122.2 📚 國考版醫垫國考 / PGY OSCE

122.2.0.1 📌 Cram Sheet

122.2.0.1.1 🔥 高 yield 12
  1. Virchow’s triad: stasis + endothelial injury + hypercoagulability
  2. Factor V Leiden = 最垞 inherited thrombophilia (Caucasian 5%); FV resistant to protein C cleavage
  3. Prothrombin G20210A = 2nd 最垞 inherited (2-3% Caucasian)
  4. AT deficiency = 颚險最高 inherited
  5. APS Triple positive (LA + anti-cardiolipin + anti-β2-GPI) = 最危險犁 DOAC (TRAPS trial)
  6. VTE 22E first-line: Apixaban 10 bid × 7 d → 5 bid (no heparin lead-in)
  7. CAT 22E: DOAC ≥ LMWH for most cancers (CARAVAGGIO)GI/GU cancer 仍 prefer LMWH
  8. Massive PE (BP < 90) → Systemic thrombolysis
  9. Provoked transient 3 mo / unprovoked indefinite if low bleed risk
  10. Wells + D-dimer rule out low/mod probability VTE
  11. Trousseau syndrome = mucinous cancer (pancreas, GI, lung) + 反芆 migratory thrombophlebitis
  12. PNH thrombosis: complement-mediated; eculizumab + ravulizumab prevent
122.2.0.1.2 🔢 必背敞字
項目 æ•žå­—
Factor V Leiden Caucasian 5% het, 0.06% homo
Prothrombin G20210A 2-3% Caucasian
Apixaban for VTE 10 bid × 7 d → 5 bid
Rivaroxaban for VTE 15 bid × 21 d → 20 qd
Provoked transient duration 3 mo
Unprovoked first ≥ 3 mo, consider indefinite
APS LA + aCL + β2-GPI cut-off > 40 GPL/MPL
APS test interval ≥ 12 wk
Wells DVT high ≥ 3
Wells PE high > 6

122.2.0.2 ⭐ 高 yield è¡š

122.2.0.2.1 Hereditary Thrombophilia 比范
條件 颚險倍敞 (het)
Factor V Leiden het 4-8x
Factor V Leiden homo 50-100x
Prothrombin G20210A het 2-3x
Protein C def high
Protein S def high
AT deficiency highest
122.2.0.2.2 APS Diagnostic Criteria (must persist ≥ 12 wk)
Lab
Lupus anticoagulant (functional, mixing 䞍 correct, phospholipid 校正)
Anti-cardiolipin Ab IgG/IgM > 40
Anti-β2-GPI Ab IgG/IgM > 40
Triple positive = highest risk
122.2.0.2.3 VTE 治療 22E
Drug Lead-in Maintenance
Apixaban None 10 bid × 7 d → 5 bid
Rivaroxaban None 15 bid × 21 d → 20 qd
Dabigatran LMWH 5-10 d 150 bid
Edoxaban LMWH 5-10 d 60 qd
Warfarin LMWH bridge INR 2-3 (most), 2.5-3.5 (mech mitral, recurrent)
LMWH alone — enoxaparin 1 mg/kg bid (CAT, pregnancy)
122.2.0.2.4 CAT (Cancer-Associated Thrombosis) 遞擇 22E
Cancer type First-line
倧倚 cancer Apixaban or rivaroxaban (CARAVAGGIO, SELECT-D)
GI / GU cancer LMWH (lower GI bleed)
Brain mets LMWH (avoid intracranial bleed)
Heparin allergy / HIT DOAC
Severe thrombocytopenia (< 50K) LMWH dose-adjusted or hold
122.2.0.2.5 PE Risk Stratification
Class BP RV strain Treatment
Massive < 90 systolic + Thrombolysis (alteplase 100 mg / 2 hr)
Submassive normal + RV + ↑ tropo AC ± thrombolysis (個別)
Low risk normal − AC outpatient
122.2.0.2.6 Workup Unprovoked VTE
Test
APS panel (LA, aCL, β2-GPI)
Factor V Leiden + Prothrombin G20210A
Protein C + S + AT (off AC + outside acute episode)
PNH (if hemolysis)
JAK2 V617F (if 高 Hb / Plt)
Age- + sx-appropriate cancer screen (no extensive workup unless symptoms)

122.2.0.3 🎯 自我檢枬 12 題

  1. Virchow’s triad 䞉芁玠 → stasis + endothelial injury + hypercoag
  2. 最垞芋 inherited thrombophilia? → Factor V Leiden
  3. 最高颚險 inherited thrombophilia? → AT deficiency
  4. APS triple positive 甹 DOAC 結果 → ↑ recurrence (TRAPS)應甚 warfarin
  5. VTE 22E first-line oral? → Apixaban (no lead-in)
  6. CAT 22E first-line for non-GI/GU cancer? → DOAC (CARAVAGGIO)
  7. Massive PE 治療? → Systemic thrombolysis
  8. Provoked transient VTE duration? → 3 mo
  9. APS test 間隔 confirm? → ≥ 12 wk
  10. Trousseau syndrome 倚哪 cancer? → Mucin-secreting (pancreas, GI, lung)
  11. PNH thrombosis 預防? → Eculizumab / ravulizumab
  12. APS pregnancy 治療? → LMWH + low-dose aspirin

122.2.0.4 🩺 PGY OSCE 堎景

122.2.0.4.1 Scenario 130 歲女 unprovoked DVT + 䞍 OCP user + 家族史
  • Workup: APS + Factor V Leiden + prothrombin gene + PC/PS/AT (off AC)
  • 確認 thrombophilia → 與病人蚎論長期 AC vs scheduled discontinuation 颚險
122.2.0.4.2 Scenario 2cancer pt + new DVT
  • 評䌰 cancer type + bleed risk + drug interaction
  • 遞 apixaban (most cancer) or LMWH (GI/GU 或 thrombocytopenia)
  • Active cancer → indefinite
122.2.0.4.3 Scenario 3APS pregnancy 芏劃
  • Pre-pregnancy: optimize warfarin → switch to LMWH + aspirin
  • 1st trimester: LMWH + aspirin
  • Continue 至 6 wk postpartum
  • 之埌 transition back to warfarin (long-term)

⚠ AI 草皿。