysfx
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What will you find in a Uremia induced platelet dysfx. pt. re: ristocetin and VWF
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Ristocetin and VWf will be normal
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What is the best treatment for uremia induced platelet dysfxn/
|
Desmopressin (DDAVP)
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What is the first test to determine the difference btwn a clotting factor defic and a factor inhib antibody?
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Mixing study
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What will happen on the mixing study if there is a clotting factor defic.
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aPTT will normalize with the mixing study
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What will happen on the mixiing study if there is a factor inhib antibody?
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aPTT will not normalize
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If you see a pt. with joint bleeding or a hematoma in a young male child...what should you think of ?
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Factor 8 defic
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If you see a pt. with joint bleeding or a hematoma that is less common what should you think of?
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Factor 9 defic
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If you see a pt. with rare bleeding in a trauma or surgery, what should you think of?
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Factor 11
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What if you have a pt. with no bleeding and you suspect a factor defic?
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Factor 12
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Waht is the diagnostic test of choice when trying to determine factor defic?
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Mixing studies, then the specific factor level
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What woudl you order to diagnose a pt. with joint bleeding in a young male? and what would you treat with if your suspicion is correct?
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Diag--mixing study and Factr 8 level
Treat with Factor 8 in severe defic OR DDAVP in mild cases |
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What other disease can use the same treatment as Factor 8 defic?
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vWF
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What woudl you do to diagnose and what treatment would you give to a less common factor defic with joint bleeding or hematoma?
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Mixing study
Factor 9 level Treat with Factor 9 |
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Waht woudl you do to diagnose and treat a pt. with rare bleeding with trauma or surgery?
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Diag with mixing study and
Factor 11 level Treat with FFP with bleeding episodes |
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Is tehere a treatment for Factor 12 defic?
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NO
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What do you do if you see a woman bleeding into her thigh after minor trauma the aPTT is prlonged, the PT is nomral and Mixing study does not correct the aPTT to normal what is the diagnosis?
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Factor 8 antibody
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What is the most common cause of prolonged aPTT and bleeding that doesnt correct with mixing study?
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Factor 8 ANTIBODY
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wHAT do suspect if a pt. with stable afib is started on therapy and develops a drop in platelets after a few days?
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HIT
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What type of rxn is HIT/
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allergic
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What will you find on clinical manifestion most commonly assoc with HIT?
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Thrombosis
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The thrombosis assoc with HIT are more commonly venous or arterial?
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Venous (3X)
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Can Lovenox cause HIT?
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YES, but less likely
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What is the best inital test to diagnose HIT?
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platelet 4 antibodies OR
heparin-induced antiplatelet antibodies |
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What is the treatment for HIT
|
STOP heparin and
START direct thrombin ihibitor like argatroban or lepirudin |
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Is unfractionated Heparin and Lovenox both heparin?
|
YES
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What are the 4 thrombophilia/hypercoaguable states?
|
Lupus or anti-cardiolipin
Prot C def Factor V Leiden Anti-thrombin def |
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What if you see a pt. with Venous thrombosis, elevated aPTT and normal PT and had a spont. abortion, what are you thinking
|
Antiphospholipid or
Anti cardiolipin Ab |
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What if you have a pt with venous thrombosis, elevated aPTT adn normal PT with false positive VDRL, what would you order to diagnose?
|
mixing study then
Russel viper venom test--for lupus anticoagulant |
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Waht is the treatment in a pt. with venous thrombosis, elevated aPTT adn normal PT with false positive VDRL,
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Heparin followed by warfarin
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What if you see skin necrosis with the use of warfarin, what are you thinking?
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Prot C defic
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What would you diagnose to determine skin necrosis with the use of warfarin?
|
Prot C level
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What would you treat with to skin necrosis with the use of warfarin?
|
heparin followed by warfarin
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What is the most common cause of thrombophilia?
|
Factor V mutation
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What is teh best diagnostic test to determine Factor V mutation?
|
Factor V mutation test
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What is the best treatment for Factor V mutation?
|
Heparin followed by warfarin
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What are you thinking if you see a pt. with no chage in aPTT with a bolus of Heparin?
|
Anti-thrombin defic.
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What would you diagnose with a pt. who has no chage in aPTT with a bolus of heparin?
|
Level of anti-thrombin III
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What treatment would you offer a pt. with no change in aPTT with a bolus of IV heparin?
|
large amounts of heparin or
Direct thrombin inhib followed by warfarin |
