GP assistantship 1 Flashcards
cancer causing MSCC most common
prostate, myeloma, lymphoma , breast, renal, lung
Sympotms of MSCC (break into 2 categories)
Back pain: severe, band around body, radiate down arms/legs, exacerbated by coughing/straining, not relieved by rest, localised tenderness on palp, preventing sleep
Neuro Sx: limb weakness, altered gait, unsteadiness, falls, urinary retention/dribbling/incontinence, faecal incontinence/constipation, altered sensation
Cauda equina is
tumour pressure below L1/2
Causa equina Sx
- sciatic pain - often bilateral
- weakness/ wasting of gluteal muscles
- urinary retention/overflow/incontinence
- saddle anaesthesia - loss of anal sphincter tone
diagnosis of MSCC
MRI spine
if contraindicated = discuss w MSCC co-ordinator to determine most appropriate imaging
neutropenic sepsis dictionary definition
neutrophil count < 0.5 AND a temperature >38 at any time or >37.5 for >1 hour, or other signs and symptoms consistent with clinically significant sepsis.
when does neut sepsis normally happen
7-14 days post chemo
Ix for neutropenic sepsis
sepsis 6 , full septic screen, cxr, coags, lactate
initial Mx of neut sepsis
IV piptaz empirically
malignant hypercalcaemia definition
corrected calcium level of > 2.60 in a patient with a known cancer diagnosis
prognosis if admitted w hypercalcaemia
survival of 3-4 months (less if malignant hyperCa is resistant)
cancers most assoc w hypercalcaemia
myeloma / lymphoma / breast / renal / prostate / SCC of bronchus
can occur in the absence of bony mets
Sx of hypercalcaemia (divide into general / GI / Neuro / Cardio
General : dehydration / thirst / polydipsia / pruitus / fatigue / lethargy / worsening pain
GI: anorexia / wloss/ n+v / constipation
Neuro : confusion / drowsiness / myopathy / seizures / psychosis / coma
Cardio : arrhythmias / brady / prolonged PR / reduced QTc / wide T waves
Mx of hypercalcaemaia
- admit
- stop thiazide diuretics
- rehydrate with IV 0.9% NaCl (aim to 2-4L/day)
- after 1-2L of NaCl give IV bisphosphonates (zolendronic / pamidronate)
if hyperCa doesnt improve w bisphosphonates specialist advice re –> desonumab / calcitonin
other non-malignant causes of hypercalcaemia
primary hyperparathyroidism
sarcoidosis / TB
endocrine conditions = thyrotoxicosis / phaemchromocytoma / primary adrenal insufficency
Drugs = thiazide / vit D + A supplements
cancers causing MSVC obstruction
lung cancer or lymphoma –> primarily caused by tumour in mediastinum
Onset of MSVC obstruction
usually over weeks–>months but ca be more rapid
clincial Fx of SVC obstruction
- Increased SOB, cough, chest pain, stridor, cyanosis.
- Neck and facial swelling, redness, periorbital oedema, engorged conjuctivae.
- Trunk and arm swelling, prominent distended veins on neck and chest wall
- Sensation of choking
- Headache or “fullness”, worse on bending/ lying
- Dizziness
- Visual changes
Decreased level of consciousness (cerebral oedema)
Pembertons sign
rising arms causes facial redness
Diagnosis of MSVC obstruction
usually clincial but to support diagnosis
Imaging –> CXR and CT chest
Initial Mx of MSVC obstruction
- Give dexamethasone 16mg stat (oral or equivalent IV/SC) with a PPI for gastric protection.
- Oxygen as required.
- Elevation of the head.
- Discuss urgently with the Acute Oncology Team and arrange required imaging.
Consider anticoagulation if evidence of thrombosis.
definitive Mx of MSVC obstruction
treat the cause = lung cancer –> chemo/radio
Surgery = stenting and/or angioplasty
If SVCO is suspected in pt at the end of life / too unwell for Ix
- Manage the symptoms in the patient’s preferred place of care.
- Agree an emergency healthcare plan.
- Consider steroids, anticoagulation, symptomatic measures and nursing at 45 degrees for comfort
- Agree an emergency healthcare plan.
how common is major haemorrhage in cancer
Bleeding of all types occurs in 14% of patients with advanced cancers. Haemorrhage causes death in approximately 6% of patients.
Signs of haemorrhage in cancer pts
Cardiovascular compromise: hypotension, tachycardia
Haematemesis, melaena, haemoptysis, PV or PR bleeding, haematuria or visible external bleeding from a lesion/tumour.
Preparing pts and family for anticipated haemorrhage
- Counselling the patient and the family on what may happen and what to do. Answer questions honestly but sensitively.
- Agree an Emergency Healthcare Plan to document Ivan’s wishes.
- Review risk vs benefit of any anticoagulants.
- Review resuscitation status with Ivan and his family.
- Prescribe anticipatory medications including one off 10mg midazolam crisis dose.
- Advise the use of dark towels and dark bedding.
Seek support from specialist palliative care services.
Mx options of smaller, recurrent bleeds
oral = transexamic acid
topical = sucralfate paste / adrenaline soaked gauze / trnaexamic soaked gauze
Diathermy / radiotherapy / immobilisation
Mx of catastrophic bleeding at end of life
- Try to remain as calm possible as to help the dying person achieve a peaceful death.
- Stay with the person, giving reassurance as needed.
- Use dark towels to absorb blood loss. If at home, consider dark bedding.
- If a patient is imminently dying during a bleed and distressed, use a one off crisis dose of 10mg midazolam.
causes of parkinsonism
PSP - posturtal instability, vertical gaze palsy, baxkwards falls
MSA - autonomic dysfunction
Lewy body dementia - dementia within 1 year of onset of motor Sx (FLUCTUATING COGNITION)
Drug induced - metoclopramide, prochlorperazine, anti-psychotics, lithium , sodium valproate
in younger people diagnosed with parkisons should ypu start L-dopa
DELAY as long as poss as response wanes + SE increases
but dopamine agonists and MAO-B inhibitors tend to have worse SE profile than L-dopa
