first weeks Flashcards
spinal cord compression secondary to mets management
16mg oral dexamethasone + proton pump inhibitor (protect against peptic ulceration)
metastatic spinal cord compression imaging
MRI whole spine
neutropenic sepsis definition
Neutropenic sepsis is defined as fever >38 °C or features of sepsis in a patient with a neutrophil count of <0.5 × 109/L.
breast cancer with liver metastasis, - lower abdominal pain and back pain. fallen twice at home,
abdomen is distended and she is tender suprapubically.
What complication of breast cancer is most important to rule out?
Breast cancer commonly metastasises to bone, and spinal metastasis can lead to malignant cord compression.
Acute spinal cord compression is a medical emergency, as delays can lead to irreversible neurological dysfunction.
Symptoms can be subtle, and can manifest as back pain and lower limb weakness. The presenting complaint may be falls due to weakness of the lower limbs.
Her abdominal tenderness may be due to urinary retention, another effect of spinal cord compression.
This patient requires urgent imaging and therapeutic steroids +/- radiotherapy.
neutropenic sepsis Mx
Intravenous piperacillin + tazobactam is a broad-spectrum antibiotic regimen that covers a wide range of potential pathogens, including Pseudomonas aeruginosa, which is a common concern in febrile neutropenia.
line infection organism
Staphylococcus epidermis
This is a coagulase-negative staph, and is a common cause of line infections (particularly in neutropenic patients, from which they can develop neutropenic sepsis)
hepatocellular carcinoma marker
AFP
SVC syndrome Mx
steroids
epidural and A fib, recent surgery, in a cancer patient most likely cause of spine symptoms
Epidural haematoma
This is the correct answer. Acute cord compression in the setting of anticoagulation (atrial fibrillation) and possible iatrogenic dural puncture (epidural analgesia) should prompt consideration of an epidural haematoma, and an MRI whole spine should be performed
SVCO causes
Cancers such as small cell lung cancer, non-small cell lung cancer and lymphomas commonly cause superior vena cava obstruction (SVCO.)
Diffuse large B-cell lymphoma - abdominal pain, cramps and vomiting.
Three days post his second cycle of chemotherapy consisting of Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone.
anuria last 13 hours.
His observations are as follows: Heart rate 110 beats per minute, Blood pressure 90/55, Respiratory rate 25, Oxygen saturation 95% on room air, Temperature 37.4oC.
Which of the following is the most appropriate initial management?
Fluid resuscitation with 500 mL 0.9% sodium chloride
This is the correct answer. This man is presenting with symptoms of tumour lysis syndrome. This is a condition which typically presents a few days after chemotherapy and is common for haematological malignancies, particularly non-Hodgkin lymphomas. The administration of chemotherapy can cause significant cell death in mitotically active tumours, resulting in the extravasation of intracellular contents such as nucleic acids into the circulation. These are then broken down into uric acid and phosphate. Uric acid can precipitate in renal tubules leading to an acute kidney injury, which may cause the anuria as reported by this patient. Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting.
This man has significant risk factors for tumour lysis syndrome and combined with anuria means that he may have an acute kidney injury. The most appropriate management for this should be fluid resuscitation in the first instance, particularly given his hypotension
blood results in TLS
Therefore, hyperkalaemia, hyperphosphataemia and hyperuricaemia (from the metabolism of nucleic acids) are seen.
TLS treatment
Allopurinol can be used in the prevention of tumour lysis syndrome by inhibiting the formation of uric acid. However, in established TLS, rasburicase is preferred due to its faster action in lowering uric acid levels, making it more suitable for acute management
when to consider anti fungals in neutropenic sepsis
In the management of neutropenic sepsis, anti-fungal therapy should be considered in patients who remain febrile after 4-7 days of broad-spectrum intravenous antibiotics
young man with raised AFP and testicular lump most likely to be
non seminoma germ cell tumour
