exam 3 Flashcards
Non-Pharm Tmtx of fatigue
hydration exercise schedules cluster activities naps
Pharmacologic tmtx of fatigue in CA patients
Ritalin/Adderall (Psychostimulants)
Caffeine
BID stimulants dosing should be when?
in AM with breakfast and noon-3pm
when are cancer patients at their lowest point?
when chemo is in full effect
—> maximum side effects
What is Pancytopenia
Anemia (fatigue/pallor)
Thrombocytopenia (petchiae/purpura/bleeding/bruising)
Neutropenia (fever/infection)
Zofran
Treats N/V in cancer patients:
- created for the purpose of treating nausea in cancer patients
- 5HT receptor blocker
- increase in free seratonin, decrease in usable seratonin
Compazine
Treats N/V in cancer patients
- dopamine receptor antagonist
side effects:
- Pseudoparkinsons
- EPS
- tremors
Common S/S of brain tumor
Dizziness
N/V
HA that wakens from sleep
new onset < 5 or > 50 years
Less common S/S of brain tumor
Seizures
Anisocoria
Characteristics of Retinoblastoma
Leukocoria (cast eyes - white look with a light)
Absence of red reflex
NHL Objective findings/general info
- painless lump in groin or axilla
- malignant proliferation of B or T cells
- mediastinal mass - stridor/dyspnea
- SVC syndrome
- enlarged supraclavicular/cervical nodes/epitrochlear
- weight loss
- abd distention
- rebound tenderness
NHL - B or T cells or both
both
HL B or T cells or oth
B cells only
Risk Factors NHL
pesticide exposure (increases HLA antigen)
High birth weight
immunosuppresion
EBV!!!!!!!!!!!!
Hx of treated Hodgkin (effects of chemo+XRT+immunosuppressants)
Malaria exposure (causes T cell suppression and EBV)
Genetics –> chromosomal translocation involving genes for immunoglobulin or T cell receptors
Most Deadly CAs
LUNG CA #1
prostate CA
SVC syndrome AND what type of CA do you see it in
increased CVP (pressures above the heart) increased JVD (neck vein distention) OCCURS IN NHL
Tumor lysis syndrome
tumor cells explode and release K and uric acid in to blood (generally occurs in Renal CAs)
TS genes
if mutated or missing/defective = unregulated proliferation of tumor cells
DNA repair geners
if missing or defective allows mutations and replication
TMTX NHL (most successful)
Chemo + immunotherapy + XRT
“in situ”
- encapsulated
- has not spread
- localized
Sentinel node
- draining cancer site
- first node to be metastasized
Sanctuary sites
PLACES THAT CANCER CAN HIDE FROM CHEMO
- CNS
- testes
Changing from long acting to short acting pain medications
When RTC short acting are no longer working effectively - consider Oxycotin or METHADONE
Sanctuary sites and S/S
PLACES THAT CANCER CAN HIDE FROM CHEMO
- CNS: papilledema, vomiting, lethargy, HA, nuchal rigidity
- testes: unilateral painless enlargement
Patient has a limp, what could this signify?
bone pain
bone tumor
Patient has a limp, what could this signify?
bone pain
bone tumor
Best medication for bone cancers pain
Methadone
Constipation in cancer - treatment
HYDRATION
lactulose
Mirtazapine
Helps with sleep and increasing appetite in cancer patients
Mirtazapine
Helps with sleep and increasing appetite in cancer patients
When to be concerned about an enlarged lymph node
- present > 4 weeks
- > 1 cm in size
onco emergencies
- Neutropenia (WBC < 5) with a fever > 38 degrees
- SVC syndrome
- SIADH
- Tumor lysis syndrome
WILMS TUMOR
- NEPHROblastoma
- does NOT cross midline
- presents w/hematuria and HTN
- may affect other kids
- DO NOT PALPATE - encapsulated tumor, if you break capsule you will spread CA cells and poorer prognosis
Neuroblastoma
- renal CA
- seen normally in INFANTS
- can cross midline
W/U for pediatric abdominal mass
- **Ultrasound (best in peds)
- CT
- labs: UA, CBC, lytes
Patho leukemia
- malignant hematologic disease
- normal bone marrow replaced by blast cells (poorly differentiated, abnormal cells)
- blast cells take over and cause malignancy
- PANCYTOPENIA
- can be B cell or T cell or both
S/S ALL
- bone marrow inflitration and/or extramedullary dz
- PANCYTOPENIA
- bone pain
- limp
- lymphadenopathy
- enlarged spleen
When do you see a mediastinal mass in ALL
- when the cancer is T-cell lineage
W/U ALL
- CBC (can have increased leuks w/pancytopenia)
- CMP (liver and renal panels)
- CXR IF RESPIRATORY DISTRESS AND/OR STRIDOR R/O MEDIASTINAL MASS
- U/S (especially if concern for testicular sanctuary site)
ONCOLOGY:
- bone marry biopsy
- LP r/o CNS sanctuary site
Role of PCP in ALL
- mgmt of all non-cancer related health questions.
- routine visits
- vaccines in coordination w/ oncology
- manage care of pt after DC from onco service and monitoring for further issues
Presenting S/S of NSCLC
- cough
- SOB
- hemoptysis
- likely smoking history
- likely hx of symptoms x months
- ** lung CA patients don’t present normally until CA is advanced)
Objective Findings NSCLC
- absence of breath sounds if lung collapse
- dullness on percussion, decreased breath sounds
Complications of NSCLC
- SVC syndrome
- metastatic spread to abdomen (N/V/abd pain, wt loss)
- neuro symptom involvement 2/2 spinal cord compression from mets
How does chemo work
- treats and controls cancer growth at the level of DNA replication and cell division
Side effects of chemo
- N/V/D
- hair loss
- fatigue
- stomatitis
- decreased appetite
- constipation
- pain
- blood disorders
- bone marrow suppression
- cog. dysfunction
- damage to organs
NHL presentation
- acute abdomen
- abdominal pain/distention/fullness
- constipation
- NON TENDER LYMPH NODE ENLARGEMENT
Dx of NHL / labs
- generally s/s present < 1 mo before dx
- labs : PANCYTOPENIA on CBC,
- hypercalcemia, abnormal LFTs on CMP
- prolonged clotting times on coags
Complications of NHL
- SVC
- GI obstruction/perforation
- bleeding (thrombocytopenia)
- infection (leukopenia)
W/U for NHL
- Labs (CBC, CMP, Coags, DDimer)
- Blood cultures
CMP (LFTs, Calcium, Phos + assess for tumor lysis syndrome) - CXR (PA/lateral)
- r/o mediastinal mass
evaluate airway
exclude other pulm issues such as fibrosis and pneumonia - U/S - assess size of kidneys and patency of urinary tract
- EKG
- CT scan for staging and to r/o mets
MAIN causes of onco issues in kids
- genetics
- mutations (translocations)
T/F: Kids are more responsive to chemo
True
- they tolerate higher doses because they have better organ function
In pediatrics - what causes more issues chemo/XRT or the long term effects of chemo?
Long term effects
Virus associated with increased cancer risk
Epstein-Barr - particularly Lymphoma (HL & NHL)
Red Flags Pedi cancer in Primary Care
mass or swelling (especially unilateral adenopathy present > 4 weeks > 1cm) pallor decreased energy bruising limping prolonged illness fever of unknown origin frequent HA N/V
Extramedullary
dz outside of marrow
Demographics ALL
- usually age 2-6
- T-cell > males
- white > black
s/s of bone marrow failure ALL
- PANCYTOPENIA >> neutropenia (fever/recurrent infection) >> thrombocytopenia (petechiae, bleeding, purpura) >> anemia (fatige/pallor) - bone pain/limp - lymphadenopathy hepatosplenomegaly - decreased testicular size
Most common site to find NHL
intestinal tract –> hence s/s of acute abdomen and abdominal discomfort/fullness/constipation/ N-V
T/F: Bone marrow and CNS involvement is rare in HL
True!
Age distribution for HL
bimodal:
- teens - 25 years
- 50 - 60 years
Characteristic sign of HL
persistent painless adenopathy - USUALLY cervical or mediastinal - unresponsive to ABx
Constitutional B signs in HL and significance
- these are the signs and symptoms in symptomatic HL
- fever of unknown origin 38C > 3 days
- unexplained wt loss > 10% in 6 months
- drenching night sweats
W/U HL
CBC ESR/CRP Serrum Copper/Ferritin LFTs UA (proteinuria)
TMTX HL
- often cure with XRT and/or chemo
usually in combo
Most common solid tumor of infancy
NEUROblastoma
Neuroblastomas begin where?
embryonal malignancy of SNS
Characteristics of neuroblastoma cells
small, round, blue tumors
undifferentiate
bio marker that is a sign of a bad prognosis
MYCN amplification –> rapid tumor progression and poor prognosis
Urine in neuroblastoma
urinary catecholamines are present
poor prognostic histology in neuroblastoma
- stroma-rich w/nodular patterns
- stroma-poor tumors
s/s of NEUROblastoma
- abd pain w/or w/o N/V
- wt loss, anorexia
- fatigue
- bone pain, limp
- **HTN - renal artery compression
- chronic diarrhea - secretion of vasoactive intestinal peptide
Horner syndrome
- neuroblastoma extending into neck
1. pitosis
2. miosis (constricted pupil)
3. absence of sweating on one side of the face
opsoclonus
random eye mvmt and myoclonus
paraneoplastic syndrome
S/S that neuroblastoma has extended to parasinus canal
- weakness
- limping
- paralysis
- bladder/bowel disfunction
“blueberry muffin” skin in cancer
Stage 4S metastatic neuroblastoma
W/U neuroblastoma
CBC UA CMP LFT RFT Coags LDH
MBIG test
- picks up on catacholaminergic cells of tumors
- is able to ID primary and metastatic diesase spots
Tchnetium - 99 bone scan
ID mets to bone
MOST COMMON childhood abdominal and renal malignancy
WILMS TUMOR
Cause of WILMS TUMOR
- neoplastic prolifration of embryonal renal cells
- abnormal TS genes 11p13 and 11p15
Other possible abnormals in WILMS TUMOR
- aniridia (absence of iris)
- hemihyperprophy
- cryptorchism
- hypospadias
diagnostics WILMS TUMOR
- Xray - lung mets
- Renal US - check patency of IVC
- CT/MRI
What is the concern if Wilm’s tumor invades IVC
mets to right ventricle
TMTX Wilms Tumor
- nephrectomy if unilateral
- surgery to debulk
- chemo/XRT
most common OCULAR malignancy of childhood
Retinoblastoma
Retinoblastoma has a high mortality if ….
extra ocular extension
throug sclera or along optic nerve
Leukocoria
- loss of red reflex in eye…white instead
- often called “cats eye”
Patho of Parkinsons
Destruction of dopamine producing cells
TRAP mnemonic Parkinsons
T - tremor
R - rigidity
A - Akinesia (slowed movement)
P - postural instability
Medication Progression Parkinsons
- MAO-B (selegine/rasagiline) -gilines
- Dopamine agonist (Requip/Neopress)
- Carbadopa/Levadopa (Sinemet)
- Apokyn (for gait freezing)
- Amantadine (anticholinergic)
Increase in dopamine causes what?
- Increased Side effects
- increased movement
Short term or long term memory goes first win ALZ
Short term
Antipsychotic Increase risk for:
- Stroke
- Cardiovascular disease
What chronic conditions increase risk for vascular dementia
- HTN
- HLD
- DM
What is mixed dementia
reversible dementia (delirium) with underlying progressive disease
Treatment for vascular dementia
though not reversible nor curable, progression can be slowed by ASA and Plavix
Agnosia
ALZ
- not able to recognize objects
Apraxia
- ability to recognize things but not what to do with them. For example “these are scissors, but what are they for”
Issues present in late stages of ALZ
- Wandering
- increased libido
- increased strength
- behavioral disturbances
- decreased impulse control
What may alter the results of the Folstein MMS scoring in either a better or a worse score
Educational Level
Blessed Dementia Scale
Assesses Functional and Cognitive Ability
Scoring on Blessed Dementia Scale
Higher the number the worse the Dementia
T/F Delirium may have an abrupt onset
True
T/F Dementia symptoms may wax and wane
True
Hospice vs. Palliative Care
Hospice - preparation for death
Palliative Care - supportive, symptomatic tmtx
Treatment of Delirium
Treat the underlying cause
Alteration of the FMR1 protein causes what genetic condition
Fragile X
What is Down Syndrome testing in the first trimester
- Nuchal translucency
- pregnancy associated plasma protein A
- HCG
What is the testing for Down Syndrome in the 2nd and 3rd trimester
- Quad Screening - AFP, HCG, Estradiol, Inhibin-A
- Free fetal DNA cells - in blood of mother
What are the invasive test for Down Syndrome
- CVS
- Amniocentesis
When does screening for ASD start
18 months
- MCHAT
By what age do you usually see ASD symptoms
- by age 3, but could have a delayed dx
Presbycusis
most common cause of hearing loss
Fall risk
PRIMARY PREVENTION
- fall risk interventions - ensure path is clear of items that would increase risk
most important aspect to consider in having a drivers license
- visuospatial skill
What is the most common complication in dementia
- feeding difficulties
-
most common TYPE of dementia
ALZ
ALZ
RAPID forgetfulness, especially of new material
most prevalent dementia
Frontotemporal Dementia
More trouble planning tasks, more behavioral disturbances and disinhibition
Vascular dementia
- Quickest onset, more language problesm
- less forgetful than AD especially with available cues.
Lewy Body Dementia
May have more psychiatric symptoms (psychosis) early in disease
