Cancer, Skin, Breast and Infection Flashcards
What 4 blood tests should be done on anyone with suspected metastatic disease?
FBC - Marrow infiltration can give anaemia and thrombocytopenia
Bone profile - hypercalcemia occurs with metastatic disease
U+E
LFT
What % of breast cancers are ER+ve?
80%
What % of breast cancers are HER2+ve?
15%
What is the criteria for neutropenic sepsis according to NICE?
Temp > 38
Neutrophils < 0.5x10(9)
Recent chemo
Which chemotherapy agent, used in Hodgkin lymphoma commonly causes damage to lung tissue?
Bleomycin
What common urine side effect of doxorubicin should patients be counselled on?
Makes urine red for 24 hours following treatment
What general principle of treating side effects of monoclonal antibodies should all doctors be aware of?
As it’s boosting immune system simple SE’s like diarrhoea may need high dose steroids to control
What are the different criteria for WHO performance status?
0- Normal
1- Restricted with strenuous activity but can do light work
2- Ambulatory and can self care but unable to do work, up and about >50% of waking hours
3- Symptomatic, in chair or bed >50% of the day
4- Completely disabled, no self care
A patient has been diagnosed with a brain tumour or brain metastasis, what action should they be prompted to take regarding lifestyle?
Inform DVLA
Which cancer is the BRAF mutation most commonly associated with?
Melanoma
What drugs are used to treat hepatitis C infeciton?
Ribavirin and interferon
As a general rule of thumb , what is the first choice antibiotics for anaerobic infections?
Metronidazole
The husband of a pregnant lady has chickenpox, what action should be taken?
She should be tested for VZV IgG. If positive, no action is needed. If negative give vaccine.
Which antibiotic is used first line for cellulitis?
Flucloxacillin
Which antibiotic is most strongly associated with c.diff infection?
Clindamycin
As v.active against most gut flora but not c.diff
Which are the only animals in the UK to carry rabies?
Bats
Which antibiotic is first line to be used for those who have had cellulitis due to an animal bite?
Co-amoxiclav
more broad spectrum than fluclox
When assessing a cellulitis which has pain out of keeping with clinical signs (more intense than the signs would suggest) - what should you be considering?
Deeper soft tissue infection (abscess etc.)
What is necrotising fasciitis? What are the key clues in the history?
Medical emergency, rapid progression of tissue necrosis, often following trauma/ surgery.
Key signs: Pain out of proportion to lesions, rapid spread of lesion, systemic unwellness, RF’s such as IVDU
How should necrotising fasciitis be treated?
Surgical debridement
Antibiotics are only supportive
How does staph aureus appear on a gram stain?
Gram positive cocci in clusters
What treatment is used for severe CAP (assuming CURB score >3)?
IV Co-amoxiclav and clarithromycin
A patient has an influenza infection requiring admission to AMU. How should they be managed with regard to infection control? (5)
Single room
Surgical mask within 2m (as influenza travels in droplets which can reach 2 metres)
FFP3 Mask if aerosol generating procedures
Apron, gloves, hand hygiene
Teach patient cough etiquette
You are a GP and you see a 28yoF who is 24 weeks pregnant. She visited her father yesterday in a nursing home. She is currently fit and well, but she mentions that her father was coughing and sneezing and was on treatment for that but she can’t remember the name. Yesterday you received an email from Public Health England reporting an influenza outbreak in nursing homes, including the one where the patient’s father resides.
What would be the best approach?
Start prophylactic Oseltamivir (75mg PO for 10 days)
She is at risk of complicated influenza and should be given prophylaxis
How long does an influenza illness take to resolve?
3-7 days
How long does someone who has had an influenza infection remain potentially contagious?
Up to 14 days
What is the most common causative organism of CAP?
Streptococcus pneumonia
H.influenzae
What is the most common causative organism of HAP?
Staph aureus
HAP after 4 days from admission, before this still same as CAP
What is the most common causative organism of pneumonia in those with COPD?
H.Influenzae
What is the most common causative organism of pneumonia in those who’ve been on holiday, presenting with dry cough?
Legionella
Also hyponatremia and derranged LFT’s
What is the most common causative organism of pneumonia in alcoholics?
Klebsiella pneumoniae
What is the most common causative organism of pneumonia in CF/ bronchiectasis?
Pseudomonas aeruginosa
What is the most common causative organism of pneumonia in the immunocompromised?
Pnemocystis jiroveci pneumonia
Especially if desaturation on exertion
Which medication is used to treat cytomegalovirus infections in the immunocompromised?
IV Ganciclovir
Then oral valganciclovir
When immunosuppressed patients are on broad spectrum antibiotics they are at higher risk of developing candidaemia (fungal blood infection). What is the test for this?
Serum fungal antigen test (beta-D-glucan test; BDG)
Very sensitive
What test is used to diagnose Aspergillus infections?
Serum galactomannan (GM) test
What is the most common infection sources in candidaemia? (2)
Lines
(Cannula, central line etc.)
Gut flora translocation following damage to gut lining
How is urticaria due to an allergic reaction likely to present?
Hives is urticaria (raised, itchy, nettle rash)
Itchyness
No systemic symptoms
What are the common causes of viral gastroenteritis (2)
Rotavirus
Norovirus
What is the most common cause of bloody diarrhoea in an immunocompromised patient?
CMV
Name the 5 most common bacterial causes of bloody diarrhoea (dysentery)?
Campylobacter Shigella Salmonella E.coli O157 C.Diff
What two viruses are most commonly associated with infectious mononucelosis?
EBV
CMV (similar symptoms to EBV)
What is the most common hepatitis in a) the UK, b) the world
a) Hep C
b) Hep B
Which hepatitis is spread by fecal/oral and which are spread by blood/ body fluids?
Fecal/ oral = A + E
Blood/ fluids = B, C, D
What is the most common acute hepatits?
Hep A
What test is used to diagnose acute hepatitis A infection?
IgM antibody
Appears as soon as symptoms start, this may be up to 6 weeks post exposure
What antibody suggests previous HepA infection, how long does it last?
IgG antibody to HepA (with no IgM) suggests past infection or vaccination. It appears soon after an illness has started (or vaccination) and is present for life
Which test is used to establish current Hep B infection?
HBsAg (surface antigen)
Acute disease = there for 1-6 months
Chronic disease = still present after 6 months
What does presence of the anti-HBs antibody suggest?
Immunity
(either from infection or immunisation)
Note won’t be present in acute stage
What does presence of the anti-HBc antibody suggest?
Infection with Hep B
First 6 months: IgM
After 6 months: IgG
Either current or previous HepB infection
anti-HBc is NOT present following immunisation so can distinguish
A patient has previously had HepB and gained immunity, what two antibodies will be shown in their serum?
Anti-HBs + Anti HBc
What antigen is monitored to assess the severity of HepB?
HBeAg
If HBeAg +ve then offer 48 week course of peginterferon alfa-2a
What treatment is offered for hepatitis C?
48week course of Peginterferon alfa-2a and ribavirin for all patients with Hepatitis C
What treatment is offered for acute HepA?
Supportive only
Avoid alcohol and possibly paracetamol
What management should be offered for somone with Hep B + advice (4)
- No intercourse until non-infective (HBeAg)
- Supportive (rest, fluids, no alcohol etc)
- Itch: Loose clothes, stay cool, avoid hot
- If HBeAg +ve then offer 48 week course of peginterferon alfa-2a
What test is used to assess whether there is Hepatitis C infection?
Anti- HCV serology
90% +ve after 3 months but some can take up to 9 months
What test is used to distinguish previous HepC infection from a current one?
HCV RNA
If +ve for more than 2 months then the patient needs treatment with peginterferon alfa-2s and rivavirin
Which is the best marker in the LFT’s to assess for viral hepatitis?
ALT raises significantly more than the others
A 45-year-old woman presents for review. She has noticed a number of patches of ‘pale skin’ on her hands over the past few weeks. The patient has tried using an emollient and topical hydrocortisone with no result. On examination you note a number of hypopigmented patches on the dorsum of both hands. Her past medical history includes thyrotoxicosis for which she takes carbimazole and thyroxine. What is the most likely causes of her symptoms?
Vitiligo is more common in patients with known autoimmune conditions such as thyrotoxicosis.
Name three associations of vitiligo?
T1DM
Addisons disease
Autoimmune thyroid disorders
Name 4 management options for vitiligo?
Sunblock
Topical corticosteroids (if applied early)
Topical tacrolimus and phototherapy can be considered but used with caution
Acanthosis nigricans is a dermatological manifestation of what?
Insulin resistance
Diabetes
Bloody nipple discharge is most associated with what?
Duct papiloma
note these are benign and carry no increased risk of malignancy
Brown-green nipple discharge is most commonly associated with…?
Duct ectasia
most common in menopausal women
Do breast cysts increase your risk of breast cancer?
Yes they carry a very small increased risk of developing breast cancer
What is the difference between a fibroadenoma and a phyllodes tumour?
Both benign
Fibroadenomas tend to shrink however phyllodes normally keep growing
What is the most appropriate management for a 3.5cm fibroadenoma?
Surgical excision (most over 3cm)
How do you explain duct ectasia to a patient? How is it managed?
As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.
What treatment is used for symptomatic breast cysts?
Fine needle aspiration
What % of breast lumps are cysts, and what age group most commonly experiences breast cysts?
15% of breast lumps are cysts
Most common in perimenopausal females
How would you explain fibroadenoma’s to a patient?
Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas.
What percentage of breast lesions are fibroadenomas in a) the population b) 18-25 year olds
a) 13%
b) 60%
A 22yo female has a small 2cm asymptomatic lump suspected on imaging to be a fibroadenoma, what management is appropriate?
Watchful waiting
A 22yo female has a small 4cm asymptomatic lump suspected on imaging to be a fibroadenoma, what management is appropriate?
Core biopsy
Fibroadenomas over 4cm should be biopsied to exclude phyllodes tumour
What causes peu d’orange?
Oedema (not pulling on the skin)
A patient who had Hodgkin’s Lymphoma as a 15 year old presents at age 32 with a breast lump, what is this likely to be?
Breast cancer
HL is treated with radiotherapy which gives a lifetime 50% risk of developing breast cancer
What age is the cutoff for concern when taking a family history for breast cancer?
50
A patient who had Hodgkin’s Lymphoma as a 15 year old presents at age 32 with a breast lump, what investigations should be done?
USS - Breast and axilla (as she’s young and has dense breast)
Mammogram (as US is rubbish to screen for other lumps)
Core biopsy (to complete triple assessment)
What histological investigation is done for skin changes on the breast?
Punch biopsy (for peu d'orange or paget's)
Name three blood tests which should be done for a patient with suspected liver mets?
FBC
LFT (liver mets)
Bone profile (bone mets)
How are HER2 receptor status reported?
1+ = Negative 2+ = Inconclusive 3+ = Positive
What receptor status carries best prognosis in breast cancer?
ER+ve/ HER2+ve is the best prognosis
If HER2+ve, often more aggressive cancer but responds well to Herceptin and chemo, so more intensive treatment but good outcome
What are the most common side effects of tamoxifen?
(Menopausal type)
- Hot flushes
- Vaginal dryness
- Mood changes
- Loss of sex drive
What advice are patients on chemotherapy given regarding looking out for infections?
Take temperature twice a day (as symptoms are often very insidious when on chemo so can be easily missed)
What advice should a lady who has had previous Hodgkin’s Lymphoma regarding treatment of her breast cancer lump?
Can’t do wide local incision plus radiotherapy as you can’t radiate the breast twice (risk of angiosarcoma)
Need to do mastectomy
How do you stage Breast cancers and what investigation Is used?
TNM
Do CT of thorax, abdo, pelvis
Name two side effects of isotenitoin?
Low mood
Tetratogenic
Dry mouth
How much steroid cream do you need to treat the surface area of one hand palm?
A finger tip of cream
What is the concern with putting steroid cream on the eyelids?
Cateracts
What is acitretin and what are the side effects? (2)
Retinoid (vitA) derived - immunosuppresive used for psoriasis
SE: Tertagenecity, dyslipidaemia
Name three side effects of azothioprine? (3)
Infection, liver dysfunction, anaemia, leucopenia
How does seborrhoeic dermatitis usually present?
Eczematous lesions (itchy and red) on: - Scalp (dandruff), perioribital area, nasolabial folds and around ears (all sebum rich)
Associated with HIV and parkinsons
What is the first three lines of management for seborrhoeic dermatitis in adults?
1- Head and shoulders
2- Neutrogena T/gel
3- Ketoconazole (topical)
What is the main risk factor for developing PCP infection?
Low lymphocytes (specifically, not low neutrophils)
HIV, chemo etc.
What is the most appropriate way to confirm a diagnosis of pertussis?
Nasal Swab
How does Paget’s disease of the breast present? What is it?
Paget’s disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, 90% of such patients will have an invasive carcinoma.
- Eczema involving nipple first then areola, skin thickening and possible bloody discharge
What is fibroadenosis?
Common in middle aged women - lumpy and painful breasts
- Symptoms worse prior to menstruation
How does mammary duct ectasia present?
Most common around menopause
- Tender lump around areola +/- green nipple discharge
(if ruptures can cause inflammation)
It is dilation of the large breast ducts
How does fat necrosis present in breast disease?
Obese women
Possibly following small trauma
- Inflammatory response, lump which can mimic breast cancer
How does a breast absecess present?
More common in lactating women
Red/hot/tender swelling
How should neutropenic sepsis be managed?
Immediate hospital admission ABCDE Start sepsis 6 Escalate to oncology Do sepsis screen investigations
What are the components of a triple assessment?
Examination (P1-5)
Imaging (M/U1-5)
Histology (B1-5)
How is Lyme disease contracted and what is the most common presenting feature?
From deer tick bites
A circular rash at the site of the bite (pink/red/purple), looks like a target and usually >5cm
CALLED ERYTHEMA MIGRANS (which can be caused by a number of different things, not just Lyme)
- Can also cause flu symtpoms (joint/ muscle pain, headache, fever, N+V)
How do you manage a patient with Lyme disease and an erythema migrans rash?
Take out tick with tweezers
Oral doxycycline for 2-3 weeks
Name three treatments for travellors diarrhoea?
Clear fluids
Rehydration salts
Anti-motility (Loperamide i.e. Imodium)
Name 5 possible presenting features of malaria?
- Anywhere from 6days to 6months following bite Fever/ chills/ rigors Headache Cough Myalgia GI upset Splenomegaly/ hepatomegaly Jaundice
What is the first line investigation for suspected malaria?
Thick and thin blood smears stained with Giemsa stain
What is the usual first line treatment of malaria?
Chloroquine
Plus speak to ID consultant
What comes under septic screen (i.e. to look for cause of a neutropenic sepsis)?
Bloods: FBC, U+E, CRP Urine dip and culture Sputum culture Stool culture CXR ECG
How does metastatic compression of spinal cord present? (3)
Back pain (worse on lying, throacic spine, night pain)
UMN signs?
Cauda equina symptoms
How do you manage suspected spinal cord compression?
Send patient immediately to A+E
MRI in hosp
Dextamethasone
Urgent oncological assessment/ MDT
How does SVC obstruction present?
Dyspnoea
Swelling of face, neck, arms
Periorbital oedema + visual changes
What malignancies commonly cause SVC compression?
Lymphoma
Lung cancer
Thyroid cancer
How do you manage SVC obstruction?
ABCDE
Immediate hospital admission
Steroids (oral dext)
Can then do stenting, surgery etc
How do you manage a hypercalcaemic emergency?
Commonly caused by squamous cell LC ABCDE - Do ECG Fluid resus Bisphonates following rehydration (takes 2-3 days to work) Calcitonin works quicker
Small cell lung cancer commonly makes which ectopic hormones?
ACTH
ADH
How does hypercalacemia present?
Dehydration
Stones, moans, pyschic groans
How does tumour lysis syndrome present?
Raised urate, raised potassium, raised phosphate, low calcium
How do you treat tumour lysis syndrome?
Fluids
Stop chemo
Treat electolyte abnormalities
Refer to renal team
CA15-3 is associated with?
Breast cancer
CA19-9 is associated with?
Pancreatic tumour
AFP raised is associated with what cancers?
Hepatocellular carinoma
Testicular teratoma
An agitated patient on the ward can be sedated with what drugs?
Lorazepam
Halloperidol
How do you reduce respiratory secretions?
Hyocine bromide
When using steroids and emolients when would you use each one (if applying at same time)?
Emollient first
- Steroid on afterwards
How do you treated scabies?
Permethrin
Treat whole family as very infective
Name one agent used as prophylaxis for tumour lysis syndrome?
Allopurinol
Ca 19-9 is a tumour marker for which cancer?
Pancreatic
Ca 15-3 is a tumour marker for which cancer?
Breast
Ca 125 is a tumour marker for which cancer?
Ovarian
AFP is a tumour marker for which cancers?
Hepatocellular carinoma
Testicular teratoma’s
CEA is a tumour marker for which cancer?
Colorectal
What characterises denge fever?
Low platelet count with raised ALT in patient who has been abroad
