CCC revision Flashcards
(231 cards)
1
Q
risk factors for breast cancer
A
- uninterrupted oestrogen exposure e.g. nulliparity, not breastfeeding, early menarche, late menopause, HRT, prolonged use OCP, obesity (after menopause)
- alcohol and smoking
- chest and mediastinal radiotherapy
2
Q
characteristics of inherited breast cancers (BRCA 1 and 2)
A
- often younger presentation
- cluster in family of young members, male and ovarian cancers
- bilateral BC
3
Q
between what ages are women screened for breast cancer
A
50-70 years - mammogram every 3 years
4
Q
what are interval cancers
A
cancers occurring between each episode of screening
5
Q
why is peau d’orange / breast inflammation an important sign to pick up on
A
can indicate inflammatory breast cancer - rapid onset, metastases quickly and has poorer cure rates and responses to treatment
6
Q
breast cancer triple assessment
A
- imaging: mammogram/USS/MRI, CT or bone scan for mets
- clinical examination of breast and axilla
- biopsy - core needle or FNA
= confident diagnosis in 95% cases
7
Q
questions to ask in breast cancer history
A
- how long
- any skin/nipple changes
- pain/discharge
- related to menstrual cycle?
- lumps under arm?
8
Q
tumour markers for breast cancer
A
Ca15.3, CEA
9
Q
what is a triple negative breast cancer
A
negative for oestrogen receptor (ER), progesterone receptor and HER2 receptor
difficult to treat with conventional therapy - most common subtype in BRCA1 carriers
10
Q
poor prognostic factors for breast cancer
A
- > 5cm
- higher grade
- ER negative
- HER2 positive
- LN involvement
- triple negative
11
Q
types of curative surgery for breast cancer
A
breast: wide local excision, mastectomy
axilla: sentinel node biopsy - axillary clearance if evidence of spread to LNs
12
Q
3 main areas of metastatic spread in breast cancer
A
lung bones liver
13
Q
which type of breast cancer responds best to chemo
A
ER negative/HER2 positive
50% of breast cancers are ER positive (oestrogen receptor positive)
14
Q
during the menopause where is oestrogen produced
A
adipose tissue skin liver muscle breast tissue
15
Q
3 main types of hormonal treatments for breast cancer
A
- oestrogen antagonists (tamoxifen)
- oophorectomy (younger women)
- aromatase inhibitors
16
Q
what type of breast cancer does tamoxifen work on
A
ER positive - because blocks oestrogen receptors = reduced tumour growth
17
Q
how do aromatase inhibitors (anastrozole, letrozole) work
A
aromatase = rate limiting enzyme in oestrogen synthesis = reduces oestrogen levels in body
used in post-menopausal women or in combination with something else in pre-menopausal
18
Q
what are tamoxifen side effects similar to
A
menopause symptoms - because due to reduced oestrogen
NB: increases risk of VTE and PE
19
Q
how effective is adjuvant radiotherapy for breast cancer
A
reduces risk of local relapse by 50-66%
20
Q
how often are the chemotherapy cycles for breast cancers and how many cycles are given
A
cycle every 3 weeks
6-8 cycles
21
Q
how does HER-2 receptor breast cancer function
A
- HER2 receptors send signals to the cells to grow and divide
- too many HER2 receptors can send too many growth signals = cells grow too quickly
22
Q
what is used for the treatment of HER2 positive breast cancer
A
HERCEPTIN - trastuzumab
23
Q
how does Herceptin work
A
monoclonal Ab - specific for HER2 - binds to HER2 = slows tumour growth
NOT chemotherapy
three weekly regimen
risk of allergic reaction
24
Q
major side effect of herceptin
A
cardio toxicity - so must have good cardiac function and needs cardiac monitoring during treatment
25
most common type of lung cancer
NSCLC 85%
adenocarcinoma (35%)
SCC (30%)
large cell (10%)
26
types of pain common in lung cancer (especially late disease)
chest pain
bone pain (mets)
RUQ pain (liver pain)
headaches (brain mets)
27
when might haemoptysis be an early sign of lung cancer
very central cancer - T3/4
28
what syndrome might be associated with an apical tumour (Pancoast tumour)
Horner's syndrome - ptosis, miosis, anhidrosis
29
main treatment of SCLC
chemotherapy - responsive but high relapse rate
30
why to give prophylactic brain radiotherapy in SCLC
often metastasise to brain
31
2 main mutations driving adenocarcinomas lung cancer
ALK
| EGFR
32
which receptors are implicated in immunotherapy for lung cancer
PD-1
| PDL
33
side effects of cancer immunotherapy
not as many as chemo
but can lead to autoimmune side effects e.g. lung fibrosis and destruction of thyroid gland
34
T1-T4 staging for colorectal cancer
- T1 = tumour invades submucosa only
- T2 = tumour also invades muscularis propria (muscle)
- T3 = tumour invades peri-colonic tissues
- T4a = tumour invades local peritoneum
- T4b = tumour invades local organs
35
M1a-M1c staging for colorectal cancer
```
M1a = 1 organ
M1b = >1 organ
M1c = peritoneal surface
```
36
5 year survival of stage 1-4 CRC
```
1 = 95%
2 = 80-90%
3 = 65%
4 = 5-10%
```
37
red flag bowel cancer symptoms
```
PR bleeding
weight loss
change in bowel habits
PR mucous
anorexia
```
38
2 main referral options for urgent suspected CRC
- straight to test if are fit - colonoscopy or flexible sigmoidoscopy
OR
- colorectal surgeon/gastro review within 14 days if significant comorbidities or frail
39
another method of bowel cancer screening (apart from the FIT test age 60-74)
bowel screening scope (sigmoidoscopy) at 55 - one off test to detect left sided polyps) - if normal then go to normal bowel screening at 60 years
40
how is CRC treated
neoadjuvant chemo (usually)
before surgery
might have radiotherapy alone for rectal cancer
41
why is rectal cancer treated more aggressively (neoadjuvant therapy) than colon cancer
more local recurrence
42
what are patients tested for before receiving 5FU/capecitabine therapy
DPD enzyme deficiency - results in an inability to metabolise 5FU = toxicity and much more severe side effects to the chemo
43
follow up investigations for CRC
CEA 6-monthly
CT 18 months, 3 years and 5 yearly
colonoscopy within 12 months if not completed at diagnosis and 3 years post last colonoscopy
44
at what age can men request a PSA test from their GP
over 50
45
urinary symptoms which might merit a PSA test
reduced flow
increased frequency
nocturia
hesitancy
46
metastatic symptoms of prostate cancer
anaemia
bone pain
fatigue
47
what would be the pathway after an elevated PSA
1. urology clinic on 2-week wait (urinary symptoms, sexual and bowel functions, other comorbidities, DRE)
2. referral for pre-biopsy MRI scan
3. TRUS biopsy
48
histological grading system for prostate adenocarcinoma
Gleason grading (being replaced with ISUP score)
49
T1-T4 staging of prostate cancer
T1. No palpable/visible cancer
T2. Cancer WITHIN the prostate
T3. Cancer breaching prostate capsule
T4. T4 is cancer growing into rectum/bladder
50
what would constitute a low risk prostate cancer
T1c/T2a, GS<=6, PSA<=10
51
what would constitute an intermediate risk prostate cancer
T2b/c or GS 7 or PSA 10-20
52
what would constitute a high risk prostate cancer
GS>=8 or PSA>=20
53
main treatment options for prostate cancer
- surgery - in men <70 with no comorbidities (long term incontinence and impotence risks)
- radiotherapy including brachytherapy
- hormonal treatment
- active surveillance
54
when might radiotherapy be used for prostate cancer instead of surgery
older men or with comorbidities - long term bowel problems risk
55
when might brachytherapy be used for prostate cancer and who should it be avoided in
fit men with no comorbidities
avoid in men with larger prostates/significant urinary symptoms
56
options for advanced prostate cancer
chemo, palliative radio
androgen deprivation therapy (ADT) - side effects such as hot flushes, shrinkage of penis, loss of muscle, weight gain, higher risk DM, osteoporosis, hyperlipidaemia, mood changes
57
major risk of ADT
increase in CV mortality in those with pre-existing CVD
58
2 gene mutations increasing risk of prostate cancer
BRCA II
| pTEN
59
most common metastatic spread from prostate cancer
bones - especially lumbar spine (MSCC) and pelvis
60
where does BPH vs prostate cancer occur
BPH = centre of gland
adenocarcinomas = posterior/peripheral parts of gland
61
why is prostate cancer often asymptomatic
1st affected area is peripheral/posterior zone = far from urethra = no symptoms
62
investigations for prostate cancer apart from DRE
TRUS biopsy
MRI scan
isotope radio nucleotide bone scan - bone mets
63
TNM staging for prostate cancer
TX: Primary tumour cannot be assessed
T0: No evidence of primary tumour
T1: Clinically unapparent tumour not palpable nor visible by imaging
T2: Tumour confined within prostate
T3: Tumour extends through the prostate capsule
T3a: Extracapsular extension (unilateral or bilateral)
T3b: Tumour invades seminal vesicle(s)
T4: Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
N0 No regional lymph node involvement.
N1 Regional lymph node involvement
```
M0: No distant metastasis
M1: Distant metastasis
M1a: Non-regional lymph node(s)
M1b: Bone(s)
M1c: Other or multiple site(s) with or without bone disease
```
64
LFT which might suggest bone mets in prostate cancer
raised ALP
65
4 main types of hormonal treatment for prostate cancer (advanced disease or in conjunction with radiotherapy)
chemical castration
- LHRH agonists: leuprorelin, goserelin
- GNrH antagonist: degarelix
- oestrogen therapy
- anti-androgens: bicalutamide, enzalutamide
66
side effects of LHRH agonists
- loss of libido
- tumour flare on initiation of treatment
- long term = increased cardiac risk, osteoporosis
67
benefit of GNrH antagonists
no risk of tumour flare
given monthly via SC injection when tumour flare can lead to significant symptoms e.g. with MSCC
68
how might chemotherapy be used in prostate cancer
cytotoxic treatment with docetaxel and prednisolone + carbazitaxel with metastatic disease
69
prognosis of prostate cancer
- low risk = 99% at 10 years
- all patients = 84% at 10 years
- metastatic disease = median survival 3.5 years
70
what is raised in hepatocellular carcinoma
alpha fetoprotein
71
how is oxycodone metabolised and when should it be avoided
metabolised and excreted hepatically
so should be avoided in liver injury - use morphine instead
72
most common sites of metastases for lung cancer
BRAIN
liver
bones
adrenals
73
another name for herceptin
trastuzumab
74
what should be monitored during Herceptin treatment
left ventricular function due to risk of cardiomyopathy = frequent ECHOs
75
what can venlafaxine be used to treat in context of breast cancer
hot flushes due to medical/surgical menopause
76
what is the CHAD2DS2-VASc score
```
CHF/LVEF <40%
Hypertension
Age >75 years = 2
Diabetes
Stroke/TIA/Thromboembolism = 2
```
Vascular disease
Age 64-75 years
Sex category (female)
77
what is the HAS BLED score
Hypertension (>160mmHg)
Abnormal liver/renal function
Stroke
Bleeding Hx/predisposition
Labile INR
Elderly >65 years
Drug/alcohol use
78
normal HbA1c levels
20-42
79
main antibiotic used for prophylaxis of neutropenic sepsis
levofloxacin
80
what is extrinsic vs intrinsic asthma
- extrinsic - more commonly starts in childhood, common in atopic people
- intrinsic - tends to develop in adulthood = 'non-allergic' asthma
81
what is FeNO and when is it offered to diagnose asthma
fractional exhaled nitrous oxide
measures amount of fractional exhaled NO which is increased by eosinophil activity
should be offered to adults aged 17+ AND if there is diagnostic uncertainty in under 17s, OR normal/obstructive spirometry with negative BD reversibility
82
asthma spirometry
FEV1/FVC <70% - obstructive
83
how is the bronchodilator test carried out
1. Patients are asked to stop their SABA 6 hours beforehand, and LABA 12 hours beforehand
2. Carry out the initial spirometry if not already done so
3. Patient given 400 micrograms of Salbutamol and must wait for 15 minutes
4. Carry out spirometry:
84
what would indicate a positive bronchodilator reversibility result
increase in FEV1 of 12% or more and 200ml or more increase in volume
negative test result = COPD??? v mild increase could be COPD on a background of asthma???
85
when might PEFR be used for asthma
Should be carried out over 2-4 weeks weeks in adults if there is diagnostic uncertainty after initial assessment and FeNO test with normal spirometry OR obstructive with normal FeNO
VERY COMMONLY USED IN CHILDREN
86
when are asthma symptoms usually worst
evenings - lowest cortisol levels
87
normal PEFR of adults
80-100% of their normal means asthma is well controlled
400-700ml for an adult
88
absolute gold standard for diagnosing asthma
direct bronchial challenge test with histamine/metacholine
89
what allergens to avoid in asthma
high levels pollution
smoke
NSAIDs
beta blockers
90
how much can CO be reduced by in AF
20% - ventricles not fully filled by atria
91
characteristics of:
a. initial episode
b. paroxysmal AF
a) . Initial episode:
- AF > 30 seconds diagnosed on an ECG
b). Paroxysmal AF
- > 2 Self-terminating, recurrent episodes lasting 30 seconds to 7 days
OR
- <48 hours terminated with cardioversion
92
characteristics of
a. persistent AF
b. long-standing AF
a) . Persistent:
- Episodes lasting more than 7 days CONTINUOSLY
- OR AF >48 hours which needs cardioversion
After 48 hours, spontaneous termination unlikely after this length of time
b). Continuous AF >12 months
93
what is permanent AF
This is characterised by joint decision by patient and doctor to cease further attempts at sinus rhythm
1. AF that doesn't stop DESPITE cardioversion
2. AF that stops but then reoccurs within 24 hours OR
3. AF that lasts >1 years when cardioversion is not attempted
94
PIRATES mnemonic for causes of AF
```
PE, pneumonia
Infection
Rheumatic or valvular disease
Anaemia, alcohol and caffeine
Thyroid (hyperthyroidism)
Elevated BP
Sleep apnoea/obesity
```
95
4 big risk factors for AF
AGE - over 65
hypertension
COPD
hyperthyroidism
96
what causes dyspnoea in AF
pulmonary back pressure to the lungs and congestion
97
what is apical-pulse deficit
in AF - when apical pulse at the apex of the heart is > than radial pulse in the wrist
98
investigations into AF
1. 1st line: ECG
2. 24 hour ambulatory ECG if suspected paroxysmal AF
3. Exercise Tolerance test if exacerbated by exercise
4. Bloods: cardiac enzymes. eGFR, TFT's, FBC's, blood pressure
5. CXR: for heart failure
99
how can atrial flutter be cured
radio frequency catheter ablation
100
what should be done before cardioversion (in AF)
heparinisation
101
1st line treatment for AF
```
rate control:
most commonly a Beta-Blocker such as:
- Atenolol (cardioselective)
- Bisoprolol
- NOT sotalol
```
OR a CCB
- Verapamil
- Diltiazem
102
when might digoxin or amiodarone be used for rate control
1. Digoxin: only for elderly, sedentary people with NON-paroxysmal AF
2. Amiodarone: short term
103
then might rhythm control be considered for AF
1. Patients with REVERSIBLE cause of AF: chest infection
2. Chronic heart failure
3. new onset AF
4. Atrial flutter
OR when clinical judgment dictates rhythm control as 1st line in under 65's
104
main method of rhythm control for AF
electrical/DC cardio version if AF has been happening for LESS than 48 hours
105
what must be done if the AF has been happening for more than 48 hours and cardio version is still 1st line
period of therapeutic anticoagulation - minimum of 3 weeks prior and 4 weeks afterwards with INR>2 OR on a NOAC
106
1st line medical drug for paroxysmal AF
beta-blockers
107
drug used in AF if there is an underlying heart disease
amiodarone
108
why must stall be initiated by a specialist if used for AF
side effect of life-threatening arrhythmias and QTc interval
109
other rhythmic control drugs which can be used if there is no underlying heart disease
sotalol
flecainide
propafenone
110
when might flecainide only be used in reality for AF
life-threatening SVTs or when symptoms can't be managed with other antiarrhythmics
111
CHAD2DS2-VASc scores for men and women which would normally require anticoagulation
```
men = 1+
women = 2+
```
112
how much does AF increase the risk of stroke
5%
113
management of a patient with 2+ on chadvasc score
vit K antagonist - warfarin
DOAC
consider also if score of 1
114
what type of operation relieves the need for anticoagulation (in AF) and what is it
left atrial appendage occlusion - last resort for those with very high HASBLED score
- in 90% of thrombus formation are in left atrium
115
1st line drug for rate control of AF
beta blocker OTHER THAN SOTALOL
can also use rate limiting CCB (diltiazem) or combination therapy of BB, diltiazem and digoxin
116
when is digoxin used for AF
non-paroxysmal AF for sedentary patients OR in HF
117
what are the screenings for CKD
- bloods: eGFR, serum urea, serum creatinine
- BP
- urine dip: proteinuria/albuminuria
118
what can cause a disproportionately high serum urea
low protein intake
| liver failure
119
what is eGFR multiplied by if patient is afro-caribbean or black
X1.2
120
over how long is proteinuria measured for CKD
how is it actually measured in practice
traditionally = 24 hour urine collection
in practice = spot urine sample (preferably morning for P:Cr ratio OR albumin/creatinine radio
121
some investigations into CKD
- clinical history
- biochemistry/haematology
- urine: dipstick, microscopy (cells and casts)
- immunology screen: SLE, vasculitis, myeloma
- renal USS: obstruction/cystic disease, renovascular, small kidneys
- +/- renal biopsy
- angiogram in some cases
122
metabolic complications of CKD
- anaemia (normocytic) due to reduced EPO production
- bone mineral disorder: low serum Ca2+, high PO4, high PTH
- metabolic acidosis: low serum bicarbonate on VBG
- hyperkalaemia
123
renal features of CKD
- fluid retention
- polyuria
- nocturia
124
cardiovascular features of CKD
- HTN
- pulmonary oedema
- LVH/dysfunction
- vascular disease
- dyslipidaemia
- vascular calcification
125
GI features of CKD
- anorexia
- N+V
- malnutrition
- peptic ulceration
126
neurological features of CKD
- peripheral neuropathy
| - restless legs
127
dermatological features of CKD
- pigmentation
| - pruritis
128
endocrine features of CKD
- erectile dysfunction
- oligmenorrhoea
- reduced fertility
129
MSK features f CKD
- bone pain
- fractures
- arthropathy
130
at what eGFR does CKD need specialist referral
<30, stage 4
131
management of CKD
1. Treatment of underlying cause if possible
2. Lifestyle changes
3. Blood pressure control
4. CVS risk reduction
5. Dietary changes
6. Anaemia management (EPO given)
7. Bone disease: treated with Vitamin D analogues, reduced phosphate diet, phosphate binders
8. Bicarbonate supplements for acidosis
9. Education, planning, preparation for end-stage renal disease
10. Survival and QofL
132
which antiemetic should be avoided in Parkinson's and why
metoclopramide and prochlorperazine
dopamine antagonists - make Parkinson's worse
133
possible infectious trigger of T1DM
autoimmune response to Coxsackie or rubella infection
134
how is gestational DM diagnosed
- fasting venous blood glucose of >5.6mmol/L OR
| - 2 hour plasma glucose level 7.8mmol/L or above
135
why does GDM increase risk of perinatal death
poor placental perfusion due to vascular impairment
136
what is MODY
maturity onset diabetes of the young
B cell dysfunction due to genetic mutations in transcription factors etc
mutation in a single gene - if one parent has the gene mutation then child has 50% chance of inheriting it
usually develops <25 years old
137
what mutation is in MODY 70% of the time and how would it be treated
HNF1-alpha mutation
lowers the amount of insulin produced in pancreas - don't need to take insulin, just small doses of a sulphonylurea
138
random plasma glucose cut off for diagnosing diabetes
>11.1
139
2 fasting blood glucose values needed to diagnose diabetes
>7
140
value needed from OGTT for diabeters
11.1
141
what should be done if the 2nd HbA1c is less than 48
treated as high risk for developing diabetes - should be tested again at 6 months or sooner if symptoms develop
142
when is HbA1c NOT appropriate
- ALL children and young people
- Patients of any age suspected of TD1M
- Patients with sx of diabetes for LESS than 2 months
- Patients at high risk who are acutely unwell
- Patients taking meds that can cause rapid glucose rise
- Patients with acute pancreatic damage, including pancreatic surgery
- Pregnancy
- Presence of genetic, haematological or illness factors that influence HbA1c
143
what states can cause a raised HbA1c
- Iron deficiency
- Vitamin B12 deficiency
- Decreased RBC production
- Alcoholism
- Chronic renal failure
- Decreased intra-erhtyhrocyte pH
144
what is a DAFNE course
course for T1DM
dose adjustment for normal eating course: 5 days plus follow up 8 weeks later 6-12 months after diagnosis
145
what is a DESMOND course
diabetes education self management for newly diagnosed
course for T2DM
146
most common cause of end stage renal disease
diabetic nephropathy - damage to small blood vessels = nephrosclerosis and less efficient filtration (takes about 20 years)
147
what type of skin lesion can affect diabetics
necrobiosis lipodica
mostly affects female patients
148
what examinations should be carried out of diabetic feet
temp
cap refill
pulses including doppler
ABPI
149
ABPI values
- ABPI 1.0 - <1.3 Normal - symptom free
- ABPI < 0.99 - > 0.5 indicates some arterial disease and can be associated with intermittent claudication and if symptoms warrant it the patient should be referred for a vascular opinion.
- ABPI < 0.5 indicates severe arterial disease symptoms include rest pain, gangrene and ulceration and requires urgent referral to vascular team.
150
what is accelerated hypertension
clinic BP >180/110 PLUS signs of:
- papilloedema
- retinal haemorrhage
151
immediate management of accelerated hypertension
same-day referral to secondary care: phaeochromocytoma
152
what percentage of heart attacks and stroke are related to HTN
50%
153
in stage 1 HTN can the COCP be used
no
154
main side effect of CCBs
peripheral oedema
- abdo pain
- nausea
- tiredness
155
when must drug treatment be offered for HTN
if stage 2 or higher
156
when should an ACEi be taken at first and why
at night because brings down BP v quickly so can get more side effects standing up in the day
157
can you combine ACEi and ARB
NEVER
158
who with stage 1 HTN should be offered an antihypertensive
anyone UNDER 80 years with any of the following:
- organ damage
- established CBD
- renal disease
- diabetes
- 10 year CVD risk 20%+
159
what antibiotics would be used in addition to tazocin for neutropenic sepsis if there are:
a. signs and symptoms of respiratory tract infection
b. suspicion of catheter related infection OR history of MRSA
a. clarithromycin
| b. teicoplanin
160
how long to give antibiotics for neutropenic sepsis
- until patient is no longer febrile and neutropenic
- if blood cultures negative and no source identified can stop antibiotics once patient has been apyrexial for at least 48 hours
161
antibiotic given for neutropenic sepsis if patient has a mild allergic reaction to penicillin
meropenem
162
antibiotic given for neutropenic sepsis if patient has a severe allergic reaction to penicillin
teicoplanin + aztreonam/ciprofloxacin
163
2 drugs patients undergoing myelosuppressive chemotherapy might be given
- levofloxacin (to prevent neutropenic sepsis)
| - co-trimoxazole (prophylaxis against pneumocystis jiroveci (PJP))
164
potential fungal cause of pneumonia in patients on chemotherapy (immunosuppressed)
pneumocystitis jiroveci (PJP) - bilateral interstitial ground glass appearance on lung CT
165
how is PJP diagnosed
- PCR respiratory specimen
| - beta-D-glucan
166
treatment of PJP
high dose IV co-trimoxazole
14-21 days that can be switched to oral when patient shows clinical improvement
167
most common causative agent of infected indwelling catheters and lines (in chemotherapy)
coagulase negative staph
e.g. Staph epidermidis
also staph aureus v common
168
what are endogenous vs exogenous catheter infections
- endogenous: flora from patient's own skin/newly acquired flora leading to infection
- exogenous: operator's flora
169
where is the concentration of organisms at its greatest and lowest in an intravascular catheter infection
- highest = at biofilm INSIDE the catheter lumen
| - lowest = peripheral blood
170
what is time to positivity (TTP)
time taken from receiving and testing blood cultures to the time the blood culture flags up positively for bacterial colonisation
determined by the number of organisms put into the blood culture bottle
171
what TTP time is strongly indicative of a line infection
if the line cultures become positive MORE than 2 hours before the peripheral cultures do (paired blood cultures)
172
how is a line infection managed
- remove line
| - TEICOPLANIN (due to high prevalence of MRSA)
173
typical Abx regime for a line infection in those
a. under 65 years
b. over 65 years
a. IV teicoplanin +/- ceftazidime
| b. IV taxocin
174
what is VAP
pneumonia developing 48 hours after intubation/mechanical ventilation
early onset VAP = within 4 days admission
late onset VAP = after 4 days admission
175
good empirical Abx regime for VAP
IV tazocin (particularly in late infections in which pseudomonas cover is necessary)
OR meropenem
176
neutropenic sepsis - what to ask in history
how long ago their chemo was - usually 7-14 days post chemo
- line and access (IV vs oral)
- localising symptoms: infection source? e.g. mucositis, SOB, chest pain, abdo pain, diarrhoea, headaches/neck stiffness
- allergies!!
NB: 60-70% of all febrile neutropenic patients have no identifiable aetiology of the fevers
177
3 cancers most prone to developing neutropenic sepsis
- haematological malignancies
- germ cell cancers
- breast cancers
178
how many blood cultures should be taken and where
X2 for anaerobes and aerobes
lines (all ports) and peripheral or 2X peripheral if no line
179
3 common gram +ves causing neutropenic sepsis (70% +ve)
staph aureus
coagulase negative staph
alpha and beta haemolytic strep
180
common gram -ves causing neutropenic sepsis
E. coli
klebsiella pneumoniae
pseudomonas aeruginosa
181
what is sometimes given in addition to Abx in neutropenic sepsis
G-CSF: colony stimulating factor such as:
- filgrastim
- lenograstim
haematopoietic growth factors that promote stem cell proliferation and shorten the duration of neutropenia
given when low neutrophils, predicted neutropenia >10 days, severe sepsis, multi organ failure, co-morbidities
182
1st and 2nd most common causes of hypercalcaemia
1st = primary hyperparathyroidism
2nd = cancer
183
2 main pathophysiologies of hypercalcaemia in cancer
- TGF-alpha = polypeptide stimulator of cell growth and replication produced by tumour cells, very powerful stimulator of bone reabsorption
- PTHrP - produced by some tumours which mimic PTH but doesn't need low calcium levels to work
184
most common malignancies which cause hypercalcaemia
- Non-small cell lung cancer (squamous cell)
- Breast cancer
- Prostate cancer
- Renal cell carcinoma
- Multiple myeloma & lymphoma
- Head & neck cancers
185
CNS S&S of hypercalaemia
- confusion
- seizures
- proximal myopathy
- hyporeflexia
- coma
- depression and anxiety
186
general S&S of hypercalcaemia
- fatigue
- weakness
- bone pain
- dehydration
187
GI S&S of hypercalcaemia
- Constipation
- Weight loss/anorexia
- N&V
- Abdominal pain
- Constipation
- Ileus
- Dyspepsia
- Ileus
- Pancreatitis
188
cardiac S&S of hypercalcaemia
- Bradycardia
- Short QT interval
- Wide T-wave
- Prolonged PR interval
- BBB
- Arrhythmia
- Cardiac arrest
189
genitourinary S&S of hypercalcaemia
- stones
| - polyuria
190
treatment for hypercalcaemia if level <3.0mm/L
rehydration with IV fluids - saline 1L every 4 hours for 24 hours then 6 hourly for 48-72 hours with adequate K+
191
treatment for hypercalcaemia if level >3.0/symptomatic
at least 3L of saline in 24 hours and consider furosemide
PLUS consider bisphosphonate
192
bisphosphonates to use in hypercalcaemia
- IV zolendronic acid
| - IV pamidronate (if renal function is poor)
193
what is also added in hypercalcaemia if calcium is very high
calcitonin + corticosteroids
194
presentation of MSCC if the compression is ABOVE L1
UMN symptoms - hypertonia, hyperreflexia, spasticity, positive babinski sign
195
presentation of MSCC if lesion is BELOW L1
cauda equina:
- sciatica in both legs
- weakness of legs
- saddle anaesthesia
- faecal incontinence
- urinary retention
196
which MSCC patients are considered for neurosurgery
- single area of MSCC
- good performance status
- predicted survival >3 months
- not paraplegic for >48 hours (poor prognostic sign)
otherwise radiotherapy
197
what percentage of patients treated within 24 hours will walk again
57%
198
S&S of SVCO
- Breathlessness
- Headache (worse on coughing)
- Facial/neck/arm swelling
- Distended neck & chest veins
- Cyanosis
- Visual disturbance
199
2 main investigations into SVCO
- CXR
| - contrast CT thorax
200
benign causes of SVCO
- Non-malignant tumours (goiter)
- Mediastinal fibrosis (idiopathic/post-RT)
- Infection: TB
- Aortic Aneurysm
- Thrombus asx with indwelling catheter
201
maximum number of oromorph doses in 24 hours
6 doses
202
adjunctive analgesics outside of the WHO pain ladder
- Tricyclics: amitriptyline
- Gabapentin
- Pregabalin
- NSAIDs
- Steroids
- Radiotherapy
- TENS
most effective at treating neuropathic pain
203
side effects of opiates
- CONSTIPATION
- 30% N+V - settles within 3-4 days
- drowsiness - settles within 3 days
- itchiness
- addiction??
204
2 methods of titrating a patient's MST morphine
- PRN oromorph
| - 30-50% increase
205
when would vomiting not usually help the nausea
chemotherapy patients
206
management for nausea induced by raised ICP
- dexamethasone 16mg
| - cyclizine - 1st line antiemetic for raised ICP
207
causes of cerebral N&V
- raised ICP
- emotions
- radiotherapy
208
features of toxic-induced nausea
- frequent vomits
- small volumes: 'possets'
- constant nausea
- vomiting doesn't relieve nausea
209
1st and 2nd line managements of toxic causes of N&V
1st = haloperidol 1.5-5mg PO/SC nocte
2nd = levopromazine
210
2 main treatments for vestibular causes of N&V
- cyclizine
| - hyoscine
211
features of gastric-induced N&V
- 1/2 vomits daily
- satiety
- nausea relieved by vomiting
- MINIMAL NAUSEA BETWEEN VOMITING
- hiccups
- heartburn
212
1st line treatment of gastric vomiting
Metaclopramide (pro-kinetic so moves contents through digestive system faster)
10-20mg PO/SC 30 minutes before food
OR
30-60mg SC over 24 hours
213
treatments of anxiety/anticipatory related vomiting
- CBT
- benzos
- complementary therapies
214
what is used to treat indeterminate vomiting
levomapromazine 6.25-12.5mg nocte PO/SC
215
what is used to treat chemotherapy-induced N&V
ondansetron (very constipating!!)
216
1st line laxative used in opioid constipation
co-dansthrusate/co-danthramer OR Movicol
217
3 medications to stop at the end of life
- corticosteroids
- antiepileptics
- hypoglycaemics
218
what to do when taking patients off steroids at the end of lie
if have been on them for a while - adrenals might have stopped producing corticosteroids (hypoadrenalism) = wean off slowly
219
up to how many medications can be delivered in a syringe driver
4
220
normal starting dose of midazolam in a syringe driver
10mg over 24 hour period in water for injection
221
what substance for syringe drivers can NOT be added with sodium chloride
cyclizine
222
main treatments for bone pain in cancer
- NSAIDs
- radiotherapy
- bisphosphonates - pamidronate
223
how can neuropathic pain be treated
- TCAs
- anticonvulsants: gabapentin, pregabalin
- corticosteroids if there is nerve compression
224
most common cause of SVCO
SCLC (65%)
225
3 main treatments of SVCO
- elevation of head and bed
- diuretics
- dexamethasone 16mg + PPI cover
226
when to give dexamethasone for MSCC
BEFORE MRI
227
4 electrolyte disturbances in tumour lysis syndrome
- hyperkalaemia
- hyperphosphataemia
- hyperuricaemia
- hypocalcaemia
228
pathological SR sign for osteosarcoma (most common primary malignant tumour in paediatrics)
sunburst lesion
229
max dose of co-codamol REGARDLESS of codeine strength
2 tablets 4 times a day - this is due to the paracetamol levels limiting the amount you can give (500mg paracetamol per tablet)
230
what is Oramorph
liquid form of MST - but is used for breakthrough pain
takes 20-30 mins to work and works for 4 hours
max 6 doses in 24 hours
should be prescribed as 1/6 of the total daily morphine dose
231
good starting dose for modified release morphine when going from weak opioids or going from non-opioids
weak opioids = around 15mg BD MST (30mg/24hr)
| non-opioids = around 10mg BD MST (20mg/24hr)
