disease related sx

Question 1

calcium upper limit of nml

Answer 1

8.5-10.5 mg/dl

12-14 moderate hypercalcemia

> 14 severe

Question 2

hypercalcemia sx

Answer 2

renal: polyuria, polydypsia, dehydration, dec in GFR, nephrocalcinosis

GI: constipation, N, anorexia, V, acute pancreatitis

Neuro: lethagy, fatigue, confusion, irritability, depression, sleep, muscle weakness, stupor, seizure, coma

cardiac: short QT, widened t, heart block, asystole, a-v arrhythmia, (DO NOT give digoxin)

Question 3

corrected Ca

Answer 3

serum Ca + 0.8 (4-albumin)

Question 4

hypercalcemia initial tx

Answer 4

200-400 ml/hr 0.9% NaCl, after rehydrated switch to maintenance fluids.

onset 6 hours, max 24-48h; watch extravasation, fluid overload

stop diuretics

Question 5

hypercalcemia tx algorithm - if <12

Answer 5

asx: send home, 3L fluids/day, repeat Ca in 4 wks
sx: consider other causes, if none->rehydrate, give bisphos

Question 6

hypercalcemia tx algorithm - if >12-14, asx

Answer 6

rehydrate, after urine output give bisphos Z 4mg or P 60-90mg (FOR EXAM PICK Z 4mg)

Question 7

hypercalcemia tx algorithm - if >12-14, sx OR if >14 severe

Answer 7

rehydrate, after urine output give bisphos Z 4mg or P 90mg

onset 24-48h, max 5-7day, duration 17-40d

PLUS calcitonin 4units/kg

onset 1-4h, duration 48-72h

(FOR EXAM PICK Z 4mg)

Question 8

salmon calcitonin ADR

Answer 8

rare anaphylactic rxn (salmon allergy),

facial flushing,

abd cramping

Question 9

bisphosphonate ADR

Answer 9

transient pyrexia, 
malaise, 
thrombophlebitis, 
hypophosphatemia, 
rare osteonecrosis of jaw (association with dental dz, tooth extraction)

NO RECOMMENDATIONS FOR DOSE REDUCTION WITH HYPERCALCEMIA for dental w/u OR for renal dz

Question 10

If Ca remains high at day 7?

Answer 10

repeat bisphos dose

Question 11

if Ca remains high after repeat day 7 bisphos dose?

Answer 11

gallium nitrate OR denosumab

Question 12

SVC pathophysiology

Answer 12

airway obstruction,

cerebral edema,

dec cardiac filling (dec output),

ultimately death

Question 13

SVC clinical signs and sx

Answer 13

signs: thoracic vein distension, neck vein distenction and edema of face, plethora of face, cyanosis
sx: dyspnea, tachypnea, cough, chest pain, dysphagia, sensation of head fullness

Question 14

SVC dx tests

Answer 14

CXR,

CT scan neck and chest,

venography,

bx of mass

Question 15

SVC management

Answer 15

eval sx: mentation (confusion from cerebral edema), airway, hemodynamic function / cardiac compression

If grade 1-3 w/u new primary dx or restage->tx if sensitive to XRT/chemo/surgery,

IF poor sens, recurrent or persistent sx->stent or direct XRT or supportive care (grade 3 consider stent/RT earlier)

if grade 4: stent OR thrombolytics for clot

FOR stenting give anticoag post procedure

Question 16

SVC best supportive care

Answer 16

bed rest with head of bed elevated

oxygen

steroids

diuretics (don’t work well because dec perfusion)

low salt diet to reduce edema

Question 17

pleural effusion lytes criteria

Answer 17

transudate: low protein, low LDH, present because of organ failure

exudate (malignant): high protein, high LDH, more inflammatory marker (cancer or infx)

cytology: cancer

gram stain: infx

Question 18

pleural effusion - symptoms

Answer 18

do not correlate with rate of fluid accumulation (are pt’s able to compensate)

#progressive dyspnea
#persistent cough
#tachypnea
#dull chest pain constant
#tachycardia
#hypoxia
#dullness to percussion

Question 19

pleural effusion - dx tests

Answer 19

CXR,

thoracentesis

exam fluid: cx, gm stain, acid fast stains, cell counts, LDH, protein

Question 20

pericardial effusion - dx tests

Answer 20

CXR,

ekg,

pericardialcentesis,

MUGA, ECHO

exam fluid: cx, gm stain, acid fast stains, cell counts, LDH, protein

Question 21

pleural effusion - tx - initial and ADR

Answer 21

thoracentesis often dx and tx

Question 22

pleural effusion - Denver drain

Answer 22

small pigtail catheter

PleurX catheter

Question 23

pleural effusion - pleurodesis/sclerotherapy for rapid re-accumulation of fluid

Answer 23

obliteraction of pleural space: scar parietal pleura and visceral pleura together

need daily drain output to be <50-100ml /day

lidocaine THEN talc, bleomycin, or doxycycline

Question 24

fatigue score

Answer 24

0 to 10,

NCCN recommends checking every visit,

use 1 to 5 scale for kids

mild (1-3), moderate (4-6), severe (7-10)

Question 25

cancer related fatigue is multifactorial (9pts)

Answer 25

unknown, 
altered sleep, 
meds, 
malnutrition, 
anemia, 
pain, 
immobility, 
emotional distress, 
pre-existing condition

Question 26

cancer related fatigue - management

Answer 26

address multifactorial things you can,
consider PT (not all pts can have)
screen for depression (NOTE tx depression does not necessarily cure fatigue)
nutrition.
modafinil, methylphenidate
(BOTH PROBABLY ONLY WORK FOR SEVERE FATIGUE)

Question 27

coagulation - risk factors (7pts)

Answer 27

#pancreatic CA (adenocarcinoma)
#venous catheter
#inflammatory condition
#drugs (imides, vegf inhibitors)
#damaged or necrotic tumor/nml tissue
#turbulent blood flow
#cancer procoagulants (activates factor 10 ->THIS IS WHY WARFARIN does not work as well)

Question 28

coagulation - best tx to prevent VTE recurrence

Answer 28

dalteparin (OVER enoxaparin, dabigatran» warfarin).

PICK DALTEPARIN ON EXAM

Question 29

coagulation - DVT tx duration

Answer 29

3-6mo if in remission.

Question 30

coagulation - DVT px - negative clot hx

Answer 30

inpt: UFH, lmwh, fondaparinux UNLESS contraindx
outpt: std risk - NONE
outpt: high risk - imides - px but best agent TBD - use UFH, LMWH, or ASA