120.2 📚 國考版醫垫國考 / PGY OSCE

120.2.0.1 📌 Cram Sheet

120.2.0.1.1 🔥 高 yield 12
  1. Mucocutaneous bleeding (petechiae, 錻血, 牙霊, 月經量倧) = platelet / vesseljoint bleed = factor
  2. ITP = isolated thrombocytopenia + no splenomegalyTPO-RA (eltrombopag/romiplostim/avatrombopag) 22E 取代 splenectomy 為 first-choice 2nd line
  3. TTP pentad: MAHA + thrombocytopenia + neuro + renal + feverADAMTS13 < 10%TPE 立即 + steroid + rituximab + caplacizumab 22E
  4. STEC-HUS = E. coli O157:H7 verotoxin → 兒童䞍應 antibioticsupportive
  5. aHUS = complement dysregulation (CFH/CFI/MCP/C3 mutation) → eculizumab
  6. HIT = 5-14 day post-heparin + platelet ↓ 50% + new thrombosis4Ts + anti-PF4 ELISA + SRA → stop heparin + argatroban / fondaparinux / DOAC
  7. HIT 䞍絊 platelet transfusion + 䞍盎接 warfarin (avoid limb gangrene)
  8. Glanzmann (GPIIb/IIIa) vs Bernard-Soulier (GP1b) vs MYH9-related (giant + Döhle)
  9. Drug-induced thrombocytopenia: quinine, sulfa, vancomycin, anti-epileptic
  10. Gestational thrombocytopenia 80-150K 第䞉期自限HELLP = MAHA + LFT ↑ + low plt → 立即 deliver
  11. HHT = telangiectasia + AVM (lung/brain/GI) → bleeding + paradoxical embolus
  12. Uremic platelet dysfunction → DDAVP, conjugated estrogen, dialysis 改善
120.2.0.1.2 🔢 必背敞字
項目 æ•žå­—
TPE for TTP timing 立即hour-zero
ADAMTS13 cut-off TTP < 10%
HIT timing post-heparin 5-14 day
HIT platelet drop ≥ 50% from baseline
4Ts score high ≥ 6
ITP 治療閟倌 < 30K or active bleeding
Spontaneous bleed risk < 10K
Procedure plt threshold < 50K
Neurosurgery plt threshold < 100K
TPO-RA response rate ~60-80%

120.2.0.2 ⭐ 高 yield è¡š

120.2.0.2.1 Thrombocytopenia 鑑別
機制 䟋子
產生 ↓ Aplastic, MDS, leukemia, chemo, B12/folate, alcohol
砎壞 ↑ (immune) ITP, drug-induced, post-transfusion purpura
砎壞 ↑ (consumption) TTP, HUS, HIT, DIC, mechanical (heart valve)
Sequestration Hypersplenism (cirrhosis, MPN)
Dilutional Massive transfusion
Pseudo EDTA-induced clumping → recheck citrate tube
120.2.0.2.2 TTP vs HUS vs DIC vs HELLP 鑑別
TTP HUS DIC HELLP
MAHA + + + +
Plt ↓↓ ↓ ↓ ↓
Coag (PT/PTT) normal normal ↑↑ + 䜎 fibrinogen + ↑ D-dimer normal
Renal mild ↑↑ varies varies
Neuro + mild varies + (eclampsia)
䞻因 ADAMTS13 Verotoxin / complement 倚原因 Pregnancy
治療 TPE + caplacizumab aHUS → eculizumab Treat underlying Deliver
120.2.0.2.3 ITP 治療階梯
Line Option
First Steroid (prednisolone or dex pulse) ± IVIg ± Anti-D
Second 22E TPO-RA (eltrombopag, romiplostim, avatrombopag) — 取代 splenectomy 為銖遞
Other 2nd Rituximab, splenectomy, fostamatinib (SYK i 22E)
Refractory Vinca, danazol, MMF, cyclophosphamide
120.2.0.2.4 HIT 4Ts Score
Item 0 1 2
Thrombocytopenia < 30% drop 30-50% > 50% drop
Timing < 4 d 5-10 d typical 5-10 d
Thrombosis None Suspected Confirmed new thrombosis
T other cause Likely Possible None
Score Risk Action
≀ 3 Low Continue heparin OK
4-5 Inter Anti-PF4 + non-heparin AC
≥ 6 High Stop heparin + alternative AC + SRA
120.2.0.2.5 HIT Treatment Algorithm
Step Action
1. Stop ALL heparin UFH, LMWH, flushes, coated catheter
2. Alternative AC Argatroban or fondaparinux or bivalirudin or DOAC (rivaroxaban)
3. NOT platelet transfusion (陀非 life-threatening bleed)
4. NOT warfarin until plt > 150 (avoid limb gangrene)
5. Anti-PF4 ELISA → SRA confirm
6. Long-term: avoid heparin lifelong (record)

120.2.0.3 🎯 自我檢枬 12 題

  1. ITP 治療閟倌 → < 30K or active bleeding
  2. ITP 22E 2nd line 銖遞 → TPO-RA (eltrombopag, romiplostim, avatrombopag)
  3. TTP 五聯 → MAHA + thrombocytopenia + neuro + renal + fever
  4. TTP ADAMTS13 cut-off → < 10%
  5. TTP 22E 加藥 → Caplacizumab (anti-vWF nanobody)
  6. STEC-HUS 治療原則 → Supportive䞍絊 antibiotic
  7. aHUS 治療 → Eculizumab
  8. HIT 4Ts → Thrombocytopenia + Timing + Thrombosis + Other cause
  9. HIT 治療䞉步 → Stop heparin → 替代 AC (argatroban/fondaparinux) → NO platelet, NO warfarin until plt > 150
  10. Glanzmann thrombasthenia 猺什麌 → GPIIb/IIIa
  11. Bernard-Soulier 猺什麌 → GP1b-IX-V (with vWF)
  12. HHT 衚珟 → Telangiectasia + AVM (lung/brain/GI) + paradoxical embolus

120.2.0.4 🩺 PGY OSCE 堎景

120.2.0.4.1 Scenario 130 歲女 急性 ↓ platelet 5K + 党身 petechiae + 錻血
  • 排陀 secondaryHCV, HIV, H. pylori, drug, lymphoma, 劊嚠
  • BMBx if > 60 æ­² / 䞍兞型
  • 確蚺 ITP → Prednisolone or dexamethasone pulse + IVIg if severe bleed
  • 監枬 plt + bleed
  • Long-term plan: TPO-RA / rituximab / splenectomy 芖 response
120.2.0.4.2 Scenario 235 歲女 急性 fever + headache + 意識改變 + Hb 8 + plt 15 + smear schistocytes + creatinine 1.4
  • TTP 高床懷疑 → TPE 立即 + glucocorticoid
  • ADAMTS13 < 10% confirm
    • Caplacizumab 22E + early rituximab
  • 䞍絊 platelet transfusion
120.2.0.4.3 Scenario 3post-CABG + UFH × 6 day + plt 250→100 + new RUE DVT
  • 4Ts: 8 (high) → HIT
  • Stop UFH (含 line flushes)
  • Argatroban infusion
  • 䞍絊 platelet transfusion
  • Warfarin 等 plt > 150
  • Document allergy: heparin (lifelong)

⚠ AI 草皿。