The hematology Gods must be hungry. I'll leave you with three board type scenarios. Scenarios we internists must know to pass our board exams. If you don't know your differential diagnosis, you are of no use to the patient. So, here goes....
- A 65 year old with acute onset of pancytopenia and severe mucositis.
WBC 0.2
Hgb 6.9
Plt 12K
Afebrile. stable vital signs.
PE petechia. mucositis.
Let's hear the differential diagnosis.
- 89 year old vomiting blood.
PTT 130
PT 70
PT INR testing of 6.
Not on coumadin dosing. Not on anticoagulants. No response to Vit K. Partially corrects with FFP. What's your differential diagnosis.
- 31 year old with fatigue.
Hgb 3.2. Profuse bleeding with surgical interventions. Menorrhagia. MCV 57. normal PTT/PT/plt. Her periods last 20-30 days a month. Stable vitals. What's your differential diagnosis.
A 65 year old with acute onset of pancytopenia and severe mucositis.
ReplyDelete. Medular aplasy secondary to quimioterapy treatment.
89 year old vomiting blood.
. Acute Intravascular diseminated cuagulation cause of sepsis
. cronic Intravascular diseminated cuagulation cause of cancer
31 year old with fatigue.
. Von Villenbrand disease. (Most likely)
. Glanzmann disease
. Bernard soulier disease
. rendu Osler disease.
Ferropenic Anemia Secondary to bleeding
I'd say acute leukemia in the first.
ReplyDeleteLive enzymes on the 2nd?
What Alexy said for #1, (chemotherapy) for/or leukemia, those chemos do that stuff.
ReplyDelete#2, could be what Alexy said, but think something is missing. IDK.
#3 bleeding from what type procedure - hysteroscopy? endometrial hyperplasia and or endometrial cancer. (is pt on BCPs especially continuous?)
-Second career nursing student
My first post is asking for LIVER enzymes, not "live enzymes" whatever the hell those are.
ReplyDeleteOh... got it Alexy, you meant to say Von Willebrand's disease, right?
ReplyDelete-second career nursing student
My Diff.
ReplyDelete3 Patients that won't being seeing their next birthday under socialized medicine.
Jeez, do you practice in Chernobyl??? OK, its gonna delay me for 10 seconds before my next cataract, but I'll play..
ReplyDelete1: Side effects of Chemo guy probably smokes so eff him.
2: Bleeding Varices/Cirrhosis, guy probably used to smoke, so eff him..
3: Some GYN thing...IV estrogen should slow it down, oh wait a minute, she's got nicotine stains, eff her.
Wow, we're all really impressed you guys passed a test with this stuff on it... so how come you can't start a friggin A-line without leaving the room lookin like friggin Sharon Tates bedroom???
You know there's only 5 anesthetic gases???
5. F-I-V-E... and they're all pretty much the same.
Frank
Frank, Happy's rules are... "By posting here I promise to do something nice for someone today." Have you done something nice for someone today?
ReplyDelete-Second career nursing student
65 y/o leukemia, girl severe menorrhea, with acute surgical blood loss. just a guess.
ReplyDeleteyou guys are boring. really. oh, and self loved and totally obvious. peace.
ReplyDeleteyou guys are boring. really. oh, and self loved and totally obvious. peace.
ReplyDeleteand you are so high and mighty. lol
lol omgz lmao idk.
ReplyDeleteThanks for the input.
First case: Chemo tx, colchicine, or clozoril - induced anplastic anaemia.
ReplyDeleteSecond case: DIC from sepsis
Third Case: What was the platelet count? Did she have petechia? Could be ITP or as other's have said, Von Willibrand's
We've had a couple JW's. They never survive.
ReplyDeleteHey!! I got 2.5/3 right and haven't cracked an IM textbook since 1987...
ReplyDelete1) Methotrexate induced
ReplyDelete2) Factor V and Factor X deficiencies (possible inhibitor) in the setting of a positive antiphospholipid antibody, thought to be a coconspirator.
3) VW disease with chronic uterine bleeding.
Alexy,
ReplyDeleteThe only info Happy gave us was the PT/PTT were prolonged, that it didn't correct with Vit K and that it partially correct with FFP. In severe end stage liver disease (which would have been clincally obvious - but we weren't given the info)very little coag factors are produced and Vit K levels won't fix severe defiencies. The coags would correct with FFP since the FFP contains the all of the coag factors.
Happy - I obviously don't have very much data, but I seriously doubt that this lady has BOTH factorv V and X inhibitors. These are both quite rare and quite difficult to sort out in the context of antiphospholipid antibody. You also wouldn't correct these (unless mild) with FFP. In addition Factor V inhibitor would be associated with clotting, not bleeding. I would go back to the drawing board, but I bet this is only antiphospholipid antibody.