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Adam's Weak Spots > Diagnoses > Flashcards

Diagnoses Flashcards

1
Q

What percentage of cancer patients will develop MDD?

A

> 10%

But ranges 2-50% depending on study. 10% is from a n = 9000 lit review

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2
Q

What percentage of depressed cancer patients also suffer with clinically significant anxiety?

A

2/3

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3
Q

Does depression worsen cancer prognoses?

A

Yes
25-40% higher mortality

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4
Q

Which cancers are most likely to be associated with clinical depression?

A

Lung
Pancreatic
ENT

Lowest in localised skin ca

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5
Q

What point in the cancer journey are depression diagnoses highest?

A

At cancer diagnosis

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6
Q

What two features of a cancer are associated with higher clinical depression rates?

A

Metastases
Pain

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7
Q

Which age group is least likely to be depressed in cancer?

A

Children and adolescents

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8
Q

What two laboratory tests are altered in depressed cancer patients?

A
  • IL-6 (high)
  • Cortisol (less diurnal variation)
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9
Q

What are possible biological (i.e. nonpsychosocial) causes of depression in cancer?

A

Tissue damage leading to inflammatory cytokine release, causing:

  1. Cytokine-mediated NE/serotonin uptake
  2. Increased cortisol levels
  3. Reduced neural growth factors
  4. Increased tryptophan catabolism

IL-1, TNF-a, IL-6, interferons

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10
Q

What is the main external cause of poorer survival in cancer + depression?

A

Declining cancer treatment

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11
Q

What side effect of SSRIs is especially concerning in patients on chemo?

A

NV

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12
Q

What nonpharmacological factors help manage cancer + depression?

A
  1. Strong therapeutic relationship
  2. CBT
  3. ACT
  4. Relaxation techniques
  5. Exercise
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13
Q

What demographic risk factors exist for depression in cancer?

A
  1. Female gender
  2. Older age (likely)
  3. Less education
  4. Lower income
  5. No intimate partner
  6. Distressed caregivers
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14
Q

What psychological risk factors exist for depression in cancer?

A
  1. Preexisting depression
  2. Pessimism
  3. “Giving up”
  4. Neuroticism
  5. Rumination
  6. Disagreeable personality
  7. Avoidant/antisocial coping strategies
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15
Q

Is suicidality solely found in cancer patients who are depressed (vs. not depressed)?

A

No–it is not diagnostic of depression

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16
Q

What is a pheochromocytoma?

A

Catecholamine-secreting tumour of either the adrenal medulla or sympathetic ganglia.

Technically, the latter are “catecholamine-secreting paragangliomas”

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17
Q

What percentage of pheochromocytomas are sporadic vs. genetic?

A

60% sporadic
40% familial

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18
Q

What is the “classic” pheo presentation?

A

Episodic headache / sweating / tachycardia

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19
Q

What is the most common presenting pheo symptom?

A

Hypertension
(paroxysmal or sustained)

85-95% at diagnosis

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20
Q

What is a pheochromocytoma crisis?

A

Acute:
1. BP changes (high or low)
2. Hyperthermia >40 C
3. Cognitive changes
4. Organ failure

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21
Q

What metabolic disorder can pheo induce/mimic?

A

T2DM
- catecholamines can cause insulin resistance

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22
Q

What % of pheos are found incidentally?

A

60%

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23
Q

What important treatment must be given before manipulating a pheochromocytoma?

A

Sympathetic antagonism

a-blockade
(phenoxybenzamine)

then

low-dose B-blockade w. nonspecific BB

never begin B-blockade before a
consider high-Na diet to maintain volume

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24
Q

Are most catecholamine-secreting tumours benign?

A

Yes

90%

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25
Q

What is a hyperadrenergic spell?

A

Acute, self limited episode for:
- palpitations
- sweating
- HA
- tremor
- pallor

MOST ARE NOT PHEO-RELATED

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26
Q

Which medications should be discontinued prior to pheochromocytoma investigations?

(because they increase catecholamine levels)

A
  1. TCAs
  2. Decongestants
  3. Amphetamines
  4. Ethanol
  5. L-dopa
  6. Most psychoactive rx (not SSRIs)
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27
Q

What is the standard first test for suspected pheo?

A

24-hour urine catecholamines/metanephrins

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28
Q

Which 2 cancers are most associated with SCVO?

A

NHL
lung

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29
Q

What are the most common SVCO symptoms?

A

Dyspnea (most common)
Facial/upper limb edema
Chest pain

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30
Q

How is SVCO graded?

A

0-5

  1. Edema + vascular distension
  2. Functional impairment from edema
  3. Cerebral or laryngeal edema
  4. Severe cerebral or laryngeal edema (stridor), or hemodynamic compromise (spontaneous syncope)
  5. Death

Most presente grade 1-2

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31
Q

What is the best imaging modality for SVCO?

A

CT w. contrast

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32
Q

What grade of SVCO is considered a medical emergency?

A

4

  • severe laryngeal edema
  • reduced LOC from cerebral edema
  • central airway obstruction
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33
Q

What is the immediate approach to SVCO, grade 4 presentation?

A

ACLS to stabilise, then emergent stenting or thrombectomy

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34
Q

What is the approach to SVCO, grade 1-3 presentation?

A
  1. Identify cause
  2. Stent (esp. if chemo/radioresistant tumour)
  3. Chemotherapy if lymphoma/SCLC
  4. Radiotherapy if sensitive
  5. Surgery (rare)
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35
Q

What two signs are indicative of inflammatory breast ca?

A

Skin erythema
Peau d’orange (edema)

1/3+ of breast

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36
Q

What are the diagnostic criteria for inflammatory breast ca?

A
  1. Erythema or edema or warmth on 1/3+ of breast
  2. Duration <6mo
  3. Pathology+ breast ca
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37
Q

What percentage of breast ca are inflammatory?

A

1-2%

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38
Q

For which cancer is paracentesis not an ideal treatment for ascites?

A

Ovarian

(tends to be mucinous)

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39
Q

In which population is diuresis the first-line treatment for ascites?

A

Portal hypertension
- cirrhosis
- large-volume liver disease
- HCC

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40
Q

What test distinguishes ascites likely to respond to diuresis?

A

Serum-ascites albumin gradient >11

this indicates transudative ascites

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41
Q

What is the usual dose ratio for diuretics in ascites?

A

5:2

Spironolactone 100mg + furosemide 40mg

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42
Q

What intervention for ascites has a poor risk:benefit ratio?

A

Peritoneovenous shunting

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43
Q

In which population are large-volume paracenteses safer, malignant- or portal-hypertention-related ascites?

A

Malignant ascites

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44
Q

Do patients with malignant ascites require post-para albumin?

A

Probably not

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45
Q

What volume of transudative ascites likely warrants albumin infusion?

A

> 5L

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46
Q

What is the albumin dose post-paracentesis, if indicated?

A

6-8g per L of fluid, maybe lower

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47
Q

What is the most common cause of “malignant” or transudative ascites?

A

Peritoneal metastases

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48
Q

What is the first test for patients with restless leg syndrome?

A

iron studies

(and workup of the cause of iron deficiency if present)

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49
Q

What substances can worsen the symptoms of restless leg syndrome?

A
  1. EtOH
  2. Caffeine
  3. Dopamine antagonists
  4. Antidepressants
  5. First-gen antihistamines
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50
Q

List some nonpharm. options for managing restless leg syndrome.

A
  1. Good sleep hygiene
  2. Distractions when resting (e.g. games, work)
  3. Regular exercise
  4. Moist heat on legs
  5. Leg massage
  6. SCDs
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51
Q

What is the first prn drug for occasional RLS symptoms?

A

Sinemet

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52
Q

When is regular therapy indicated in RLS?

A

symptoms 2+ days/wk
symptoms impact QOL

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53
Q

What is the best class of drugs first-line for regular treatment of RLS?

A

HS gabapentinoids

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54
Q

What is the second-line drug class for RLS?

A

dopamine agonists

e.g. pramipexole, ropinirole, rotigotine

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55
Q

What is the third-line approach to RLS?

A
  1. Combine gabapentinoid + dopamine agonist
  2. Low-dose opioid
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56
Q

What are the core clinical features of Lewy Body Dementia?

A
  1. Fluctuating attention/LOC
  2. Well-formed visual hallucinations
  3. REM sleep disorder
  4. Bradykinesia or rigidity or resting tremor
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57
Q

What secondary features may develop in Lewy Body Dementia?

A
  1. Profound sensitivity to antipsychotics
  2. Parkinson-type symptoms
  3. ANS dysfunction
  4. Psychotic features
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58
Q

What class of drug is first-line treatment for LBD?

A

Cholinesterase inhibitors (e.g. donepezil, rivastigmine)

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59
Q

What are possible effects of antipsychotic medication in LBD?

A
  1. Parkinsonian crisis
  2. Severe ANS dysfunction
  3. Confusion
  4. Death
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60
Q

If using antipsychotics in LBD, name 2 options.

A

Quetiapine
Clozapine

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61
Q

What are the 3 realms of symptoms present in Huntington disease?

A
  1. Movement/neurological
  2. Psychiatric
  3. Cognitive
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62
Q

What is the defining cognitive impairment in Huntington disease?

A

Exective dysfunction

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63
Q

List some psychiatric symptoms of Huntington disease

A
  1. Depression
  2. Dysphoria
  3. Apathy
  4. Anxiety
  5. Irritability
  6. Agitation
  7. Psychosis
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64
Q

What are the first- and second-line treatments for HD chorea?

A

1st line:
- vesicular monoamine transporter 2 (VMAT 2) inhibitors
- deu/tetrabenazine
- can cause depression

2nd line:
- atypical antipsychotics
- first line in patients with psychiatric disturbance

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65
Q

What is the currently accepted term for “complicated grief”?

A

Prolonged grief disorder

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66
Q

What is (probably) the general prevalence of prolonged grief disorder among the bereaved?

A

10%

studies suck

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67
Q

What is the prevalence of prolonged grief disorder in those who have lost their SO?

A

10-20%

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68
Q

What is the prevalence of prolonged grief disorder in those who have lost a child?

A

60%

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69
Q

List 5 risk factors for prolonged grief disorder (9)

A
  1. Age >60
  2. Female
  3. Low SES
  4. Marginalised populations
  5. Previous mood disorder
  6. Loss of child or spouse
  7. Young decedent
  8. Death by trauma
  9. Multiple losses
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70
Q

What are 3 characteristic features of grief in prolonged grief disorder?

A
  1. “Separation distress”: yearning/preoccupation with decedent
  2. Loss of interest in the world/withdrawal
  3. “Traumatic distress”: disbelief, sense of being dazed, intrusive memories

6+ mo

71
Q

What are 6 maladaptive cognitive patterns associated with prolonged grief disorder?

A
  1. Denial
  2. Ruminating on alternative versions of the death
  3. Self-blame/anger
  4. Intense reactions to reminders of decedent
  5. “Shrine building” or extreme avoidance of reminders of decedent
  6. Emotional dysregulation

not inherently abnormal, but abnormal when prolonged

72
Q

What is the rate of suicidal ideation in prolonged grief disorder?

A

40-60%

73
Q

Name a screening tool for prolonged grief disorder and its 5 components.

A

Brief Grief Questionnaire
1. Difficulty accepting death
2. Grief impairs function
3. Disturbing thoughts about the death
4. Avoiding reminders of decedent
5. Feeling cut off from others

each rated 0-2; 4+ is a positive screen

74
Q

What is the three-part CSPCP mission statement?

A

To promote Palliative Medicine in Canada through advanced education, strengthening the workforce, and advocacy.

75
Q

What is the four-part CHPCA mission?

A

The Canadian Hospice Palliative Care Association is the national voice for quality hospice palliative care in Canada by providing education, raising awareness, influencing public policy, and collaborating with provincial associations.

76
Q

What % of patients with cancer will develop hypercalcemia?

A

20-30% (c. 1/4)

77
Q

List 4 cancers in which hypercalcemia is common (6)

A
  1. Lung
  2. Breast
  3. Renal cell
  4. Myeloma
  5. Lymphoma
  6. Squamous cell
78
Q

What are the 4 mechanisms of malignant hypercalcemia?

A
  1. Humoral (PTHrP)
  2. Ectopic PTH secretion
  3. dihydroxy-Vitamin D secretion
  4. Osteolytic metastases
79
Q

List 2 cancers associated with humoral hypercalcemia.

A
  1. Squamous cell
  2. Renal cell
80
Q

List 1 cancer and 1 noncancer entity associated with dihydroxy-Vitamin D secretion.

A
  1. Lymphoma (all types)
  2. Granulomatosis
81
Q

List 3 cancers associated with osteolytic metastases leading to hyperCa.

A
  1. Lymphoma
  2. Myeloma
  3. Leukemia
  4. Breast

(i.e. hematological malig + breast)

82
Q

List 2 cancers associated with ectopic PTH secretion.

A
  1. Lung
  2. Ovarian
83
Q

What tests, in order, could be ordered to determine the etiology of hyperCa of malignancy?

A
  1. Ca++ with PTH
  2. PTHrP and dihydroxyvitamin D
  3. Myeloma workup
  4. TSH + Vitamin A
84
Q

List 3 medications that can cause hypercalcemia (5)

A
  1. High-dose vitamin D
  2. High-dose Ca salts + renal failure
  3. Teriparatide (PTH) for osteoporosis
  4. Thiazides
  5. High-dose vitamin A or analogs
  6. Lithium
85
Q

What is the initial dose of calcitonin for hyperCa?

What if the initial dose is ineffective?

A

4u/kg q12h x maximum 48h

8u/kg q12h x 4 max

86
Q

What is the typical onset of bisphosphonates for hyperCa?

A

2-4d

87
Q

At 1 week, are bisphosphonates superior, inferior, or equal to Xgeva/denosumab?

A

Equal (response rates c. 90%)

88
Q

What are the two most common causes of hypercalcemia of malignancy?

A

Humoral (c. 80%)
Osteolytic mets (c. 20%)

89
Q

What are the two most common causes of hypercalcemia of malignancy?

A

Humoral (c. 80%)
Osteolytic mets (c. 20%)

90
Q

What are the two most common causes of hypercalcemia of malignancy?

A

Humoral (c. 80%)
Osteolytic mets (c. 20%)

91
Q

What level could be tested and supplemented (if necessary) prior to bisphosphonate therapy?

A

Vitamin D

92
Q

Which bisphosphonate is superior for hypercalcemia of malignancy management?

A

Zolendronic acid

(superior to pamidronate with response c. 90% vs. 70%)

93
Q

What are the most common side effects of bisphosphonates?

A
  1. Flu-like symptoms
  2. HypoCa
  3. HypoPO4
  4. AKI
  5. Uveitis
94
Q

Which population is less likely to respond to pamidronate (vs. ZA)?

A

Humoral hypercalcemia (i.e. elevated PTHrP)

95
Q

List 4 ways in which neuropathic pain differs from nociceptive

A
  1. Related to direct nerve damage
  2. Dermatomal/innervation involvement
  3. Burning/tingling/shooting/electric quality
  4. May have a central contribution
  5. Presence of hyperalgesia/allodynia
96
Q

List 3 ways in which visceral pain differs from somatic.

A
  1. Poorly localised/large area
  2. Cutaneous referral
  3. Related to internal organ involvement
97
Q

What percentage of cancer patients with pain have a neuropathic component?

A

40%

98
Q

What is the midline retroperitoneal syndrome?

A

Tumour invasion of any midline abdominopelvic structure leading to posterior abdominal wall irritation/nerve plexus involvement.

Pain is epigastric/low thoracic

99
Q

Give 4 examples of visceral pain as related to cancer.

A
  1. Hepatic distension
  2. Bowel obstruction
  3. Peritoneal carcinomatosis
  4. Ureteric obstruction
  5. Retroperitoneal syndrome
  6. Adrenal metastases
100
Q

In order, list the pathways of a visceral nociceptive signal to the cortex.

A
  1. Internal tissues/nerves (e.g. organs)
  2. Local parasympathetic ganglia
  3. Splanchnic nn.
  4. Pre/paravertebral ganglia
  5. Dorsal horn of ipsilateral spinal cord
  6. Spinothalamic tract of the contralateral spinal cord
  7. Reticular activating system (brainstem)
  8. Thalamus
  9. Cortex
101
Q

In order, list the pathways of a somatic nociceptive signal to the cortex.

A
  1. Peripheral tissues/nerves
  2. Dorsal horn of ipsilateral spinal cord
  3. Spinothalamic tract of the contralateral spinal cord
  4. Reticular activating system (brainstem)
  5. Thalamus
  6. Cortex
102
Q

List 4 peripheral pain mediators

A
  1. Substance P
  2. Serotonin
  3. Prostaglandins
  4. Histamine
  5. Bradykinin
  6. ACh
103
Q

List 4 causes/risk settings of bleeding in palliative care (8)

A
  1. Large ENT cancers
  2. Large central lung ca
  3. MDS –> thrombocytopenia
  4. End-stage leukemias
  5. Oral anticoagulants
  6. Severe liver disease (metastatic or cirrhotic)
  7. High-dose radiation
  8. Fungating tumours
104
Q

List 3 classes of drugs associated with increased bleeding risk (6)

A
  1. Anticoagulants
  2. Antiplatelets
  3. Antidepresants, SNRI/SSRI
  4. Corticosteroids
  5. NSAIDs
  6. Chemotherapy (many classes)
105
Q

What 3 features of “hemoptysis” point away from UGIB?

A
  1. Alkalinity
  2. Foaminess
  3. Purulence
106
Q

What % of malignant spinal cord compressions are related to metastatic (vs. primary) disease?

A

90%

107
Q

What are the 4 mechanisms of metastasis leading to SCC?

A
  1. Arterial hematogenous spread to bone (most)
  2. Venous hematogenous spread to bone (prostate ca only)
  3. Ingrowth via neural foramen
  4. (rare) Direct epidural spread
108
Q

What is the order of pathophysiological events in the development of SCC?

A
  1. Growth around thecal sac
  2. White matter edema
  3. Grey matter edema
  4. Spinal infarction
109
Q

What is the first-line imaging modality for malignant SCC?

A

MRI w/ and w/o contrast

CT w contrast if MRI contraindicated

110
Q

Describe the epidural-spinal-cord-compression scoring on MR

A

0: no SCC, tumour in adjacent bone
1. Epidural tumour without contact/just abutting
1a. No compression of sac
1b. Compression of sac but no cord contact
1c. Compression of sac and cord contact w/o compression
2. Compression of cord without circumferential involvement/still some CSF
3. Circumferential involvement or severe SCC

1 is “low grade”
2-3 are high grade

111
Q

What uncommon test is the gold standard / alternative to MR?

A

CT myelography, with dye injection into intrathecal space

112
Q

What are the 3 classic features of leptomeningeal disease?

A

Cranial nn palsies
Headache
Mental status changes

113
Q

What is the defining neurological feature of ALS?

A

Upper + lower motor neuron involvment

114
Q

What are the 2 most common patterns of ALS at presentation?

A
  1. Asymmetric limb weakness (80%)
  2. Bulbar sx (dysarthria or dysphagia) (20%)
115
Q

List 5 good prognostic signs for ALS at diagnosis.

A
  1. Younger age
  2. Limb onset (vs. bulbar)
  3. Longer duration of symptoms prior to diagnosis.
  4. High FVC at diagnosis (>60% predicted)
  5. Higher function at diagnosis
116
Q

List 8 s/sx suggestive of respiratory failure in ALS

A
  1. Dyspnea at rest/minimal exertion
  2. Orthopnea
  3. Nighttime waking with dyspnea
  4. Daytime fatigue
  5. Accessory muscle use
  6. Paradoxical abdominal breathing
  7. Cough weak / accumulating secretions
  8. Hypophonia
117
Q

List 3 indications for BiPAP in ALS

A
  1. FVC <50% predicted
  2. Nocturnal hypoventilation
  3. Dyspnea at rest/minimal activity
118
Q

What is the mean survival from onset of invasive ventilation in ALS?

A

30 months

119
Q

What 3 vaccines should be offered to patients with ALS?

A
  1. Flu shot
  2. COVID
  3. Pneumococcal
120
Q

What are the indications for enteral feeding in ALS?

A
  1. BEFORE FVC <50%
  2. Near diagnosis
  3. Dysphagia
  4. Weight loss
121
Q

What is the current evidence around life-prolongation with enteral feeding in ALS?

A

c. 6-month benefit, no QOL improvement

122
Q

List 5 medication options for ALS related muscle spasticity/cramping

A
  1. Mexiletine
  2. Anticonvulsants
  3. Tizanadine
  4. Baclofen
  5. Gabapentin
  6. Botox
123
Q

List 3 ways to manage thick secretions in ALS

A
  1. Hydration
  2. Mucolytics (NAC, guaifenesin)
  3. Humidified air
  4. Cough augmentation
  5. Suction
124
Q

What is the pseudobulbar affect?

A

Sudden uncontrolled episodes of laughter or crying.

Potentially related to impaired descending modulation of emotional expression.

Also called emotional lability or incontinence

125
Q

What is the standard pharmacological treatment for pseudobulbar affect?

A

Quinidine + dextromethorphan
30mg each bid (lower quinidine may work)

Quinidine serves to reduce DM metabolism by CYP

126
Q

What form of dementia are patients with ALS at higher risk for?

A

Frontotemporal

127
Q

Which class of antidepressants should be considered first-line in ALS?

A

TCAs

(they also treat sialorrhea, pseudobulbar affect, insomnia)

128
Q

What is the main dividing line in neuroendocrine tumours, other than system of origin?

A

Well-differentiated vs. poorly
- affects prognosis/treatment
- aka “neuroendocrine tumour” vs. “NE carcinoma”

129
Q

What is the alternative (old) name for well-differentiated neuroendocrine tumours of the hollow digestive organs?

A

Carcinoid tumours

130
Q

What is a neuroendocrine tumour of the lung?

A

Small cell lung ca

131
Q

What peptides cause symptoms of carcinoid syndrome?

A
  1. Serotonin
  2. Vasointestinal peptide (VIP
  3. Gastrin
  4. Histamine
  5. Bradykinin
132
Q

Neuroendocrine tumours of what embryological origin tend to cause carcinoid syndrome?

A

Midgut (small intestine + colon)

133
Q

List 5 peptides secreted by functional pancreatic NETs.

A
  1. Insulin
  2. Somatostatin
  3. VIP
  4. Gastrin
  5. Glucagon
134
Q

Describe the carcinoid syndrome.

A
  1. Chronic episodic flushing
  2. Chronic episodic hypotn/tachycardia
  3. Chronic episodic diarrhea
  4. +/- R sided heart valve failure
  5. +/- Chronic episodic bronchospasm
135
Q

What is the classic triad of a functional somatostatinoma?

A
  1. Diarrhea/steatorrhea
  2. Cholelithiasis
  3. T2DM
136
Q

What is the mechanism of paraneoplastic syndromes of the nervous system?

A

Antibody/humoral immunity cross-reactivity between tumour and nervous system antigens.

137
Q

What areas of the nervous system can be affected by paraneoplastic syndromes?

A

All!

  • CNS
  • PNS
  • neuromuscular junctions
  • muscle tissue directly
  • retinas
138
Q

What percentage of lung ca are associated with paraneoplastic hyperCa?

A

6%

139
Q

What cancer accounts for 75% of malignant SIADH?

A

SCLC

10% of SCLC cause SIADH

140
Q

What are the symptoms of malignant SIADH?

A
  1. Confusion
  2. Anorexia/NV
  3. Cerebral edema (if acute)
141
Q

What is the mechanism of Lambert-Eaton syndrome?

A

Autoantibodies targeting voltage-gated-Ca-channels
- reduced ACh release at NMJ

142
Q

What is the presentation of Lambert-Eaton syndrome?

A
  1. Progressive proximal muscle weakness (esp. legs)
  2. Reduced DTRs
  3. Ptosis and/or diplopia
  4. Recovery of reflexes/strength with brief vigorous exercise (unique to LES)
  5. Limited respiratory muscle involvement
143
Q

What hematological changes are commonly found in lung cancer?

A
  1. Anemia (40%)
  2. Leukocytosis (15%)
  3. Thrombocytosis (15%)
144
Q

What bony paraneoplastic syndrome can be seen in lung ca?

A

Hypertrophic osteoarthropathy
- clubbing of nails
- symmetrical pain in joints/long bones
- esp. distal joints (elbows/knees down)
- treated with steroids/NSAIDs/cancer treatment

145
Q

What 3 features point away from a rheumatoid arthritis diagnosis and toward paraneoplastic polyarthritis?

A
  1. Male sex
  2. Asymmetry
  3. High serum inflammatory markers
146
Q

What three cancer types are most associated with paraneoplastic syndromes?

A
  1. Lung
  2. Gyne
  3. Lymphoma
147
Q

Do the majority of paraneoplastic syndromes present before or after cancer diagnosis?

A

Before (60%)

148
Q

What % of patients in PC struggle with sexuality?

A

50-70%

149
Q

List 3 common barriers to assessing sexuality in PC patients.

A
  1. Inadequate training
  2. Clinician discomfort
  3. Assuming old people don’t have sex
  4. Assuming sex is only intercourse
  5. Assuming treatments are not available
  6. Assuming other providers will ask
  7. Assuming single people don’t have sex
  8. Discomfort with nontraditional sexualities (heterosexism)
150
Q

List 3 sample questions in a PC sexual history.

A
  1. Many of my patients have challenges with sexuality. Do you have any?
  2. Treatment may impact intimacy. Has it affected you?
  3. Is your physical relationship important? Has your illness impacted it?
  4. Does your living situation affect intimacy?
  5. Can we help you reestablish physical intimacy?
  6. Would you like help talking about this with your partner?
151
Q

List 3 issues that impact female sexuality in PC.

A
  1. Libido loss
  2. Vaginal dryness
  3. Dyspareunia
  4. Vaginismus
  5. Pelvic floor dysfunction
152
Q

List 3 issues that impact male sexuality in PC.

A
  1. Libido loss / ED
  2. Urinary incontinence
  3. Vasomotor symptoms
  4. Penile shortening d/t treatment
153
Q

List 8 non-symptom topics to discuss with families at the deathbed.

A
  1. DNR/ACP
  2. Funeral home
  3. SDM
  4. Encourage them to talk/touch
  5. Prognosis
  6. Educate around thirst/hunger/oral care
  7. Explain/provide plans for any crises
  8. Discuss any culturally relevant EOL/postmortem needs (e.g. lying in state, family washing body)
154
Q

What is the survival curve post-dialysis withdrawal?

A
  1. 10 days: 70% dead
  2. 30 days: 97% dead
  3. 100 days: 99%
155
Q

List 5 factors that predict earlier mortality after dialysis is d/c

A
  1. Male sex
  2. White
  3. Hospital inpatient
  4. Lower PPS
  5. O2 needs
  6. Peripheral edema
  7. Reduced oral intake
  8. DNR
156
Q

List 5 symptoms expected after dialysis withdrawal.

A
  1. Fatigue
  2. Pruritus
  3. Drowsiness
  4. Dyspnea
  5. Edema
  6. Agitation
  7. Pain
  8. Nausea/vomiting
157
Q

Define “frailty”

A

Age-related syndrome of physiological decline, characterised by vulnerability to complications from medical and surgical treament.

Other features include:
- weakness/fatigue
- multimorbidity

158
Q

What is the prevalence of frailty?

A

Difficult to say–definitions vary.
c. 10-15% of >65
c. 45% of >65 + cancer
c. 40% >95

159
Q

What three major outcomes does frailty increase one’s risk for?

(outcomes not related to comorbidities)

A
  1. Hip #
  2. Disability/institutionalisation
  3. Hospitalisatiom
160
Q

What are the 2 main conceptual frameworks of frailty?

A

Syndromic/phenotypical frailty: based on symptoms and signs such as wakness, slow gait, and fatigue.

Index frailty: based on the accumulation of comorbidities/insults resulting in frailty.

161
Q

Name a simple 5-part frailty screening scale and its components.

A

FRAIL scale
1. Fatigue (most/all of the past 30d)
2. Resistance (difficulty on 1 flight of stairs)
3. Ambulation (difficulty walking 1 block)
4. Illnesses (5+ of a list I won’t include)
5. Loss of weight (5%+ in past year)

Each scored 0-1
0 = robust
1-2 = pre-frail
3-5 = frail

162
Q

What is the key physiological aspect of frailty?

A

Senile sarcopenia

163
Q

At diagnosis of frailty, what is an essential intervention?

A

Goals of care!
- tests and interventions are often less beneficial
- frail patients at higher risk of complications

164
Q

List 4 interventions for frailty with evidence for efficacy

A
  1. Group (but not individual) exercise
  2. Nutritional enhancement (diet, SLP, dental, mood, medication s/e)
  3. Cognitive training
  4. OT assessment for ADLs
  5. Vitamin D (maybe)
  6. Deprescribing
165
Q

What are the cytokines associated
with tumour-related fever?

A
  1. IL-1
  2. IL-6
  3. TNF-a
  4. Interferons
166
Q

Which cancer types are most ass’d with fever?

A
  • RCC
  • Lymphomas
  • HCC
167
Q

Define febrile neutropenia

A
  1. Neutrophils <0.5 (ANC <500)
    AND
  2. 1 temp 38.5+ or 2 temps 38.0+ in 24h
168
Q

Which two populations suffer
from iatrogenic hot flashes in PC?

A

Women in ovarian failure/post TSO
Men on estrogens/GnRH agonists

169
Q

What are the core elements
of clinically diagnosing brain death?

A
  1. GCS 3
    a. No movement in response to stimuli
    b. No seizures
  2. Absent cranial nerve reflexes
    a. Pupillary response
    b. Corneal reflex
    c. Neg- caloric testing
    d. No gag/cough with deep suction
170
Q

What are invx to support a
brain death diagnosis?

A
  1. No vagal nerve response to atropine
    a. i.e. HR changes <10bpm
  2. Absent central respiratory drive
    a. Ventilate on 100% O2 x 20 min.
    b. ABG
    c. Stop ventilation
    d. Repeat ABG in 10 minutes
    e. If PaCO2 is >60mmHg, brain dead
    f. Stop early if hypoxemic
  3. Cerebral perfusion imaging
  4. EEG (isoelectric = brain dead)
  5. Transcranial Doppler (no diastolic drop)
  6. ICP = SBP
171
Q

Describe key aspects of preparing
to withdraw a ventilator support

A
  1. Close contact with family
    a. Encourage comforting rituals
    b. Describe what will/may happen in explicit and simple terms
    c. Describe your plan for comfort care
  2. Ensure family can be present
  3. Document GOC, plan, outcome
  4. Reduce medications/tubes/restraints
  5. Stop paralytics
  6. Ensure sedation before/during/after
172
Q

Describe an approach to sedation
during ventilator withdrawal

A
  1. Sedate all patients, even comatose
  2. Physician present until stable sx
  3. Ideally use IV > subq route
  4. Midazolam 5mg bolus then 1-5mg/h
  5. Phenobarb bolus, 1-2mg/kg at 50mg/h rate
    a. Then infuse 2mg/kg/h
    b. Superior if patient more wakeful
  6. Consider propofol (req. anesthesia)
173
Q
A

Adam's Weak Spots (8 decks)

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