林醫師 CBC
第一屆公費生,
台大第二屆CP
住院醫師時沈明鏡教授叫他到腫瘤科Run.
早上六點半上班 晚上十二點半回家
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Doctors'
doctor
AP, CP 各四年
美國都是雙專科
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PRC叫檢驗醫師
台灣以前叫實驗診斷科
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衛福部只能登記兩個專科
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Anemia workup
Blood smear
RPI
Beta
thalassemia
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IDA
常合併Thrombocytosis
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Reticulocyte
會有Polychromatosis
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Evans syndrome; Immunopancytopenia
- Thrombocytopenia
- Retuiculative giant platelet
The diagnosis is made
upon blood tests to confirm not only hemolytic anemia and immune
thrombocytopenic purpura, but also a positive
direct antiglobulin test
(DAT) and an absence of any known underlying cause.
[2]
Other antibodies may
occur directed against
neutrophils
and
lymphocytes,
[7] and "immunopancytopenia"
has been suggested as a better term for this syndrome.
[8]
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MCHC
Hb/Hct
Hemolysis也會高(Hct↓)
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Intracellular
hemolysis
Pseudo hyper
Hb
Hb 12.5 很喘
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Spherocytosis
- Microcytic, immune,
life-threatening
- Macrocytic, hereditary
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Fragmented RBC
Pseudo
thrombocytosis 有些儀器無法區分
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Cold
agglutinin
拿一滴血在玻片加冰塊
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NRBC
- 現在不用校正WBC
- 常用在Newborn
- Cancer, bone cancer, bone
metastasis
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Giant
platelet
- 看MPV大小
- Platelet count 會fluctuates
- PDW不是很準
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Plt clumping
- Pseudothrombocytopenia,
不要直接切spleen，先想原因:EDTA-Induced, Poor sampling, Macrothrombocytopenia( Giant
platelet, hereditary disease)
- Hit; heparin-induced
thrombocypenia
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APL會DIC要緊急輸血
其他情況沒有出血不要急著輸血，先找underlying
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沒有好的檢查
可以Experience therapeutic trial
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Band現在證實跟infection無關
Neonatal
infection才看immature/segmented ratio
Rheumatologist用ESR,
因為藥物會影響CRP
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PFA-100美國用在vWD
screening
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Bleeding,
closure time
100,000以下做一定長，不用做
常受到Alcohol, chocolate, flu drug，感冒藥影響
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VeryfyNow
monitor of anti-platelet
PMCID: PMC2683811
Comparison of VerifyNow-P2Y12 test and Flow
Cytometry for monitoring individual platelet response to clopidogrel. What is
the cut-off value for identifying patients who are low responders to
clopidogrel therapy?
Conclusion
In conclusion our findings show that a cut-off value of ≤ 15% inhibition or > 213 PRU in the VerifyNow-P2Y12 test may provide the best accuracy for the
identification of patients with LR.
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Plavix
resistance (Plavix是Prodrug)
做完心導管restenosis
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PT,
aPTT檢查管要上下搖六下，共12下
Insensitive
千萬不要用在early
DIC診斷. Tertiary hemostasis
Check liver
reserve
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TMA; Thrombotic microangiopathy
- TTP 1982年 B61-09 Han-Mou Tsai蔡漢謀學長發現ADAMTS13
Physician,
Professor of Medicine and Pathology, M. Elaine Eyster Professor of Hematology
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DIC時Kidney, lung capillary最受影響
- Acidosis
- TPR
- 做blood smear
High
sensitive D dimer 配合pretest clinical 才能 rule out
Well's
score只能用在門急診，住院、手術後不能使用
減少sono, CT 支出
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Antiphosphatase
syndrome
(repeated 12
weeks ACA, anti-Beta2 )
Lupus
anticoagulant. DRVVT, with LA-sensitive
aPTT test (較少的phosphalipid)
Prolong
thrombin time
- Thrombosis
- Recurrent abortion
- IUFD
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Factor XII deficiency
- aPTT prolong but thrombosis
- Paradoxical finding
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NOAC比較安全
Antidote會慢慢上市
告誡病人不要過量，忘記吃千萬不要補吃
緊急時打
Prothrombin complex concentrate (
PCC,
trade names Beriplex,
Octaplex,
[1] Kcentra,
Cofact, among others) is a combination of
blood
clotting factors II,
VII,
IX and
X, as well as
protein C and
S,
[1] prepared from fresh-frozen human
blood plasma. It is used
to reverse the effects of oral
anticoagulation
therapy when bleeding occurs (e.g. in the brain or gut) requiring rapid
action to accelerate
coagulation.
[2][3] PCC is effective but expensive.
[vague] In the UK, it is prescribed in discussion
with a haematologist. It is available as a powder and solvent for solution for
injection.
[2]
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Warfarin
老鼠藥的親戚
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High
sensitive CRP 用在評估血管功能
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INR 受飲食習慣影響
確認實驗室aPTT的治療時間對應: heparin
level 0.3-0.7
最好搭配anti-Xa
activity檢查
Heparin
resistance受到antithrombin影響
Low
molecule heparin 則要用Xa monitor
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Fibrinogen
Monitor tPA
therapy
Target 在
100-200
補充cryoprecipitate,
or fibrinogen concentrate
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Protein S
C4b complex
binding
Pregnancy(ProteinS增加), nephrotic syndrome
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NOAC;
Anti-coagulation guideline 由胸腔科制定
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