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CCC Flashcards

1
Q

What are the causative factors associated with cancer?

A

1) Inherited conditions
2) Chemicals
3) Radioactivity
4) Diet
5) Drugs
6) Infective
7) Immune deficiencies

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2
Q

What are examples of inherited conditions that can cause cancer?

A
  • Neurofibromatosis
  • Adenomatous polyposis coli
  • Familial breast cancer
  • von Hippel Landau syndrome
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3
Q

What are examples of chemicals that can cause cancer?

A
  • CIGARETTE SMOKE -p53 tumour suppressor gene
  • AROMATIC AMINES- associated with bladder cancer
  • BENZENE- leukaemia
  • WOOD DUST- nasal adenocarcinoma
  • VINYL CHLORIDE- angiosarcomas
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4
Q

What are examples of radioactive causes of cancer?

A
  • high energy radiation (photons or electrons)

- high level of exposure to radioactive isotope

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5
Q

What are examples of dietary causes of cancer?

A
  • low fibre diets (colorectal cancer)
  • smoked food (gastric carcinoma)
  • nitrosamines
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6
Q

What are examples of the ways that drugs can cause cancer?

A
  • cytotoxic drugs induce DNA damage and are associated with increased risk of malignancy
  • topoisomerase inhibitors can induce characteristic translocations
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7
Q

What are examples of infective causes of cancer?

A

1) HPV (cervical and anal cancers)
2) Epstein Barr Virus (non-hodgkins lymphoma)
3) Hepatitis B virus (hepatocellular cancer)
4) Retrovirus (T-cell lymphomas)
5) Helicobacter pylori (MALT tumours)

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8
Q

What are the common presenting complaints of those with cancer?

A
  • LUMPS
  • BLEEDING
  • PAIN
  • CHANGE IN FUNCTION
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9
Q

What are some examples of lumps in a cancer patient?

A
  • breast lumps
  • changes in moles
  • nodes, nodules and MSK lumps
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10
Q

What are the types of bleeding in a cancer patient?

A
  • haemoptysis
  • rectal bleeding
  • haematuria
  • post-menstrual or intermittent bleeding
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11
Q

What are the typical types of pain in a cancer patient?

A
  • chest pain
  • abdominal pain
  • bone pain
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12
Q

What are examples of ‘change in function’ for a patient with a history of cancer?

A
  • change in bowel habit
  • new cough
  • dyspnoea
  • weight loss
  • fever
  • acute confusional state
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13
Q

How is cancer diagnosis made?

A

CONFIRMED HISTOLOGICALLY

- By biopsy of a superficial mass or lymph node or by endoscopic techniques in the lung or GI tract.

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14
Q

What is the most common way in which cancers are staged?

A

TNM

  • tumour
  • node
  • metastasis
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15
Q

What are the parameters for the T section of cancer staging?

A

T: PRIMARY TUMOUR

TX- primary tumour cannot be assessed
T0- No evidence of primary tumour
Tis- Carcinoma in situ
T1,2,3,4- Increasing size and/or local extent of the primary tumour

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16
Q

What are the parameters for the N section of cancer staging?

A

N: REGIONAL LYMPH NODE

NX- regional lymph nodes cannot be assessed
N0- No regional lymph node metastasis
N1,2,3- Increasing involvement of regional lymph nodes

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17
Q

What are the parameters for the M section of cancer staging?

A

M: DISTANT/ORGAN METASTASIS

MX: presence of distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis

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18
Q

What are the definitions of cancer grading?

A

GX: grade of differentiation cannot be assessed
G1: well differentiated: similarities remain to normal tissue of the organ of origin
G2: moderately differentiated
G3: poorly differentiated: bizarre cells

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19
Q

What role does imaging play in the staging of cancers?

A
  • CT is the standard imaging tool for the evaluation of chest and abdominal malignancies.
  • MRI is used for imaging bone and soft tissue lesions, and regions where bone causes artifact in the CT appearances e.g. pelvis/posterior fossa of the brain.
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20
Q

What is the process for assessing response to cancer treatment ?

A

CT and MRI accurately measure changes in tumour dimensions.

The RECIST system is a standardized way to classify the response of disease to treatment

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21
Q

What is the RECIST classification system?

A

1) COMPLETE RESPONSE (CR)- no disease detectable radiologically
2) PARTIAL RESPONSE (PR)- all lesions have shrunk by >30% but disease still present
3) STABLE DISEASE (SD)- <20% increase in size or <30% decrease in size
4) PROGRESSIVE DISEASE (PD)- new lesions or lesions increased by >20%

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22
Q

Use of imaging in cancer screening:

A
  • Screening mammography to detect breast cancer is well established
  • Other radiological screening examination has not proven effective
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23
Q

What is the purpose of contrast in CT?

A
  • to demonstrate intra-luminal pathology or bowel obstruction
  • delineate vascular structures
  • demonstrate tumour enhancement
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24
Q

What is the main indication for MRI in cancer imaging?

A
  • neurospinal tumours
  • rectal tumours
  • prostate tumours
  • MSK tumours
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25
What is contraindicated for MRI use?
- Pacemakers and implantable cardiac defibrillators | - Foreign bodies in the eye or brain (vascular clips, surgical staples, metallic shards)
26
In what way is ultrasound used for the detection of cancer?
- Duplex and Doppler ultrasound are used to assess tumour blood flow
27
What are alternative methods of imaging for cancer?
- Nuclear medicine | - PET scanning
28
What are the various classes of tumour markers?
- CELL-SURFACE GLYCOPROTEINS - ONCOFETAL PROTEINS - ENZYMES - INTERMEDIATE METABOLITES - HORMONES - IMMUNOGLOBULINS - NUCLEIC ACIDS
29
What are examples of cell surface glycoproteins?
- Carcino-embryonic antigen (CEA) - CA125 - CA19.9
30
What are examples of oncofetal proteins?
- human chorionic gonadotrophin (hCG) | - alpha feto protein (aFP)
31
What are examples of enzymes as tumour markers?
- acid phosphatase - alkaline phosphatase - lactate dehydrogenase - neuronespecific enolase
32
What are examples of intermediate metabolites as tumour markers?
- 5-hydroxyindoeacetic acid | - vanillyl mandelic acid
33
What are examples of hormones as tumour markers?
- thyroglobulin - antidiuretic hormone - adrenocorticotrophic hormone
34
What are examples of immunoglobulins as tumour markers?
- Bence Jones Protein | - Light chains
35
What are examples of nucleic acids as tumour markers?
- tumour specific DNA/RNA | - tissue specific DNA/RNA
36
What is the common clinical use of CEA?
Marker for colorectal carcinoma
37
What is the common clinical use of CA125?
Marker for ovarian carcinoma also raised in pancreatic, lung, colorectal and breast cancer
38
What is the common clinical use of alpha fetoprotein (aFP)?
Marker for hepatocellular carcinoma and teratoma high levels predict a poor prognosis in malignancy
39
What is the oncological clinical use of HCG?
Marker for gestational trophoblastic disease (hydatiform mole, choriocarcinoma) obvs raised in pregnancy too
40
What is the clinical use of prostatic specific antigen (PSA)?
Marker in prostate cancer... however elevated by BPH, rectal examination, prostatitis, UTI.
41
What is the use of immunoglobulin in tumour markers?
Measure of paraproteinaemias (myeloma and Waldenstroms macroglobulinaemia)
42
What are the surgical techniques for biopsy?
- FINE NEEDLE ASPIRATION CYTOLOGY - TRU-CUT NEEDLE BIOPSY- a piece of tumour is sampled under local anaesthetic - INCISIONAL BIOPSY- a piece of the tumour is sampled at surgery - EXCISIONAL BIOPSY- the whole of a mass is removed
43
What is the purpose of surgical axillary node assessment?
- to allow an accurate assessment of lymph node involvement in breast cancer - therefore more accurate assessment of risk of future relapse
44
How well is cancer treated by surgery?
- 30% of patients are curable by surgical resection - this requires that the cancer is localized - adequate margins of clearance are required to minimize risk of local recurrence
45
What is cytoreductive surgery?
- Surgery to reduce the bulk of tumour | - most likely to be of benefit if there is effective therapy for the residual tumour
46
What is chemotherapy?
- Cytotoxic agents used in systemic management of cancer - Hormonal and biological treatments - Treatment to eradicate occult cancer cells must include effective systemic treatment
47
What is the mechanism of action for chemotherapy?
- Target DNA directly/indirectly | - Most are preferentially toxic towards actively proliferating cells
48
What are the indications for chemotherapy?
1) NEOADJUVANT 2) PRIMARY 3) ADJUVANT 4) PALLIATIVE 5) CURATIVE 6) PROPHYLACTIC
49
What are the main principles of chemotherapy?
- Administer drugs in combinations - Schedule treatment in cycles of a few weeks - Administer the optimal dose - Use the most effective route of administration
50
Why should chemotherapy drugs be administered in combinations?
1. Different classes of drugs have different actions and may kill more cancer cells together with several sub-lethal cell injuries. 2. There is less chance of drug resistant malignant cells emerging 3. When drugs wth different sites of toxicity are combined, dose can be maintained for each drug.
51
Why should chemotherapy treatment be scheduled in cycles every few weeks?
- The cells affected are the HAEMATOPOIETIC STEM CELLS and the lining of the GI tract, producing low blood counts and mucositis - Treatment every 3-4 weeks allow these cells to recover - Each cycle on kills a proportion of tumour cells, so repeated cycles are required to get tumour clearance - Most treatments are maximally effective after a 6 month course
52
When is chemotherapy toxicity justified?
Only when long term survival or cure are possible | e.g. HODGKINS DISEASE AND EWINGS SARCOMA
53
What is an example of prolonged chemotherapy treatment?
- CHILDHOOD LEUKAEMIA | - 18 months maintenance chemotherapy following induction of a complete remission
54
What are the features of oral administration of chemotherapy?
- advantage of freeing the patient from lengthy hospital visits and invasive procedures - doesn't reduce toxicity - regular review still required
55
Which chemotherapy drugs are available orally?
- CYCLOPHOSPHAMIDE - ETOPOSIDE - CAPECITABINE - TAMOXIFEN
56
What are the features of systemic chemotherapy treatment?
- most given intravenously as bolus injection or short infusion - some given as a continuous infusion via a central venous line, either peripherally placed or tunneled under the skin to reduce the chances of infection
57
What are the three forms of regional administration for chemotherapy?
1) INTRAVESICAL - superficial bladder cancer 2) INTRAPERITONEAL- directly into the peritoneal cavity for tumours that spread trans-coelomically (e.g. ovarian cancer) 3) INTRA-ARTERIAL- tumours that have well-defined blood supply is potentially suitable for intra-arterial chemotherapy
58
How are chemotherapy doses calculated?
PATIENT'S BODY SURFACE AREA
59
What is the formula used for Body Surface Area calculation?
-DuBois and DuBois
60
What are some specific forms of dose calculation for specific drugs?
CARBOPLATIN- dose calculated using renal function MONOCLONAL ANTIBODY TRASTUZUMAB- calculated on body weight alone
61
What are the main aims for the use of combination chemotherapy regimes?
1) MAXIMIZE CELL KILL 2) MINIMIZE TOXICITY 3) MINIMIZE DRUG RESISTANCE
62
What are the immediate complications/SEs of chemotherapy?
- Nausea and vomiting - Myelosuppression - GI - Alopecia - Neurological - GU - Cardiac - Hepatic - Skin and soft tissue toxicity - Others
63
Features of N+V SE in chemotherapy:
- most drugs cause N+V - Nausea because there is direct stimulation of the vomiting centre - treatment for this is 5-HT serotonin antagonist drugs (ONDANSETRON)
64
Features of myelosuppression SE in chemotherapy
- This occurs due to the killing of haematopoeitic progenitor cells. - Leads to leucopenia and thrombocytopenia 10-14 days after the beginning of each cycle - NADIR= lowest point of this drop - Haematopoietic recovery usually occurs after 3-4 weeks, enabling further cycles of chemotherapy to be given
65
Features of GI SE in chemotherapy
- oral mucositis - diarrhoea due to colitis or small bowel mucosal inflammation - constipation fue to dehydration
66
Features of alopecia SE in chemotherapy
- rapidly dividing cell population at the hair follicle | - alopecia can be controlled by the use of a cold cap which reduces blood flow to the scalp
67
Features of neurological SE in chemotherapy
- peripheral neuropathies - autonomic neuropathy - central neurological toxicity - ototoxicity
68
Features of genitourinary SE in chemotherapy
- nephrotoxicity | - bladder toxicity
69
Features of cardiac SE in chemotherapy
- Doxorubicin and paclaitaxel cause ACUTE ARRHYTHMIAS | - 5-FU causes CORONARY ARTERY SPASM
70
Features of hepatic SE in chemotherapy
transient rise of liver enzymes
71
Features of skin and soft tissue SE in chemotherapy
- extravasion - palmar plantar erythema - photosensitivity - pigmentation
72
What are the long term side effects of chemotherapy?
- SECOND MALIGNANCIES - INFERTILITY - PULMONARY FIBROSIS - ACUTE CONDUCTION DEFECTS - CARDIAC FIBROSIS - PSYCHOLOGICAL DAMAGE
73
What is neutropenia?
TOTAL WHITE CELL COUNTS <1x10^9/L FEVER >38 SIGNS OF SEPSIS
74
How is neutropenia managed?
It is an EMERGENCY - A, B, C - Gain IV access for bloods and rehydration - Urgent broad spectrum intravenous antibiotics (tazocin within 1 hour) - Monitor urine output, BP, O2 sats, pulse - O2 if required - septic screen to find source BUT no rectal/vaginal examinations
75
What are the septic signs associated with neutropenia?
- systolic blood pressure <90mmHg (or >40mmHg fall from baseline) - heart rate >130 bpm - oxygen saturations <91% - RR >25 breaths per minute - responds only to voice or pain/unresponsive - lactate >2.0mmol
76
What is involved in the septic screen for a neutropenic patient?
- FBC, U+E, CRP, LFT - Blood culture (x2 anaerobes and aerobes. 2x from line (all ports) and 2x peripheral - swabs - sputum culture - urine analysis and culture - stool analysis and culture
77
What should be elicited in the history of a neutropenic patient?
- chemo drugs and timing (7-14 days), line and access, stents - previous episodes - localize the symptoms to look for source - allergies
78
What should be done in examination of a neutropenic patient?
- ABC - MEWS - Full systematic examination of each system - focus on potential site
79
What should be done if there is failure to respond to antibiotics in a neutropenic patient?
- failure to respond within first 48 hours, change to second line broad spectrum antibiotics - if persistently fever, consider anti fungal/antiviral agents
80
What are example of targeted agents in cancer treatment?
- MONOCLONAL ANTIBODIES (drug name ends in -mab)- IV - TYROSINE KINASE INHIBITORS (drug name ends in -ib)- ORAL - mTOR INHIBITORS (drug name ends in -us)
81
Why are targeted agents dosed chronically?
- better tolerated | - ongoing target blockade may be necessary for benefit
82
What does chronic dosing lead to?
1) Chronic toxicity: low grade symptoms 2) Emergent toxicity: thyroid disturbance 3) Risk of drug interaction 4) Mounting costs
83
How is hormone therapy used in cancer treatment?
- Used to shrink primary tumours before/ instead of surgery - Used to prevent or delay the growth of micro metastases following surgery - Used to shrink established metastases and improve quality and duration of life
84
What are the three main forms of hormone therapy in cancer treatment?
- REMOVING THE SOURCE OF A GROWTH PROMOTING HORMONE - HORMONE INHIBITORS - INCREASING HORMONES
85
How do hormone inhibitors work?
- drugs that block the binding of hormones to their receptors in tumour cells e. g. TAMOXIFEN= anti-oestrogen in breast cancer
86
What are the two main type of anti-androgen?
1) STEROIDAL (cyproterone acetate) | 2) NON-STEROIDAL (bicalutamide)
87
How does increasing hormones help with cancer treatment?
GLUCOCORTICOIDS in high concentration induce apoptosis in malignant lymphoid cells and help treat lymphoid leukemias, lymphomas, myeloma and Hodgkin's disease
88
What is radiotherapy?
Ionizing radiation in the management of cancer
89
What are the ways in which radiotherapy can be used?
1) RADICAL/CURATIVE/DEFINITVE e.g. prostate 2) NEO-ADJUVANT SETTING 3) ADJUVANTLY 4) PALLIATION
90
What is the science behind radiotherapy?
- X-Rays = high energy and short wavelength - X-rays penetrate body tissue whilst sparing the over-lying skin, producing secondary electrons and free radicals - these cause DNA damage - cancer cells commonly have defective DNA repair pathways and die
91
What is the unit of a dose of radiation?
gray (Gy)
92
What is the typical schedule for a head a neck cancer?
70Gy in 35 fractions over 7 weeks
93
What are the factors associated with tumour kill and radiotherapy toxicity?
1) total dose, the total volume treated, dose per fraction and overall treatment time 2) co-morbidities 3) intrinsic radio-sensitivity of the cancer cells
94
What are the main 2 side effects of radiotherapy?
1) ACUTE- after first 5-10 fractions | 2) LATE- >3months after radiotherapy
95
What is the management for radiotherapy with head and neck cancer?
- Mouth care- mudguard, saline mouthwash, aspirin gargles - skin care - opiate analgesia - nutritional support PEG/NG - admission
96
What is brachytherapy?
Radiation treatment where radiation sources are placed within or close to the tumour.
97
What are the benefits of brachytherapy?
This minimizes damage to local tissue whilst delivering high dose to a small area.
98
When is brachytherapy used?
- used in prostate cancer - gynaecological cancers - esophageal cancer - head and neck cancer
99
What are the two main types of brachytherapy?
1) INTRACAVITY | 2) INTERSITIAL
100
What is intracavity brachytherapy?
the radioactive material is placed inside a body cavity such as the uterus and cervix
101
What is interstitial brachytherapy?
where the material is put into the target such as the prostate
102
What is the most common radioisotope?
radioactive iodine I-131 | used in the management of thyroid cancer
103
What are the main objectives of phase 1 clinical trials?
1) to determine toxicity and establish maximum tolerated dose 2) to trial new anti-cancer treatment on patients wth any tumour in whom no conventional therapy is appropriate 3) patients must be fit have near normal renal and hepatic function
104
What are the main features of phase 2 clinical trials?
1) to assess the particular anti-tumor activity of a new treatment in a range of different cancers 2) radiological tumour shrinkage 3) not necessary to have a control arm and random allocation of treatment
105
What are the main features of phase 3 clinical trials?
1) randomised trials comparing new with stablished treatments 2) primary endpoints assessed are usually length of life whatever the cause of death or length of life until the cancer grows 3) radiological shrinkage and quality of life are secondary
106
What is the definition of overall survival in clinical trials?
time between entry into trial and death from whatever cause
107
What is the definition of disease free survival in clinical trials?
time between entry into trial and recurrence of the tumour, or death from other causes
108
What is the definition of time to progression in clinical trials?
time between entry into the trial and disease progression or recurrence
109
How are WHO toxicity criteria classified?
grade 1= least toxic | grade 4= most toxic
110
What is the benefit of randomisation in clinical trials?
Reduces bias by assigning individuals to each arm of the trial by chance alone.
111
What determines the number of patients in a trial?
The size of the effect under study and the statistical significance required
112
What are 'survival curves'?
(Kaplan Meier curves) with the probability of survival plotted against time. The data represented can be: 1) ACTUAL SURVIVAL - follow-up data is complete for patients 2) ACTUARIAL SURVIVAL- patients lost to follow up
113
What is the definition for quality of life?
- the subjective evaluation of life as a whole - patient's appraisal of and satisfaction with their current level of functioning compared with what they perceive to be possible or ideal - physical, mental and social well-being, not merely the absence of disease or infirmity
114
How is quality of life measured?
1) PHYSICAL FUNCTIONING- self care activities, functional status, mobility, physical activities, role activities 2) DISEASE AND TREATMENT RELATED SYMPTOMS- pain, SoB, or SE of therapy 3) PSYCHOLOGICAL FUNCTIONING- emotional distress, anxiety, depression 4) SOCIAL FUNCTIONING- family interactions, time with friends, recreation activities 5) OTHERS- spiritual/existential concerns, cognitive function, sexual functioning and body image, satisfaction with health care
115
What are examples of generic quality of life instruments?
- Medical Outcome Study (MOS)
116
What are examples of cancer specific quality of life instruments?
- EORTC QL Questionnaire | - FACT (Functional Assessment of Cancer Therapy)
117
What are examples of cancer site specific quality of life instruments?
- Breast Cancer Chemotherapy Questionnaire | - EORTC Lung Cancer Module
118
What are examples of QL domain specific instruments?
- Hospital Anxiety and Depression (HAD) - Karnofsky Performance Status - Memorial Symptom Assessment Scale (MSAS) - Morrow Assessment of Nausea and Emesis (MANE) - McGill Pain Questionnaire (MPQ) - Memorial Pain Assessment Card (MPAC)
119
What are the three main clinical applications for assessing quality of life?
1) CLINICAL TRIALS 2) HEALTH ECONOMICS 3) PSYCHOSOCIAL ONCOLOGY
120
What are the characteristics that make tumours more suitable to be screened?
- Curable when detected early in the majority of patients - Be relatively common - Have a long pre-invasive or non-metastatic stage - be able to be detected by relatively simple tests - be distinct from benign lesions
121
What are the ADVANTAGES of cancer screening?
- reduction of mortality by detecting early disease that is curable - less radical treatment hence reducing morbidity - saving on health service resources by increased cure rates - reassurance given by a negative test
122
What are the DISADVANTAGES of cancer screening?
- increased length of anxiety and morbidity if no effective intervention is possible - the over-investigation of false positive cases with associated morbidity - false reassurance from a false negative result - possible harmful effects if the screening test - cost of screening a large population
123
What are the key ways to achieve useful screening programs?
1) Limit screening to at-risk populations, improving compliance, sensitivity and specificity 2) Develop an effective infra-structure to increase awareness and uptake of at-risk populations
124
What are the features of cervical cancer screening?
- Most effective screening programme to date - All women between 25-64 - 25-49= every 3 years - 50-64= every 5 years - In Scotland and Wales, starts at 20 - Long pre-invasive period during which early detection can occur and an effective treatment for early disease
125
What are the features of breast cancer screening?
- Regular mammography all women between 50 and 70 every 3 years - Ability to reduce mortality is controversial - Younger patients who are at increased risk should be considered for a package of care including screening if appropriate by referral to a breast cancer service
126
What are the features of colorectal cancer screening?
- Men and women are offered bowel screening using faecal occult blood - Every 2 years from 60-74 - Scotland 50-74 - At risk patients (UC, strong family history, or previous primary tumour)
127
What is the WHO definition of palliative medicine?
Improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems (physical, psychosocial and spiritual)
128
What are the features of palliative care?
- relief from pain and other distressing symptoms - physical, psychological, social and spiritual care - affirms life and regards dying as a normal process - neither hastens or postpones death - helps patients to live as actively as possible until death - offers support to help the family/carers during the patients illness and into bereavment
129
Which patients are eligible for palliative care?
- Oncology patients - Any other advanced progressive disease - e.g. motor neurone disease - heart failure - COPD
130
Who is on the MDT for palliative medicine?
- Doctors - Nurses - Social Workers - Chaplains - Physiotherapists - Occupational therapists - psychologists
131
What is cancer pain?
- Has physical psychological, social and spiritual dimensions - Occurs in 80% of patients - May be caused by disease, or treatment of disease
132
How is cancer pain assessed?
- SOCRATES - Effects on sleep, work, mood - Current treatment - treatments tried and results - understanding of illness - expectations
133
What are the features of bone pain in cancer?
- Dull ache over a large area or well localized tenderness over the bone - Worse on weight bearing or with movement
134
What is the treatment for bone pain in cancer?
- NSAIDs (diclofenac 50mg tds) - Radiotherapy - Bisphosphonates (e.g. pamidronate infusion)
135
What are the features of headache in cancer?
- Dull oppressive pain - worse on waking - worse on coughing, sneezing, N+V
136
What is the treatment for headache in cancer?
- Corticosteroids to reduce oedema (DEXAMETHASONE 16mg PO daily in the morning with PPI) - NSAIDs - paracetamol - review response after 7 days
137
What are the features of neuropathic pain in cancer?
- Pain in an area of abnormal sensation - Localised to specific dermatomes or over a wider, less defined area - Altered sensation e.g. numbness or hyperesthesia - Autonomic changes such as pallor or sweating - Pins and needles of burning
138
What is the treatment of neuropathic pain in cancer?
- Antidepressants [TCA] (AMITRIPTYLINE 10-75mg NOCTE) - Anticonvulsants (GABAPENTIN 100-1200mg TDS/ PREGABALIN 25-300mg BD) - Compression of a nerve may be helped by corticosteroids
139
What are the features of visceral pain in cancer?
- Dull, deep seated, poorly localized pain - Tenderness over a particular organ (e.g. liver) - Visceral pain is spasmodic such as bladder spasm or bowel colic
140
What is the treatment for visceral pain in cancer?
- Analgesic ladder - NSAIDs or corticosteroids to reduce inflammation - ANTICHOLINERGIC DRUGS e.g. SC hyoscine butylbromide for bowel colic - Oral oxybutynin for bladder spasm
141
What are the features of infection pain in cancer?
- Pleuritic pain of pneumonia | - Pain of cellulitis
142
What is the treatment for infection pain in cancer?
TREAT INFECTION | abx
143
What is on the analgesic ladder for the management of cancer pain?
- NON OPIOID - WEAK OPIOID - STRONG OPIOID
144
How should pain medication be given?
Drugs should be used at optimal dose regularly | Drugs should be given orally if patient can swallow
145
When should alternative routes of administration be considered in cancer patients?
- dysphagia - gastric stasis - intractable vomiting - impaired consciousness (syringe driver)
146
What are the doses and strengths of co-codamol?
WEAK: 8mg CODEINE/500mg PARACETAMOL (2 tablets QDS) 15MG CODEINE/500MG PARACETAMOL (2 tablets QDS) STRONG: 30mg CODEINE/500mg PARACETAMOL (2 tablets QDS)
147
What are the main SEs associated with the use of strong opioids?
- CONSTIPATION is universal- ALWAYS prescribe a laxative e.g. co-danthramer - NAUSEA AND VOMITING- prescribe prn anti-emetic - DROWSINESS - CONFUSION AND VISUAL HALLUCINATION (rare) - RESPIRATORY DEPRESSION (rare)
148
What are the signs and symptoms indicative of opioid toxicity?
- persistent nausea and vomiting - persistent drowsiness - confusion - visual hallucinations - myoclonic jerks - respiratory depression
149
What is parenteral diamorphine?
An SC preparation of morphine that is 3 TIMES more potent than oral morphine
150
How should parenteral diamorphine be administered?
TOTAL 24h SC CONTINUOUS INUSION DIAMORPHINE DOSE SHOULD BE 1/3 OF THE TOTAL 24h ORAL MORPHINE DOSE
151
What are examples of transdermal analgesics?
- FENTANYL TRANSDERMAL PATCHES - Duration: 72 hours - Suitable for patients with severe chronic pain already stabilized on other opioids.
152
What are alternative examples of stone opioids?
OXYCODONE to be given second line for those who cannot tolerate morphine - alfentanil - methadone - fentanyl (sublingual, buccal, nasal)
153
What are non-pharmacological treatments for pain in cancer?
- palliative radiotherapy (for bone pain) - palliative chemotherapy (for masses compressing viscera/nerves) - surgery - anesthetic and neurosurgical interventions (e.g. paravertebral nerve block) - psychological interventions (CBT) - Transcutaneous Electrical Nerve Stimulations (TENS) - Complementary therapies (e.g. aromatherapy)
154
What are the main gastrointestinal problems associated with palliation?
- MOUTH PROBLEMS - ANOREXIA - NAUSEA AND VOMITING - CONSTIPATION - INTESTINAL OBSTRUCTION
155
What are some of the causes of mouth problems in palliation?
- dry moth (xerostomia) from reduced intake of oral fluid - SE from drugs - radiotherapy to head and neck - loss in taste, halitosis, dysphagia, infection - oral candidiasis (treat with systemic antifungals)
156
What are some of the causes of anorexia in palliation?
- Elicit any reversible cause (e.g. thrush, nausea, pain, constipation, depression) - Megetrol acetate 160mg is effective for long term but may cause fluid retention
157
What are the main causes for nausea and vomiting in palliation?
1) GASTRIC STASIS AND IRRITATION 2) TOXIC 3) CEREBRAL CAUSES 4) ANXIETY/ANTICIPATORY N+V 5) INDETERMINATE 6) HYPERCALCAEMIA 7) VESTIBULAR DISTURBANCE 8) DISTENSION, COMPRESSION/ DISTURBANCE OF ABDOMINAL/PELVIC ORGANS
158
What are the simple measures to manage nausea and vomiting in palliation?
- Access to a large bowl, tissues and water - Calm environment away from where food is usually prepared/consumed - Small and palatable meals - Cool fizzy drinks - Parenteral hydration (may help reduce persistent nausea) - CBT for anticipatory nausea/vomiting - AVOID nasogastric suction
159
What is the management for gastric stasis/irritation in palliation?
SC METOCLOPRAMIDE 10-20mg every 8hrs OR SC (continuous infusion) METOCLOPRAMIDE 30-100mg/24hrs
160
What is the management for toxic causes of nausea and vomiting in palliation?
PO/SC HALOPERIDOL 1.5-5mg NOCTE | up to 10mg daily (5mg BDS)
161
What is the management for cerebral causes of nausea and vomiting in palliation?
PO DEXAMETHASONE 8-16mg up to 7days AND PO* CYCLIZINE 25-50mg every 8 hours (max dose 150mg/24hr) *SC 150mg/24hr
162
What is the management for anticipatory nausea and vomiting in palliation?
BENZODIAZEPINES - SUBLINGUAL LORAZEPAM 0.5mg-1mg - PO LEVOMEPROMAZINE 3-6mg - SC LEVOMEPROMAZINE 2.5-6.25mg CBT COMPLEMENTARY THERAPIES
163
What is the management for the indeterminate causes of nausea and vomiting in palliation?
HALOPERIDOL - PO 1.5mg NOCTE or BDS (max of 10mg/24h) - PRN 1.5mg, SC 1.25-2.5mg - Syringe Driver: 2.5-10mg/24h if not effective, ADD CYCLIZINE - PO 25-50mg every 8hrs (max of 150mg/24h) - PRN: PO/SC 1.5mg - Syringe Driver: 50-150mg/24h If end of life: - SC LEVOPROMAZINE 6.25mg
164
What is the management for hypercalcemia causing nausea and vomiting in palliation?
- HOSPITAL ADMISSION - intravenous rehydration and BISPHOSPHONATES - PO/SC HALOPERIDOL 1.5-5mg NOCTE (max 10mg/24h)
165
What is the management for vestibular disturbance causes of nausea and vomiting in palliation?
- CYCLIZINE | - HYOSCINE
166
What is the management for nausea and vomiting in palliation caused by distension, compression or disturbance of abdo/pelvic organs?
CYCLIZINE
167
Which drugs for nausea and vomiting should NOT be combined?
PROKINETICS (metoclopramide/domperidone) with ANTIMUSCARINICS (hyoscine/cyclizine/levopromazine)
168
What investigations should be done in those with nausea and vomiting in palliation?
- IF ANY (dependent on patient wishes) - Blood tests to exclude hypercalcaemia or uraemia - Radiography to exclude constipation/ ultrasonography to detect ascites
169
How which classes of laxatives can be used in constipation for palliative patients?
- STOOL SOFTENERS - STIMULANTS NOT BULK FORMING
170
What are examples of stool softeners that can be used in constipation for palliative patients?
- LACTULOSE (may cause significant bloating and flatulence) | - MOVICOL/MACROGEL (softener but may also stimulate bowel motions)
171
What are examples of stimulants that can be used in constipation for palliative patients?
- SENNA - DANTRON - BISACODYL
172
How does subacute intestinal obstruction in advanced cancer present?
- incomplete, intermittent and in multiple sites. | - high incidence in patients with ovarian/bowel cancer
173
What are the symptoms of subacute intestinal obstruction?
- nausea and vomiting - colicky pain - abdominal distension - dull aching pain - diarrhoea and/or constipation
174
What should be considered in palliative patients if there is a sudden onset of dyspnoea?
- asthma - pulmonary oedema - pulmonary embolism
175
How should sudden onset of dyspnoea in palliative patients be managed?
- asthma- BRONCHODILATORS - pulmonary oedema- DIURETICS, DIAMORPHINE - pulmonary embolism- ANTICOAGULANTS
176
What should be considered in palliative patients if there is dyspnoea arisen over several days?
- exacerbation of COPD - Pneumonia - Bronchial obstruction by tumour - SVC obstruction
177
How should dyspnoea that has arisen over several days in palliative patients, be managed?
- exacerbation of COPD- ANTIBIOTICS/BRONCHODILATORS - Pneumonia- ANTIBIOTICS/PHYSIOTHERAPY - Bronchial obstruction by tumour- DEXAMETHASONE/ STENTS/LASER - SVC obstruction- DEXAMETHASONE- URGENT STENTING
178
What should be considered in palliative patients if there is a gradual onset of dyspnoea?
- congestive cardiac failure - anaemia - pleural effusion - ascites - lymphangitis carcinomatosis
179
How should gradual onset of dyspnoea in palliative patients be managed?
- congestive cardiac failure- DIURETICS, DIGOXIN, ACEi - anaemia- TRANSFUSION - pleural effusion- PLEURAL ASPIRATION+PLEURODESIS - ascites- PARACENTESIS - lymphangitis carcinomatosis- DEXAMETHASONE
180
What is the non-pharmacological treatment for palliative patients with dyspnoea?
- breathing retraining (pursed lip breathing, breathing exercise, coordinated breathing training) - relaxation - fan directed onto the face
181
What iii the pharmacological treatment for palliative patients with dyspnoea?
OPIOIDS (low doses) e.g. ORAL MORPHINE 2.5mg/4h BENZODIAZEPINES e.g. LORAZEPAM 0.5mg-1mg sublingual
182
What are examples of palliative care emergencies?
- METASTATIC SPINAL CORD COMPRESSION - SUPERIOR VENA CAVA OBSTRUCTION - HYPERCALCAEMIA - MAJOR HAEMORRHAGE
183
What are the common cancers in which MSCC occurs?
- breast - bronchus - prostate but CAN occur with any tumour
184
What is MSCC?
tumour or metastases in the vertebral body or paraspinal region pressing on the spinal cord
185
What are the symptoms of MSCC?
- Back pain/ nerve root pain may be aggravated my movement, coughing or laying flat - Leg motor weakness - subjective sensory disturbance "feels like i'm walking on cotton wool" - urinary retention/faecal incontinence - pyrexia - contant pain at night and at rest
186
What are the signs associated with MSCC?
- weakness/paraparesis/paraplegia - changes in sensation occur below the level of compression - reflexes increased below the level of the lesion - clonus and painless bladder distension may be present
187
What is the investigation for MSCC?
WHOLE SPINE MRI
188
What is the management for MSCC?
- Adequate analgesia - Corticosteroids (DEXAMETHASONE 16mg) with PPI if a clinical suspicion of cord compression pending definitive investigations - Surgery (advanced metastatic disease, comorbidities, poor prognosis) - radiotherapy (single fraction to that particular site) - chemotherapy
189
What is the prognosis for MSCC?
if treated <24h, 57% will walk again | if all motor function lost for >48h, unlikely to walk again
190
What is superior vena cava obstruction?
Caused by extrinsic compression, thrombosis or invasion of the wall of the SVC - common in lung cancer and lymphoma
191
What are the malignant causes of SVC obstruction?
- lung cancer - lymphoma - mediastinal lymphadenopathy - germ cell tumours - thymoma - oesophageal - tumour associated thrombus
192
What are the benign causes of SVC obstruction?
- non-malignant tumours (goiter) - mediastinal fibrosis - infection (e.g. TB) - aortic aneurysm - thrombus associated with indwelling catheters
193
What are the symptoms associated with SVC obstruction?
- Headache/ feeling of fullness in the head - facial/arm/neck swelling - dyspnoea - cough - hoarse voice - visual disturbance - collateral vessels across the chest
194
What are the signs of SVC obstruction?
- facial oedema - prominent (swollen) blood vessels on the neck, trunk and arms - cyanosis
195
What is the management of SVC obstruction?
- High dose corticosteroids (DEXAMETHASONE 16mg daily with PPI) - Arrange imaging - speak to interventional radiology - vascular stent followed by radiotherapy or chemotherapy depending on the primary tumour
196
Dependent on the cause... what are other management options for SVC obstruction?
- Vascular stent (radiological guidance) - Radiotherapy - Chemotherapy - LMWH
197
In which cancers does hypercalcaemia typically present?
- breast cancer - lung cancer - squamous cell carcinomas - myeloma
198
Why does hypercalcaemia occur in cancer?
Due to INAPPROPRIATE PTH SECRETION from cancer cells
199
What is the mechanism for increased plasma calcium in cancer?
- a tumour associated protein that mimics PTH, stimulates bone reabsorption and increases plasma calcium
200
What are the early symptoms associated with hypercalcaemia in cancer?
- lethargy - malaise - anorexa - polyuria - THIRST - NAUSEA AND VOMITING - CONSTIPATION
201
What are the late symptoms associated with hypercalcaemia in cancer?
- confusion - drowsiness - fits - coma
202
What are the investigations associated with hypercalcaemia?
SERUM CALCIUM corrected for SERUM ALBUMIN
203
What is the management for hypercalcaemia in cancer?
REHYDRATION SALINE IV BISPHOSPHONATE* (pamdronate or zoledronic acid) *bisphosphonates inhibit osteoclastic bone resorption
204
What is the management for hypercalcaemia if there have been arrhythmias or seizures?
CALCITONIN and CORTICOSTEROIDS can be used in combination and are effective at lowering the serum calcium (usually SC/IM calcitonin is given with PO prednisolone)
205
What is the best way to manage major haemorrhage in palliative patients?
- Symptom control | - Green towels to absorb AND reduce the visual impact of blood loss.
206
What key factors are important in terminal care?
- Recognise when death is imminent - Withdraw unnecessary treatments - Prepare patient and family/carers for death - Must have irreversible life threatening illness or advanced/progressive disease
207
What are the signs and symptoms to indicate that prognosis is short?
- Step wise change in physical functioning - Profound weakness - Bed bound for most of the day - Drowsy and disorientated for extended periods - Severely limited attention span - losing interest in food and drink - too weak to swallow medication - managing sips only
208
What should be done in the last days of life?
- DIAGNOSE DYING - Communication - Preferred place of death and goals of care - Psycho-spiritual needs - Family needs - Nursing needs - Physical symptoms - Medication review
209
Which drugs are ESSENTIAL in terminal care?
1) ANALGESIC 2) ANTIEMETIC 3) ANXIOLYTIC 4) ANTISECRETORY
210
Which drugs should you consider stopping in terminal care?
- Corticosteroids (in ICP headache) - Hypoglycaemics (keep in DM1) - Anticonvulsants (can stop if commenced on midazolam)
211
Which drugs are non essential in terminal care?
- Antihypertensives - Antidepressants - Laxatives - Anti-ulcerr drugs - Anticoagulants - Long term antibiotics - Iron - Vitamins - Diuretics - Arrhythmics
212
What are the FOUR KEY drugs in terminal care?
1) DIAMORPHINE (analgesic) 2) LEVOMEPROMAZINE (antiemetic) 3) MIDAZOLAM (anxiolytic) 4) HYOSCINE BUTYLBOMIDE (anti-secretory)
213
What is the management for terminal restlessness?
- look for reversible causes e.g. pain, urinary retention etc. - if there is no reversible cause, consider sedation - SC MIDAZOLAM either by stat doses (2.5-5mg) or INFUSION starting at 10mg/24h
214
What is death rattle?
- Movement of secretions in the upper airways generally in patients who are woo weak to expectorate effectively
215
How can death rattle be managed?
- Repositioning | - Antisecretory drugs (HYOSCINE BUTYLBROMIDE)
216
What are the indications for using syringe drivers?
- Inability to swallow drugs due to reduced conscious level, often in the last few days of life - persistent nausea and vomiting - intestinal obstruction - malabsorption of drugs - dysphagia
217
Which drugs are unsuitable for subcutaneous administration as too irritant?
1) DIAZEPAM 2) CHLORPROMAZINE 3) PROCHLORPERAZINE
218
What are the risk factors for breast cancer?
- increasing age - oestrogen exposure (late childbearing, nulliparity, early menarche, late menopause) - obesity - use of HRT - prolonged use of OCP - alcohol - smoking - diet - ionizing radiation - family history (BRCA1, BRCA2, P53)
219
What is the histology of breast cancer?
1) INFILTRATING OR INVASIVE DUCTAL CARCINOMA 2) LOBULAR CARCINOMA 3) MEDULLARY, COLLOID, COMEDO AND PAPILLARY
220
What is the presentation of breast cancer?
- breast lump - nipple change - nipple discharge - bloodstained discharge from the nipple - skin contour changes - axillary lumps - breast pain/mastalgia - symptoms of metastatic disease
221
What are the investigations for suspected breast cancer?
TRIPLE ASSESSMENT - CLINICAL EXAMINATION (full history and examination) - MAMMOGRAPHY - ULTRASOUND + BIOPSY of symptomatic breast and axillae
222
How is diagnosis of breast cancer confirmed?
- fine needle aspiration cytology (FNAC) - needle biopsy - incisional or excisions biopsy
223
What should be done if there is a high risk of disseminating disease?
- isotopic bone scan - liver imaging - ultrasound/ CT scan
224
When should an MRI be performed in breast cancer investigation?
- if there is a discrepancy between clinic examination, mammogram and ultrasound findings. - if breast density preludes accurate mammogram assessment - if histology is lobular
225
What is the T classification within TNM staging for breast cancer?
``` T0- No primary tumour Tis- in situ disease, non-invasive T1- Invasive tumour <2cm T2- Tumour between 2-5cm T3- Primary tumour >5cm T4- Skin involvement ```
226
What is the N classification within TNM staging for breast cancer?
N0- No lymph nodes N1 - Mobile axillary nodes N2- Fixed axillary nodes N3- Internal mammary nodes
227
What is the M classification within TNM staging for breast cancer?
M0- No metastases | M1- Distant metastases
228
What is the staging for breast cancer?
``` STAGE 0: Tis, N0, M0 STAGE 1: T1, N0, M0 STAGE 2: T2/3, N0, M0 OR T0/1/2, N1, M0 STAGE 3: T or N > stage II, M0 STAGE 4: Any T, Any N, M1 ```
229
What is the surgical management for breast cancer?
- mastectomy - wide local excision - with post operative radiotherapy - axillary clearance - sentinel node biopsy
230
What is the radiological management for breast cancer?
- ALL have radiotherapy to the residual breast tissue
231
What is the systemic therapy for breast cancer?
- ENDOCRINE OR CHEMOTHERAPY to treat both micro metastatic disease in an adjuvant setting and recurrent/metastatic disease.
232
What are examples of adjuvant endocrine therapies for breast cancer?
TAMOXIFEN AROMATASE INHIBITORS (anastrozole) TRASTUZAMAB (herceptin)
233
How does tamoxifen work?
Blocks the effects of estrogen on ER receptors. This helps to stop breast cancer cells to grow. Use for 5 years
234
What are the side effects associated with tamoxifen?
- hot flushes - mood changes - vaginal discharge - loss of libido - endometrial changes - DVT/PE/Stroke - Fluid retention
235
When should aromatase inhibitors be used in breast cancer management?
ONLY IN POST-MENOPAUSAL women with breast cancer
236
How does trastuzamab work?
It is effective in over-expression of the target epithelial growth factor receptor (HER-2)
237
What are the risk factors for colorectal cancer?
1) DIET (animal fats and meat) 2) INFLAMMATORY DISEASE (uc) 3) FAMILIAL ASSOCIATION
238
What are the familial risk factors of colorectal cancer?
- HNPCC (Hereditary Non-Polyposis Colon Cancer) - FAP (Familial Adenomatous Polyposis) - Gardner's syndrome
239
What is the histology for colorectal cancers?
ADENOCARCINOMAS (95%) - epithelial (mucinous/signet ring) - carcinoid - gastrointestinal stromal tumour - primary malignant lymphoma
240
What is the clinical presentation for colorectal cancer?
- altered bowl habits - weight loss - rectal bleeding - vague abdominal pain
241
What are the red flag symptoms associated with colorectal cancer?
- weight loss - altered blood rectally - change in bowel habit - abdominal pain - rectal mucous - anorexia
242
What can be seen on examination of those with colorectal cancer?
- loss of weight - signs of anaemia - abdominal mass - mass on rectal examination
243
What investigations should be done for patients with suspected colorectal cancer?
- digital examination - rigid sigmoidoscopy - flexible sigmoidoscopy - colonoscopy - CT (provides staging) - Tumour marker CEA (not diagnostic but can be useful to monitor disease?
244
What is the T classification within TNM staging for colorectal cancer?
TX: Primary tumour cannot be assessed T0: No evidence of primary tumour T1: Tumour invades submucosa T2: Tumour invades muscular propria T3: Tumour extends through muscular propria into peri-colic tissues T4: Tumour invades visceral peritoneum or invades/adheres to adjacent organ or structure
245
What is the N classification within TNM staging for colorectal cancer?
N0: No regional lymph node involvement N1: Involvement of 1-3 lymph nodes N2: Involvement of 4 or more lymph nodes
246
What is the M classification within TNM staging for colorectal cancer?
MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis M1a: Confined to one organ or site, but not peritoneum M1b: 2 or more sites (but not peritoneum) M1c: Peritoneal spread
247
What is the Duke Staging for colorectal cancer?
A- Invasion into but not through the bowel wall B- Invasion through the bowel wall but not into the nodes C- Lymph node involvement D- Distant metastasis
248
What are the management options for rectal cancer?
1) NEOADJUVANT THERAPY 2) RADIOTHERAPY 3) SURGERY
249
What are the surgical options for rectal cancer?
- Anterior resection (higher tumours, join ends, no stoma) - APER (lower tumours, proximal tumours) - Hartmans (higher tumour, no anastomosis, stoma) - Total mesorectum excision
250
What are the management options for colon cancer?
1) NEOADJUVANT THERAPY | 2) SURGERY
251
What are the features of surgical management for colorectal cancer?
- Early stage colorectal carcinoma can be cured by surgical resection alone - Resection of liver metastases in addition to the primary may be beneficial
252
What are examples of adjuvant chemotherapy in colorectal cancer?
- 5-FU (Fluorouracil) is the most active agent in colorectal carcinoma. - e.g. OXALIPLATIN and IRINOTECAN
253
What is assessed in follow up for colorectal cancer patients?
- bowel changes - bladder changes - sexual impotence - infertility - psychological (stoma) - financial
254
What are the risk factors for lung cancer?
- Age- risk increases >40 years old - Smoking - Occupation - Asbestos exposure
255
How are lung tumours classified?
1) SMALL CELL LUNG CANCER (15%) | 2) NON-SMALL CELL LUNG CANCER (85%)
256
What are the features of small cell leg cancers?
- highly aggressive tumours which grow rapidly - usually metastasized and become inoperable prior to diagnosis - poor prognosis - associated with paraneoplastic syndromes (SIADH, Cushing's, LEMS)
257
What are the main types of non-small cell lung cancers?
- SQUAMOUS CELL CARCINOMAS - ADENOCARCINOMAS - LARGE CELL CARCINOMAS
258
What are the features of squamous cell lung carcinomas?
- central - close to the bronchi - can present with bronchial obstruction - closely linked to cigarette smoking - secrete PTH related peptide (PTHrp) which can lead to hypercalcaemia
259
What are the features of adenocarcinoma?
- peripheral - more frequent in women - non-smokers - patients with previous asbestos exposure - associated with activation mutations in EGFR and ALK
260
Wha are the features of large cell carcinomas?
- less differentiated the other NSCLCs | - tend to metastasis early
261
What are the other types of NSCLCs?
- carcinoid - mesothelioma - sarcoma - lymphoma
262
What is the clinical presentation* for lung cancer?
* Most present at stage 4 (metastasis) - cough - dyspnoea - haemoptysis - chest pain - recurrent chest infection - bone pain - RUQ pain - headaches/nausea/neurological
263
What clinical features will be present in apical tumours?
- HORNER'S SYNDROME (miosis, anhidrosis, ptosis) | - PANCOAST'S SYNDROME (pain in the distribution of the brachial plexus nerve routes)
264
What clinical features will present in mediastinal disease?
- Recurrent laryngeal nerve palsy (hoarsness, difficulty speaking) - SVC obstruction
265
What clinical presentations are associated with specific histologies in lung cancer?
1) CLUBBING- squamous cell carcinoma 2) EXCESSIVE SPUTUM PRODUCTION- broncho-alveolar carcinoma 3) NEURO-ENDOCRINE FACTORS- small cell lung cancers
266
What investigations are done in lung carcinoma?
- CXR - Sputum cytology - Bronchoscopy - Other biopsy techniques (trans thoracic biopsy, mediastinoscopy and biopsy) - CT chest and upper abdomen (for staging) - PET scan - Other diagnostic tests - Tumour markers CARDIOPULMONARY EXERCISE TESTING (to assess fitness for surgical resection
267
What is the T classification within TNM staging for lung cancer?
T1- <3cm surrounded by lung or visceral pleura not invading a main bronchus T2- >3cm but <7cm OR invading main bronchus OR invading visceral pleura T3- >7cm or local invasion T4- Organ invasion: mediastinum, heart, great vessels, recurrent laryngeal nerve, oesophagus, vertebral body, carina or separate tumour nodules in a different ipsilateral lobe
268
What is the N classification within TNM staging for lung cancer?
N1- Ipsilateral bronchopulmonary and hilarious nodes N2- Ipsilateral mediastinal node or subcarinal N3- Contralateral mediastinal or contralateral hilar nodes, or supraclavicular nodes
269
What is the M classification within TNM staging for lung cancer?
M0- No metastases M1a- Separate tumour nodes in contralateral lung, malignant pleural of pericardial effusion M1b- Distant metastases
270
What are the management options for SCLC?
- radiotherapy | - chemotherapy
271
What are the features of chemotherapy use in the management of SCLC?
-90% of SCLC will respond to combination chemotherapy
272
What are the 3 indications for radiotherapy in the management of SCLC
1) Treatment of primary tumour 2) Prophylactic cranial irradiation (reduce brain mets) 3) Palliative
273
What are the prognostic factors for SCLC?
WITHOUT TREATMENT- median survival 2-4months | TREATED WITH SYSTEMIC CHEMO- median survival 11 months
274
What are the management options for NSCLC?
CURATIVE treatment- Stage 1,2,3 SYMPTOM management- Stage 4 - SURGERY - RADIOTHERAPY - CHEMOTHERAPY
275
What are the features for surgical management of NSCLC?
- Stage 1+2- surgical resection has a good prognosis and possibility of cure - Mediastinal involvement is considered a contraindication to surgery by most surgeons - Following surgery adjuvant chemotherapy is given to fit patients
276
What are the features of radiotherapy in NSCLC?
- If patients aren't suitable for surgery, radical radiotherapy - Use of CHART
277
What is CHART?
Continuous Hyperfractionated Accelerated RadioTherapy: - given 3 times a day for 12 consecutive days
278
What are the features of chemotherapy in NSCLC?
- response rate of 30% - CARBOPLATIN and PACLITAXEL - In large bulky tumours, chemotherapy can be given to shrink the tumour so that radical radiotherapy may follow
279
What is targeted therapy in NSCLC?
``` TYROKINASE INHIBITORS (erlotinib or gefitinib). - can be used first like as alternative to chemotherapy ```
280
What are the risk factors for prostate cancer?
- radiation exposure - diet - anabolic steroids - age - Afro-Caribbean - family history - maternal breast cancer
281
What is the histology of prostate cancer?
>95% are ADENOCARCINOMAS in glandular tissue in the posterior or peripheral part of the prostate gland
282
What histological grading system is used in prostate cancer?
GLEASON GRADE
283
What are the clinical features of prostate cancer?
- Diagnosed by routine rectal examination - Enlarged, hard, craggy gland - Obliteration of the median sulcus - Prostatism: poor stream, nocturne, dribbling, increased frequency, impotence - Metastatic symptoms- anaemia, pathological fracture/bone pain, spinal cord compression
284
What investigation is done in prostate cancer?
- Transrectal biopsy under ultrasound guidance - PSA - isotope bone scan - MRI
285
What is the T classification within TNM staging for prostate cancer?
TX: Primary tumour cannot be assessed T0: No evidence of primary tumour T1: Clinically unapparent tumour not palpable or visible with imaging T2: Tumour confined within the prostate T3: Tumour extends through the prostate capsule T3a: Extracapsular extension (uni/bilateral) T3b: Tumour invades seminal vesicle T4: Tumour is fixed or invades adjacent structures: bladder neck, external sphincter, rectum, levator muscles, pelvic wall
286
What is the N classification within TNM staging for prostate cancer?
N0: No regional lymph node involvement NI: Regional lymph node involvement
287
What is the M classification within TNM staging for prostate cancer?
MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis M1a: Nonregional lymph nodes M1b: Bone M1c: other/multiple sites, with or without bone disease
288
What are the management options for prostate cancer?
- OBSERVATION - SURGERY - RADIOTHERAPY - HORMONAL THERAPY - CHEMOTHERAPY
289
What are the features of surgical management for prostate cancer?
- Localised disease= radical prostatectomy | - TURP can be used to relieve prostatic symptoms/obstruction
290
When is radiotherapy appropriate management for prostate cancer?
- Alternative to surgery in T1/T2 cancers where PSA is low | - more appropriate for the control of advanced local disease
291
What are the side effects of radiology treatment of prostate cancer?
- dysuria - rectal bleeding - diarrhoea - impotence - incontinence
292
What are the indications of hormonal therapy and how does it work in management of prostate cancer?
- ADVANCED DISEASE | - Inhibits endogenous androgens
293
What are examples of hormonal therapies for prostate cancer management?
- LHRH agonists (GOSERELIN + BUSERELIN) - Oestrogen therapy - Anti-androgens (BICALUTAMIDE, MEGESTROL ACETATE) - Bilteral orchidectomy - GnRH antagonist
294
What is an example of a chemotherapy drug used to treat prostate cancer?
- docataxel | - cabazitaxel
295
What are the risk factors of testicular cancer?
- Maldescent of testes - testicular atrophy - family history
296
What is the histology of testicular cancer?
- SEMINOMAS - NON-SEMINOMATOUS GERM CELL TUMOURS - (malignant teratoma) - (combined seminoma/non-seminoma) - (yolk sac tumour)
297
Does testicular cancer often spread?
- spread is common via lymphatics to para-aortic nodes | - reflecting the embryological origin from primitive para-renal tissue
298
What is the clinical presentation for testicular cancer?
- painless testicular swelling - cough/dyspnoea due to lung mets - lower back pain due to para-aortic involvement
299
What are the investigations associated with testicular cancer?
- TUMOUR MARKERS (bHCG and AFP) - Orchidectomy - CT scanning of chest, abdomen, pelvis
300
What is the Royal Marsden Staging?
STAGE 1- Confined to the testicle STAGE 2- involving para-aortic lymph nodes below the diaphragm STAGE 3- involving para-aortic lymph nodes above the diaphragm STAGE 4- involving visceral metastases
301
What is the IGCCC?
International prognostic grouping to assess severity of testicular cancer
302
What is the management for testicular cancer?
- SURGERY - CHEMOTHERAPY - RADIOTHERAPY
303
What are the surgical options for management of testicular cancer?
- orchidectomy (via the inguinal canal) | - resection of residual mass following chemotherapy in metastatic teratoma
304
What are the chemotherapy options for testicular cancer?
BEP - Bleomycin - Etoposide - Cisplatin
305
What markers are associated with a poor prognosis?
- Markedly raised AFP - bHCG - LDH
306
What are the possible sites of primary cancer in cancer of unknown primary?
LIVER METS- Colon, lung, breast primaries LUNG METS- breast, lung, kidney primaries BRAIN METS- lung, breast, melanoma primaries BONE METS- breast, bronchus, kidney, prostate, thyroid primaries PERITONEAL METS- ovary, GI tract, pancreas primaries HIGH CERVICAL NODE METS- head, neck, thyroid, lung primaries LOWER CERVICAL NODE METS- head, neck, lung, breast, GI tract primaries AXILLARY NODE METS- breast, lung, melanoma primaries INGUINAL NODE METS- ovary, prostate, anorectal, vulval primaries
307
What are the investigations for cancer of unknown primary?
- Full clinical assessment and examination - FBC, U+Es, LFTs, calcium, urinalysis - CXR - Myeloma screen - Symptom directed endoscopy - CT chest, abdo, pelvis - PSA - CA125, AFP, bHCG - Testicular US - Biopsy
308
What is COPD?
Airflow limitation/obstruction that is not fully reversible by bronchodilator. - It is an ABNORMAL INFLAMMATORY response of the lungs to noxious particles or gases - Combines CHRONIC BRONCHITIS, CHRONIC ASTHMA, EMPHYSEMA
309
What is the ratio definition of COPD?
FEV1/FVC < 0.7
310
What are the red flag symptoms associated with COPD?
- weight loss - effort intolerance - waking at night - ankle swelling - fatigue - occupational hazards - chest pain - haemoptysis
311
What are the three main mechanisms that lead to limitation of airflow in the small airways?
1) LOSS OF ELASTICITY and alveolar attachments due to EMPHYSEMA. This reduces the elastic recoil, and airways collapse during expiration 2) INFLAMMATION AND SCARRING which causes the small airways to narrow 3) MUCUS SECRETION that blocks the airways
312
How does cigarette smoking contribute to COPD?
- increased number of neutrophil granulocytes that release elastase and proteases. - Inhibits alpha-antitrypsin (anti-protease)
313
What is the MRC Dyspnoea Scale?
1- Not troubled by breathlessness except on strenuous exercise 2- Short of breath when hurrying to walking up a slight hill 3- Walks slower than contemporaries on level group because of breathlessness, or has to stop for breath when walking at own pace 4- Stops for breath after walking about 100m or after a few minutes on level ground 5- Too breathless to leave the house, or breathless when dressing or undressing
314
What are the clinical features of COPD?
Must be >35 with chronic symptoms of: - SOB - Wheeze - Smoker's cough - White/clear sputum normally but purulent when infective exacerbation - Recurrent chest infections - History of smoking or occupational exposure
315
What are the clinical signs of COPD?
- cyanosis - raised JVP - cachexia - hyper inflated chest - use of accessory muscles - pursed lip breathing - wheeze or quiet breath sounds - peripheral oedema
316
What is cor pulmonale?
- Right heart failure secondary to lung disease | - caused by pulmonary hypertension due to hypoxia
317
What are the features of cor pulmonale?
- peripheral oedema - raised JVP - systolic parasternal heave - a loud pulmonary second heart sound (over 2nd left intercostal space) - widening of the descending pulmonary artery on chest X-ray - right ventricular hypertrophy on ECG
318
What are subsequent systemic effects of COPD?
- hypertension - osteoporosis - depression - metabolic problems causing weight loss and loss of muscle mass
319
What can be seen in late disease of COPD patients?
RESPIRATORY FAILURE - PaO2<8kPa OR - PaCO2> 7kPa
320
What are the differential diagnoses associated with COPD?
- asthma - bronchiectasis - heart failure - lung cancer - interstitial lung disease - anaemia - tuberculosis
321
How is diagnosis of COPD made?
- SPIROMETRY which measures the volume of air that the patient is able to expel after full inspiration - spirometry is done post bronchodilator
322
What is FEV1?
The volume of air that the patient can exhale in the FIRST SECOND of forced expiration
323
What is FVC?
The total volume of air that the patient can forcible exhale in one breath.
324
What is PEF?
The greatest flow that can be sustained for 10ms on forced expiation starting from maximal inspiration (monitors conditions of upper/large airways)
325
What other investigations are relevant in COPD?
CXR - can show over inflation of lungs - flattened diaphragms - large bullae - blood vessels FBC - Hb level may be raised due to prolonged hypoxemia ECG - in advance cor pulmonale- p waves TALLER and RBBB
326
What are the management options for COPD?
- SMOKING CESSATION - Various inhaled therapies - Add theophylline to treatment if symptomatic - Mucolytics (e.g. CARBOSYSTEINE) for productive cough with excess sputum - Oral corticosteroids (prednisolone) for acute exacerbations - if >65 prophylactic treatment for osteoporosis - Bullectomy or transplant in late stages - Nutritional support - physiotherapy - palliative care - annual review
327
What is the pathway for inhaled therapy in COPD?
1) SABA (e.g. salbutamol inhaler) or SAMA (e.g. ipratropium) 2) LABA (e.g. salmeterol inhaler) 3) LABA + ICS (e.g. salmeterol plus fluticasone propionate [SERETIDE 500/ Symbicort] 4) LAMA (e.g. tiotropium inhalation powder)
328
What are the indications for LTOT (long term oxygen therapy)?
- PaO2 <7.3kPa when stable - 8kPa >PaO2 >7.3kPa when stable AND ONE OF: - - secondary polycythemia - - nocturnal hypoxaemia - - peripheral oedema - - pulmonary hypertension
329
What is an acute exacerbation of COPD?
Sustained worsening with worsening SOB, cough, increased sputum production and change in sputum colour, FEVER
330
What are the investigations for acute exacerbation of COPD?
- Sputum culture in hospital - SpO2 - CXR - ABG - ECG - FBC - blood cultures
331
What is the management for acute exacerbation of COPD?
1) Nebulised bronchodilators 2) Systemic corticosteroids (PREDNISOLONE 30mg OD 7-14days) 3) Antibiotics (AMOXICILLIN 500mg TDS OR CLARITHROMYCIN 500mg BD) 4) IV THEOPHYLLINE 5) O2 therapy 6) NIV in hypercapnia respiratory failure
332
What are the side effects of beta2-agonists?
- Fine tremor - Palpitations - Headache - Seizure - Anxiety
333
What is asthma?
A chronic inflammatory condition of the airways. Asthma is characterized by recurrent episodes of dyspnoea, cough and wheeze caused by reversible airway obstruction.
334
What are the three factors that contribute to airway obstruction in asthma?
1) Bronchial muscle contraction: triggered by a variety of stimuli 2) Mucosal swelling/inflammation: caused by mast cell and basophil degranulation resulting in the release of inflammatory mediators 3) Increased mucus production
335
What are the different types of asthma?
1) EXTRINSIC: definite external cause for asthma | 2) INTRINSIC: no causative agent found. Usually starts at middle age
336
What are the triggers for asthma?
- Allergens: house dust mites, animal dander, pollen, fur - Pollution - Cold air - Exercise - Emotion - Smoking (including passive) - URTI - Drugs: NSAIDs, beta blockers
337
What are the risk factors for asthma?
- family history of asthma or atopy - inner city environment - viral infection in early childhood - Prematurity and low birth weight - maternal smoking - smoking - work triggers e.g. paint sprays, welders
338
What are the clinical features for asthma?
- Dyspnoea - Wheeze (bilateral, expiratory) - Cough (often nocturnal) - Sputum production - disturbed sleep - chest tightness - Diurnal variation (worse at night) - Tachypnoea - Hyperinflated chest - Hyper-resonant percussion note - Diminished air entry - Prolonged expiration - Increased RR
339
How is asthma diagnosed in children?
MAINLY CLINICAL DIAGNOSIS If symptomatic and there is a high probability of asthma: - start a trial of bronchodilators and assess response
340
How is asthma diagnosed in adults?
MAINLY CLINICAL DIAGNOSIS - trial of bronchodilators - Spirometry: low FEV1 (FEV1:FVC<0.7) showing obstruction and reversibility - PEFR - CXR (hyper inflated chest)
341
What is the management for asthma in <5
STEP 1: Inhaled SABA STEP 2: Add ICS or leukotriene antagonist STEP 3: Add ICS or LRA if not taking it STEP 4: Refer to Paeds
342
What is the management for asthma in 5-12?
``` STEP 1: Inhaled SABA STEP 2: Add ICS (200mcg) STEP 3: Add LABA. Increase ICS to 400mcg STEP 4: Increase to 800mcg STEP 5: Daily OCS. Refer to paeds ```
343
What is the management for asthma in >12?
STEP 1: Inhaled SABA STEP 2: Add ICS (400mcg) STEP 3: Add LABA. Increase ICS to 800mcg STEP 4: Increase to 2000mcg, add LRA, theophylline STEP 5: Daily OCS. Refer to secondary care
344
What is the primary prevention for asthma?
- avoid triggers, NSAIDs, BB - healthy diet, exercising - breast feeding during pregnancy
345
What is the secondary prevention for asthma?
- clean to remove dust mites - stop smoking - weight loss - physiology and breathing exercises
346
What are the clinical features of hypertension?
- often asymptomatic - sweating - palpitations - headaches
347
What are the clinical features of severe hypertension?
- headaches - epistaxis - nocturia - SOB due to LVH or HF - angina - PVD
348
What are the primary causes of hypertension?
1) GENETICS 2) LOW FETAL BIRTH WEIGHT 3) LIFESTYLE- (obesity/smoking/alcohol/ stress/anxiety/ salt) 4) METABOLIC SYNDROME 5) HYPERINSULINAEMIA 6) AGE
349
What are the secondary causes of hypertension?
1) CONGENITAL (e.g. adrenal hyperplasia, aortic coarctation.) 2) ACQUIRED: renal disease, diabetic neuropathy, chronic glomerulonephritis 3) ENDOCRINE: Conn's syndrome, adrenal hyperplasia, phaechromocytoma, Cushing's syndrome, acromegaly 4) Drugs: OCP, NSAIDs, cyclosporin, steroids 5) Pregnancy 6) White coat syndrome
350
How is hypertension diagnosed?
ABPM or HBPM (2x daily readings for 7 days)
351
How is hypertension classified?
STAGE 1: >140/90mmHg STAGE 2: >160/100mmHg SEVERE: >180 systolic OR >110 diastolic ACCELERATED HTN: 180/110 with signs of papilloedema and/or retinal haemorrhage POSTURAL HYPOTENSION: Systolic BP decreases by 20mmHg on standing for 1min
352
What are the classifications for hypertension on fundoscopy?
KEITH WAGENER Grade 1: Tortuosity of retinal arteries with increased reflectiveness (silver wiring) Grade 2: grade 1 + A-V nipping producing when thickened retinal arteries pass over retinal veins Grade 3: grade 2 + flame haemorrhages and soft exudates due to small infarcts Grade 4: grade 3 + papilloedema (blurring margins of optic disc)
353
Which of these fundoscopy findings are indicative of malignant hypertension?
GRADES 3 + 4
354
What other investigations should be done in hypertension?
- ECG: LVH, haematuria - Urine: protein, blood, albumin: creatinine ratio - bloods: fasting blood for lipids and glucose, serum total cholesterol and HDL, cholesterol, U+Es, HbA1c - CXR: coarctation of aorta - Examine funds for HTN retinopathy
355
What are the conservative treatments for hypertension?
- diet (salt, caffeine), exercise, relaxation therapy, alcohol + smoking, local initiatives for healthy living
356
What are the criteria for pharmacological treatments in hypertension?
STAGE ONE: Offer treatment if- - <80 - end organ damage - CV or renal disease - Diabetes - 10 year CV risk of >20% STAGE ONE: <40- specialist evaluation STAGE TWO: everyone gets treatment
357
What is step 1 in hypertension pharmacological management?
AGE <55- ACE INHIBITOR OR AGE >55/ AFRO-CARIBBEAN- CALCIUM BLOCKER
358
What is step 2 in hypertension pharmacological management?
ACEi + CALCIUM BLOCKER
359
What is step 3 in hypertension pharmacological management?
ACEi + CALCIUM BLOCKER + THIAZIDE DIURETIC
360
What is step 4 in hypertension pharmacological management?
RESISTANT HYPERTENSION ACEi + CALCIUM BLOCKER + THIAZIDE DIURETIC + additional DIURETIC OR alpha/beta blocker
361
What should be used if ACEi is not tolerated?
ARB | but NEVER combine the two.
362
What should be considered when prescribing an ACEi?
- START LOW DOSE (2.5mg) - advise first dose in the evening - check renal function (creatinine and eGFR) before upward titration - maximum dose 10mg
363
What are the side effects associated with ACEi?
- hypotension - persistent dry cough - hyperkalaemia - cause/ worsen renal failure
364
Where are ACEi contraindicated?
- recurrent angioedema - pregnancy - breastfeeding
365
What should be considered when prescribing a CCB?
- START LOW (5mg) | - titrate up for 4 weeks until target BP achieved
366
What are the side effects associated with CCB?
- ankle swelling - headache - flushing - nausea - dizziness
367
Where are CCBs contraindicated?
- hepatic impairment - renal impairment - heart failure - cardiac outflow obstruction - 2nd degree heart block
368
How do CCBs work?
- decreases calcium entry into vascular + cardiac cells, thus reducing intracellular calcium concentration - cause relaxation and vasodilation in arterial smooth muscle - reduce myocardial contractility - suppresses cardiac conduction
369
What should be considered when prescribing thiazide-like diuretic?
- check creatinine, eGFR, U+Es before starting treatment | - recheck in 4-6 weeks after upward titration
370
What are the side effects associated with thiazide-diuretics?
- excessive diuresis - hypokalaemia - postural hypotension - gout - DM - impotence - dizziness
371
When are thiazide-diuretics contraindicated?
- gout - refractory hypokalaemia - hyponatraemia - hypercalcaemia - severe hepatic impairment - Addison's - pregnancy - eGFR
372
What is type 1 diabetes?
An absolute insulin deficiency causing persistent hyperglycemia caused by autoimmune destruction of insulin producing beta cells in the pancreatic islets of Langerhans.
373
What are the clinical features of type 1 diabetes?
RAPID ONSET (over days/ weeks) - polyuria - polydipsia - weight loss - hyperglycemia - lack of energy and fatigue - ketonuria and breath smelling of ketones - infections: UTIs, candida - cramps and abdominal pain
374
What is diabetic keto acidosis characterized by?
- nausea and vomiting - acidotic breathing - ketones on the breath
375
What are the investigations for type 1 diabetes?
- OGTT (oral glucose tolerance test) - fasting blood glucose - random blood glucose - urinalysis (positive for glucose and ketones) - bloods: FBC, U+Es, LFTs, TFTs, random lipids and HbA1c - Autoantibody test: confirming autoimmune disease
376
OGTT:
> 11.1 mmol/l , 2hrs after 75g anhydrous glucose
377
Fasting blood glucose
> 7 mmol/l
378
Random blood glucose:
> 11 mmol/l
379
HbA1c:
> 48mmol/l
380
How is the diagnosis for type 1 diabetes made?
- CLASSICAL SYMPTOMS + 1 raised glucose measurement | - NO CLASSICAL SYMPTOMS + 2 raised glucose measurements
381
What is the conservative management for type 1 diabetes?
- Give dietary advice and offer referral to dietician - smoking cessation and reduced alcohol consumption - medical emergency ID bracelet - advise DVLA of diagnosis (drivers stop every 2 hrs to check glucose)
382
What are the blood sugar targets for type 1 diabetes?
- blood sugar before meals: between 4-7mmol/l | - blood sugar after meals: between 5-9 mmol/l
383
What is available in insulin therapy?
1) SHORT ACTING INSULINS: give 15-30mins before meals and in emergencies 2) INTERMEDIATE and LONG ACTING: used to mimic the effect of basal insulin that is secreted continuously. 3) BIPHASIC INSULIN PREPARATIONS: contain a premixed combination of a short acting and an intermediate acting insulin
384
What are the insulin regimes?
- ONCE DAILY: long acting given at bedtime (T2) - TWICE DAILY: Biphasic given pre-breakfast and pre-dinner - BASAL-BOLUS: Long acting given at bedtime. Short acting before meal times - CONTINOUS SUBCUT INSULIN INFUSION: Useful in pts with recurrent hypos, unpredictable lives and delayed meals.
385
What should be checked in the annual review for type 1 diabetes?
- HbA1c levels monitored every 3-6 months - Blood pressure (intervene if >140/80) - Cholesterol and triglyceride levels - Weight monitoring - Microalbumin screen- urine albumin:creatinine ratio and blood serum creatinine - Kidney damage - abdominal adiposity - annual retinopathy screening - diabetic foot check - monitor sexual dysfunction - diet advice - psychological check
386
What are the metabolic complications associated with T1DM?
- hyperglycaemic ketoacidosis - hypoglycaemia - dyslipidaemia
387
What are the macrovascular complications associated with T1DM?
- Cardiovascular disease (MI) - Cerebrovascular disease (stroke) - peripheral vascular disease
388
What are the microvascular complications associated with T1DM?
- retinopathy - nephropathy - sensory, motor, and autonomic neuropathy
389
What are the psychological complications associated with T1DM?
- depression | - anxiety
390
What are the complications in children and your adults associated with T1DM?
- family conflict | - risky behaviour (non-adherence to recommended management)
391
What are the infective complications associated with T1DM?
- fungal infections | - skin conditions, for example granuloma annulare or necrobiosis diabeticorum
392
What is Type 2 Diabetes Mellitus?
Insulin resistance and a relative insulin deficiency result in persistent hyperglycemia
393
What are the risk factors associated with T2DM?
- obesity - lack of physical activity - calorie and alcohol excess - genetic influence (polygenic) - history of gestational diabetes - impaired glucose tolerance/ impaired fasting glucose - drugs - smoking - PCOS
394
What are the clinical features associated with T2DM?
- polyuria - polydipsia - weight loss - lethargy - fatigue - blurred vision
395
How is the diagnosis for type 2 diabetes made?
- CLASSICAL SYMPTOMS + 1 raised glucose measurement | - NO CLASSICAL SYMPTOMS + 2 raised glucose measurements
396
What are the investigations for T2DM?
- OGTT >11mmol/l - fasting blood glucose >7mmol/l - random blood glucose >11mmol/l - HbA1c >48mmol/l
397
What is the overall management for T2DM?
- Stepwise approach - Diet and lifestyle changes - Oral antidiabetic drug - Insulin - Monitored by measuring the level of HbA1c in the blood, every 3-6 months - Every 6 months once blood glucose levels and treatment is stable
398
What is the lifestyle advice associated with T2DM?
- Diabetes education - Dietary advice - Weight loss if over weight - Encourage regular exercise - Smoking cessation
399
What is the general process for the administration of oral anti-diabetics?
1) Metformin 2) Metformin + gliclazide /sitagliptin/ pioglitazone/emaglifozain 3) Metformin + gliclazine + sitagliptin 4) Insulin therapy
400
What is metformin?
A BIGUANIDE that improves responsive to insulin
401
What should be considered when initiating metformin?
- assess renal function - starting dose of 500mg OD (with breakfast) for 1 week - 500mg BD (with breakfast and dinner) 1 week - 500mg TDS (breakfast, lunch, dinner) 1 week - maximum daily dose 2g - can drink alcohol BUT no more than 1 pint or glass of wine/day
402
What are the contraindications associated with metformin?
- impaired renal function
403
What are the side effects associated with metformin?
- GI side effects - abdo pain - diarrhoea - nausea - altered taste - lactic acidosis - impaired renal function - allergic reaction
404
What is gliclazide?
A SULFONYLUREA that increases insulin secretion and only effective when some residual pancreatic B-cell function is present
405
What should be considered when starting a sulfonylurea?
- Discuss the possibility of hypoglycaemia and how to minimize the risk (carry sweets) - Start with a low dose and titrate up to 1-2 weeks - Take in the MORNING with BREAKFAST - inform DVLA of medication - MAX DOSE: 320mg (2x80mg at breakfast and at dinner) - During pregnancy switch to insulin
406
What are the side effects associated with gliclazide?
- hypoglycaemia - weight gain - stomach ache or indigestion - nausea - vomiting/diarrhoea - constipation - allergy= rash swelling - GI and liver
407
What are the early warning signs of hypoglycaemia?
- feeling hungry - trembling or shaking - sweating - confusion - difficulty concentrating
408
What is sitagliptin?
it is a DDP-4 INHIBITOR that causes an increase in insulin secretion.
409
What should be considered when prescribing sitagliptin?
- ONE tablet per day - same time every day - swallow with glass of water - 100mg once daily
410
What are the side effects associated with sitagliptin?
VERY FEW - headache - constipation - renal or liver disease - allergic reaction
411
What is pioglitazone?
a THIAZILODNINEDIONE that increases insulin action.
412
What are the adverse effects associated wth pioglitazone?
- Heart failure - oedema - fluid retention - anaemia - fractures
413
What are the contraindications associated with pioglitazone?
- cardiac disease | - severe liver/renal disease
414
What can be used in secondary prevention for diabetes?
- MANAGING THE BLOOD PRESSURE (monitor yearly if no diagnosis of HTN, 4-6months if diagnosis present) - STATIN (aim for cholesterol level of <4mmol) - ASPIRIN 75mg- - diabetic foot exam - yearly retinopathy screening - assess for renal damage
415
What is epilepsy?
Epilepsy is a disorder of the brain characterized by a predisposition to epileptic seizures with at least 2 seizure more than 24 hours apart
416
What is an epileptic seizure?
Epileptic seizure is a transient disturbance of consciousness, behaviour, emotion, motor function, or sensation, due to abnormal electrical activity in the brain.
417
What are the risk factors for epilepsy?
- FHx of epilepsy - Childhood epilepsy or neurocutaneous syndromes - Febrile seizures in childhood - Previous intracranial infections, brain trauma or surgery - CVA or tumours
418
What are precipitating factors for seizures in epileptics?
- Inadequate sleep - alcohol abuse - medications: tricyclic antidepressants
419
How are seizures classified?
- SIMPLE: NO loss of consciousness | - COMPLEX: loss of consciousness
420
What are the features of a partial seizure?
- focal onset, with features referable to a part of one hemisphere of the brain - focal motor: jerking movements start in the face or hand and spread to the limbs - focal sensory: abnormal sensations - temporal complex: auras
421
What are the features of generalized seizure?
- simultaneous onset of electrical discharge throughout the cortex
422
What can be seen in a tonic seizure?
- impairment of consciousness and increased muscle tone
423
What can be seen in clonic seizure?
- jerking rhythmically with impairment of consciousness
424
What can be seen in tonic- clonic seizures?
- post-ictal confusion and drowsiness
425
What can be seen in absence seizures?
- pauses and stares for 10 secs
426
What can be seen in myoclonic seizures?
- brief shock like contraction of the limbs, face or trunk
427
What can be seen atonic (akinetic) seizures?
- brief, sudden loss of tone associated with falls, without loss of consciousness.
428
What are the clinical features of epilepsy?
- PRODROME - AURAS - POST-ICTALLY - RESIDUAL SYMPTOMS
429
What is prodrome?
Change in mood or behaviour lasting hours to days, may rarely precede the seizure; not part of the seizure itself.
430
What are auras?
Stereotyped perception caused by initial focal electrical events before a partial seizure - unexpected tastes - smells - paraesthesia - flashing lights - deja vu
431
What can be experienced post-ictally?
- headache - confusion - myalgia - sore tongue - temporary weakness after a partial motor
432
How is diagnosis of epilepsy made?
- clinical with collateral history - if the diagnosis cannot be established, consider further investigations/referral to an epilepsy specialist - Classify epileptic seizures and epilepsy syndrome using a multi-axial diagnostic scheme - Consider: description of seizure, seizure type: syndrome and aetiology
433
What investigations are done in epilepsy?
TO SUPPORT CLINICAL DIAGNOSIS - EEG - ECG TO DETERMINE CAUSE OF EPILEPSY / SEIZURE - MRI/CT - Bloods - urine biochemistry - genetic testing
434
What is the management for those with epilepsy?
- REFERRAL (confirm diagnosis within 2 weeks) | - ANTI-EPILEPTIC DRUGS
435
Match the seizure type to the anticonvulsant: | FOCAL SEIZURES
CARBAMAZEPINE OR LAMOTRIGINE
436
Match the seizure type to the anticonvulsant: | ABSENCE SEIZURES
ETHOSUXIMIDE OR SODIUM VALPROATE
437
Match the seizure type to the anticonvulsant: | TONIC-CLONIC SEIZURES
SODIUM VALPROATE (LAMOTRIGINE IF WOCBA)
438
Match the seizure type to the anticonvulsant: | MYOCLONIC SEIZURES
SODIUM VALPROATE
439
Match the seizure type to the anticonvulsant: | TONIC/ATONIC SEIZURES
SODIUM VALPROATE
440
What should be considered when prescribing sodium valproate?
- 600mg daily in 1-2 divided doses - Increase insteps of 150-500mg every 3 days - maintenance dose of 1-2g daily - monitor liver function - avoid abrupt withdrawal
441
When is sodium valproate contraindicated?
- pregnancy - hepatic impairment - family history of severe hepatic dysfunction - acute porphyria
442
What are the side effects associated with sodium valproate?
- nausea - gastric irritation - weight gain - thrombocytopenia
443
What should be considered when prescribing lamotrigine?
25mg OD for 14 days - increase dose gradually - maintenance dose: 100-200mg daily - monitory for signs of hypersensitivity syndrome
444
When is lamotrigine contraindicated?
- myoclonic seizures | - hepatic/renal impairment
445
What are the side effects associated with lamotrigine?
- nausea and vomiting - diarrhoea - dry mouth - aggression, agitation - headache, drowsiness, dizziness - tremor, insomnia, blurred vision, rash
446
What are COMMON INTERACTIONS with anticonvulsants?
1) WARFARIN 2) OCP 3) MACROLIDE ANTIBIOTICS 4) SSRIs 5) STATINS
447
What should be done in an annual review for an epileptic patient?
- seizure control - adverse effects and compliance with treatment - appropriate anti-epileptic drug prescribing - any social or psychological issues - carer's skills in managing seizures - contraception needs and pregnancy planning
448
What is the management for a tonic-clonic seizure lasting >5mins?
- look for epilepsy card/ jewellry - protect them from injury: cushion their head; remove harmful objects from nearby - do not restrain them or put anything in their mouth - when seizure stops, check airway and put them in the recovery position - observe them until they have recovered - examine for and manage any injuries - arrange emergency admission if it is their first seizure
449
What is the management for status epilepticus seizure lasting >5mins or >3 seizures in 1hr?
- ABCDE - Treat with buccal midazolam or rectal diazepam - IV lorazepam if in hospital - urgent hospital admission if do not respond promptly
450
What is a stroke?
Clinical syndrome caused by disruption of blood supply to the brain, characterized by rapidly developing signs of focal/global disturbance of cerebral functions, lasting for >24hrs or leading to death.
451
What is a TIA?
Transient ischemic attack which solves in <24hrs.
452
How are strokes classified?
1) ISCHAEMIC (85%) | 2) HAEMORRHAGIC (15%)
453
What are the features of ischemic stroke?
- THROMBOTIC: a blood clot spontaneously forms in an artery in the brain- a common complication of atherosclerosis - EMBOLIC: part of the fatty material from an atherosclerotic plaque or a clot in a larger artery or heart travels downstream. Common complications of AF and atherosclerosis of the carotid arteries.
454
What are the features of haemorrhagic stroke?
- INTRACEREBRAL: bleeding from a blood vessel within the brain (HTN main cause) - SUBARACHNOID: bleeding from blood vessel between the surface of the brain and the arachnoid tissues that cover the brain
455
What are the risk factors associated with stroke?
- HTN - smoking - excess alcohol - obesity - DM - heart disease - past TIA/ stroke - contraceptive pill - hyperlipidemia, hypercholestrolaemia - polycythemia - clotting disorders
456
What are the 4 main presenting areas for stroke in the brain?
1) TACS 2) PACS 3) POCS 4) LACUNAR STROKE
457
Where does a TACS affect?
TOTAL ANTERIOR CIRCULATION stroke - large cortical stroke - MCA/ACA territory
458
How does a TACS present clinically?
- unilateral weakness and/or sensor disturbance of arm/leg - homonymous hemianopia - higher cerebral dysfunction (dysphasia, visuospatial disorder)
459
Where does a PACS affect?
PARTIAL ANTERIOR CIRCULATION stroke - cortical stroke - MCA/ACA territory
460
How does a PACS present clinically?
TWO of: - unilateral weakness and/or sensor disturbance of arm/leg - homonymous hemianopia - higher cerebral dysfunction (dysphasia, visuospatial disorder)
461
Where does a POCS affect?
POSTERIOR CIRCULATION stroke - brain stem - cerebellum - occipital lobe
462
How does a POCS present clinically?
ONE of: - cerebellar or brainstem syndrome - loss of conciousness - isolated homonymous hemianopia
463
Where does a LACS affect?
LACUNAR stroke | - subcortical stroke
464
How does a LACS present clinically?
ONE of: - unilateral weakness and/or sensory deficit to face and arm, arm and leg, or all three - pure sensory stroke - ataxic hemiparesis
465
What are the clinical features associated with stroke?
- facial weakness (one side 2/3 forehead spared) - unilateral weakness - sensory loss - speech problems - visual defects (amaurosis fugax) - perception and balance - coordination disorder
466
Match the clinical feature to the corresponding structure involved: HEMIPARESIS/ TETRAPARESIS
CORTICOSPINAL TRACTS
467
Match the clinical feature to the corresponding structure involved: SENSORY LOSS
MEDIAL LEMNISCUS AND SPINOTHALAMAIC TRACTS
468
Match the clinical feature to the corresponding structure involved: DIPLOPIA
OCULOMOTOR SYSTEM
469
Match the clinical feature to the corresponding structure involved: FACIAL NUMBNESS
5TH NERVE NUCLEI
470
Match the clinical feature to the corresponding structure involved: FACIAL WEAKNESS
7TH NERVE NUCLEUS
471
Match the clinical feature to the corresponding structure involved: NYSTAGMUS, VERTIGO
VESTIBULAR CONNECTIONS
472
Match the clinical feature to the corresponding structure involved: DYSPHAGIA, DYSARTHRIA
9TH AND 10TH NERVE NUCLEI
473
Match the clinical feature to the corresponding structure involved: DYSARTHRIA, ATAXIA, HICCUPS, VOMITING
BRAINSTEM AND CEREBELLAR CONNECTIONS
474
Match the clinical feature to the corresponding structure involved: HORNERS SYNDROME
SYMPATHETIC FIBER
475
Match the clinical feature to the corresponding structure involved: COMA, ALTERED CONSCIOUSNESS
RETICULAR FORMATION
476
Match the clinical feature to the corresponding structure involved: LOCKED IN
BRAINSTEM
477
Match the clinical feature to the corresponding structure involved: PURE MOTOR/SENSORY
LACUNAR
478
What are the features of an UPPER neurone stroke?
tone: INCREASED atrophy: ABSENT fasciculation: ABSENT reflex: HYPERACTIVE babinski: PRESENT
479
What are the features of a LOWER neurone stroke?
tone: DECREASED/ABSENT atrophy: PRESENT fasciculation: PRESENT reflex: DECREASED/ABSENT babinski: ABSENT
480
What are the differential diagnoses associated with stroke symptoms?
- MS - Migraine with/without aura - Epilepsy - Syncope - Hypo/hyperglycaemia - Hypercalcaemia - Subdural haemorrhage - Beauty parlor syndrome (bending neck back occluding blood vessels at base of the neck)
481
When should brain imaging be performed IMMEDIATELY with acute stroke?
- indications for thrombolysis or early anticoagulation treatment - on anticoagulant - known bleeding tendency - depressed level of consciousness (GCS<13) - unexplained progressive/fluctuating symptoms - papilloedema, neck stiffness or fever - severe headache at onset of stroke symptoms IN ABSENCE OF THESE IMAGE WITHIN 24hrs
482
What other investigations should be done in someone presenting with stroke symptoms?
- FBC - BM (glucose) - ESR - U+Es - BP - ECG
483
What is the stroke risk assessment tool used in patients with TIA?
ABCD2 score
484
What is the ABCD2 score?
A- Age: >60 (1pt) B- Blood pressure: >140/90mmHg (1pt) C- Clinical features: unilateral weakness (2pts), speech disturbance without weakness (1pt) D- Duration of symptoms: >60mins (2pts), 10-59mins (1pt) D- Diabetes (1pt)
485
What is classified as HIGH risk of an early stroke?
- ABCD2: >4 - AF - More than one TIA in one week - A TIA whilst on an anticoagulant
486
What is the management for a TIA patient at high risk for an early stroke?
- ASPIRIN 300mg immediate - Refer for specialist assessment TIA clinic within 24h - Carotid ultrasound
487
What is classified as LOW risk of an early stroke?
- ABCD2: <3 | - Present >1 week after their last symptoms have resolved
488
What is the management for a TIA patient at low risk of an early stroke?
- ASPIRIN 300mg immediate | - Refer for a specialist assessment within one week
489
What is the overall management for TIA patients?
- MRI - Assess risk factors - CLOPIDOGREL 300mg loading dose - CLOPIDOGREL 75mg daily - STATIN (ATORVASTATIN 40mg) - If patient has GI disease, prescribe a PPI -
490
What should be done in the follow up after TIA?
- Follow up should be arranged within 1 month - Annually in primary care - Check and optimise lifestyle measures - annually check and record BP and lipid profile - arrange pre winter flu jab
491
What is the acute management for a stroke?
- Ensure patient airway - Monitor blood glucose (maintain 4-11mmol) - Monitor BP - Give O2 if sats fall <95% - NBM until swallowing assessed - Keep hydrated: IV fluid - FBC, U+E, cholesterol, glucose, TFT, INR
492
What medication should be used in ischaemic stroke?
THROMBOLYSIS- Alteplase | ASPIRIN 300mg- orally, rectally, enteral tube
493
When should alteplase be prescribed?
- treatment 4.5 hours of onset of stroke symptoms - intracranial haemorrhage has been excluded - calculated 0.9mg/KG up to 90mg - cardiac monitoring - regular BP - 24hr after finishing course, CT to check for bleeding
494
What are the contraindications for alteplase?
- WARFARIN | - MEDICAL PROCEDURE IN THE LAST 10 DAYS
495
What is the medical management for an embolic stroke?
- Full dose anticoagulation treatment - Give a PPI if previous dyspepsia - Statin: 48 hours after acute stroke - Carotid imaging and carotid endarterectomy - Control BP and cardiovascular risk factors
496
What is the medical management for a haemorrhagic stroke?
- Refer to neurosurgery - Decompressive hemicraniectomy for MCA involvement - Always consider subarachnoid haemorrhage if thunderclap headache
497
What is the conservative management associated with stroke?
- Stop smoking - Cardioprotective diet, including reducing salt intake - regular exercise - reduce alcohol consumption - achieving and maintain a satisfactory BMI
498
What is the definition of chronic kidney disease?
CKD= GFR <60 for >3months OR GFR>60 together with the presence of kidney damage, present for >3months
499
What are the causes of CKD?
1) Diabetic nephropathy 2) Congenital and inherited disease (PCKD) 3) Glomerular disease 4) Vascular disease 5) Tubulointerstitial disease 6) Urinary tract obstruction (e.g. prostatic disease) 7) Cardiovascular causes (HTN, heart failure) 8) Nephrotoxic drugs (NSAIDs) 9) Unknown
500
What are the risk factors associated with CKD?
- DM - Age >60 - recurrent UTIs - urinary obstruction - systemic illness that effects the kidneys
501
What are the clinical features associated with CKD?
often ASYMPTOMATIC but picture often shows common symptoms when Urea >40mmol/l - Urea >60mmol/L- there are severe uremic symptoms and CNS involvement - incidental finding - Monitoring at risk individuals
502
What are the clinical signs of uremia?
- short stature - brown discoloration of the nails - fluid overload: pleural effusion - pericardial friction rub - mitral regurgitation - glove and stocking peripheral sensory loss - High BP
503
What are the clinical signs associated with CKD?
- impalpable kidneys unless PCKD, tumour, obstruction - cutaneous vasculitic lesions in systemic vasculitis - retinopathy in diabetes - evidence of PVD - evidence of spinal bifida or other causes of neurogenic bladder - hydration status- JVP, cap refill, turgor
504
What are the complications of CKD?
1) Anaemia 2) Renal osteodystrophy 3) Pruritis 4) Nephrogenic systemic fibrosis 5) fluid overload 6) GI problems 7) Gout and DM 8) Endocrine 9) Muscles 10) Nervous system: seizures 11) CV: increased risk of MI, HF, sudden death 12) Malignancy
505
What are examples of nephrotoxic drugs (DIAMOND H)?
``` D- Diuretics I- Iodine A- Aminoglycosides (gentamicin) M- Metformin O- Opiates N- NSAIDs D- Digoxin ``` H- Heparin
506
What BLOOD investigations should be done in CKD?
BLOODS - FBC (low Hb, normocytic, normochromic), eosinophilia - ESR (raised) - U+E (low eGFR) - metabolic acidosis - immunology
507
What should be checked for in URINALYSIS for CKD?
- haematuria - proteinuria - urinary ACR
508
What other investigations should be done in CKD?
- ECG - US - AXR: renal stones - CT: retroperitoneal fibrosis - RENAL BIOPSY - bone scan
509
How is CKD diagnosed?
- eGFR persistently <60 and/or ACR persistently <3
510
What is the normal function of the kidney?
``` EXCRETE - inorganic substances (potassium, phosphate) - organic substances (urea, creatinine) - larger molecules HOMEOSTASIS - fluid balance etc PRODUCE- erythropoetin- makes RBCs Helps bone formation Affects blood pressure (renin) ```
511
What is the conservative management for CKD?
MONITOR eGFR REGULARLY AND PROTEINURIA ANNUALLY - Manage CVD risk factors - Treat underlying cause - Slow progression - Treat complications - Refer to specialist at stage 4 - Stop nephrotoxic drugs
512
What are the other forms of management for CKD?
1) HAEMODIALYSIS 2) HAEMOFILTRATION 3) PERITONEAL DIALYSIS 4) KIDNEY TRANSPLANT 5) CONSERVATIVE/PALLIATIVE CARE
513
What are the GFR stages of kidney disease?
``` G1- >90 (normal) G2- 60-89 (mild reduction) G3a- 45-59 (mild-moderate reduction) G3b- 30-44 (moderate-severe reduction) G4- 15-29 (severe reduction) G5- <15 (kidney failure) ``` (Above 60 is essentially normal unless they have associated kidney disease)
514
What are the ACR stages of kidney disease?
A1- <3 (normal- mildly increased) A2- 3-30 (moderately increased) A3- >30 (severely increased)
515
What are the risk factors associated with coronary heart disease?
- hypercholesterolaemia - smoking - hypertension - diabetes - age - low blood LDL - high blood triglyceride - insulin resistance - overweight - physical inactivity - diet high in fat, sodium and sugar - stress, lack of social support, depression, anxiety - alcohol - social class
516
What are the clinical features associated with coronary heart disease?
- chest pain radiating to the neck, left shoulder and arm - exertion dyspnoea - fatigue on exertion - arrhythmias - heart failure - stable angina
517
What investigations should be done in coronary heart disease?
- BMI, BP, CV examination - ECG (normal at rest, pathological Q waves, LBBB, ST depression/elevation, T-wave flattening/elevation) - Bloods: FBC, HDL, LDL, cholesterol, U+Es, TFTs, troponin - ECHO
518
What is the management for coronary heart disease?
- Assess lifestyle - Explain angina - GTN spray - Beta blocker (ATENOLOL) - ASPIRIN/CLOPIDOGREL 75mg - ACEi - STATIN - Angioplasty
519
How should a GTN spray be taken?
- When an attack occurs, stop and rest - Use GTN spray/tablet - Take a second dose after 5 mins if not setled - Call 999 if not settled 5 mins after 2nd dose - Take third dose
520
What are the side effects associated with GTN spray?
- Transient hypotension - Headache - Burning/stinging/ tingling in the mouth
521
What are the main interactions associated with GTN?
PHOSPHODIESTERASE INHIBIOTS (sildenafil/tadalafil/vardenafil) - can produce excessive hypotension - may precipitate myocardial infarction
522
What should be done in an CHD review in primary care?
- ongoing symptoms of angina (at rest or with exercise) - Assess CVD risk and any modifiable CV risk factors - Any complications of angina treatment and provide information - Review medication - Mood
523
What is AF?
A cardiac arrhythmia with: - irregular RR intervals - no distinct P waves on the surface ECG - rapid and chaotic atrial activity
524
How is AF classified?
1) INITIAL 2) PAROXYSMAL 3) PERSISTENT 4) LONG STANDING PERSISTENT 5) PERMANENT
525
What are the features of initial episode of AF?
AF >30s diagnosed by ECG
526
What are the features of paroxysmal AF?
recurrent >2 episodes that terminate within 7 days
527
What are the features of persistent AF?
- continuous >7 days | - AF> 48h which decision made to perform CV
528
What are the features of longstanding persistent AF?
Continuous AF of >12 months duration
529
What are the features of permanent AF?
- Where a joint decision has been made by patient and clinician to stop further attempts to restore/maintain sinus rhythm
530
What are the clinical features of AF?
- Palpitations - SOB - fatigue - dizziness - syncope - decreased exercise capacity - left ventricular function
531
What are associated conditions with AF?
- HTN - HF - diabetes, obesity - sleep apnea, chronic lung disease - valvular heart disease - congenital heart disease - coronary artery disease - hyperthyroidism - chronic kidney disease - infection - atrial flutter and SVT
532
What is the purpose CHADSVASC?
A score to aid in stroke prevention
533
What is CHA(2)DS(2)VASC?
``` C- Congestive hear failure H- HTN A- Age >75 D- Diabetes S- Stroke/TIA V- vascular disease A- Age 65-74 Sc- Sex Category (F) ```
534
What are the objectives of treatment of AF?
- Stroke prevention - Symptom relief - Ventricular rate control - Correction of rhythm disturbance - Optimal management of cardiovascular disease
535
What are the investigations associated with AF?
- ECG: 24h ambulatory - Bloods: FBC, U+Es, TFTs, LFTs, coagulation screen - Transthoracic ECHO if murmur
536
What is the management of AF?
1) ANTICOAGULATION 2) RATE CONTROL 3) RHYTHM CONTROL
537
What is the anticoagulation treatment for AF?
- warfarin | - NOAC (APIXABAN, DABIGATRAN, RIVAROXABAN
538
What is used for rate control in treatment for AF?
BETA BLOCKERS - BISOPROLOL - ATENOLOL - PROPRANOLOL RATE LIMITING CCB - DILTIAZEM 60mg TDS - DIGOXIN (only in non-paroxysmal AF)
539
What are the side effects associated with beta blockers?
- bradycardia - cold extremities - sleep disturbance - fatigue - sexual dysfunction
540
What are the side effects associated with CCBs?
- dizziness - AV block - palpitations - GI disorders - erythema - malaise - fatigue
541
What methods are used for rhythm control?
- BETA BLOCKERS (amiodarone, flecainide, propafenone) - CARDIOVERSION - CATHETER LEFT ATRIAL ABLATION
542
What is heart failure?
A complex syndrome resulting from a structural or functional cardiac disorder that impairs the pumping ability of the heart and the heart's ability to maintain the circulation of blood - inadequate cardiac output - peripheral under perfusion
543
What are the three main classifications of heart failure?
1) LEFT VENTRICULAR SYSTOLIC DYSFUNCTION 2) RIGHT VENTRICULAR FAILURE 3) CONGESTIVE CARDIAC FAILURE
544
What are the cardiac muscle causes of heart failure?
- Coronary artery disease - hypertension - cardiomyopathies - toxins - DM, hypo/hyperthyroidism, Cushing's - Adrenal insufficiency, excessive growth hormone - Sarcoidosis, amyloidosis, hemochromatosis
545
What are the low cardiac output causes of heart failure?
- hypertension - arrhythmias - pericardial diseases - aortic stenosis
546
What are the high cardiac output causes of heart failure?
- anaemia - thyrotoxicosis - septicaemia - liver failure - AV shunts - paget's disease - Thiamine deficiency
547
What are the clinical features associated with heart failure?
- BREATHLESSNESS (orthopnea, PND) - FATIGUE - FLUID RETENTION - NOCTURIA, cold peripheries - nocturnal cough - chest pain, tightness and palpitations
548
What are the clinical signs associated with heart failure?
- laterally displaced apex beat - raised JVP - hepatomegaly - third/fourth heart sound (gallop rhythm) - tachycardia - pulmonary crepitations - dependent oedema: legs, sacrum, ascites - anorexia, cachexia
549
What is the New York Classification system of heart failure symptoms?
CLASS 1- no limitations CLASS 2- slight limitation of physical activity CLASS 3- marked limitation of physical activity CLASS 4- symptoms of heart failure are present even at rest
550
What are the investigations for heart failure if there has been previous MI?
ECHO to assess: - LV systolic function - diastolic function (HFPEF) - LV wall thickness - Valvular disease - pulmonary artery systolic pressure - BNP
551
What are the investigations for heart failure if there has been NO previous MI?
- BNP and NT-proBNP - if BNP >100 refer and assess <6 weeks - if BNP>400 refer and ECHO <2 weeks ``` 12 lead ECG Bloods: FBC, U+E, creatinine, TFT, LFT Urinalysis Lung function tests (peak flow, spirometry) CXR ```
552
What can be seen on chest X ray of heart failure patients (ABCDE)?
``` A- Alveolar oedema (bat wings) B- kerley B lines C- Cardiomegaly D- Dilated prominent upper lobe vessels (tram lines) E- pleural Effusion ```
553
What is the conservative management for heart failure?
- weight control - reduce salt intake - restrict alcohol - restrict fluid intake - aerobic exercise - smoking cessation - sexual activity - flu vaccine - heart failure nurses
554
What is the pharmacological treatment for heart failure?
1) DIURETIC 2) ACEi 3) BETA BLOCKER 4) ALDOSTERONE ANTAGONIST 5) IVABRADINE 6) DIGOXIN 7) AMIODARONE 8) AMLODIPINE 9) WARFARIN 10) ASPIRIN
555
What should be considered when prescribing diuretic in HF?
- LOOP diuretics are preferred - FUROSEMIDE 40mg - BUMETANIDE 1mg Monitor renal function and serum electrolytes before starting treatment and 1-2 weeks after starting treatment
556
What are the interactions with diuresis in HF Management?
- Lithium - digoxin - phenytoin - theophylline
557
What are the adverse effects associated with HF?
- orthostatic hypotension - dehydration - renal dysfunction - electrolyte imbalances - hyperuricaemia - precipitate/ aggravate gout
558
What should be considered when starting ACEi for HF?
It is the FIRST line therapy - RAMIPRIL 2.5mg OD - ENALAPRIL, LISINOPRIL, TRANDOLAPRIL START LOW AND TITRATE UP Monitor renal function and serum electrolytes before starting treatment and 1-2 weeks after starting treatment monitor 1-2 weeks after increased dose monitor every 6 months when stable
559
What are the adverse effects associated with ACEi in HF?
- orthostatic hypotension | - dry cough
560
What should be offered as an alternative in a chronic cough?
ARB - candesartan - losartan - valsartan hydralazine if ARB not tolerated
561
What should be considered when prescribing a beta blocker in HF?
FIRST line in combination with ACEi BISOPROLOL 1.25mg-10mg, (carvedilol, nebivolol) start on low dose and aim to increase Monitor clinical status for symptoms and signs of HF
562
What are the associated adverse effects of beta blockers in HF?
- Deteriorating symptoms of heart failure - hypotension - bradycardia - sexual dysfunction - cold extremeties - paraesthesia - asthenia - sleep disturbance - depression
563
When should aldosterone antagonist be added?
If diuretic+ ACEi + BB is not effective
564
What aldosterone antagonist should be used?
SPIRONOLACTONE 25mg-50mg OD or EPLERENONE
565
What are the adverse effects associated with aldosterone antagonist?
- HYPERKALAEMIA - GYNACOMASTIA - fatigue - GI disturbances - menstrual disruption - skin symptoms - blood disorders
566
What is Ivabradine?
- heart rate lowering drug | - to be considered when beta-blockers are contraindicated
567
What are the doses used for digoxin?
125 micrograms to 250 micrograms
568
What are the non pharmacological treatments for HF?
- revascularisation (CABG or PCI) - surgical repair of valves - cardiac resynchronization therapy - LVADs - heart transplant - ICDs
569
What should be covered in the annual review for heart failure?
- Assess functional capacity (NYHA) - Assess fluid status - Assess cardiac rhythm - Assess mood for signs of depression/anxiety - FBC, U+Es, LFTs, clotting, TFTs - ADLs and level of social support - Review management plan - Discuss palliation and end of life if appropriate
570
When should an urgent referral be made in LUNG cancer?
- haemoptysis - >3wk history of significant resp. signs - persistent hemoptysis in smokers/ex-smokers >40 - CXR suggestive of lung cancer
571
When should an urgent referral be made in BREAST cancer?
- lump: discrete, hard with fixation, with/without skin tethering - >30 with discrete lump - <30 with lump that enlarges
572
When should an urgent referral be made in PROSTATE cancer?
- Hard, irregular prostate felt on DRE | - LUTS symptoms and high PSA
573
When should an urgent referral be made in TESTICULAR cancer?
- any patient with a swelling or mass in the body of the testis
574
When should an urgent referral be made in COLORECTAL cancer?
- >40, rectal bleeding, change in bowel habit, increased frequency >6weeks - >60, rectal bleeding for >6 weeks OR change in bowel habit without anal symptoms - palpable rectal mass - any man with unexplained iron deficiency anaemia and <11g/100ml - non-menstruating woman with unexplained iron deficiency anaemia and Hb <10
575
What is the pathophysiology of MS?
- DEMYELINATION of neurones causes scar tissue to form, allowing or blocking signals to and from the brain and spinal cord affecting movement and sensation
576
What are the patterns of MS?
- RELAPSING/REMITTING - Secondary progressive MS - Primary progressive MS - Acute attacks are followed by periods of remission when there is remyelination but this process fails
577
What is the clinical presentation of MS?
- MONOSYMPTOMATIC - disturbances in vision, hearing, balance, sensation - deteriorating mental health - numbness - weakness - bladder (incontinence/ urinary retention)
578
How is the diagnosis of MS made?
- clinical - MRI can exclude other causes and show plaques - CSF: oligoclonal IgG can indicate CNS inflammation - MOG/MBP antibodies
579
What is the management of MS?
- INTERFERON BETA (reduces relapses and reduces lesion accumulation) - MONOCLONAL ANTIBODIES (Natalizab - METHYLPREDNISOLONE 1g OD IV/PO
580
What is the pathophysiology for MND?
Degenerative condition affecting the ANTERIOR HORN CELLS of the SPINAL CORD and MOTOR CRANIAL NUCLEO Affects both upper and lower motor neurones
581
What is the clinical presentation of MND?
- weakness, stiffness, cramping - often focal onset, limb, bulbar or respiratory - LMN signs tend to be predominant with a mixed picture
582
What is the management of MND?
RILUZOLE may prolong life by 2-4 months - muscle cramps can be treated with diazepam/beclofen survival usually 3-5 years
583
What is the pathophysiology of Parkinson's disease?
- Movement disorder due to degeneration of the DOPAMINERGIC NEURONES in the SUBSTANTIA NIGRA which causes decrease in striata dopamine levels
584
What are the risk factors of Parkinson's disease?
- Increasing prevalence with age - Slightly more common in males - Smoking - Pesticide exposure
585
What are the clinical features associated with Parkinson's disease?
- insidious onset - reduced dexterity - fixed facial expression - quiet voice - tremor - rigidity - bradykinesia
586
What is the classic triad of signs:
1) TREMOR: worse at rest, pin-rolling action of thumb over fingers 2) RIGIDITY: increased tone 'cogwheel rigidity' 3) BRADYKINESIA/HYPOKINESIA: slowness of movement initiation- reduced arm swing and shuffling steps in gait
587
What are the non-motor features associated with Parkinson's disease?
- Anosmia - Depression - Dementia - Visual hallucinations - Dribbling saliva - Postural instability - REM behavioural sleep disorder - mild urinary frequency and urgency
588
What investigations should be done in Parkinson's disease?
Diagnosis based on clinical history and examination | - investigations can be used to exclude alternative diagnosis: CT or MRI
589
What is the management for Parkinson's disease?
- LEVODOPA (sine met, madopar) - DOPAMINE AGONISTS (pramipexole, bromocrpitine, cabergoline) - MAOBIs (selegiline, rasagiline)
590
What is the progression for Parkinison's disease?
- Festinating gait, worsening of earlier symptoms - Parkinson's related dementia now more common - mean duration: 15 years
591
What is the pathophysiology of osteoarthritis?
- joint pain associated by varying degrees of physical limitation - peripheral joints are more affected - occurs in synovial joints and is characterized by LOSS OF CARTILAGE with accompanying PERIARTICULAR BONE response - inflammation to the articular and periarticular bones
592
What are the risk factors of OA?
- GENETIC FACTORS - Ageing - female sex - obesity - bone density - joint injury - occupation/recreational stresses
593
What are the clinical symptoms associated with OA?
JOINT PAIN - exacerbated by exercise - relieved by rest - pain worse at the end of the day - rest and night pain can occur in advance OA - knee pain due to OA is usually bilateral - hip pain felt in groin and anterior/lateral thigh JOINT STIFFNESS in the morning or after rest - reduced joint function
594
What are the clinical signs associated with OA?
- reduced range of movement - joint swelling/synovitis - periarticular tenderness - crepitus - joint instability - muscle weakness/ wasting around the affected joint - Bony swelling and deformities due to osteophytes: - HEBERDEN'S NODES: DIP swelling - BOUCHARD'S NODES: PIP swelling
595
What are the investigations associated with OA?
- Clinical examination - Plain x-rays LOSS (Loss of joint space, Osteophytes, Subarticular sclerosis, Subchondral cysts) - Blood tests: CRP slightly raised - MRI - Arthroscopy - Aspiration of synovial fluid
596
What is the conservative management of OA?
- weight loss - exercises to improve muscle strength and joint stability - keep active - physiotherapy, hydrotherapy
597
What is the pharmacological management of OA?
- paracetamol - topical NSAIDs - Opioid analgesics (codeine) - Oral NSAIDs (co-prescribe PPI) - intraairticular steroid injections - surgical: joint replacement
598
What is the pathophysiology of RA?
- RA is a common chronic inflammatory autoimmune disease characterized by an inflammation of the synovial joints leading to joint and periarticular tissue destruction - Causes chronic symmetrical polyarthritis with systemic involvement due to synovial inflammation - Rheumatoid factor self aggregate and form immune complex and result in synovitis
599
What are the causes of rheumatoid arthritis?
- HLA DR4 AND DR1 have a strong association
600
What are the risk factors associated with rheumatoid arthritis?
- women before menopause - smoking - possible infective aetiology - onset is more common in winter
601
What are the clinical symptoms associated with rheumatoid arthritis?
- symmetrical swollen, painful, stiff small joints of the hands and feet - worse in the MORNING - NORMOCYTIC NORMOCHROMIC ANAEMIA - Joint inflammation: heat, redness, pain, swelling, stiffness
602
What are the early clinical signs of rheumatoid arthritis?
- inflammation, no joint damage - swollen MCP, PIP, wrist, MTP joints - look for tenosynovitis or bursitis
603
What are the late clinical signs of rheumatoid arthritis?
- joint damage and deformity - Ulnar deviation of the fingers and dorsal wrist sublaxation - Boutonniere's deformities of the fingers: flexed PIP, extended DIP - Swan neck deformities of the fingers: hyperextended PIP, flexed DIP - Z- deformities of thumbs - Hard extensor tendons - foot changes - muscle wasting and tendon rupture
604
What are the extra-articular signs of rheumatoid arthritis?
- Rheumatoid nodules - lymphadenopathy - vasculitis - fibrosis alveolitis - pleural and pericardial effusion - Raynaud's disease - carpel tunnel syndrome - peripheral neuropathy - splenomegaly - scleritis, episcleritis - osteoporosis - amyloidosis
605
What are the blood test investigations associated with rheumatoid arthritis?
- Rheumatoid factor is positive in >70% - NORMOCYTIC NORMOCHROMIC ANAEMIA in chronic disease - Raised ESR, CRP, platelets and plasma viscosity - Anti-cyclic citrulinated peptide antibodies (anti-CCP)
606
What can be seen on Xray in rheumatoid arthritis?
- soft tissue swelling - juxta-articular osteopenia - reduced joint space - erosions, sublaxation or complete carpal destruction
607
How is rheumatoid arthritis diagnosed?
4 OUT OF 7 1) Morning stiffness (>1hr lasting >6wks) 2) Arthritis of >3 joints 3) Arthritis of hand joints 4) Symmetrical arthritis 5) Rheumatoid nodules 6) Positive RhF 7) Radiographic changes
608
When should a 2 week referral be made for rheumatoid arthritis?
- small joints of the hands or feet are affected - more than one joint is affected - there was a delay of >3months between onset of symptoms and medical advice
609
What is the management for rheumatoid factor?
INITIAL: pain relief with paracetamol (+/- codeine) - if pain is not controlled, add an NSAIDs (plus PPI) - DMARDS (methotrexate, sulfasalazine) - TNF-ALPHA INHIBITORS (infliximab, entanercept, adalimumab) - CORTICOSTEROIDS: rapidly reduce symptoms and inflammation - regular exercise, physiotherapy, OT - surgery: joint prosthesis, may relieve pain and improve function.
610
What are the red flags associated with chronic back pain?
- recent violent trauma/minor trauma in people with osteoporosis - age at onset <20 or >50 years - history of cancer, drug abuse, HIV immunocompromised - constitutional symptoms - recent bacterial infection e.g. UTI - Pain that is worse when supine, severe at nighttime, thoracic - non-mechanical without relief from bed rest or postural modification - unchanged despite treatment for 2-4 weeks, accompanied by severe morning stiffness - accompanied by saddle anaesthesia, urinary retention, incontinence
611
What is bronchiectasis?
A permanent dilatation and thickening of the airways characterized by: - chronic cough - excessive sputum production - bacterial colonisation - recurrent acute infection It can be diffuse (widespread) or focal (more localized)
612
What are the morphological classifications of bronchiectasis?
1) CYLINDRICAL: bronchi are enlarged and cylindrical 2) VARICOSE: bronchi are irregular with areas of dilatation and constriction 3) SACCULAR/CYSTIC: dilated bronchi form clusters of cysts
613
What is the pathophysiology of bronchiectasis?
- The affected airways are inflamed and easily collapse - There is an impairment of airflow and drainage of secretions, leading to accumulation of a large amount of mucus in the lungs - The mucus collects bacteria, predisposing to frequent and often severe LRTIs
614
What is the cause of bronchiectasis?
- CHRONIC INFLAMMATION of the airways - associated with: lung infections, immunodeficiency, cystic fibrosis, connective tissue disease, asthma, allergic bronchopulmonary aspergillosis, gastric aspiration, congenital defects
615
What are the clinical features of bronchiectasis?
- chronic cough - excessive sputum production - bacterial colonisation - recurrent acute infections - dyspnoea - chest pain - haemoptysis
616
What are the clinical signs of bronchiectasis?
- coarse crackles (heard in early inspiration and often in the lower zones) - large airway rhonchi (low-pitched snore-like sounds) - wheeze - clubbing (infrequent)
617
What investigations are done in suspected bronchiectasis?
- CHEST X RAY | - High Resolution Computed Tomography (HRCT)
618
What is the management of bronchiectasis?
CANNOT BE CURED - therefore treatment is to manage symptoms and slow down further deterioration - treatment of underlying causes - LIFESTYLE: dietary, smoking cessation, immunisations - PHYSIOTHERAPY: airway clearance techniques and exercise - ANTIBIOTICS: AMOXICILLIN 500mg TDS, CLARITHROMYCIN 500mg BD 14days
619
What pulmonary fibrosis?
A group of diseases which produce interstitial lung damage and ultimately fibrosis and loss of elasticity in the lungs
620
What are the three types of lung fibrosis?
1) REPLACEMENT FIBROSIS :secondary to lung damage e.g. infarction/TB/pneumonia 2) FOCAL FIBROSIS: in response to irritants e.g. coal dust and silica 3) DIFFUSE PARENCHYMAL LUNG DISEASE: occurs in fibrosis alveoli's and extrinsic alveoplitis
621
What are the risk factors associated with lung fibrosis?
- Occupational causes - Smoking - GORD - infectious agents - genetic factors
622
What are the clinical features associated with pulmonary fibrosis?
- gradual onset dyspnoea - chronic cough (non productive) - wheezing - haemoptysis - chest pain
623
What are the clinical signs associated with pulmonary fibrosis?
- central cyanosis - fine and expiratory pulmonary crackles - low-grade fever and myalgia - finger clubbing - late signs: pulmonary hypertension, RHF
624
What investigations should be done in suspected pulmonary fibrosis?
- Detailed history: OCCUPATIONAL (asbestos?) - Bloods: FBC, ESR/CRP (raised), LFTs, autoantibodies - ABG (O2 desats) - lung function tests - CXR: honeycombing - CT scan - bronchoalveolar lavage
625
What is the definitive investigation for pulmonary fibrosis?
OPEN/ THORACOSCOPIC LUNG BIOPSY
626
What is the management for pulmonary fibrosis?
- treatment of underlying cause - smoking cessation - O2 therapy - pulmonary rehabilitation - corticosteroids, cytotoxic drugs (AZATHIOPRINE) - lung transplantation
627
What is Crohn's disease?
A chronic inflammatory GI disease characterized by: - TRANSMURAL GRANULOMATOUS INFLAMMATION - autoimmune disease of unknown aetiology - Can affect any part of the gut but favors terminal ileum and proximal colon - There is UNAFFECTED BOWEL (skip lesions) between areas of active disease
628
What are the risk factors associated with Crohn's disease?
- Genetic susceptibility: mutations of NOD2/CARD15 gene - Environmental - Smoking - Oral contraception - Appendectomy
629
What are the clinical features associated with Crohn's disease?
- diarrhoea (may be bloody) - abdominal pain (colicky) - weight loss/ failure to thrive in children - fever/ malaise and anorexia in active disease
630
What are the clinical GI signs associated with Crohn's disease?
- right iliac fossa mass - abdominal tenderness - apthous ulcerations - perianal abscesses/ fistulas, skin tags - anal/ rectal strictures
631
What are the extra intestinal signs associated with Crohn's disease?
- Clubbing - Erythema nodosum - Pyoderma gangrenosum - Conjunctivitis - episcleritis - iritis - large joint arthritis - fatty liver/ liver granulomas - cholangiocarcinoma - renal stones - osteomalacia - malnutrition - amyloidosis - anaemia/leukocytosis/thrombocytosis
632
What are the bio investigations for Crohn's disease?
- FBC (low Hb, high WCC) - ESR (high) - CRP (high) - U+E - LFT - Blood culture - stool MC+S
633
What are the imaging investigations for Crohn's disease?
- sigmoidoscopy - rectal biopsy - small bowel enema - barium enema (cobble stoning) - colonoscopy - MRI
634
What are the complications associated with Crohn's disease?
- Small bowel obstruction - Toxic dilatation - abscess formation - fistulae - perforation - rectal haemorrhage - colonic carcinoma - toxic megacolon - stricture - small bowel syndrome
635
What is the conservative management for Crohn's disease?
- smoking cessation | - enteric nutrition (low fat ad low linoleic content for 28 days)
636
What is the pharmacological management for mild attacks in Crohn's disease?
- LOPERAMIDE - CODEINE PHOSPHATE - PREDNISOLONE
637
What is the pharmacological management for severe attacks in Crohn's disease?
- HYDROCORTISONE 100mg/6h IV | - METRONIDAZOLE 400-500mg/8h PO or IV
638
What are additional pharmacological managements for Crohn's disease?
``` - INFLIXIMAB (to maintain remission) - AZATHIOPRINE - 6-MERCAPTOPURINE - MYCOPHENOLATE - MOFETIL ```
639
What are the surgical options for the management of Crohn's disease?
- Panproctocolectomy and end-ileostomy - Stricturoplasty - Resection of the worst areas
640
What is ulcerative colitis (UC)?
- inflammatory disorder of the colonic mucosa
641
Where does UC spread?
- RECTUM (proctitis 50%) - LEFT SIDED COLITIS (30%) - ENTIRE COLON (pancolitis 20%) -UC "never" spreads proximal to the ileocaecal valve
642
What is the common histological feature of UC?
- hyperaemic/haemorrhagic granular colonic mucosa +/- pseudo polyps formed by inflammation - punctuate ulcers may extend into the lamina propriety, but inflammation is not typically transmural
643
What are the risk factors associated with UC?
- non-smokers - stress and depression - oral contraceptives - APPENDECTOMY IS PROTECTIVE
644
What are the clinical features associated with ulcerative colitis?
- gradual onset of diarrhoea - cramps abdominal discomfort - bowel frequency is related to severity of disease - systemic symptoms during attacks (fever, malaise, anorexia, weight loss) - urgency and tenesmus - constipation - rectal bleeding - anaemia
645
What are the clinical signs associated with ulcerative colitis?
- fever - tachycardia - tender, distended abdomen
646
What are the extra-intestinal signs associated with ulcerative colitis?
- Clubbing - apthous ulcers - Erythema nodosum - Pyoderma gangrenosum - Conjunctivitis - episcleritis - iritis - large joint arthritis, sacroilitis, ankylosing spondylitis - fatty liver - cholangiocarcinoma - malnutrition - amyloidosis - nutritional deficits
647
What are the complications associated with ulcerative colitis?
- colorectal cancer - perforation - haemorrhage - toxic dilatation of the colon - venous thrombosis - colonic cancer - stricture
648
What are the bio investigations associated with ulcerative colitis?
- FBC - ESR - CRP - U+E - LFTs - blood cultures - stool MC+S
649
What imaging investigations are associated with ulcerative colitis?
- ABDOMINAL X-RAY: no faecal shadows, mucosal thickening, colonic dilation - ERECT CHEST XRAY - SIGMOIDOSCOPY: inflamed friable mucosa - RECTAL BIOPSY: inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers, crypt abscesses - COLONOSCOPY
650
What is the management for mild UC?
- if <4 motions per day and systemically well: PREDNISOLONE, MESALAZINE - mild distal disease: PR STEROID FOAMS (predsol, colifoam)
651
What is the management for moderate UC?
- 4-6 motions per day but systemically well: - PREDNISOLONE - 5-AMINOSALYCILIC ACID
652
What is the management for severe UC?
Systemically unwell and passing >6 motions a day - admit for NBM and maintenance hydration - HYDROCORTISONE 100mg/6h IV - RECTAL STEROIDS e.g. HYDROCORTISONE 100mg in 100ml saline PR - daily bloods
653
What is the surgical management for UC?
- PROCTOCOLECTOMY - TERMINAL ILEOSTOMY - COLECTOMY WITH LATER ILEO-ANAL POUCH
654
What is coeliacs disease?
Disorder of the small intestine causing malabsorption | - T CELL MEDIATED immune disease in which prolamin intolerance causes villous atrophy and malabsorption.
655
What are the risk factors for coeliacs disease?
- HLA DQ2 - HLA DQ8 - Rotavirus infection in infancy
656
What are the clinical features of Coeliacs disease?
- Steatorrhoea - Diarrhoea - Abdominal pain - Bloating - Nausea and vomiting - Apthous ulcers - angular stomatitis - weight loss - fatigue - weakness - iron deficiency anaemia - osteomalacia - failure to thrive - dermatitis herpetiformis
657
When should coeliac disease be suspected?
ALL THOSE WITH DIARRHOEA AND WEIGHT LOSS
658
What investigations should be done in coeliac disease?
- ANTIBODIES: alpha gliadin, transglutaminase and anti-endomysial - DUODENAL BIOPSY: done at endoscopy - HISTOLOGY: subtotal villous atrophy, increased intra-epithelial WBCs and crypt hyperplasia, reversing on gluten free diet - HLA TYPING
659
What is the management for Coeliacs disease?
- GLUTEN FREE DIET - Verify diet by endomysial antibody testing - Replacement minerals and vitamins
660
What are the complications associated with coeliacs disease?
- Anaemia - secondary lactose intolerance - GI T-cell lymphoma - increased risk of malignancy - myopathies - neuropathies - hyposplenism - osteoporosis
661
What is chronic liver disease?
- liver loses the ability to regenerate or repair so that decompensation occurs.
662
What is chronic liver disease marked by?
- HEPATIC ENCEPHALOPATHY - ABNORMAL BLEEDING - ASCITES - JAUNDICE
663
What are the toxic causes of chronic liver disease?
- chronic alcohol abuse - paracetamol poisioning - drug toxicity - illicit drugs including ecstasy and cocaine - Reyes syndrome
664
What are the infectious causes of chronic liver disease?
- viral hepatitis - adenovirus - EBV - CMV - viral haemorhagic fevers
665
What are the neoplastic causes of chronic liver disease?
- Hepatocellular carcinoma | - metastatic carcinoma
666
What are the metabolic causes of chronic liver disease?
- Wilson's disease - Alpha 1 anti-trypsin deficiency - galactosaemia - tyrosinaemia
667
What are the pregnancy related causes of chronic liver disease?
- acute fatty liver of pregnancy
668
What are the vascular causes of chronic liver disease?
- ischemia - veno-occlusive disease - Budd-Chiari syndrome
669
What are other causes of chronic liver diseases?
- Autoimmune liver disease | - Unknown 15%
670
What should be assessed in chronic liver disease history?
- haematemesis or melaena - date/onset of jaundice - alcohol use - full drug history - family history of liver disease - exposure risk factors (needles, sexual contact, occupation) - toxic ingestion (mushrooms, organic solvents) - past medical history
671
What should be assessed on examination in chronic liver disease?
- MSE may show drowsiness and possibly confusion - jaundice - abdominal distension - abdominal masses - hepatomegaly - splenomegaly - cerebral oedema with increased ICP - papilloedema, HTN, bradycardia - palmar erythema and hepatic flap - hepatic encephalopathy
672
What bloods should be done on investigation of chronic liver disease?
- FBC (thrombocytopenia) - raised INR - transaminases are very markedly raised - bilirubin raised - ammonia levels high - elevated lactate, hypoxia and raised creatinine - blood cultures - free copper for Wilson's disease - paracetamol levels in case of posioning
673
What is the imaging used in investigation for chronic liver disease?
- DOPPLER ULTRASOUND: could detect patent hepatic vein, ascites, tumour - CT/MRI
674
What is the management for chronic liver disease?
- liver transplantation - monitor glucose - lactulose and neomycin to reduce ammonia production - fresh frozen plasma - platelet concentrates - antifibrinolytic drugs - prothrombin complex - recombinant activated factor VII
675
What are the complications associated with chronic liver disease?
- Spontaneous peritonitis - infection of access line - opportunistic infection - cerebral oedema - haemorrhage - AKI
676
What is a diverticulum?
- herniation of mucosa though the thickened colonic muscle. | common in the SIGMOID and DESCENDING COLON
677
What is diverticulosis?
Presence of diverticula which are asymptomatic
678
What is diverticular disease?
Diverticula associated with symptoms
679
What is diverticulitis?
Evidence of diverticular inflammation with or without localized symptoms and signs
680
What are the risk factors for diverticular diseases?
- Age >50 - Low dietary fibre - Obesity - smoking - NSAID - paracetamol use
681
What is the presentation of uncomplicated diverticular disease?
- Frequently an incidental finding - lower abdominal pain - pain exacerbated by eating and diminished with defecation/ flatus - bloating, constipation - rectal bleeding
682
What is the presentation of diverticulitis?
- generally present with left lower quadrant pain - pain may be intermittent or constant and associated with change in bowel habit - fever - tachycardia - anorexia - nausea - localized tenderness - palpable mass - reduced bowl sounds
683
What investigations are done in diverticular disease?
- colonoscopy | - Bloods: (WCC raised)
684
What are the investigations specific to uncomplicated diverticular disease?
- Barium enema
685
What are the investigations specific to diverticulitis?
- CHEST X-RAY: detection of pneumoperitoneum - ABDOMINAL X-RAYS: small/large bowl ileus, bowel obstruction on soft tissue densities - contrast enemas - CT scanning with contrast
686
What is the management for diverticular disease?
- No treatment for asymptomatic patients - prophylactic benefit of high fibre diet - adequate fluid intake - bulk forming laxatives
687
What is eczema?
Characterized by papule and vesicles on erythematous base
688
What are the risk/exacerbating factors of eczema?
- family history of atopy - genetic defects in skin barrier function exacerbated by: - infections - allergens - sweating - heat - severe stress
689
Way are the clinical features of eczema?
- Commonly present as itchy erythematous dry scaly patches - more common on face and extensor limbs of infants - common on flexural spaces of children and adults - acute lesions: erythematous, vesicular and weepy - chronic scratching/rubbing can lead to excoriations and lichenification
690
How is a diagnosis of eczema made?
A history of an itching condition and 3 of the following: - history of rash in skin folds - history of generally dry skin in the past year - onset under the age of 2 years - visible flexural dermatitis - personal history of asthma or hayfever
691
What is the management for eczema?
- avoid known exacerbating agents - frequent emollients - bandages - bath oil/ soap substitutes - topical steroid - topical immunomodulators (TACROLIMUS) - Antihistamines for symptomatic relief - Antibiotics for bacterial infections - Antivirals for herpes infections - Phototherapy and immunosuppresion
692
What are the varying strengths of topic steroid for eczema?
MILD: HYDROCORTISONE 0.5%/1%/2.5% MODERATE: BETNOVATE RD POTENT: BETNOVATE N/C VERY POTENT: DERMOVATE
693
What is psoriasis?
- Chronic inflammatory skin disease due to HYPERPROLIFERATION of KERATINOCYTES and inflammatory cell infiltration - T-ce;; mediated autoimmune disorder
694
What are the different types of psoriasis?
- Chronic plaque psoriasis - Guttate - Seborrhoeic - Flexural - Pustular - Erythrodermic
695
What are the precipitating factors for psoriasis?
- trauma (may induce Köebner's phenomenon) - infection - drugs - stress - alcohol - smoking - postpartum hormonal changes
696
What are the clinical features of psoriasis?
- well demarcated erythematous scaly plaques - distribution is symmetrical and common on extensor surfaces of the body and scalp - itchy, burning/ painful lesions - Auspitz sign (bleeding under scales) - Nail changes (pitting, onycholysis) - psoriatic arthropathy
697
How is diagnosis of psoriasis made?
- clinical findings | - PASI score
698
What is the management for psoriasis?
- Avoid known precipitating factors - emollients to reduce scales - vitamin D analogues - topical corticosteroids - coal tar preparations - phototherapy - UVB and photochemotherapy - methotrexate - retinoids - ciclosporin - biologics (infliximab, etanercept)
699
How does haemorrhage appear on CT?
- white blob
700
How does an infarct appear on CT?
- darkened area (hypodense)
701
What is malignant MCA syndrome?
- Large MCA infarct leading to extracellular oedema and rise in ICP - Mass effect - Decompressive craniotomy is needed to relieve pressure
702
What is agnosia?
Inability to process sensory information in the absence of sensory or memory impairment
703
What is anosognosia?
lack of isight in to recognition of impairment
704
What is apraxia?
disorder of motor planning; unable to perform tasks or movements when asked, despite understanding
705
What is ideomotor apraxia?
Can explain and do action but can not mime it
706
What is conceptual apraxia?
Inability to conceptualise a task, unable to complete multistep actions
707
What is constructional apraxia?
Inability to draw figures
708
What is hemineglect?
The inability to process and perceive a stimulus on one side, when that inability is not due to lack of sensation typically due to RIGHT PARIETAL LOBE INJURY
709
What are the various types of gait?
- parkinsonian - frontal gait disorder - hemiparetic - cautious - paraparetic - scissor - Trendelenburg - Waddling - Dementia - Choreic
710
What are the features of expressive aphasia?
- BROCA'S AREA - stilted, difficult flow of speech - Difficulty finding words - reading, writing and comprehension relatively intact - e.g. MCA stroke
711
What are the features of receptive aphasia?
WERNICKE'S AREA - neologisms - mistake closely related words - comprehension, reading, writing impaired - e.g. MCA stroke
712
What is dysarthria?
MOTOR SPEECH PROBLEM - neuromuscular barin stem, cerebellum, cranial nerve nuclei - normal comprehension and content of speech - changes in voice quality: speech slurred - facial drooping or impaired movement of mouth - chewing or swallowing difficulty

YEAR 4 (5 decks)

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