Geriatrics/Oncology/Palliative care

Question 1

List some hall marks of cancer.

Answer 1

Resisting cell death
Inducing angiogenesis
Avoiding immune destruction
Genomic instability and mutation
Evading growth suppressors
Sustaining proliferating signals

Question 2

What is tumour lysis syndrome?

Answer 2

Metabolic abnormalities + Renal impairment
Due to lysis of rapidly proliferating tumour cells releasing their content into the circulation
AKI + Hypocalcaemia/HypoMg, Hyperkalaemia, Hyperuricaemia, hyperphosphatemia

Question 3

List some classes of chemotherapy, an example and their MOA.

Answer 3

Anti-metabolic - 5FU - Incorporates itself in to DNA generating DNA damage
Alkylating agents - Cisplatin, carboplatin - Covalently bind to DNA inhibiting protein synthesis
Taxanes - Docetaxel - Binds tubulin and inhibits mitotic spindle, induces apoptosis

Question 4

What are some indicators of a dying patient?

Answer 4

Reduced level of functioning
Reduced consciousness
Difficulty swallowing medication and solid food
Withdrawal
Reduced cognition
Death rattle - breathing changes and secretions
Poor appetite
Terminal restlessness 
Profound weakness

Question 5

List some causes of falls.

Answer 5

DAME
Drugs - plus alcohol
Age - related change (Gait, sensory impairment, muscle weakness, balance problems)
Medical - CVD, heart disease
Environment - Carpets, pets, lighting

Question 6

What drugs may cause postural hypotension?

Answer 6

Nitrates, ACEi, Diuretics, L-DOPA, Antidepressants

Question 7

What is postural hypotension?

Answer 7

A fall in systolic bp by at least 20mmHg (or 30mmHg if HTN) ± a fall in diastolic by at least 10mmHg with sx, within 3 min of standing

Question 8

What is the difference between pyramidal and extrapyramidal tracts?

Answer 8

Pyramidal - VOLUNTARY mouvement - from motor cortex

Extra-pyramidal - INVOLUNTARY movement - from brainstem nuclei

Question 9

Explain the grading of pressure ulcers.

Answer 9

Grade 1 - Non-blanching localised erythema, intact skin, may be a different temperature to the surrounding skin and be tender.
Grade 2 - Partial thickness - superficial skin loss, a shallow open ulcer without slough
Grade 3 - full thickness skin loss - subcutaneous fat exposed, may have sinus formation. slough
Grade 4 - Full thickness tissue loss- exposed to the tendon, muscle or bone, sinus formation

Question 10

Define unintentional weight loss

Answer 10

5% reduction in body weight over 6-12 months without a known cause.
In a 70kg (11stone) adult - 3.5kg (0.5 stone)

Question 11

List some causes of weight loss.

Answer 11

Psychiatric - Eating disorder, depression, dementia, stress
Endo- diabetes, hyperthyroidism, addisons
Malnutrition - poor dietary intake, malabsorption
GI - coeliac, IBD, ulcers
Inflam - RA, SLE, polymyalgia rheumatica
Infective - TB, HIV, bacterial or viral
Neuro - MS, MND, Stroke
medications, malignancy, intentional

Question 12

What triad is associated with frailty and define it.

Answer 12

Sarcopenia, polypharmacy, multimobidity
A common clinical syndrome of increased vulnerability and functional impairement due to progressive changes in multiple organ systems

Question 13

What scoring systems are used in fraility?

Answer 13

Fried

Rockwood clinical fragility score

Question 14

Define sarcopenia?

Answer 14

Loss of skeletal muscle mass and strength as a result of ageing

Question 15

What tests could you do on a geriatric pt who presents with low mood?

Answer 15

PHQ-9 is standard GP assessment tool
MOCA (montreal cognitive assessment)
GDS (geriatric depression score)

Question 16

What is the commonest complication of chemotherapy?

Answer 16

Neutropenic sepsis

Question 17

How might you treat tumour lysis syndrome?

Answer 17

Aggressive IV fluid resus
Allopurinol
10U insulin 50ml 50% dextrose, 10ml 10% calcium gluconate if hyperK

Question 18

What are some side effects of the chemotherapy group Alkylating agents - cisplatin, carboplatin?

Answer 18

Myelosuppression, neurotoxicity, ototoxicity, nephrotoxicity, VTE risk

Question 19

What is neuropathic pain?

Answer 19

Pain due to damage to the PNS ± CNS, electric shock, tingling, burning, shooting, vice like, pins and needles
e.g. diabetic retinopathy

Question 20

What is nociceptive pain?

Answer 20

Somatic or visceral. Pain due to injury, inflammation or physical pressure detected by the receptors.
Somatic - Arising from infiltration or injury - stabbing pain, localised ache, throbbing, pressure like - e.g. cellulitis pain
Visceral - arising from infiltration, compression or distention of thoracic or abdominal viscera. - liver capsules pain, cramping, gnawing, aching, sharp

Question 21

What are the ways you can give morphine?

Answer 21

1. Twice daily modified release - 10mg bd
2. Regular short acting immediate release morphine

PRN - 1/10 - 1/6 of 24 hour total morphine dose

Question 22

What prognostic tools can be used in palliative care?

Answer 22

SPICT
ECOG - are they fit enough to have intervention 
Rockwood frailty score 
Palliative prognostic index (ppi)
Glasgow prognostic score

Question 23

What are some anticipatory care medications that may be given through a syringe driver?

Answer 23

Morphine, Hycosine butyl bromide, midazolam, levopromazine

Question 24

What might be the cause if back pain worse with coughing or the valsalva manoeuvre?

Answer 24

herniated disc

Question 25

What signs may be present in cervical myelopathy?

Answer 25

UMN in LOWER LIMBS

LMN in UPPER LIMBS

Question 26

What scoring system can be used in Sarcopenia?

Answer 26

SARC - F
Strength 
Assistance in walking 
Rising from a chair
Climbing stairs
Falls

Question 27

What are some common problems in geriatric patients? (geriatric giants)

Answer 27

Falls (instability), Incontinence, confusion (intellectual impairment), immobility, iatrogenic