CPRS Case 9: Lung Carcinoma Flashcards
***Assessing pain Mnemonic
SOCRATES Site Onset Character Radiation Association Time course (any pattern) Exacerbating factors Severity
***ADA approach in breaking bad news
- Assessment phase
- establish rapport
- willing to discuss problem
- identify misunderstanding
- leave time for patient to respond to questions
- express empathetic concern - Disclosure phase
- tailor information
- appropriate rate
- appropriate information
- avoid telling exact duration of remaining life
- identify reasons for emotions - Assimilation phase
- answer honestly
- understand process of denial
- consider effects on family
- additional support system
- empathy and realistic reassurance
***Kubler-Ross model (5 stage of grief)
- Denial
- Anger
- Bargaining (most common e.g. any ways to prolong life expectancy)
- Depression
- Acceptance
***Steps in breaking bad news
SPIKES (setting, perception, invitation, knowledge, empathy, strategy)
Setting up interview
assessing patient’s Perception
obtaining patient’s Invitation
giving Knowledge and information to patient
addressing Emotions with empathetic responses
Strategy and summary
***Differential diagnosis Mnemonic
VINDICATE Vascular Infection / inflammation Neoplasm Drugs / degenerative Iatrogenic / idiopathic Congenital Autoimmune Trauma Endocrine
Common causes of cough and sputum production
Cough: clean foreign material, microbes, irritants and excess secretion from central airway
Cough reflex: abdominal muscle contraction, closure of glottis
Causes:
- Respiratory tract infections
- common cold
- pneumonia
- TB
- Pertussis - Respiratory disease (asthma)
- Asthma
- Chronic bronchitis - GERD
- Foreign body
- Tobacco smoke / air pollutant
Sputum: Blood-streaked sputum: Lung malignancy Massive blood: TB, Embolism Purulent sputum: Pneumonia, Chronic bronchitis Frothy pink: Pulmonary oedema Rust/brown: Pneumonia by S. pneumoniae
***Pathology, mode of spread and principles of tumour staging of lung cancer
Normal —> metaplasia/hyperplasia —> epithelial dysplasia —> carcinoma-in-situ —> invasive malignant cells
Genetic changes: - loss of TP53 tumour suppressor gene - RAS oncogene mutation - EGFR mutation - ALK translocation —> abnormal intracellular signalling, increased cell proliferation and survival
Mode of spread 1. Direct spread (adjacent structure) - brachial plexus: pain, wasting of arm muscle - oesophagus: dysphagia - pleura: pleural effusion - chest wall: mass —> Chest X-ray
- Lymphatic spread
- Regional nodes (N1): hilar, perbronchial
- Mediastinal nodes (N2): mediastinal, subcarinal
- Cervical nodes (N3): contralateral mediastinal, hilar, supra-clavicular, scalene - Haematogenous spread (M1)
- distant metastasis
- liver, adrenals, bone, brain
Tumour staging:
TNM
Lymphatic drainage of lung in relation to growth and spread of lung cancer
See lecture
Intrapulmonary —> Bronchopulmonary —> Tracheobronchial —> Paratracheal —> Bronchomediastinal —> Thoracic duct (left) / Right lymphatic duct (right) —> Brachiocephalic vein —> SVC —> Right atrium
General concepts of carcinogenic mechanisms to lung cancer and understand the principle of molecular targeted therapy
See lecture
EGFR mutation —> no EGF required to trigger signalling of EGFR —> cell proliferation, survival, motility, formation of blood vessels
Treatment to SCLC, AD, SCC, LCC —> see lecture
Epidemiology of lung cancer in HK
- Commonest cancer worldwide
- MEN: Highest incidence and mortality
- WOMEN: 3rd highest incidence (behind breast and colon) and 1st highest mortality
Dilemma of medical care policy for expansive procedures and items
- General financial assistance
- Comprehensive Social Security Assistance (CSSA)
- Hong Kong Cancer Fund
- Hardship fund - Samaritan Fund
- Financial assistance to meet expense for designated PPMI (privately purchased medical items)
- Erlotinib, Gefitinib (self-financed drugs supported by SF)
- referred by doctors to medical social workers
4 principles of patient referral for specialist medical care
- All appropriate examinations have been carried out
- Referral will improve accuracy of diagnosis and better management
- Any delay will expose to harm, appropriate treatment should be initiated ASAP
- Referral to service / individual who can best help them
Clinical history about relationship of work exposure and diseases
- Importance of adequate occupational history
- label illness as occupational
- avoid missing diagnosis
- improve fate of patient - Determination of exposure
- full description of jobs
- identification of chemical exposure / other hazards
- duration of exposure
- intensity of exposure
- availability of PPE - Determining causality
- Bradford-Hill criteria
—> Temporality (when start in relation to exposure)
—> Reversibility (when not exposed)
—> Exposure-response (worse when higher exposure)
—> Strength (other workers suffer?)
—> Specificity (other factors affecting?)
—> Consistency (same symptoms with same exposure)
—> Analogy (similar agent lead to same symptom?)
—> Plausibility (known mechanism?)
Importance of communication in reducing stress of cancer patient
- Keep communication open
- listen instead of learning
- conversation does not need to confine to cancer information
- ask if any questions - Respectiveful
- respect needs to be alone
- allow period of silence
- anger and frustration from patient should not make doctors take it personally - Active support
- offer assistance
- comfort the patient
- eye contact
- listen attentively
Importance:
- Communication:
- better doctor-patient relationship
- effective information exchange
- acknowledgement, understanding and tolerance of uncertainty - Medical:
- prevention and early detection
- accurate diagnosis - Society:
- cost-effective utilisation of health services
