For He's a Jolly Good Fellow

Heme

100

What is used initially to screen for HIT?

4T score - NPV 98-100% when < 4

Only send Anti-Platelet Factor 4 with or w/o Serotonin Release Assay if 4T is positive. 

200

Which patient populations does the American Hematologic Society Guidelines suggest should be treated with indefinite anticoagulation after diagnosis of DVT? 

Unprovoked DVT

Provoked DVT 2/2 chronic risk factor (Immobility, BMI > 30, HF, Chronic lung disease, GFR<60, Autoimmune disease)

300

What does the American Society of Hematology recommend for antiplatelet/anti-coagulant management in patients with stable CVD on chronic aspirin who are diagnosed with a new DVT/PE?

Hold aspirin for the duration of therapeutic anticoagulation. 

See AQUATIC trial

For patients with DVT/PE with stable cardiovascular disease, the ASH guidelines suggest suspending aspirin therapy when initiating anticoagulation. The combination of anticoagulation plus aspirin increases the risk of bleeding without clear evidence of benefit for patients with stable cardiovascular disease.

400

What laboratory testing can help differentiate DIC from liver-induced coagulopathy, and what result might be expected?

Factor VIII levels, which are produced by endothelial cells and independent of liver function.

DIC: consumption of all factors - usually low

Liver-induced coagulopathy: endothelial cells increase production to offset coagulopathy - usually high

500

Which patient populations do the American Hematologic Society Guidelines suggest should not undergo testing for thrombophilia conditions after a new diagnosis of venous thromboembolism at a usual site (2)?

Patients with venous thromboembolism (VTE) at a usual site (lower extremity DVT or PE) when the event is provoked by major transient risk factors (surgery, trauma, or prolonged immobility). 

Unprovoked VTE after completion of primary treatment, as it does not change management or outcomes. 

Conditional and based on very low certainty evidence.

Consider testing in select scenarios (e.g. unusual site thrombosis, strong family history, age < 45, pregnancy)

Weight Loss Surg

100

Compare Roux en Y with Sleeve regarding

Weight loss

Nutritional deficiencies

Roux en Y 70% excess weight loss vs. 60%, more sustained at 10 years

Roux en Y more nutritional deficiencies - B12, iron, calcium, vitamin D, B1, B9, trace minerals - MVI for all. Roux mainly concerned for vitamin D + B12

200

Name 3 complications of Roux en Y that are rarely seen in Sleeve Gastrectomies

Roux en Y anastamotic leak, marginal ulcers, obstruction, internal hernia and dumping syndrome

SG - mainly causes and worsens GERD, overall much less complications

300

Draw the anatomy of a

Roux and Y

Sleeve 

400

How did the 2022 guidelines from the metabolic and bariatric surgery change regarding candidates for surgery by BMI alone and by BMI with comorbid conditions?

BMI alone >40 changed to >35

BMI w/ metabolic disease >35 changed to >30

BMI thresholds in Asian population BMI > 27.5 with comorbities and > 30 for BMI alone

500

What infection should you consider screening gastric bypass candidates as a part of their evaluation?

H pylori

If positive, should undergo eradication with confirmatory testing prior to surgery. 

increases risk of marginal ulcer formation post-operatively.

Lab Value Limbo

100

Glucose: 160 mg/dL

Sodium: 132 mmol/L

Potassium: 3.2 mmol/L

Bicarbonate: 15 mmol/L

Anion gap: 20

B-hydroxybutyrate: 4.5 mmol/L

pH: 7.28

Euglycemic DKA

200

Na: 120

Serum Osm: 260

Urine Osm: 500

Urine Na 45

BUN/Cr: normal

SIADH (after rule out adrenal insufficiency, hypothyroidism)

Low serum Osm -> hypotonic hyponatremia

Urine Osm > 500 -> innappropriately concentrated urine

Urine Na > 20 -> ADH is on, pt is continuing to naturiese

Normal BUN/Cr -> suggests euvolemia (no hypovolemic AKI)

300

Sodium: 122 mmol/L

Potassium: 6.2 mmol/L

Chloride: 92 mmol/L

Bicarbonate: 16 mEq/L

Glucose: 58 mg/dL

BUN: 32 mg/dL

Creatinine: 1.6 mg/dL

Calcium: 11.2 mg/dL

Eosinophils: 8%

TSH: Mildly elevated

Urine sodium: 48 mmol/L

Acute Adrenal Insufficiency (Addisonian Crisis)

Hypo - natremia, glycemia

Hyper - eosinophilia, calcemia, kalemia

NAGMA

Need both glucocorticoid (cortisol, give hydrocort) and mineralocorticoid replacement (aldosterone, give fludrocortisone)

400

pH 7.50

PaCO2 22 mmHg

HCO3 − 10 mEq/L

AG - 20  

Primary respiratory alkalosis + concomitant AGMA

pH -> primary alkalosis

Low CO2 -> Respiratory alkalosis

HCO3 - much lower than compensation for either chronic (4-5 lower HCO3 per 10 PCO2) or acute (2 lower HCO3 per 10 PCO2), thus it cannot be compensatory

Classic presentation for aspirin toxicity, though can be seen in any combination of primary resp alk + AGMA

500

Calcium 13.5

PTH low

Phosphate high

Vit D - normal

1,25(OH)2 Vit D - Elevated

Granulomatous disease (sarcoidosis, TB etc) or calcitriol-producing lymphoma

Independent of PTH, driven by excess activated vitamin D

The Price is Right

100

2 Mg of Magnesium

$5.06

200

Serotonin Release Assay

$21.13

300

Gastrointestinal Panel PCR

$479.30

400

TTE w/ Dopplar Complete

$630.55

500

MRI Brain With and Without Contrast

$277.98