07. AKT: Cancer/Heart Flashcards
What are some clinical manifestations of Marfan’s syndrome?
- Aortic disease: aortic root disease, leading to aneurysmal dilatation, aortic regurgitation, aortic dissection
- Cardiac: mitral valve prolapse
- Skeletal findings: excess linear growth of the long bones and joint laxity, arachnodactyly, pectus carinatum
- Ectopia lentis
Which class of antihypertensive is contraindicated in bilateral renal artery stenosis?
Angiotensin II receptor blockers
What are first line statin therapies for primary and secondary prevention of cardiovascular disease?
- Atorvastatin 40 to 80mg daily PO
- Rosuvastatin 20 to 40mg daily PO
What are the different diagnostic criteria for hypertension?
- Clinic BP: S > 140 and/or D > 90
- ABPM awake: S > 135 and/or D > 85
- ABPM asleep: S > 120 and/or D > 70
- ABPM 24 hours: S > 130 and/or D : 80
- Home BP: S > 135 and/or D > 85
What are some indications for using ambulatory blood pressure monitoring?
- Suspected white-coat hypertension
- Hypertension despite appropriate treatment
- Suspected episodic hypertension
- Patients with a high risk of future cardiovascular events (even if clinic BP is normal)
Which blood pressure measures are recommended to be used in absolute CVD risk calculators?
- Clinic BP
- Home BP
- Ambulatory monitoring BP
Clinical blood pressure - due to risk of underestimation with other measures
What do you need to ensure for an accurate ambulatory blood pressure monitor dataset?
- Atleast 2 measurements per hour during waking hours AND
- Average consists of at least 14 daytime measures AND
- 70% of readings obtained over 24 hour period
What is the definition of a “non-dipper” on ambulatory blood pressure monitoring and what is the significance?
- Mean night-time systolic ambulatory blood pressure should be at least 10% lower than the daytime level
- Non-dippers do not show a night-time lowering of blood pressure and are at increased CVD risk
What are the preferred DOACs for VTE treatment?
- Apixaban 10mg BD PO for 7 days and then 5mg BD PO or
- Rivaroxaban 15mg BD PO for 21 days and then 20mg daily PO
What are suggested timeframes for anticoagulant therapy for acute VTE in the following clinical situations?:
- Proximal DVT or PE that was unprovoked or associated with a transient (nonsurgical) risk factor
- DVT or PE associated with active cancer
- Proximal DVT or PE caused by major surgery or trauma that is no longer present
- Distal DVT that was unprovoked
- Distal DVT caused by a transient provoking factor
- Proximal DVT or PE that was unprovoked or associated with a transient (nonsurgical) risk factor: 3 to 6 months and consider extended therapy
- DVT or PE associated with active cancer: 3 to 6 months and consider extended therapy
- Proximal DVT or PE caused by major surgery or trauma that is no longer present: 3 months
- Distal DVT that was unprovoked: 3 months
- Distal DVT caused by a transient provoking factor: 6 weeks
Order the options for angina prevention in terms of preference
- Beta blockers/Non-dihydropyridine calcium channel blockers
- Dihydropyridine calcium channel blockers
- Long acting nitrates
- Nicorandil
When should diltiazem or verapamil (non-dihydropyridine calcium channel blockers) be avoided?
Left ventricular dysfunction (ejection fraction < 40%)
What are some factors that increase the risk of statin-related adverse effects?
- Pre-existing muscle, liver or kidney disease
- Acute kidney injury (rosuvastatin)
- High dose or high potency statin therapy
- Concurrent drugs that cause myopathy (e.g. colchicine, gemfibrozil) or inhibit the metabolism of statins (e.g. amiodarone, diltiazem, clarithromycin)
- Concurrent illness
- Frailty and advanced age
What are some modifiable predisposing factors for muscle symptoms with statins?
- Arthritis
- Alcohol consumption
- Diabetes
- Hypothyroidism
- Obesity
- Strenuous exercise
- Significant vitamin D deficiency
What are some features suggestive of statin-related muscle symptoms?
- Bilateral pain
- Aching or stiffness (rather than shooting pain or cramping)
- Pain located in the large muscle groups (e.g. thighs, buttocks)
- Onset 4 to 6 weeks after starting or increasing the dose of a statin
- High-dose or high-potency statin therapy
- Elevated serum CK concentration that decreases with statin withdrawal
Management of elevated triglycerides?:
- Mild (4mmol/L or less)
- Moderate (4mmol/ or more)
- Severe (>10mmol/L)
- Mild: Statin, if not responding to non-drug measures
- Moderate: Statin + fish oil +/- fenofibrate, if not responding to non-drug measures
- Severe: Statin + fenofibrate + fish oil + non-drug measures
What is the blood pressure target for patients wtih diabetes and albuminuria/proteinuria?
<130/80mmHg
Which antihypertensive classes receive the rate of progression of albuminuria?
- Angiotensin receptor blockers
- Angiotensin converting enzyme inhibitors
Do fibrates improve cardiovascular outcome?
They do not, but may prevent progression to severely elevated triglycerides and the associated risks (e.g. pancreatitis)
What are the ideal conditions for screening of primary aldosteronism?
- Ideally tested before starting antihypertensives
- If on therapy, use verapamil SR, prazosin, moxonidine and/or hydralazine for atleast 6 weeks
- Ensure normokalaemia
What is the most common cause of secondary hypertension?
Primary aldosteronism
When should renovascular hypertension be considered?
- Significant hypertension before 30yo
- Significant decline in renal function after ACEi
- Hypertension with significant renal size asymmetry
- Accelerated and severe progression of hypertensive state
Which clincial situations would you suspect and test for primary aldosteronism?
- Sustained BP > 150/100mmHg on 3 different measurements
- Hypertension resistant to three conventional antihypertensives
- Controlled BP on 4 or more antihypertensives
- Hypertension and spontaneous or diuretic-induced hypokalaemia
- Hypertension and adrenal incidentaloma
- Hypertension and sleep apnoea
- Hypertension and a family history of early-onset hypertension or stroke at a young age (<40 years)
- All hypertensive first degree relatives of a patient with primary aldosteronism
When should bupropion be considered for treating tobacco smoking and nicotine dependence?
- Cannot tolerate varenicline or combination NRT or found them ineffective
- Require concomittant treatment for depression
Contraindications for use of bupropion?
- History of seizures
- Eating disorders
- On monoamine oxidase inhibitors
- During abrupt withdrawal from alcohol or benzodiazepines (because seizure risk may be increased)
Management of oedema caused by dihydropyridine calcium channel blockers?
Combination of:
- Reduction in dose and/or
- Switch to non-dihydropyridine calcium channel blocker and/or
- Add RAS-blocking agent (venodilation helps reduce transcapillary pressure)
What are the definitions for the subclassification of heart failure?
- Heart failure with reduced ejection fraction (LVEF < 41%)
- Heart failure with mildly reduced ejection fraction (LVEF 41-49%)
- Heart failure with preserved ejection fraction (LVEF >49%)
Drug classes that improve HFrEF (start all at the same time or within 2 to 4 weeks)
- Renin-angiotensin system inhibitors
– Angiotensin receptor neprilysin inhibitor
– Angiotensin converting enzyme inhibitors
– Angiotensin II receptor blockers - Heart failure-specific beta blockers
- Mineralocorticoid receptor antagonists
- Sodium-glucose co-transporter 2 (SGLT2) inhibitors
When is sacubitril+valsartan contraindicated in HFrEF?
Hypotension
Factors where you would consider reclassifying up a risk category for cardiovascular disease?
- Coronary artery calcium score > 75th percentile for age and sex
- First Nations people
- Maori, Pacific Islander or South Asian ethnicity
- Family history of premature CVD
- Chronic kidney disease
- People living with severe mental illness
What is the recommended therapy for individuals with a Coronary Artery Calcium score > 100?
Preventative therapy with aspirin and a statin
What are the clinical manifestations of this cause of chest pain?
- Muscle strain
- Tenderness over the affected muscle is present and increases with stretching the muscle (e.g. taking a deep breath)
- Particularly of the intercostal muscles
What are the clinical manifestations of this cause of chest pain?
- Costosternal syndromes (costochondritis)
- Multiple areas of tenderness that reproduce the described pain, usually in the upper costal cartilages at the costochondral or costosternal junctions
- There is no swelling
What are the clinical manifestations of this cause of chest pain?
- Tietze syndrome
- Painful, nonsuppurative localised swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving one joint in the area of the second and third ribs
- Rare, primarily affects young adults
What are the clinical manifestations of this cause of chest pain?
- Lower rib pain syndromes
- Pain in the lower chest or upper abdomen with a tender spot on the costal margin
- Pain can be reproduced by pressing on the spot
Treatment options for isolated musculoskeletal chest wall pain?
- Reassurance and explanation for all patients
- Temporarily avoiding aggravating activities
- Stretching
- Application of heat for muscle spasm or ice for swelling
- Simple analgesia
- Consideration of formal physiotherapy if symptoms persist
- Injection of local anaesthetic/corticosteroid
Main risk factors for melanoma are?
- Multiple common melanocytic naevi
- Dysplastic or atypical naevus syndrome
- Family history of melanoma
- Blistering sunburns as a child or adolescent
- History of melanoma or non-melanoma skin cancer
- Solarium use
- Fair complexion and a tendency to burn
- Marked sun exposure (e.g. during work and leisure time) and solar skin damage
- Immunodeficiency
What are some non-pharmacological management steps for anxiety in palliative care?
- Continuity of care and emotional support
- Ensuring adequate explanation of current and future treatment needs
- Addressing specific fears and concerns
- Specific behavioural interventions for anxiety management (e.g. relaxation techniques)
Management for an individual with average or only slightly higher risk of breast cancer?
- Mammogram every two years from 50 to 74 years of age
- Breast awareness
Who is at average or only slightly higher risk of breast cancer?
- No confirmed family history of breast cancer
- One first degree relative diagnosed with breast cancer >/= 50 years of age
- One second degree relative diagnosed with breast cancer at any age
- Two second degree relatives on the same side of the family diagnosed with breast cancer >/= 50 years of age
- Two first degree or second degree relatives diagnosed with breast cancer, aged >/= 50 years, but on different sides of the family
Management for an individual with moderately increased risk of breast cancer?
- Mammogram: atleast every two years from 50 to 74 years of age
- Annual mammograms from 40 years of age may be recommended if the woman has a first degree relative aged <50 years diagnosed with breast cancer
- Breast awareness
- Consider referral to family cancer clinic for further assessment and management plan
Who is at moderately increased risk of breast cancer?
- One first degree relatived diagnosed with breast cancer <50 years (without the additional features of the potentially high risk group)
- Two first degree relatives, on the same side of the family, diagnosed with breast cancer (without the additional features of the potentially high-risk group)
- Two second degree relatives on the same side of the family diagnosed with breast cancer, at least one aged <50 years (without the additional features of the potentially high-risk group)
Masculinising hormone therapy in transmen - what are some early changes with testosterone therapy? (<6 months)
- Acne
- Oily skin
- Increased libido
- Increase in clitoral size
Masculinising hormone therapy in transmen - what are some changes with testosterone therapy over 6 to 12 months?
- Amenorrhoea
- Body fat redistribution
- Muscle growth
- Increase in body and facial hair
- Voice deepening
Who constitutes high risk for melanoma?
- Previous history of melanoma
- > 5 atypical (dysplastic) naevi
What is recommended for people at high risk of melanoma?
- Skin self examination every 3 months AND
- Clinical skin examination every 6 months
List some sun protection advice.
- Use shade including broad-brimmed or bucket hats
- Protective clothing
- Sunglasses
- Sunscreens with sun protection factor (SPF) >30 (which need to be reapplied every two hours)
What is Koebner phenomenon?
The appearance of new skin lesions on areas of cutaneous injury in otherwise healthy skin. Psoriasis is the most-researched condition that exhibits the Koebner phenomenon. Plaques exhibiting the Koebner phenomenon can appear on any area of the body, even those not usually involved by psoriasis
Factors that aggravate psoriasis?
- Streptococcal tonsillitis and other infections
- Injuries such as cuts, abrasians, or sunburns (koebnerised psoriasis)
- Sun exposure in ~10% of psoriasis patients (usually is more often beneficial)
- Dry skin
- Obesity, smoking, excessive alcohol
- Medications e.g. NSAIDs, beta-blockers, lithium
- Steroid withdrawal rebound (stopping steroids)
- Other environmental factors such as stressful event
Describe the parameters for an excisional biopsy.
2mm lateral margin, preferably excised as an ellipse, with a deep margin in the subcutaneous fat, and repaired by primary closure.
When should wide local excision be performed when a melanoma is confirmed but some lesion is left behind?
Ideally within 4 weeks
When should be a melanoma be referred to a multidisciplionary specialist melanoma unit?
- If the melanoma is greater than 1mm thick OR
- Greater than 0.75mm thick with other high risk pathological features (e.g. ulcertation, mitotic rate > 1, Clark level IV or V, lymphovascular invasion)
Main risk factors for melanoma are?
- Multiple common melanocytic naevi
- Dysplastic or atypical naevus syndrome
- Family history of melanoma
- Blistering sunburns as a child or adolescent
- History of melanoma or non-melanoma skin cancer
- Solarium use
- Fair complexion and a tendency to sunburn
- Marked sun exposure (e.g. during work and leisure time) and solar skin damage
- Immunodeficiency
Melanoma warning signs?
- New or changing
- “Ugly duckling” prominent
- Rapidly growing
- Particular concern to the patient
- Atypical on dermoscopy (e.g. asymmetric pigmentation, blue-white veil, multiple brown dots, pseudopods, radial streaming)
- Changed on sequential dermoscopy
What are the clinical scenarios where beta-blocker therapy greater than 12 months after ACS is most beneficial?
- Ongoing angina/ischaemia
- Heart failure
- Left ventricular dysfunction
What is erythema nodosum?
- It is a type of panniculitis, an inflamamtory disorder affecting subcutaneous fat.
- It presents as tender red nodules bilaterally, usually on anterior shins, erupting over one to several weeks
- Ill-defined, warm, oval, round or arciform, and without ulceration
- Spontaneously resolve within eight weeks
Causes of erythema nodosum?
- Most are idiopathic
- Infections: throat infections, primary TB, chlamydia, herpes, viral hepatitis, HIV, campylobacter
- Drugs: Amoxicillin, COCP, NSAIDs, sulfonamides
- Inflammatory: IBD, sarcoidosis, malignancy, lymphoma, leukaemia
Investigations for erythema nodosum?
- Diagnosis is usually clinical
- Reasonable diagnostic tests: FBC, ESR, EUC, LFT, throat swab, streptococcal serology, chest XR
- Biopsy is usually not required, but if needed, it needs to be deep and include fat. Biopsy of the lower limbs is usually associated with scarring and slow healing
Management of erythema nodosum?
- Bed rest + NSAIDs
- May assist in recovery: leg elevation, compression bandages and stockings
- If severe symptoms: prednisolone 25mg daily PO for 2 weeks, then taper dose according to response
What is the difference between malingering and factitious disorder?
- Both characterised by deceptive behaviour to simulate an illness
- Malingering: illness falsification to obtain obvious external benefits such as money, medications, time off work, child custody, or avoiding criminal prosecution
- Factitious disorder: deception is not fully accounted for by external rewards
- Additionally, diagnostic and therapeutic procedures (especially those that are painful or invasive) are avoided in malingering but readily accepted in factitious disorder
What is conversion/functional neurological disorder?
- Both can involve neurologic symptoms that are inconsistent with neurologic pathophysiology
- BUT conversion disorder has no evidence of deceptive behaviours or falsification of symptoms
- Conversion disorder always involves symptoms related to the nervous system but factitious disorder can manifest with symptoms involving any organ system
When should you suspect somatic symptom disorder?
- Illness is vague and inconsistent
- Health care concerns are rarely alleviated despite high utilisation of medical care; provides only temporary relief
- Multiple courses of standard treatment fail to mitigate the symptoms
- Attributing normal physical sensations to medical illnesses
- Repeatedly checking one’s body for abnormalities
- Unusually high sensitivity to medication side effects
- Seeking care from multiple doctors for the same somatic symptoms
Diagnostic criteria for somatic symptom disorder?
- One or more somatic symptoms that cause distress or psychosocial impairment
- Excessive thoughts, feelings or behaviours associated with the somatic symptoms
— Persistent thgouths about the seriousness of the symptoms and/or
— Persistent, severe anxiety about the symptoms or one’s general health and/or
— The time and energy devoted to the symptoms or health concerns is excessive - Disorder is persistent (usually more than 6 months) but specific somatic symptom(s) may change
Which side is a varicocele most commonly found?
Left side (left side also usually hangs lower)
If a pregnant woman is due for her cervical screening test, when can it be done?
- Anytime with the right sampling equipment
- An endocervical brush should not be inserted into the cervical canal because of the risk of associated bleeding
- Self-collection of a vaginal swab for HPV testing can be offered, with counselling about the small risk of bleeding
- If HPV is detected -> advise for a healthcare professional collected cervical sample for LBC
- Cyto-broom is recommended for use in pregnant women, NOT endocervical brush
What is the recommended management of high-grade squamous intraepithelial lesions (HSIL) during pregnancy?
- Conservative management of HSIL is recommended during pregnancy
- Colposcopy is performed to exclude the presence of invasive cervical cancer, to confirm the presence of pre-invasive disease and reassure the pregnant woman that it is safe to continue with her pregnancy
- When HSIL is diagnosed during pregnancy, treatment can be delayed until after delivery because progression of cervical intraepithelial neoplasia (CIN) to invasive disease during pregnancy is rare, with a range of 0-3% of cases
- Postpartum regression of CIN lesions is common
In the context of acute injury, when is an ankle x-ray required (Ottawa rule)?
Any pain in the malleolar zone and:
- Bone tenderness at the posterior edge or tip of the lateral malleolus OR
- Bone tenderness at the posterior edge or tip of the medial malleolus OR
- An inability to bear weight both immediately and in the emergency department for four steps
In the context of acute injury, when is a foot x-ray required (Ottawa rule)?
Any pain in the midfoot zone and:
- Bone tenderness at the base of the fifth metatarsal OR
- Bone tenderness at the navicular OR
- An inability to bear weight both immediately and in the emergency department for four steps
What is average weight gain in the first year of life for an infant?
- 0 to 3 months: 150-200g/week
- 3 to 6 months: 100-150g/week
- 6 to 12 months: 70-90g/week
Is there a difference between defecating frequency for breastfed vs bottle-fed babies?
- Breastfed babies may have a poo following each feed, or only one poo each week
- Bottle-fed babies and older children will usually have a poo at least every 2-3 days
When do you refer an umbilical hernia for repair in infants?
- 2 years of age (if still present) OR
- Parental anxiety at the large size in infancy
- Incarceration is very rare in childhood
When is esotropia normal in a child?
- When esotropia is intermittent/variable and before 3 months of age
What is the blood pressure aim for all patients with chronic kidney disease?
< 130 / 80mmHg
What organisms cause protracted bacterial bronchitis?
- Nontypeable Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
Clincal features of protracted bacterial bronchitis?
- Cough longer than 4 weeks
- Cough is an isolated symptom, and child is otherwise well
- Cough is wet or moist, with a rattly sound
- Cough is present day and night; it worsens when changing posture
- Coughing episodes can cause shortness of breath
Management of protracted bacterial bronchitis?
- Amoxicillin + clavulanate Q12hourly for 2 weeks
- If symptoms improve, it confirms the diagnosis. Complete the full 2 week course because symptoms often return if the course is shortened
- If the cough does not resolve within 2 weeks, extend antibiotic therapy for a further 2 weeks (4 weeks total duration)
Complication of Kawasaki’s disease?
Coronary artery aneurysms
Diagnostic criteria for Kawasaki’s disease?
Presence of prolonged unexplained fever >/= 5 days (fever > 38.5C) with at least 4 of the following criteria:
- Bilateral non-exudative conjunctivitis
- Polymorphous rash
- Cervical lymphadenopathy (at least 1 lymph node > 1.5cm in diameter)
- Mucositis - cracked red lips, injected pharynx or strawberry tongue
- Extremity changes - erythema of palms/soles, oedema of hands/feet (acute phase), and periungal desquamation (convalescent phase)
Clinical presentation of chicken pox?
- Short prodrome of fever, lethargy and anorexia followed by eruption of rash over the next 3-5 days
- Rash: crops of small papules, quickly becomes vesicular and then crust over after vesicles have ruptured
If you were suspecting a PE, what scores/rules could you apply?
- Well’s score
- PERC rule (used when low risk Well’s)
Management choice for moderate to severe traveller’s diarrhoea without fever or bloody stools?
- Rehydration
- Azithromycin 1g PO STAT +/- antimotility drugs
Management choice for moderate to severe traveller’s diarrhoea with fever or bloody stools?
- Rehydration
- Azithromycin 1g PO STAT and then 500mg daily for 2 days afterwards
Differentials for flashes and floaters?
- Retinal tear or detachment
- Vitreous haemorrhage
- Posterior vitreous detachment
- Diabetic vitreous haemorrhage
- Migraine
Symptoms of vitreous haemorrhage?
- Painless unilateral floaters or visual loss
- Significant haemorrhage will affect acuity and visual fields
- Vision worse in the morning (blood settled in the back, covering the macula)
Indications for ophthalmologist referral for chlamydial conjunctivitis?
- Pain
- Photophobia
- Reduced vision
Reason: corneal complications
Complications of GORD?
- Oesophageal ulceration
- Stricturing
- Bleeding
- Metaplasia of the lower oesophageal mucosa
Indications for upper GI endoscopy in patients with suspected GORD?
- Alarm symptoms: anaemia, dysphagia/odynophagia, haematemesis or malaena, vomiting, weight loss
- New symptoms in an older person
- Changing symptoms
- Severe or frequent symptoms
- Inadequate response to treatment
- Atypical symptoms
Food restrictions for GORD symptoms?
- High fat meals
- Alcohol
- Coffee
- Chocolate
- Citrus fruits
- Tomato products
- Spicy foods
- Carbonated beverages
- Stopping smoking
Only continue with limiting foods if they improve symptoms
When is PPI therapy most effective?
When taken 30 to 60 minutes before a meal
Clinical features of acromegaly?
- Acral overgrowth (enlarged extremeties e.g. nose, ears, jaws, hands, feet)
- Increased sweating
- Frontal bossing
- Splayed dentition
- Enlarged tongue
- Skin tags
- Oily skin
- Arthritis
- Sleep apnoea
- Impaired glucose tolerance
- Neuropathy
- Hypertension
- Cardiomyopathy
How is acromegaly diagnosed?
- Increased serum growth hormone concentration that does not suppress during an oral glucose tolerance test
- Elevated plasma insulin-like growth factor 1 concentration (MOST important; as growth hormone has a pulsed release)
- Pituitary MRI (if caused by pituitary adenoma)
Symptoms of bacterial vaginosis?
- Malodorous vaginal discharge
- Thin white or greyish homogenous vaginal discharge
- Change from a Lactobacillus dominant state to one with high diversity and quantities of anaerobic bacteria
Management of symptomatic bacterial vaginosis?
- Metronidazole 400mg BD PO with food for 7 days
Diagnostic criteria for bacterial vaginosis?
Amsel criteria - atleast 3 of the following features:
- Thin, white, homogenous discharge
- Vaginal fluid pH more than 4.5
- Clue cells (epithelial cells covered with small curved coccobacilli and mixed flora) on a wet preparation of a vaginal swab or Gram-stained smear
- Fishy odour when adding alkali (potassium hydroxide 10%) to discharge
Differentials for bacterial vaginosis?
- Candidal vulvovaginitis - itch, pain, red rash on vulva
- Retained foreign body (e.g. toilet, tissue, tampon, condom)
- Irritation (e.g. from over washing)
- Dermatoses
- Atrophic vaginitis
- Trichomonas vaginalis
Contraindications to oral estrogen or systemic HRT?
- Risk factors for VTE including obesity, smoking, thrombophilia
- Risk factors for cardiovascular disease including previous cardiovascular disease, insulin resistance, diabetes, obesity, hypertension (even if controlled), smoking
- Elevated triglycerides
- Liver disease or gallbladder disease
