Other: Palliative, Geriatrics, Immunology, Oncology Flashcards
What are the different types of allergy testing? When are they done?
Skin Prick Test
- Most commonly used. Large no. allergens can be tested in one session.
- Wheal develops within 15mins if patient has allergy.
- Useful for: food + pollen
Radioallergosorbent test (RAST)
- Used if skinprick unsuitable e.g. extensive eczema or patient taking antihistamines
- Determines amount of IgE that reacts w/ suspected/known allergens e.g. IgE to egg protein
- Useful for: food, pollen, wasp/bee stings
Skin Patch Testing
- Useful for contact dermatitis. Patches removed at 48h. Results read 48h after this.
Dementia
- How is suspected dementia investigated?
- What are the different types, including presentation + management?
Investigation
- Assessment tools in primary care: 10point cognitive screener (10-CS) or 6-item cognitive impairment test (6CIT)
- Bloods in primary care (to exclude reversible cause): FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vit B12, folate.
- Secondary care: neuroimaging (r/o other cause + guide tx)
Alzheimer’s (most common)
- RFs: age, fam hx, mutatous in amyloid precursor protein, apoprotein E allele E4, caucasian, Down’s syndrome
Changes:
- Macroscopic: widespread cerebral atrophy
- Microscopic: cortical plaques (amyloid protein deposition) + neurofibrillary tangles (abnormal tau protein aggregation)
- Biochemical: defecit of acetylcholine
Treatment:
Non-pharm: activities to promote wellbeing, group cognitive stimulation, group reminisence therapy + cognitive rehab
Pharm:
1st: Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
2nd: memantine (NMDA receptor antagonist) - for: moderate AD intolerant to Achesterase inhibitors; add-on drug in mod-severe AD, monotherapy in severe AD
N.B. donepezil = relatively contrindicated in bradycardia + SE includes insomnia
NB. Can get mixed dementia (vasc + AD)
Vascular Dementia (2nd most common)
- Can be: stroke related (multi or single infarct) OR subcortical (small vessel disease)
- RFs: Hx of stroke/TIA, AF, HTN, DM, hyperlipidaemia, smoking, obesity, CHD, fam hx, can be inherited (CADASIL)
- Presentation: stepwise deterioration
- Can incllude: focal neuro abnormalities, attention difficulty, seizures, memory, gait, speech, emotional disturbance
- MRI: infarcts + extensive white matter changes
- Management: symptomatic + CVS risk factors
- AChE inhibitors/memantine only if suspected comorbid AD, Parkinson’s disease dementia or Lewy Body
Lewy Body Dementia (3rd)
- Presentation:
- Progressive cognitive impairment, fluctuating cognitiion, early impairment to attention + executive function, parkinsonism, visual hallucinations
N.B. LBD - cognitive impairment occurs prior to parkinsonism (but both usually within 1yr of each other), Parkinson’s disease dementia you get motor sx at least 1yr prior to cognitive sx
Diagnosis:
- Clinical
- SPECT/DaTscan
Management:
AChE inhibitors + memantine
Avoid dopamine blocking antipsychotics as can -> irreversible parkinsonism
Frontotemporal Lobar Degeneration (4th)
- 3 types:
- frontotemporal dementia (Pick’s) (personality change, disinhibition, hyperorality, increased appetite)
On imaging: atrophy of frontal/temporal lobes, pick bodies, gliosis
- progressive non-fluent aphasia (–> short utterances that are agrammatic)
- semantic dementia (fluent progressive aphasia, speech fluent but conveys little meaning)
- No specific treatment
Other causes
- Huntington’s
- CJD
- HIV (50% of AIDS patients)
- N.B. normal pressure hydrocephalus can present as a triad of: abnormal gait, urinary incontinence, dementia
Delirium/ Acute Confusional State
- Risk factors
- Presentation
- Differentiation from Dementia
- Management
Risk Factors
- RFs: age >65, dementia, significant injury eg. hip #, frailty/multimorbidity, polypharmacy
- Precipitating events:
- infection (esp UTI)
- metabolic (dehydration, hypo/hyperglycaemia)
- Change of environement
- Severe pain
- Alcohol withdrawal
- Constipation
- Significant CVS, resp, neuro or endocrine condition
Presentation
- Memory disturbance
- Agitated OR withdrawn
- Disoriented
- Mood change
- visual hallucinations
- Disturbed sleep cycle
- poor attention
Differentiation from Dementia
- Factors favouring delirum:
- Impaired consciouness
- Fluctuating sx: worse at night, periods of normality
- Abnormal perception (illusions, hallucinations0
- Agitation, fear
- Delusions
Management
- Treat underlying cause + modify environment
- Medications:
- - 1st: haloperidol 0.5mg
- 2nd: olanzapine
- N.B. PD is hard as antipsychotics can worsen parkinsonism sx - can consider careful reduction in parkinsonism meds OR atypical antipsychotics e.g. quetiapine or clozapine
Give the mechanism of action and possible side effects of the following agents
- Cyclophosphamide
- Bleomycin
- Doxorubicin
- Methotrexate
- Fluorouracil (5-FU)
- 6-Mercaptopurine
- Cytarabine
- Vincristine + Vinblastine
- Docetexael
- Irinotecan
- Cisplatin
- Hydroyurea (hydroxycarbamide)
Alkylating Agent
- Cyclophosphamide
Alkylating agent -> cross-linking of DNA
Haemorrhagic cystitis, myelosupression, TCC
Cytotoxic Antibiotics
- Bleomycin
Degrades DNA
Lung Fibrosis
- Doxorubicin (Anthracycline)
Stabilises DNA topisomerase II + inhibits DNA/RNA synthesis
Cardiomyopathy
Antimetabolites
- Methotrexate (anti-folate)
Inhibits dihydrofolate reducatase + thymidylate synthesis
Myelosupression, mucositis, liver fibrosis, lung fibrosis
- Fluorouracil (5-FU) (anti-pyramidine)
induces apoptosis by blocking thymidylate synthase
Myelosupression, mucositis, dermatitis - 6-Mercaptopurine (anti purine)
Decreases purine synthesis
Myelosupression - Cytarabine (anti pyramidine)
Pyrimidine antagonist
Myelosupression, ataxia
Acts on Microtubules
- Vincristine + Vinblastine
Inhibits formation of microtubules
Vincristine: peripheral neuropathy (reversible), paralytic ileus
Vinblastine: myelosupression
- Docetexael
Prevents microtubule depolymerisation + disassembly
Neutropenia
Topisomerase Inhibitors
- Irinotecan
Myelosupression
Other cytotoxics
- Cisplatin
Cross links DNA
Ototoxicity, peripheral neuropathy, hypomagnesaemia
- Hydroyurea (hydroxycarbamide)
Reduces DNA synthesis
Myelosupression
What are the 5 most common causes of cancer in the UK? What are the 5 most common causes of cancer death in the UK?
What screening programmes are used + give a brief overview of them
Cancer stats
- 5 most common cancers: Breast, Lung, Colorectal, Prostate, Bladder
- 5 most common deaths: Lung, Colorectal, Breast, Prostate, Pancreas
Screening Programmes
- Breast
-Age 50-70 mammogram every 3yrs. (70+ women arrange own mammograms)
-Patients at increased risk can have screening at younger age:
One 1st degree female relative w/ breast Ca <40yo
One 1st degree male relative w/ breast Ca (any age)
One 1st degree relative w/ B/L breast Ca (w/ 1st primary under 50)
1 1st +/- 1st or 2nd degree relative diagnosed at any age
3 x 1st or 2nd degree relatives diagnosed at any age
- Colorectal
- All pts age 60-74 FIT test every 2 years (over 74 can request ongoing screening)
- Abnormal results: Colonoscopy (50% of these are normal, 40% show premalignant polyps, 10% cancer)
Cervical Screening:
- 25-49 3 yearly screening; 50-64 5 yearly screening
- Sample tested for HPV first. If high risk strain (16 + 18)
- If negative -> back to normal screening
- If positive –> cytological examination. If abnormal -> colposcopy
- This can give: borderline, low, high (mod), high (severe) grade dyskaryosis, invasive SCC, glandular neoplasia
If CIN -> large loop excision of transformation zone)
If cytology normal -> repeat at 12 months + then 24 months
If sample inadequate - repeat within 3/12 (if 2 consecutive samples inadequate then colposcopy)
- If +ve HPV but -ve cytolology repeat at 1yr. If same again then repeat in a further year. If same again -> colposcopy.
- Special circumstances:
- In pregnancy it is delayed until 3 months post-partum (unless missed screening or prev abnormal smears)
- women who have never been sexually active may opt out (v low risk)
Also Abdominal Aorta Screening one off for men at 65yo
What are the tumour markers for the following cancers?
- Ovarian Cancer
- Pancreatic Cancer
- Breast Cancer
- Prostatic Carcinoma
- Hepatocellular Carcinoma
- Teratoma
- Colorectal cancer
- Melanoma
- Schwannoma
- Small cell lung cancer, gastric cancer, neuroblastoma
- Testicular cancer
- Medullary Thyroid Cancer
- Ovarian - Ca-125
- Pancreatic - Ca 19-9
- Breast - Ca 15-3
- Prostate - PSA
- Hepatocellular and teratoma - AFP
- Colorectal - CEA (carcinoembryonic antigen)
- Melanoma and schwannoma - S-100
- Small cell lung Ca, gastric Ca, neuroblastoma - Bombesin
- Testicular (germ-celll tumours specifically release markers) - Seminomas (HcG elevated in 20%), Non-seminomas AFP and/or B-HCG elevated in 80%. LDH in 40% of germ cell tumours.
- Medullary Thyroid Cancer - calcitonin
Which type of cancer are the following carcinogens associated with?
- Aflatoxin (produced by aspergillus)
- Aniline Dyes
- Asbestos
- Nitrosamines
- Vinyl Chloride
- Aflatoxin - Hepatocellular carcinoma
- Aniliin Dye - Bladder TCC
- Asbestos - mesothelioma + bronchial carcinoma
- Nitrosamines - oesophageal + gastric
- Vinyl chloride - hepatic angiosarcoma
Give possible side effects of radiotherapy
Early (within days -weeks)
- Fatigue, anorexia, nausea, malaise, mucositis, oesophagitis, alopecia, myelosupression
Late (months - years later)
- Skin - ischaemic, ulceration
- Bone: necrosis, #, sarcoma, growth arrest
- Mouth: xerostomia, ulceration
- Bowel: stenosis, fistula, diarrhoea
- Bladder: fibrosis, frequency, incontinence
- Vagina: dyspareunia, stenosis
- Lung: fibrosis, SOB
- Heart: pericardial fibrosis, cardiomyopathy
- CNS: myelopathy
- Gonads: infertility, menopause
- Secondary malig: leukaemia, thyroid
SVCO
Pathophysiology
Presentation
Management
Pathophysiology
- SVC obstruction - tumour compression e.g lung Ca, lymphoma, mets
Presentation
- Neck + upper limb vein distension + oedema
- Nasal stuffiness, headache, visual disturbance
- Stridor, SOB, cough, chest pain
- Pemberton sign - signs worse when arms lifted above head
Management
- Steroids + PPI cover
- Radiotherapy to mass (or chemo if sensitive e.g. small cell lung, some lymphoma)
- Anticoagulation
- +/- ventilatory support + vasc stents
Neutropenic Sepsis
Pathophysiology/Presentation
Management
Pathophys/Presentation
- Neutrophil <0.5 (normally due to chemo) AND one of:
- Temp higher than 38C
- Other signs/symptoms of sepsis
Management
- Prophylaxis:
If anticipated to have neut <0.5 - fluoroquinolone
- Management
- IV tazocin ASAP
- If still pyrexic after 48h +/ meropenem +/- vancomycin
- If no improvement after 4-6d -> HRCT ?fungal infection
- G-CSF in selected patients
Spinal Cord Compression
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Mets - lung, breast, prostate
Presentation
- Back pain, worse on lying down
- Motor weakness
- Reduced sensation, urinary retention, bowel dysfunction
Investigation
MRI spine to diagnose
Management
- High dose dexamethasone
- Surgery or radiotherapy
- (ambulatory patients w/ radiosensitive tumours have best prog)
N.B. don’t give steroids before biopsy in suspected (but not yet diagnosed) lymphoma as can interfere w/ diagnosis
Raised ICP (secondary to mets)
Presentation
Investigation
Management
**Presentation **
- Headache (worse in morning, lying down, cough/strain)
- Nausea + vomiting
- Other: seizures, weakness, visual disturbance, speech/memory problems, change in personality, drowsy
- N.B. focal neurology + papilloedema often late signs
Investigation
- MRI brain
Management
- high dose steroids w/ PPI cover
- +/- surgery, chemo
- Prophylaxis: in tumours e.g. small cell lung that are likley to met to brain can give whole brain radiotherapy prophylaxis
Hyperviscosity
Causes
Presentation
Investigation
Management
Causes
Occurs w/
- Hb >180
- WCC >100
- Platelets >1000
- or paraproteinaemia e.g. myeloma + some lymphomas
Presentation
- Hypoxia (pulmonary infiltrates)
- Confusion, headache
- Visual disturbance, papilledema, retinal venous dilatation
- Cardiac failure
- priapism
Management
- Leucophoresis or plasmaphoresis
- + urgent tx of underlying malignancy
How are the following symptoms managed in palliative care?
- Pain control
- Nausea and Vomiting
- Hiccups
- Agitation/Confusion
Pain
Generally:
- Typically use PO MR Morphine w/ SR Morphine for breakthrough pain (1/6th of total daily dose)
- Prescribe laxatives (all pt on morphine) +/- antiemetics (drowsiness/nausea normally transient SEs)
- If needed increase daily dose by 30-50%
Special Situations
- Renal Impairment: Alfentanil, buprenorphine or fentanyl
- Metastatic Bone Pain: Strong opioids, Bisphosphonates, Radiotherapy or Denosumab
Conversions
- PO Codeine or Tramadol to PO morphine –> divide by 10
- PO morphine to PO oxycodone –> divide by 1.5-2
- PO morphine to SC morphine -> divide by 2
- PO morphine to SC diamorphine –> divide by 3
Nausea and Vomiting (depends on cause)
Reduced Gastric Motility
- Prokinetic eg. metoclopramide or domperidone
- (N.B. no metoclopramide in PD, bowel obs, GI perf)
Chemically Mediated
- Correct any chemical disturbance
- Ondansetron, haloperidol or levomepromazine
Visceral/Serosal
- Cyclizine and levomepromazine
Raised ICP
- Cyclizine + dexamethasone
- +/- RT if due to mets
Vestibular
- Cyclizine
- 2nd: metoclopramide or prochlorperazine
Cortical (anticipatory nausea)
- Lorazepam
Bowel obstruction
- Antispasmodic (hyoscine), octreotide
- (don’t drip + suck unless u think pt is surgical candidate)
Hiccups
Chlorpromazine
(or dexamethasone if hepatic lesions present)
Agitation/Confusion
- Treat underlying cause if poss (e.g. infection)
- 1st: haloperidol
- 2nd: chlorpromazine or levomepromazine
- Terminal agitation: midazolam
How are the following symptoms managed in palliative care?
- Secretions
- Breathlessness
- Cough
- Constipation
Secretions
- Hyoscine butylbromide
Breathlessness
- Treat underlying cause as appropriate
- Hand held fan, exercise/breathing training, opioids, steroids (to reduce oedema around tumour)
Cough
- Opioids
Constipation
- Manage cause if possible
- Stimulant (senna/bisacodyl) +/- softener (docusate)
- Enema - soft-loading (bisacodyl or phosphate enema), hard loading (glycerol or arachis oil)
- N.B. osmotic laxatives eg. lactulose need ++ fluid intake so may not be so good in palliative patients
