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
------------
Doctors'
doctor
AP, CP 各四年
美國都是雙專科
------------
PRC叫檢驗醫師
台灣以前叫實驗診斷科
------------
衛福部只能登記兩個專科
------------
Anemia workup
Blood smear
RPI
Beta
thalassemia
- HbA2 >3.5%
- RBC count ↑
------------
IDA
常合併Thrombocytosis
------------
Reticulocyte
會有Polychromatosis
------------
Evans syndrome; Immunopancytopenia
- Thrombocytopenia
- Retuiculative giant platelet
Evans syndrome is an autoimmune disease
in which an individual's antibodies
attack their own red
blood cells and platelets.[1] Both of these events may occur
simultaneously or one may follow on from the other.[2]
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]
------------
MCHC
Hb/Hct
Hemolysis也會高(Hct↓)
------------
Intracellular
hemolysis
Pseudo hyper
Hb
Hb 12.5 很喘
------------
Spherocytosis
- Microcytic, immune, life-threatening
- Macrocytic, hereditary
------------
Fragmented RBC
Pseudo
thrombocytosis 有些儀器無法區分
------------
Cold
agglutinin
拿一滴血在玻片加冰塊
------------
NRBC
- 現在不用校正WBC
- 常用在Newborn
- Cancer, bone cancer, bone metastasis
------------
Giant
platelet
- 看MPV大小
- Platelet count 會fluctuates
- PDW不是很準
------------
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
------------
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
------------
沒有好的檢查
可以Experience therapeutic trial
------------
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
------------
PFA-100美國用在vWD
screening
------------
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
------------
VeryfyNow
monitor of anti-platelet
Thromb J.
2009; 7: 4.
Published online 2009
May 6. doi: 10.1186/1477-9560-7-4
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.
------------
Plavix
resistance (Plavix是Prodrug)
做完心導管restenosis
------------
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
------------
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
- HUS
------------
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
------------
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
------------
Factor XII deficiency
- aPTT prolong but thrombosis
- Paradoxical finding
------------
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]
------------
Warfarin
老鼠藥的親戚
------------
High
sensitive CRP 用在評估血管功能
------------
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
------------
------------
Fibrinogen
Monitor tPA
therapy
Target 在
100-200
補充cryoprecipitate,
or fibrinogen concentrate
------------
------------
Protein S
C4b complex
binding
Pregnancy(ProteinS增加), nephrotic syndrome
------------
NOAC;
Anti-coagulation guideline 由胸腔科制定
------------
沒有留言:
張貼留言
歡迎指教