Long case notes

Question 1

Oncology long case

Answer 1

Dx

• what, type stage
• when
• how
• RISK FACTORS - modifiable? #ISSUE/PLAN
  
  • Family risk for future generations?? #ISSUE

Treatment
- intent
- timeline
- immediate cx - how did you manage CT? did you end up in hospital?
- LONG TERM CX - did your treatment leave you with any permanent side effects?
- most treatments increase CVD
- most treatments are risk factors for renal impairment
- fertility, menopause, neuropathy, secondary malignancies, chronic pain, psychological, financial
any anxiety re recurrence?

Long term follow up

• evidence of recurrence
• evidence of new primary
• monitoring for long term complications of treatment

How does the cancer effect the other active health problems?

Question 2

Fertility & Chemo

Answer 2

Any cytotoxic** risk of infertility
breast cancer chemo
rectal cancer chemo/rad

Question 3

Anthracyclines - breast cancer

Answer 3

irreversible cardiomyopathy

Question 4

Monoclonal - breast cancer rx

Answer 4

reversible cardiomyopathy

Question 5

SLE Manifestations

Answer 5

Systemic - Fatigue, fevers, weightloss
Skin - photosensitive, vasculitis, ulcers
Arthralgia, Raynaud’s, myalgias, myositis
Sicca

Renal disease
Haematological - anaemia, antiphospholipid
Serositis - pericard/pleural
CV risk
ILD
Neurologic - seizures, psychosis, strokes, depression, cog impairment
GI - pseudo-obsdtruction, IBD

Prognosis - good in general 90% 10 yr mort
main issues, infection, renal disease, CV risk and lymphoma

Question 6

SLE Rx

Answer 6

Sun, Raynaud’s, NSAIDs, Steroids, DMARD, OP, contraception - long acting progesterone IUD/implant
?Warfarin, ?RRT ?Contraception, ?Sicca sx, ?antidepressent

NSAIDs Arthralgias 
Hydroxychloroquine - annual eye checks 
MTX (skin/joint - not organ)
Azathioprine ** 
MMF (vs cyclo)
Cyclophosphamide
Rituximab 
Steroids
Calcium/vit D - bisphos
Statin! - immunomodulatory and CV effects

Question 7

Immunosuppression and pregnancy

Answer 7

Safe:
Steroids
Azathioprine 
CNIs
Rituximab

**
MMF
Sulfasalazine - stop in men 3months 
Leflunamide *** LONG WASHOUT
MTX 3 months 
NSAIDs
Biologics - uncertain

Question 8

Osteoporosis risk and management

Answer 8

Approach:
Risk factors: smoking, etoh, steroids, fractures and FHx
2ndary causes: vit d, Ca, urinary Ca, PTH, TFTs, cortisol, SPEP/SFLC, coeliac serology/malabsorption

Baseline DEXA, then monitor 1-2 yrly
Baseline spinal imaging 
FRAX score 
Dietary calcium vs supplement
Vit D
Resistance / weights based exercise program
Smoking cessation / EtoH
(Dental check, calcium, vit D)
Bisphosphenate 
Denosumab
(2nd/3rd line) Teriparatide - monitoring bone turnover makers 
HRT for early menopause if possible

Question 9

Long term steroids (9)

Answer 9

(9) Infect, GI, bones, DM, mood, weight, myopathy, cataracts, sick-day

Infection - PJP proph >20mg > 3 weeks
GORD - PPI
OP - DEXA 12 monthly & FRAX risk -> antiresorptive, vit D, calcium
DM - risk: FHx/weight, screen for undx, monitor PP BSL
Mood/Sleep -> monitor and educate
Weight gain & Myopathy -> PT/exercise program & dietician, review other weighty meds
Cataracts
HPA axis suppression - sick day plan