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Medicine year 4 ACE > Core conditions 7 > Flashcards

Core conditions 7 Flashcards

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1
Q

Stepwise management of asthma

A
  • Step 1: SABA i.e. salbutamol
  • Step 2: SABA + ICS (beclomethasone)
  • Step 3: SABA + ICS + LRTA (montelukast)
  • Step 4: SABA + LABA (salmeterol) + ICS +/- LRTA
  • Step 5: MART +/- LRTA + ICS. MART is a combines ICS and LABA inhlaer i.e. Durosep, can be used for maintenance and relief of symptoms
  • Step 6: MART or LABA+ICS+SABA with moderate dose increase of ICS +/- LRTA
  • Step 7: MART or LABA+ICS+SABA with high dose increase of ICS +/- LRTA. Can trial an additional drug like a long acting muscarininc receptor agonist or theophylline or seek specialist advice
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2
Q

Aims of asthma treatment

A
  • No daytime symptoms
  • No night time awakening due to asthma
  • No need for rescue medication
  • No exacerbation
  • No limitations on activity including exercise
  • Normal lung function (FEV1 and or PEF >80% predicted or best)
  • Minimal side effects
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3
Q

Moderate acute asthma exacerbation

A
  • Increasing symptoms
  • PEF >50-75% best or predicted
  • No features of acute severe asthma
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4
Q

Severe acute asthma exacerbation: any one of:

A
  • PEF 33-50% best or predicted
  • Respiratory rate >25/min
  • Heart rate >110/min
  • Inability to complete sentences in a breath
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5
Q

Life threatening acute asthma exacerbation-

A

In patients with severe asthma any one of:
- PEF <33%
- SpO2 <92%
- PaO2 <8kpa
- ‘Normal’ PaCO2
- Altered consciousness
- Exhaustion
- Arrhythmias
- Hypotension
- Cyanosis
- Silent chest
- Poor respiratory effort

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6
Q

Near fatal acute asthma exacerbation

A

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures.

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7
Q

Investigations for acute asthma

A
  • Peak expiratory flow (PEF)- this is expressed as a % of the patients previous best value, in the absence of this % of predicted is a rough guide
  • Pulse oximetry/arterial blood gas- the aim of oxygen therapy is to maintain SpO2 94-98%. Patients with an SpO2 of <92% or features of life threatening asthma require ABG

chest x- ray

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8
Q

Chest x-ray is not routinely recommended in asthma patients except for:

A
  • Suspected pneumomediastinum or pneumothorax
  • Suspected consolidation
  • Life threatening asthma
  • Failure to respond to treatment satisfactorily
  • Requirement for ventilation
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9
Q

Management in acute asthma exacerbation

A
  • A to E structure
  • Controlled oxygen therapy (94-98%)
  • Salbutamol nebulisers, can be given back to back if there is a poor response to the initial dose
  • Hydrocortisone (IV) or Prednisolone (PO)
  • Ipratropium nebulisers- in severe or life threatening cases or where there is an inadequate response to initial treatment
  • Magnesium sulphate (IV) or Theophylline (as aminophylline infusion IV) can be considered under specialist guidelines
  • Incubation and ventilation may also be required
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10
Q

Asthma: how to use a metered dose inhaler

A
  1. Shake Inhaler 10-15 times.
  2. Sit or stand upright. Take a deep breath then breathe all the way out.
  3. Place inhaler in mouth.
  4. Breath in slowly and press the the inhaler once, continue to breathe in and hold breathe for 5-10 seconds.
  5. Breath out
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11
Q

Diagnosing asthma

A
  • <5: clinical diagnosis treat symptoms
  • 5-16: Spirometry then reversibility. If reversibility doesnt work test FeNo
  • > 17: ask about smoking as can lower FeNO. If spirometry positive offer reversibility, if negative offer FeNO. After reversibility you offer FeNO. If inconclusive after initial assessment and FeNO test then measure peak flow variability for 2-4 weeks (should be >20%)
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12
Q

Comparison of asthma and COPD

A
  • Age of onset: Asthma (often childhood or adolescence, can manifest after 40), COPD (Typically >40)
  • Aetiology: Asthma (allergic and nonallergic), COPD (cigarette consumption)
  • Clinical features: Asthma (episodic, symptom free phases, sudden attacks), COPD (persistent airflow limitation)
  • Medication: Asthma (good response to treatment with long term inhaled corticosteroids), COPD (good response to parasympatholytics i.e. Ipatropium bromide)
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13
Q

Classification of asthma severity

A
  • Mild intermittent: symptoms ≤ 2 days/week, rare nightime symptoms. FEV1 >80%
  • Mild persistent: symptoms >2 days/week, nightime symptoms 3-4 times/month, FEV1 >80%
  • Moderate persistent: daily symptoms, nightime symptoms 1-2 times/week, FEV1 60-80%
  • Severe persistent: symptoms throughout the say, nightime symptoms often (most nights), FEV1 <60%
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14
Q

Uncontrolled asthma

A
  • 3 or more days a week with symptoms OR
  • 3 or more days a week with required use of a SABA for symptomatic relief OR
  • 1 or more nights a week with awakening due to asthma
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15
Q

Asthma: SABA and LABA

A
  • SABA: through activation of beta 2 receptors on airway smooth muscle causing bronchodilation. Can cause fine tremor and tachycardia, associated with hypokalaemia
  • LABA: causes bronchodilation through activation of beta 2 receptors on airway smooth muscle. Causes fine tremor, headache
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16
Q

Asthma: ICS, LTRA and monoclonal antibodies

A
  • ICS: anti-inflammatory effect on bronchial mucosa reduces hyper-responsiveness to allergens. Can take 6 weeks to see effect. Side effects: oral thrush, osteoporosis and growth retardation in children
  • LTRA: effective in aspirin intolerant asthmatic patients, rhinitis associated asthma and viral wheeze
  • Monoclonal antibodies: Omalizumab given SC every 2-4 weeks and effective though expensive. Down regulates mast cells and basophils
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17
Q

Adult onset asthma

A

typically occurs >65 after an URTI. Tend to have more serious asthma and affects more women than men

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18
Q

Conservative management of asthma: age

A
  • Check inhaler technique
  • Asthma medication gets less effective as patient ages: should have asthma review once a year
  • Written asthma action plan
  • May get more side effects from their medication as they get older i.e. tremors or palpitations. Steroids can cause cataracts, osteoporosis and thinner skin
  • Vaccinated against influenza and pneumonia
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19
Q

Breast cancer: predisposing factors

A
  • BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovariancancer
  • 1st degree relative premenopausal relative with breast cancer (e.g. mother)
  • Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
  • Early menarche, late menopause
  • Combined hormone replacement therapy , combined oral contraceptive use
  • Past breast cancer
  • Not breastfeeding
  • Ionising radiation
  • P53 gene mutations
  • Obesity
  • Previous surgery for benign disease
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20
Q

Common breast cancer types

A
  • Invasive ductal carcinoma. This is the most common type of breast cancer. To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’
  • Invasive lobular carcinoma
  • Ductal carcinoma-in-situ (DCIS)
  • Lobular carcinoma-in-situ (LCIS)
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21
Q

Paget’s disease of the nipple

A

Is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

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22
Q

Inflammatory breast cancer

A

Where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.

23
Q

Clinical features of breast cancer

A
  • Breast lump: typically painless. Classically described as fixed, hard
  • Breast skin changes
  • Bloodynipple discharge
  • Inverted nipple
  • Axillary mass
24
Q

2WW for breast cancer

A
  • Aged 30 and over and have an unexplained breast lump with or without pain. OR
  • Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction, other changes of concern
  • Consider: with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla
25
Q

Management of breast cancer

A
  • Surgery: either wide local excision or a mastectomy. Will be offered breast reconstruction
  • Radiotherapy: in wide local excision you get whole breast radiotherapy. In mastectomy its offered for T3-T4 tumours and with 4 or more positive axillary nodes
  • Hormone therapy: If positive for hormone receptors. Tamoxifen is used for 5 years after diagnosis in pre-menopausal womenif ER positive. In post-menopausal women offer an aromatase inhibitor i.e. anastrozole
  • Biological therapy: trastuzumab which is sued in tumours that are HER2 positive.Monoclonal antibosies HER1 positive
  • Chemotherapy: downsize primary lesions or post surgery
26
Q

Indication for Mastectomy versus wide local excision

A
  • Mastectomy: multifocal tumour, central tumour, large lesion in small breast DCIS >4CM
  • Wide local excision: solitary lesion, peripheral tumour, small lesion in large breast, DCIS <4cm
27
Q

Side effects of tamoxifen, breast screening, triple assessment

A

Side effects of tamoxifen: endometrial cancer, venous thromboembolism and menopausal symptoms

Breast screening: 50-70: mammogram offered every 3 years. Afterwards can make their own appointments

Triple assessment: clinical assessment, imaging and biopsy

28
Q

How might breast cancer present

A
  • Breast lump – either painful / painless
  • Nipple changes / eczema / blood stained discharge
  • Nipple or skin tethering and indrawn
  • Axillary lymphadenopathy
  • How would you describe lump: Site, size, shape, surface, colour, consistency, contour, temperature, tethering, tenderness
29
Q

Fibroadenoma

A

Most are smooth or slightly lobulated and are usually 2-3 cm in diameter. They occur most commonly in women aged 16 to 30 years. They are very mobile – “breast mouse” and approximately 10% of fibroadenomas are multiple. Most can be observed, and excision is indicated if it is a large lump, if the patient chooses, or if the diagnosis is uncertain

30
Q

Breast imaging

A
  • Mammogram: dual plane x-ray of the breast. Bilateral mammogram is offered to all patients over 40. Rarely performed under 40 due to dense breast
  • Ultrasound: any patient with breast abnormality will undergo an ultrasound regardless of age, ultrasound of abnormality and not whole breast
31
Q

Inflammatory breast cancer

A
  • Widespread tenderness with oedema and erythema
  • Rapid increase in breast size
  • Sensation of heaviness or burning in breast
  • Inverted nipple
  • Swollen lymph nodes
  • Skin is pitted or ridged (peau d’orange)
  • Due to build of lymph in the breast as cancer cells have blocked lymph vessels
32
Q

Duct ectasia

A

Due to contraction, thickening and widening of milk ducts which become obstructed with debris and become infected. Common sign is a slit like nipple retraction, can be exaggerated in smokers. Frequently bilateral and presents with green-brown discharge, nipple inversion and pain.

33
Q

Breast biopsy

A

If the patient scores ≥ U2/M2 or greater then a core biopsy is performed with ultrasound guidance. The biopsy is given a score B1 to 5. If the tumour has broken through the basement membrane its invasive and graded B5b, if its localised its considered in situ and is B5a.

34
Q

Family history: BRCA

A
  • Women who have BRCA and TP53 and women with a significant family history are classified as high risk
  • Women with BRCA mutation (1 and 2) start screening at the age of 30 with yearly MRI and possibly a mammogram
  • TP53 mutation: screening at the age of 20 with yearly MRI
35
Q

Grade and size of tumour and axilla lymph node status

A
  • Grade: measure of cellular differentiation from grade 1 (well differentiated) to grade 3 (poorly differentiated)
  • Lymph nodes: 1-3 with 1 being 0 nodes affected and 3 being >3 nodes affected
  • Can be combined to give a 5 year survival probability in the Nottingham Prognostic Index (NPI): (0.2 x size) + grade + lymph node score
  • A score below 2.5 has a 93% 5-year survival, and a score of 5.5+ has a 50% 5-year survival.
  • Other prognostic factors includehistologyandstage.
36
Q

Histology of breast cancer

A
  • Ductal carcinoma in situ (DCIS): is pre-cancerous and can progress to invasive cancer if left untreated
  • Lobular carcinoma in situ (LCIS): doesn’t become invasive but is a marker for developing breast cancer (lobular or ductal and in either breast). Risk isnt reduced by removing the LCIS. Require no active treatment but need annual mamographic surveillance
37
Q

Staging of breast cancer

A
  • Tumour (“T”) scores the size and location of the cancer from 0 (no evidence of cancer) to 4 (grown into chest wall/skin, or inflammatory breast cancer)
  • Node (“N”) scores spread to lymph nodes, from 0 (no evidence of spread) to 3 (4+ axillary lymph nodes)
  • Metastasis (“M”) scores whether or not there is evidence of distant metastases, where 0 is no evidence and 1 is evidence of distant mets.
  • Can be staged from 0-4. Stage 0 refers to non-invasive breast cancers. Stages I through III describe varying tumour sizes and degrees of lymph node infiltration. Stage IV is metastatic breast cancer.
38
Q

Breast cancer: molecular subtyping

A
  • The gene expression of tumour cells: can show subtype
  • Subtype: establish oestrogen receptor (ER), progesterone receptor (PR) and HER2 receptor expression. Is either positive or negative
  • A cancer that is ER-, PR- and HER2- is termed triple negative. Often PR status is omitted because its the same as ER. In triple negative they are usually given chemotherapy
39
Q

Breast cancer: ER and HER2

A
  • ER: Gene expression of theoestrogen and progesterone receptorspredicts response tohormone therapy(also known as endocrine therapy). It isnot prognostic. Translated into Allred’s score (0-8), a negative result is 0 or 2
  • HER2: Gene expression of theHER2 receptorpredicts response to a monoclonal antibody treatment calledtrastuzumab(brand name herceptin) and indicates apoorer prognosis so normally receive chemotherapy. Either positive or negative
40
Q

Breast cancer: deciding on chemotherapy

A
  • In ER+HER- will have discussion about whether to give chemotherapy. If lots of lymph nodes involved give otherwise no
  • Oncotype Dxis a predictive test that gives the likeliness of a patientbenefitting from chemotherapy(and hormone therapy),and the likelihood ofcancer recurrence. It is carried out in some ER+ HER2- LN- patients.
41
Q

Breast cancer: key points on subtype

A
  • Molecular subtyping involves testing ER status, HER2 status, and in some patients oncotype DX
  • ER status predicts response to hormone therapy
  • HER2 predicts response to trastuzumab and has a poor prognosis
  • HER2+ and triple negative cancers are given chemotherapy
  • TNM stage and sometimes oncotype DX determine whether chemotherapy is necessary in ER+ HER2- cases
42
Q

Summary of treatment options

A
  • Local: surgery, radiotherapy
  • Systemic treatments: chemotherapy, Hormone therapy
43
Q

Breast cancer: surgery

A
  • Usually the first treatment patients receive, therapy received after surgery is adjuvant and before is neo-adjuvant
  • Surgery can be a breast operation or axilla operation
  • Breast surgery is either breast conserving or a mastectomy.
  • Breast conserving is almost always offered with radiotherapy
  • Mastectomies can be followed with reconstructive surgery, either in the same surgery (“immediate reconstruction”) or at a later time (“delayed reconstruction”)
44
Q

Breast cancer: Axillary surgery

A
  • Axillary clearance, sentinel node biopsy or omitted. Axilla surgery gives information about local recurrence, does not affect survival
  • Axillary clearance: ≥4 lymph nodes affected
  • 1-3 lymph nodes: axillary clearance or targeted axillary dissection
  • If ultrasound clear use sentinal node biopsy
  • In DCIS axillary surgery is omitted
  • Don’t take blood from the same arm axillary clearance surgery has been performed on can cause Lymphoedema
45
Q

Breast cancer: radiotherapy

A
  • Reduces risk of recurrence less impact on survival
  • Given to breast, chest wall and/or lymph nodes
  • Can be used to treat distant symptomatic metastases in a palliative setting, e.g. symptomatic bone metastases.
  • Carries out 6 weeks after chemotherapy or surgery. Used 5 days per week for 3 weeks with an occasional boost week
  • Risks: rib fracture, sunburn, blistering, lung fibrosis, osteonecrosis
  • Contraindications: connective tissue disorder with significant vasculitis, prior radiotherapy, TP53 mutation
46
Q

Breast cancer systemic treatment: hormone therapy

A
  • Anyone ER+ gets it
  • Hormone therapy aims to prevent the binding of oestrogen to oestrogen receptors by various modes of action, inhibiting ER+ tumour cell proliferation
  • In premenopausal women use tamoxifen. Its a SERM that binds to oestrogen receptors in the breast tissue
  • In postmenopausal women use aromatase inhibitors. They block non-ovarian sources of oestrogen like fat cells. Reduces recurrence
  • Usually started after all other treatment: normally a tablet taken OD for 5 years, can be used neo-adjuvant or in very elderly instead of surgery ‘primary hormone therapy’
47
Q

Breast cancer treatment: chemotherapy

A
  • Usually given as adjuvant therapy to reduce recurrence and improve survival. Can be neo-adjuvant
  • 2-3 cytotoxic medications taken IV in session lasting a few hours with a break of a couple of weeks
  • Normally have 8 cycles
  • Regime options: FEC(fluorouracil, epirubicin, and cyclophosphamide) andEC(epirubicin and cyclophosphamide).
48
Q

Breast cancer treatment: side effects and contraindications

A
  • Taxanes (i.e. docetaxel) can be added in patients with poorer prognosis i.e. node positive patients. Can cause neuropathy but reduce recurrence
  • Platinum based medication i.e. carboplatin can be added if cancer is triple negative
  • Side effects: nausea, weight loss, fatigue, change to skin and nails, immunosuppression, easy bleeding and bruising
  • Side effects: deterioration in kidney function, thrombosis
  • Severe complications: cardiotoxicity, neutropenic sepsis, death, infertility, secondary malignancy
49
Q

Medically unexplained symptoms(MUPS)

A

Persistent physical symptoms for which no underlying medical condition can be identified. For example: IBS, fibromyalgia and chronic fatigue

50
Q

Risk factors for MUPS

A
  • Female sex
  • younger people
  • underlying anxiety or depression
  • Recent personal illness, those affected by ill health or death of a relative
51
Q

Somatic symptom disorder

A

the physical symptoms are impacting upon the patients daily life and impairing function. The symptoms are due to ‘somatization’ which is the manifestation of psychological symptoms by the presentation of physical symptoms

52
Q

Diagnosis of somatic syndrome

A
  • Experience some set of unexplained physical or somatic symptoms for >6 months
  • Symptoms can be incredibly varied i.e. pain, tummy upset
  • Location, kind and severity of symptoms tends to change over time except for pain which tends to persist
  • Can have cognitive symptoms with persistent thoughts or feelings about symptoms i.e. worry, anxiety or death. Cognitive symptoms are often basis for diagnosis
53
Q

Severity and treatment of somatic syndrome

A
  • Based on cognitive symptoms
  • Mild: one cognitive symptom i.e. ruminating on symptoms
  • Moderate: two or more cognitive symptoms i.e. rumination and anxiety
  • Severe: two or more cognitive symptoms with multiple physical symptoms or one severe symptom like pain

Treatment of somatic symptoms: About improving cognitive symptoms through CBT

54
Q

Management in MUPS

A
  • Stress management: reduce any stress in their life
  • Healthy lifestyle: stop smoking, reduce alcohol, increase exercise and improve diet
  • Reassurance: get patient to discuss concerns with a healthcare professional
  • Psychological support: CBT or IAPT (Improving access to psychological therapies). An IAPT team can offer support for mild-moderate symptoms which can reduce functional impact of symptoms
  • SSRI’s help even when the patient isnt overtly depressed. Dont give painkillers in chronic pain
  • Dont give diagnostic label

Medicine year 4 ACE (9 decks)

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