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Hematology & Oncology

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How can you stratify anemia?

  • Get reticulocyte count, MCV, RDW

  • If appropriately elevated reticulocyte count → bleeding or hemolysis

  • If inappropriate reticulocyte count → problem with RBC production and eval MCV

  • MCV: size of RBC

  • RDW: variety of RBCs - if high, then could be a mix of multiple causes of anemia

  • Work-up of anemia: https://twitter.com/WilliamAird4/status/1613152245436276736

 

What are the main associations of microcytic, normocytic, and macrocytic anemia?

  • Microcytic: iron deficiency, thalassemia (VERY low MCV)

  • Normocytic: IDA, ACD (kidney, liver), primary bone marrow d/o

  • Macrocytic: B12/folate deficiency, alcohol, hypothyroidism, drugs, MDS

 

What is the work-up for a microcytic/normocytic anemia?

  • Iron studies

  • If extremely low MCV (<75), then consider thalassemia

  • Can use Mentzer index (MCV/RBC count) to distinguish between IDA/thalassemia:

    • Mentzer index = MCV/RBC. 

    • If MI >13, IDA is more likely 

    • If MI <13, thalassemia is more likely

 

What is the work-up for a macrocytic anemia?

 

How do you distinguish IDA from ACD?

 

What are the transfusion goals for anemia?

 

How much should a blood transfusion raise Hgb?

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What labs should you order if you suspect hemolysis?

  • Tbili/dbili (will have increased unconjugated bilirubin in hemolysis)

  • LDH (will be high)

  • Haptoglobin (will be low)

  • Peripheral smear

  • Direct antiglobulin (Coombs)

 

What are the causes of hemolysis?

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What is a neutropenic fever defined as?

  • Fever of 100.4° F and ANC <500/µL (or ANC expected to drop to this range)

 

What antibiotics are indicated?

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What are triggers for a sickle cell crisis?

  • Hypoxia, dehydration, cold weather, stress, infections

 

What is the management of a sickle cell crisis?

  • Warmth, oral and IV hydration, pain control with NSAIDs and opioids

 

What is the transfusion goal in a patient with sickle cell?

  • Goal Hgb ~10 g/dL, sometimes lower depending on baseline Hgb

  • Risk of hyperhemolysis in SCD patients

 

What is acute chest syndrome and how do you manage?

  • Fever + tachypnea + hypoxia + cough + dyspnea + new pulmonary infiltrate

  • Caused by infection, atelectasis, and/or thromboembolism

  • Oxygen with goal SaO2 = 100%, incentive spirometry to avoid atelectasis, IV fluids, empiric antibiotics eg CTX/Azithromycin, pain control

  • Simple vs exchange transfusion

  • https://twitter.com/MedicalGlobe_MG/status/1610977248311377921/photo/1

 

What are the indications for plasma exchange?

  • Acute chest with severe hypoxemia (>6L NC), rapid deterioration or failure to improve

  • With plasma exchange, goal Hgb <10 g/dL to avoid hyperviscosity

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What are the best-studied medications to prevent chemotherapy-induced nausea?

  • Serotonin antagonist (ondansetron)

  • Neurokinin-1 receptor antagonist (aprepitant)

  • Glucocorticoids

  • Olanzapine

https://pubmed.ncbi.nlm.nih.gov/28759346/

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What should you do if you suspect cord compression?

  • Obtain stat MRI with and without, contact neurosurgery and radiation oncology

  • Give high-dose dexamethasone (ex. 40 mg IV stat, followed by 10 mg IV q6 hrs)

 

What is tumor lysis syndrome?

  • Rapid breakdown of malignant cells leading to increased serum uric acid, potassium, phosphate, decreased calcium

  • Usually 1-5 days after treatment; most commonly in hematologic malignancies or bulky solid tumors

  • Can lead to fatal arrhythmias, seizures, tetany

 

What labs should you trend in tumor lysis syndrome?

  • LDH, uric acid, potassium, phosphate, calcium

 

How do you manage tumor lysis syndrome?

 

What are the first labs to check if a patient presents with elevated calcium? 

  • Correct calcium for albumin

  • Check PTH to determine if PTH dependent or independent 

 

How is hypercalcemia treated?

  • Avoid any medications or factors that may contribute including thiazide diuretics, vitamin D toxicity, lithium, calcium supplements

  • Isotonic saline @ 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour; may need to decrease rate in pts with HF or renal failure (can give loop diuretics in this case)

  • Calcitonin at initial dose 4 units/kg; check calcium to monitor responses and can re-dose q12 hrs (of note, not beneficial after 48 hours due to tachyphylaxis)

  • Bisphosphonates → effective but take up to 2-4 days to kick in, not helpful in acute phase

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How do you follow a solitary pulmonary nodule? 

  • Nodule 6 mm or less do not need follow-up. Greater than 6 mm - repeat CT in 1 year can be considered.

 

When would you consider biopsy for a pulmonary nodule? 

  • Enlarging nodule or red flag (spiculated or lobular, intense uptake on PET scan, diameter >1 cm)

 

2017 Fleischner Guidelines:

https://pubs.rsna.org/doi/10.1148/radiol.2017161659?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200 pubmed

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What are the platelet transfusion goals?

  • Transfuse if <10 in most patients, <20 low-risk procedures, <50 if active bleeding or surgeries

 

How can you classify?

  • Decreased production: sepsis, liver disease, bone marrow failure, nutritional deficiencies, HIV, HCV, other viruses

  • Increased destruction: HIT, ITP, TTP, DIC, catastrophic APLS, thyroid disease, meds

  • Sequestration: splenomegaly

 

What should you order to work-up low platelets?

 

What score can you use to estimate the likelihood of HIT?

  • 4T score: platelet count, timing, thrombosis, other causes

  • 0-3 = low, 4-5 = intermediate, 6-8 = high

 

What are the 5 classic associations of TTP?

  • Thrombocytopenia

  • MAHA

  • Renal involvement

  • Fever

  • CNS involvement (TIA or stroke)

 

What score can you use to estimate likelihood of TTP?

 

What is the management of TTP?

 

When do you decide to give FFP vs cryo? 

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What are standard inpatient DVT ppx and why would you use particular ones?

  • Lovenox (enoxaparin) aka LMWH: 40 mg/day (more predictable dosing and monitoring)

  • Heparin: 5000U q8 hr (in CrCl <30)

  • SCDs: pts with bleeding

  • Nothing: in pts who are already on DOAC or warfarin (therapeutic AC) for other reasons

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