Starting a two-week block of heme-onc consults today! Given that many interns may be calling their first heme-consult in the coming days, I figured it would be helpful to share important info to have for different questions! #MedTwitter #hemetwitter #onctwitter

Day 1 - anemia workup consult:
- have the MCV handy
- try to get iron studies, retic count, B12 +/- folate ahead of the consult
- worried about hemolysis? Get an LDH, haptoglobin, and bilirubin
-let us know if things have already been tried (iron repletion, Epo, etc)

Day 2 - thrombocytopenia consult:
-good med hx including new meds
-heparin exposures and 4T score
-hx of underlying liver disease?
-did the TCP develop in the hospital or was it present on admission?
-HIV and Hep C hx
-INR and PTT to assess for concurrent coagulopathy

Day 3 - anticoagulation:
- what’s the indication (DVT, PE, A-fib?)
- patients past and current anticoagulation hx including events, meds, and hypercoag work-up it done
- any renal/hepatic dysfunction that would limit which anticoagulant can be used?
- bleeding hx

Day 4 - neutropenia workup:
- was it present on admission or did it develop while inpatient?
- has the patient had neutropenia before that resolved w/o intervention?
- good med hx
- active autoimmune disease (eg SLE, RA), sarcoidosis)?
- are there other cytopenias?

Day 5 - polycythemia workup:
- is the patient hemoconcentrated?
- the the patient have an underlying cardiopulmonary disease?
- any symptoms of hyperviscosity?
- any thrombotic events?
- send off an erythropoietin level
- discuss sending JAK2 mutation vs waiting for above workup

Day 6 - concern for acute chest syndrome (ACS) in a patient with sickle cell disease:
- prior hx of ACS? Previous hx of exchange transfusion?
- vital signs and work of breathing
- consolidation on imaging?
- baseline hemoglobin
- make sure pain is well controlled!

Day 7 - protein gap:
- get an SPEP and UPEP with immunofixation along w/ free light chains
- does the patient have an chronic inflammatory disease (HIV, Hep C, SLE, other autoimmune diseases)
- does the patient have other lab findings concerning for myeloma?

And now for some onc questions!
Day 8 - concern for cord compression:
- full neuro exam (sensation, reflexes, strength, rectal tone)
- order MRI imaging and steroids as soon as you are concerned!
- consult neurosurgery and rad onc as well

Forgot to put day 9 in the thread! https://twitter.com/Anand_88_Patel/status/1277937486812057600

Day 10 - hypercalcemia of malignancy:
- symptoms or asymptomatic?
- the underlying malignancy/is there bone involvement?
- ability to tolerate aggressive fluids
- if a new dx of hypercalcemia send off PTH, PTHrP, 1,25-Vit D, 25-Vit D to make sure we aren't anchoring

Day 11 - malignant bowel obstruction:
- is this recurrent or a first-time obstruction?
- is the patient a surgical candidate?
- whats the underlying malignancy?
- have conservative measures been tried (decompression, bowel rest)?
- should a palliative G-tube be considered?

Day 12 - does this patient need rasburicase for TLS:
- what’s the most recent uric acid?
- have they already received aggressive IV hydration?
- are they showing signs of clinical TLS (organ damage like AKI)?
- do they have G6PD deficiency?

Day 13 - hyperviscosity syndrome:
- what's the potential driver (protein or cells) and malignancy?
- present symptoms (visual, CNS, respiratory, other)?
- does pt have IgM > 4000, WBC > 50K, or Hgb > 20?
- check coags for pheresis line placement
- avoid transfusions if able

And finally Day 14 - is toxicity X from the patient’s cancer treatment:
- know how long the patient has been on their current treatment
- are there alternate etiologies for this toxicity?
- is this a described toxicity of the patient’s treatment?

Hope this thread’s been helpful!