Usmle 3 Heme Onc

Front 1

most common cause of inherited thrombophilias?

Back 1

- factor V leiden 40-50%
- other causes: prothrombin gene mutation, hyperhomocysterinemia, protein C, protein S, antithrombin III deficiency, antiphospholipid

Front 2

epidural spinal cord compression

Back 2

- common complication of cancer
- cancers that tend to met to spinal cord: prostate, breast, lung, non-Hodgkins, RCC
- sx: thoracic radicular pain that wraps around the abdomen, lower exremity weakness and sensory changes
- TREAT IMMEDIATELY b/c cord compression: high dose corticosteroids followed by MRI to confirm dx, followed by radiation therapy vs surgery

Front 3

best prognostic sign for CNS lymphoma?

Back 3

- increase in CD4 count

Front 4

first step in treatment of sickle cell crisis?

Back 4

- IV fluids
- presence of sickling in bood smear is not useful

Front 5

splenic sequestration crisis

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- high risk in young children with SCC
- check CBC - large fall in hemoglobin secondary to vaso-occlusion in spleen and splenic pooling
- spleen can enlarge rapidly --> hypovolemic shock --> immediate blood transfusion

Front 6

greatest correlation w/ dvlp colon cancer? what protects?

Back 6

- alcohol possibly due to decreased alcohol intake
- protects: NSAIDS, HRT, high fiber, exercise

Front 7

risk of multiple blood transfusions?

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- development of alloantibodies --> difficulty in finding compatibility

Front 8

autoantibodies vs alloantibodies in finding match for blood transfusion?

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- alloantibodies develop in patient with long hx of transfusions
- autoantibodies usually become an issue in pts with AI anemia and taking certain drugs (methyldopa and procainamide)

Front 9

HLA allosensitization

Back 9

- increases risk of graft rejection in pts awaiting organ or bone marrow transplantation

Front 10

patient with isolated thrombocytopenia- everything else is normal including PT, PTT, plasma fibrinogen, etc?

Back 10

- idiopathic thrombocytopenic purpura
- platelet destruction secondary to specific autoantibodies
- don't give plt transfusion because they will just be destroyed anyway by antibodies
- no need to treat if plt btw 30-50
- if severe, tx with corticosteroids esp in adults or IVIG if CS fails

Front 11

tx of HUS and TTP?

Back 11

- plasmapheresis

Front 12

side effects of metoclopromide

Back 12

- D2 receptor blocker
- causes EPS when used in high doses
- being replaced by odansetron 5HT3 receptor blocker

Front 13

tx of platelet dsfx in pt who is acutely bleeding?

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- desmopressin, dialysis, estrogen tx, cryoprecipitate infusion

Front 14

clotting tests

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- PT: aka factor II, produced by liver, requires vit K, prolonged in liver disease
- PTT: detects deficiencies in all clotting factors except VII, XIII, used to monitor heparin therapy
- bleeding time: prolonged in thrombocytopenic purpura, plt abnormalities, vascular abnormalitiy, leukemia, severe liver disease, DIC, factor deficiency, hemophilia

Front 15

Heparin induced thrombocytopenia

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- Type I: w/in 2 days of heparin therapy, not as large drop (to 100), plt count return to normal once d/c heparin
- type II: 4-10 days after heparin, Ab driven, associated with venous and arterial thrombosis, so major manifestations: DVT, PE, venous limb gangrene, cerebral sinus thrombosis, stroke, MI
- prevent by using LMWH over unfractionated and using heparin < 5 days to decrease risk of Ab formation

Front 16

tx of HIT?

Back 16

- d/c heparin and warfarin if pt is on it (don't restart warfarin until plt count > 100) --> start lepirudin (don't use in renal insufficiency) or argatroban (dose adjust in hepatic dysfunction)

Front 17

what blood smear is consistent with iron deficiency anemia?

Back 17

- microcytic/hypochromic anemia with anisocytosis
- most common source is GI bleed in males --> fecal occult test

Front 18

microcytic vs macrocytic anemia?

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- microcytic: iron deficiency
- macrocytic: check b12, folate

Front 19

febrile transfusion reaction

Back 19

- 10 minutes after transfusion, pt gets chills and spikes a fever
- pathophys: pt's ab reacts to donor's leukocytes
- prevent by cell washing, using frozen deglycerolized red cells, other leukocyte depletion techniques

Front 20

dx acute hemolytic transfusion reactions

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- classic triad that you rarely see: fever, back pain, red or pink colored urine
- to r/o stop transfusion and get tests: direct antiglobulin/Coombs test and measurement of plasma-free hemoglobin level, UA to see hemoglobin

Front 21

what calcium abnormality occurs with transfusions?

Back 21

- hypocalcemia --> calcium gluconate infusion

Front 22

tx of DVT secondary to reversible cause vs idiopathic?

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- treat w/ warfarin for 3-6 months
- idiopathic: at least 6 months, reassess on whether to continue

Front 23

1 unit of platelet should raise the plts by how much? when to recheck plts after transfusion?

Back 23

- 5,000
- 10-60min after copmletion

Front 24

platelet refractoriness

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- absolute platelet increment of less than 2,000 per unit
- most common cause is alloimmuniation

Front 25

plt count rises appropriately after transfusion but then falls w/in 24 hours

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- DIC, sepsis, active bleeding, drugs that reduce plt survival

Front 26

superior vena cava syndrome

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- dyspnea, cough, facial fullness, neck pain --> hoarseness, dysphagia, chest pain, syncope
- Pex: dilated veins in arms and neck
- best dx test is CT w/ contrast
- 80% bronchogenic carcinoma

Front 27

use and risk of tamoxifen? testing?

Back 27

- use in estrogen receptor positive breast cancer for 5 years
- risk of uterine cancer
- only do further testing if pt is post menopausal w/ abnormal sx e.g. bleeding or vaginal sx --> U/S or biopsy

Front 28

tx for non-operable head and neck cancer?

Back 28

- both chemo and radiation

Front 29

ABO incompatibility

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- fever and hypotension
- stop transfusion and HYDRATE with normal saline (not LR)
- also consider dopamine infusion and osmotic diuresis

Front 30

tx of metastatic prostate cancer?

Back 30

- e.g. met to spine
- palliative rather than curative
- androgen depletion: LHRH (leutinizing hormone releasing hormone) eg. leuprolide but causes initial T surge followed by decrease so also give antiandrogen e.g. flutamide for that first week T surge

Front 31

pt with lobular carcinoma in situ on core needle biopsy, next step?

Back 31

- nonmalignant lesion but increased risk of lobular or ductal carcinoma
- do excisional biopsy because may actually be DCIS or invasive cancer
- follow up yearly surveillance or consider SERMS: tamoxifen, raloxifene or prophylactic bilateral mastectomy

Front 32

pt with elevated PSA and shoulder pain

Back 32

- get radioiostope bone scan

Front 33

elderly pts with bone pain?

Back 33

- always suspect multiple myeloma
- will see hyperCa2+ and renal dysfx
-to dx get: SPEP, UPEP, skeletal survey, bone marrow biopsy

Front 34

pt with multiple myeloma- what test to assess for bone lesions?

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- whole body xray b/c looking or lytic lesions (not radionucleotide bone scan that look for blastic lesions)

Front 35

hyperviscosity syndrome

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- increased serum vicosity due to high protein content
- seen in multiple myeloma, Waldestrom's macroglobulinemia
- sx: HA, dizziness, vertigo, nystagmus, hearing loss, visual impairment, mucosal hemorrhage from impaired plt function
- ddx ARF: not as acute
- hypercalcemia: no mucosal bleeding or blurry vision
** HY

Front 36

patient presents with elevated Hg/Hct... next step?

Back 36

- get EPO
- if pt has hx of lung disease then secondary to hypoxia and pt with high EPO
- if low EPO then think myeloproliferative d/o

Front 37

side effect of methotrexate?

Back 37

- macrocytic anemia
- methotrexate inhibits folate conversion --> folate deficiency

Front 38

what drugs cause macrocytic anemia?

Back 38

- trimethoprim, methotrexate, phenytoin --> interferes with folate
- give folinic acid (leucovorin)

Front 39

common primary sites of origin of brain metastasis

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- order of frequency: lung, breast, unknown, melanoma, colon cancer

Front 40

pernicious anemia

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- autoimmune destruction of parietal cells
- dx by measurement of autoantibodies against intrinsic factor (which is produced by parietal cells and is needed to bind to B12 for body to absorb)
- schilling test is second line
- see atrophy in fundus and body, not antrum **high yield

Front 41

bcr/abl translocation?

Back 41

- CML
- tx with tyrosine kinase inhibitor to control disease; then if stable and w/ donor tx with bone marrow transplant

Front 42

pt treated with EPO for anemia secondary to renal disease --> inadequate response in 4-6 wks... next step?

Back 42

- look if pt has other causes of anemia as well ---> measure ferritin and transferrin saturation
- avoid blood transfusion in ESRD because can sensitize pt for allograft rejection

Front 43

treatment of multiple brain metastasis

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- whole brain radiation to improve survival by a couple of months
- chemotherapy has poor penetration

Front 44

pt with pancoast's tumor: what finding requires immediate therapy?

Back 44

- asymmetric chest movement and lower DTR --> phrenic nerve involvement or invasion of intervertebral foramina --> risk of spinal cord compression
- Horner's is bad prognostically but not an emergency

Front 45

anemia of chronic disease

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- seen in pts with cancer or chronic inflammation (e.g. RA) --> suppress RBC in bone marrow
- see low iron, high ferritin, normal transferritin
- bone marrow biopsy: decreased sideroblast, increased iron storage in macrophages
- tx underlying disease, give EPO or blood transfusions
- EPO ineffective if pt's EPO is already >500

Front 46

neutropenic fever

Back 46

- isolate fever >101 and lasts more than an hour
- don't get many other symptoms
- emergency

Front 47

pt with anemia, normal MCV

Back 47

- get retic count to ddx disease of RBC production vs destruction
- ESR may be useful because anemia of chronic disease will look similar; ESR would be elevated

Front 48

palliative pain tx for pt with spine metastasis?

Back 48

- radiation therapy

Front 49

patient with squamous cell carcinoma refuses excision... next step?

Back 49

- do radiation therapy

Front 50

work up of lung cancer

Back 50

get CT

Front 51

HER2/neu overexpression

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- worse prognosis
- bad response to treatment
- tx with monoclonal ab to Her2/neu e.g. herceptin (trastuzumab)

Front 52

note: IM/IV EPO is not more effective then oral EPO, so don't choose if oral EPO is ineffective

Back 52

ok