GP assistantship 1

Question 1

cancer causing MSCC most common

Answer 1

prostate, myeloma, lymphoma , breast, renal, lung

Question 2

Sympotms of MSCC (break into 2 categories)

Answer 2

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

Question 3

Cauda equina is

Answer 3

tumour pressure below L1/2

Question 4

Causa equina Sx

Answer 4

• sciatic pain - often bilateral
• weakness/ wasting of gluteal muscles
• urinary retention/overflow/incontinence
• saddle anaesthesia - loss of anal sphincter tone

Question 5

diagnosis of MSCC

Answer 5

MRI spine

if contraindicated = discuss w MSCC co-ordinator to determine most appropriate imaging

Question 6

neutropenic sepsis dictionary definition

Answer 6

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.

Question 7

when does neut sepsis normally happen

Answer 7

7-14 days post chemo

Question 8

Ix for neutropenic sepsis

Answer 8

sepsis 6 , full septic screen, cxr, coags, lactate

Question 9

initial Mx of neut sepsis

Answer 9

IV piptaz empirically

Question 10

malignant hypercalcaemia definition

Answer 10

corrected calcium level of > 2.60 in a patient with a known cancer diagnosis

Question 11

prognosis if admitted w hypercalcaemia

Answer 11

survival of 3-4 months (less if malignant hyperCa is resistant)

Question 12

cancers most assoc w hypercalcaemia

Answer 12

myeloma / lymphoma / breast / renal / prostate / SCC of bronchus

can occur in the absence of bony mets

Question 13

Sx of hypercalcaemia (divide into general / GI / Neuro / Cardio

Answer 13

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

Question 14

Mx of hypercalcaemaia

Answer 14

1. admit
2. stop thiazide diuretics
3. rehydrate with IV 0.9% NaCl (aim to 2-4L/day)
4. after 1-2L of NaCl give IV bisphosphonates (zolendronic / pamidronate)

if hyperCa doesnt improve w bisphosphonates specialist advice re –> desonumab / calcitonin

Question 15

other non-malignant causes of hypercalcaemia

Answer 15

primary hyperparathyroidism
sarcoidosis / TB
endocrine conditions = thyrotoxicosis / phaemchromocytoma / primary adrenal insufficency
Drugs = thiazide / vit D + A supplements

Question 16

cancers causing MSVC obstruction

Answer 16

lung cancer or lymphoma –> primarily caused by tumour in mediastinum

Question 17

Onset of MSVC obstruction

Answer 17

usually over weeks–>months but ca be more rapid

Question 18

clincial Fx of SVC obstruction

Answer 18

• 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)

Question 19

Pembertons sign

Answer 19

rising arms causes facial redness

Question 20

Diagnosis of MSVC obstruction

Answer 20

usually clincial but to support diagnosis
Imaging –> CXR and CT chest

Question 21

Initial Mx of MSVC obstruction

Answer 21

• 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.

Question 22

definitive Mx of MSVC obstruction

Answer 22

treat the cause = lung cancer –> chemo/radio
Surgery = stenting and/or angioplasty

Question 23

If SVCO is suspected in pt at the end of life / too unwell for Ix

Answer 23

• 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

Question 24

how common is major haemorrhage in cancer

Answer 24

Bleeding of all types occurs in 14% of patients with advanced cancers. Haemorrhage causes death in approximately 6% of patients.

Question 25

Signs of haemorrhage in cancer pts

Answer 25

Cardiovascular compromise: hypotension, tachycardia
Haematemesis, melaena, haemoptysis, PV or PR bleeding, haematuria or visible external bleeding from a lesion/tumour.

Question 26

Preparing pts and family for anticipated haemorrhage

Answer 26

• 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.

Question 27

Mx options of smaller, recurrent bleeds

Answer 27

oral = transexamic acid
topical = sucralfate paste / adrenaline soaked gauze / trnaexamic soaked gauze
Diathermy / radiotherapy / immobilisation

Question 28

Mx of catastrophic bleeding at end of life

Answer 28

• 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.

Question 29

causes of parkinsonism

Answer 29

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

Question 30

in younger people diagnosed with parkisons should ypu start L-dopa

Answer 30

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