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A 45F with Persistent Bleeding: 20Qs Core IM Team vs. Expert

Core IM

This episode of Hoofbeats presents you with the beginning of a case, then ask you to think about what information you’d want next and in what order.

First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.


Up to 1 AMA PRA Category 1 Credits ™ and MOC Points
Expires August 7, 2022   active


Free to Members


Podcasts and Audio Content


Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

  1. Medical knowledge is necessary, but alone it is insufficient to ensure diagnostic success. Rather, this knowledge must also be structured in a way that facilitates its retrieval during the diagnostic process.
  2. A diagnostic schema is a mental framework that a clinician uses to organize their knowledge about a defined problem. (The term “schema” originates from the Greek word for “form” or “shape”.)
    • The use of a schema allows a clinician to rapidly and efficiently narrow the “problem space” within which they must search for a diagnosis.
    • Schema not only enable better utilization of existing knowledge, but serve as a framework for learning new knowledge.
    • The use of diagnostic schema is a distinctive feature of expert clinical reasoning, but it has not been conclusively proven whether or not explicitly teaching schema to trainees leads to higher rates of diagnostic success.
    • Almost everyone inherits from medical training a collection of somewhat generic schemata for basic problems like AKI and hypercalcemia. But with experience, awareness of context, and deeper understanding of pathophysiology, the schemata of an expert clinician can become highly personalized, and consequently much more powerful.
  3. An example of a diagnostic schema for abnormal bleeding (as modeled by the episode’s discussant):
    • Is the bleeding history consistent with the delayed presentation of a congenital bleeding disorder, or with an acquired bleeding disorder?
    • Does the temporal pattern of bleeding suggest a problem with primary hemostasis (which typically causes immediate or early-onset bleeding after trauma), or with secondary hemostasis (which typically causes delayed and/or recurrent bleeding)?
    • Is the source of the problem the platelets, the coagulation cascade, or the soft tissue and/or vascular structures?
    • If a platelet problem, is it a quantitative or a qualitative platelet defect? If a coagulopathy, is it due to a factor deficiency or the presence of an inhibitor?
  4. A diagnosis of AL amyloidosis requires that four criteria be met (according to the International Myeloma Working Group):
    • Positive amyloid staining by Congo Red on a tissue sample (organ biopsy, fat aspirate, bone marrow biopsy).
    • Proof the amyloid deposits are derived from light chain immunoglobulins.
    • Presence of an amyloid-related syndrome (e.g. cardiomyopathy, nephropathy, hepatic infiltration, etc.).
    • Evidence of a monoclonal plasma cell disorder (e.g. serum or urine paraproteinemia, bone marrow biopsy).
  5. Systemic amyloidosis can produce abnormal bleeding through a number of mechanisms:
    • The paraproteins can deposit within blood vessel walls, leading to vascular fragility.
    • Amyloid fibrils can adsorb coagulation factors, particularly factor X, leading to a coagulopathy.
    • Amyloid fibrils can adsorb von Willebrand factor, leading to an acquired von Willebrand disease.


John Hwang, MD - Host, Editor, CME questions

Cindy Fang, MD - Host, Editor

Lloyd Wasserman, MD - Guest

Neil Shapiro, MD - Guest

Shreya Trivedi, MD - Guest

Marty Fried, MD - Guest

Amy Ou, MD - Guest


Rebecca Berger, MD

Michael Janjigian, MD

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date:  August 7, 2019

Expiration Date: August 7, 2022

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 1 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz.  To claim CME credit and MOC points you must achieve a minimum passing score of 66%.  You may take the quiz multiple times to achieve a passing score.