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Medicine year 2 semester 1 > Case 14- breast disease and SAP > Flashcards

Case 14- breast disease and SAP Flashcards

1
Q

Gender identity

A

An individuals sense of having a particular gender

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2
Q

Gender expression

A

The ways we show our gender to the world around us

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3
Q

Gender dysphoria

A

The sense of unease or discomfort that a person may have because of a mismatch between their anatomical sex and their gender identity

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4
Q

Transgender

A

Someone whose gender identity does not correspond with the sex they were assigned at birth

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5
Q

Nonbinary

A

A person who identifies or expresses a gender identity that is neither male nor entirely female

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6
Q

Transphobia

A

Irrational fear or, aversion to or discrimination against transgender people

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7
Q

Cissexism

A

A system of attitudes, bias and discrimination in favour of a cisgender identity

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8
Q

What are transgender people more at risk of

A

Alcohol or substance abuse, violence, sexual assault, depression, stress, suicide and delayed cancer diagnosis.

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9
Q

How to make transgender people feel safe in a consultation

A
  • Use correct name and pronouns
  • Make the environment gender neutral and LGBT friendly (poster)
  • Explain what you are doing
  • Preferred term (chest, breast)
  • Put the patient in the ward that matches their gender- or ask
  • Discuss gender in a private room
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10
Q

How to increase cervical screening uptake

A
  • Gender neutral material for trans men
  • Education for healthcare providers on gender and sexuality
  • Gender neutral spaces
  • LGBT specific services
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11
Q

Differentiating between benign and Malignant breast lumps

A

Difficult to tell on examination. Benign breast lumps are normally mobile, smooth with regular borders. Malignant breast lumps are hard, have irregular borders and may be fixed to underlying structures. Usually requires specialist assessment for diagnosis.

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12
Q

Other features of Malignant breast disease

A

1) Skin or nipple changes

2) Symptoms of metastatic disease

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13
Q

Diagnosing malignant breast disease

A

Triple assessment

  1. Clinical assessment by specialist- decides if more tests are required
  2. Radiological assessment- by US or/and mammography, US is more common in younger patients because of increased density of breast tissue.
  3. Histological assessment- fine needle aspiration/core biopsy. Analysed under a microscope.
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14
Q

List of Benign breast conditions

A

1) Fibrocystic breast disease
2) Fibroadenoma
3) Fat necrosis
4) Lipoma
5) Breast cysts

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15
Q

Fibrocystic breast disease

A

Breast lumps, tenderness and pain can appear around your period (commonly the week before). Due to fibrous tissue in the breast, the lumps can be fluid filled i.e. breast cysts. When it is an issue its fibrocystic changes. 20-50 age group. It is a nodular or thickened area of the breast tissue separate from the rest of the breast

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16
Q

Fibroadenoma

A

Most common benign breast condition, seen in women in their 20s. Grow to 2-3cm. Soft, well circumscribed and painless. Highly mobile lumps. If the fibroadenomas are multiple or complex its associated with an increased risk of breast cancer.

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17
Q

Fat necrosis

A

Benign inflammation of fat cells causing palpable lumps. Occurs in larger breasts normally due to trauma (accidental or instrumental). On the breast tissue there may be bruising, erythema, dimpling or signs of trauma over the area of the lump. The lump is usually painless. Looks similar to breast cancer, may need biopsy.

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18
Q

Lipoma

A

Benign tumour of fat cells, found in the neck, abdomen and breast. Soft, well-circumscribed, smooth and non-tender. Found superficially just under the skin

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19
Q

Breast cysts

A

Develop from the terminal duct lobular unit. Common in pre-menopausal women in their 30s/40s. Difficult to distinguish from malignant lesions. They are fluid filled, round, palpable masses, which can become painful and may require aspiration. Similar to breast abscesses but without infective symptoms and tenderness.

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20
Q

Non-modifiable risk factors for breast cancer

A
  • The sex hormones oestrogen, progesterone and testosterone. Any factor which increases these hormones can cause breast cancer.
  • Female sex
  • Long interval between menarche and menopause (early menarche <12, late menopause>55)
  • Age >50, uncommon in under 40s
  • Radiation (radiotherapy, CT scans)
  • Family history, risk increases with number of family members and if they got it at a young age.
  • Genetic mutations i.e. BRCA 1 or 2, p53 gene. Personal history of some cancers and hyperplasia in the breast.
  • Geographic location i.e. Europe, north America, Australia
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21
Q

Modifiable risk factors for breast cancer

A
  • Lack of physical activity
  • Older age at first time of pregnancy (>30). Nulliparous (not having kids).
  • OCP/ HRT- remains high even after stopping medication
  • Obesity- fat tissue increases oestrogen levels
  • Alcohol intake
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22
Q

Protective factors for breast cancer

A

Having lots of children and breast feeding, because they disrupt normal hormone levels

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23
Q

Two types of breast cancer

A

Carcinoma in situ and invasive carcinoma

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24
Q

Carcinoma in situ

A

Cancerous cells are found in the structure of the breast i.e. the ducts (DCIS) or lobules (LCIS). Have not breached the basement membrane or spread into the rest of the breast tissue. Not malignant.

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25
Q

Lobular carcinoma in situ (LCIS)

A

Abnormal cell growth confined to the lobules of the breast, diagnosed on biopsy. Increased risk of future invasive breast cancer. Dependent on type of LCIS increased monitoring or surgical removal may be required.

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26
Q

Ductal carcinoma in situ (DCIS)

A

Abnormal cell growth confined to the ducts of the breast. Can present with breast lump or nipple discharge or be found incidentally. Can become invasive if not removed, surgery is the main treatment.

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27
Q

Invasive Breast carcinoma

A

Have breached the underlying basement membrane. Can metastasize to other areas of the body. Most common breast invasive carcinomas arise from the epithelial lining of the ducts.

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28
Q

Paget’s disease of the breast

A

Cancer of the aerola/ nipple complex which is associated with an underlying carcinoma in situ or invasive breast cancer. It presents as an eczematous lesion of the nipple or areola, which may have an underlying palpable lump.

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29
Q

Inflammatory breast cancer

A

Rapidly developing breast cancer that blocks the lymphatic drainage of the breast. Breast swelling, redness which feels firm, hot to touch and possibly painful. Can cause skin changes like peau d’orange or skin thickening. There may be nipple changes or a palpable breast lump.

30
Q

Route of spread of breast cancer

A
  • Direct-locally into surrounding muscle and skin, causes tethering
  • Via Lymphatics- axillary lymph nodes are the commonest lymphatic site involved. Can also involve intramammary, supraclavicular and tracheobronchial lymph nodes. Can feel hard and cause lymphadenopathy.
  • Via blood (haematogenous)- usually causes metastasis in lungs, bone, brain and liver. Can cause dyspnoea, chest pain, chronic cough, headaches and bone pain.
31
Q

Most common presentation of breast disease

A

Breast lump, can often by asymptomatic

32
Q

Symptoms of breast disease

A
  • Skin changes i.e. skin tethering, peau d’orange (skin is pitted and swollen due to lymphatic infiltration or inflammatory breast cancer). Or Eczematous changes i.e. Pagets disease.
  • Nipple discharge or inversion
  • Enlarged regional lymph nodes i.e. axillary.
  • Symptoms of metastases or late presentation with fungating mass
  • Change in size or shape of the breast, oedema or enlarged regional lymph nodes (lymphadenopathy)
33
Q

Structural causes of female subfertility

A

1) Tubal patency i.e. previous ectopic pregnancy
2) Endometriosis
3) Fibroids
4) Previous surgery

34
Q

Other causes of subfertility in females

A

1) Medications- Chemotherapy, Contraception, NSAID
2) Age >35
3) Smoking, obesity, alcohol, drugs
4) Adrenal problems- Crushing’s, Congenital adrenal hyperplasia
5) Hyperthyroidism/Hypothyroidism

35
Q

Structural causes of subfertility in males

A

1) Vas deferens/ejaculatory duct obstruction
2) Erectile dysfunction
3) Undescended testes
4) Post inflammatory i.e. Mumps

36
Q

Other causes of subfertility in males

A

1) Medication- anabolic steroids, chemotherapy, herbal remedies
2) Smoking, obesity, alcohol, drugs
3) Cystic fibrosis, renal failure, liver cirrhosis
4) Klinefelters 47XXY

36
Q

Definition of infertility

A

A couple who have not conceived after 1 year of regular (every 2-3 days) of unprotected sexual intercourse

36
Q

Initial infertility investigations in women

A

Measure mid-luteal phase progesterone, to confirm ovulation

In some…measure serum progesterone, with weekly measurements after first test and measure FSH and LH if cycles are irregular

Measure TFTs if symptoms of thyroid disease (only with women with symptoms of thyroid dysfunction) and measure prolactin if necessary

36
Q

Initial infertility investigations in men

A

Semen analysis- after 2 days of sexual abstinence but no more then 7 after. Repeat at 3 months, earlier if grossly abnormal.
The semen sample needs to be complete and if not the man should report this, should be delivered to lab within an hour

37
Q

Initial infertility investigations in mean

A

Semen analysis- repeat at 3 months

38
Q

Secondary infertility investigations in women

A

1) Hysterosalpingography, x-ray examination of a woman’s uterus, using fluoroscopy and contrast imaging
3) Hysterosalpingo-contrast ultrasonography, which is a technique to assess tubal patency
3) Diagnostic laparoscopy and dye

39
Q

Secondary infertility investigations in men

A

1) Microbiology tests
2) Sperm culture
3) Endocrine tests
4) Imaging of the urogenital tract
5) Testicular biopsy

40
Q

The Emotional issues associated with assisted conception

A

The process of pregnancy itself is highly emotionally and physically demanding and has risks associated
Only one cycle of IVF is offered over 40 years old (some trusts say 35)
Some trusts state you cannot have IVF if either partner already has children
Techniques can, and regularly do, fail
Fertility medications involve injections and have side effects (especially emotional side effects
IVF is sometimes only offered after 12 failed cycles of artificial insemination
You can pay to undergo assisted conception privately, but one cycle of IVF can cost £5000

41
Q

Infertility investigations to offer both makes and females

A

1) Full medical, sexual and social history
2) Examination
3) Screen for chylamidia

42
Q

Female infertility- things to check for if there are symptoms

A

1) Check thyroid function tests
2) Check Prolactin if signs or symptoms of Polystistic ovarian syndrome, galactorrhoea or a pituitary gland. There increased Prolactin in infertility

43
Q

Fertility- when the refer women to secondary care

A

1) Age 36 and older (refer after 6 months)
2) Amenorrhoea or oligomenorrhoea
3) Previous STI
4) Abnormal pelvic examination
5) Previous abdominal or pelvic surgery

44
Q

Infertility- when to refer men to secondary care

A

1) Previous genital pathology
2) Previous urogenital surgery
3) Previous STI
4) Significant systemic illness
5) Abnormal genital examination

45
Q

How do you engineer a 3 person baby

A

1) In the donors egg the nucleus is removed and destroyed
2) The mothers healthy nucleus is transferred to the donors healthy egg
3) IVF using the fathers sperm
4) The embryo is placed in the mothers uterus

45
Q

How do you engineer a 3 person baby

A

1) In the donors egg the nucleus is removed and destroyed
2) The mothers healthy nucleus is transferred to the donors healthy egg
3) IVF using the fathers sperm
4) The embryo is placed in the mothers uterus

46
Q

Why do you engineer 3 person babies

A

So that both parents can be related to the child and the child wont suffer from mitochondrial disease

47
Q

Conditions for someone to have a 3 parent baby

A

Women have to suffer from a mitcichindrial disease; pregnancy will be dangerous, test eggs to see whether that will have mitochondrial disease
BMI <30, non-smoker, normal HbA1c, heart scan clear

48
Q

Alternatives to a 3 parent baby

A

Voluntary childlessness, adoption, IVF techniques

49
Q

Pro-nuclear transfer

A

The procedure used to generate 3 parent babies

50
Q

Assisted pregnancy techniques

A

1) IUI- intrauterine insemination
2) In vitro fertilisation
3) ICSI= Intra-cytoplasmic sperm injection
4) In females Gonadotrophins or Clomiphene citrate to induce ovulation

51
Q

Health economics

A

Evaluates the clinical effectiveness and cost effectiveness of health care provisions, aims to produce the maximum benefit for patients whilst reducing costs

52
Q

Costs to consider in healthcare economics

A
  • The direct costs i.e. staff, drugs, equipment. Costs for patient
  • The indirect costs i.e. productivity losses for staff, knock on effect on society
  • Intangible costs i.e. pain, suffering, stigma
53
Q

QALY (quality adjusted life years)

A

A way of comparing mere survival without vitality to survival with good health. A full year of health is a full QALY; people with less than full health have a fraction of QALY each year. Thus, their total QALY is less than the total years they live.

54
Q

NICE QALY spending limit

A

There is a £20,000-£30,000 budget for every QALY for treatments and drug options

55
Q

What needs to be considered when treating patients with expensive therapies?

A 
Dependents
Societal contribution
Ability to pay
Age
Cost of treatment
Patient's responsibility for illness
Rule of rescue
56
Q

What does NICE make recommendations on?

A
  • New and existing medicines, treatments and procedures
  • Treating and caring for specific diseases and conditions
  • How to improve people’s health and prevent illness and disease
57
Q

What does QALY consider

A

1) Side effects
2) Clinical effectiveness
3) Cost
4) Quality of life- pain, mobility and general mood

58
Q

Calculating cost per QALY

A

Cost per QALY= Cost/QALY

59
Q

The incremental cost effectiveness ration (ICER)

A

Difference in price between the two treatments / Difference in QALY i.e. 700 / 0.35= £2000 per 1 QALY.

60
Q

Importance of Policy

A

If you make decisions about treatment without referring to policy, you risk introducing unfair discrimination. Discuss with your team recourse allocation decisions and be honest with patients when recourse constraints affect treatment options.
Helps provide consistency across the NHS and uses evidence based knowledge

61
Q

How should decisions about allocating recourses be made?

A

Accountability of reasonableness:

1) Promoting transparency on how decisions are made
2) Provide reasons that are relevant to that stakeholder
3) Be open to changing descisions

62
Q

Ethical principals related to recourse allocation

A

1) Does the patient have dependents?
2) Does the patient depend on others?
3) Did or does the patient contribute to society
4) Can the patient pay for treatment?
5) How old is the patient?
6) How costly is the treatment?
7) Is the patient personally responsible for the illness?
8) Is the patient in dire need?
9) Is the patient related, either personally or culturally?

63
Q

Criticisms of QALY

A
  • Prognosis may be uncertain.
  • Hard to measure quality of life
  • What if QALY is the same between several patients and one
  • Costs are unfair i.e. rare diseases are most expensive to treat then common ones
64
Q

Cost minimisation

A

Application- where evidence shows that competing therapies are equivalent
Measure- use the cheapest therapy

65
Q

Cost effectiveness

A

Application- where there are competing therapies or different treatments for a common therapeutic goal
Outcome- use the drug with the best QALY

66
Q

Cost utility

A

Application- where you want to measure the cost of something for a given outcome i.e. life years or reduction in pain
Outcome- How much does X cost per utility unit i.e. life year gained

67
Q

Cost benefit

A

Application- where the costs and benefits of a particular treatment are compared
Outcome- how much does X cost and what are its benefits

68
Q

Methods used to decide between options in a healthcare setting

A

1) Cost-minimisation
2) Cost-effectiveness
3) Cost-utility
4) Cost-benefit

Medicine year 2 semester 1 (53 decks)

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