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Y4 - Finals Edition > Med D CBLs > Flashcards

Med D CBLs Flashcards

1
Q

Red flags for spinal cord compression

A

Red flags

  1. Pain
    a. In thoracic or cervical spine
    b. Spinal pain aggravated by straining
    c. Localised spinal tenderness
    d. Nocturnal pain
  2. Motor dysfunction
  3. Sensory dysfunction
  4. Bladder and bowel dysfunction
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2
Q

Management of Spinal cord compression

A
  1. Contact the MSCC co-ordinator
  2. Lie flat, log roll
  3. MRI WHOLE SPINE within 24hrs (T1,T2 sequences)
  4. DEXAMETHASONE 16MG STAT or split dosing (8MG BD)
    • PPI
  6. Monitor glucose (due to giving steroids)
  7. Monitor for candida
  8. LMWH unless for surgical intervention
  9. WHO ladder for analgesia
  10. Consider DRE
    - loss of anal tone in cauda equina
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3
Q

Measurement of what is associated with poorer prognosis in metastatic spinal cord compression?

A
  • LDH
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4
Q

Side effects of opioids

A
  • nausea and vomiting
  • constipation
  • confusion
  • itch
  • dry mouth (xerostomia)
  • drowsiness
  • hallucinations
  • sweating
  • LONG TERM: addiction, hypogonadism
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5
Q

Signs of opioid toxicity

A
  1. Drowsiness
  2. Hallucinations
  3. Confusion
  4. Pin point pupils
  5. Vomiting
  6. Respiratory depression
  7. myoclonus (involuntary jerking)
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6
Q

How much stronger is oxycodone immediate release liquid than morphine modified release?

A

1.5x more potent

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7
Q

Indications for continuous subcutaneous infusion

A
  1. Poor swallow and unable to tolerate essential medications: analgesia and anti-seizure medication
  2. Reduced consciousness and requiring essential medications like analgesia and anti-seizure medication
  3. Nausea and vomiting
  4. If absorption via the oral route is impaired for example in bowel obstruction
  5. Requiring more than 2 doses of injectable medication within 24hrs
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8
Q

How much stronger is oxycodone injection than oxycodone liquid:

A

2x more potent

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9
Q

Morphine should not be used with a GFR of what, what could be used instead?

A

GFR < 30

Use alfentanil instead
- can bypass renal excretion
- metabolises in liver

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10
Q

Managing constipation in palliative care patients

A

1st : Give either Senna (Stimulant) or Lactulose (osmotic)

2nd: Give BOTH Senna and Lactulose

THEN consider if opioid induced or not:

OPIOD INDUCED
- methylnaltrexone
- naloxagol
—-> peripherally acting opioid receptor antagonists

NOT OPIOD INDUCED
- try another laxative
- e.g. macrogol (osmotic)
- co-danthramer
- hydrogen hydroxide

LAST RESTORT –> RECTAL INTERVENTIONS

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11
Q

What might you give to help manage a palliative patients nausea?

A
  1. Assess potential causes
  2. Carry out IX and infection screen
  3. Consider antiemetics
    —-> SUBCUT METOCLOPRAMIDE
    ———> cyclizine may help but might be constipating
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12
Q

Benefits and burdens of clinically assisted hydration for some palliative care patients:

A

BENEFITS
- symptom relief
- prolong or improve quality of life
- suffering because needs for nutrition or hydration are not met
- may worsen delirium, fatigue and thirst witholding CAH
- will make family feel better

BURDENS
- hindering natural death
- hydration may increase: nausea, dyspnoea, cough, resp secretions and need to urinate
- does not change prognosis

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13
Q

Cyclizine acts on what receptor

A

HISTAMINE H1

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14
Q

Haloperidol acts on what receptor

A

Dopamine D2 receptor

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15
Q

Odansetron acts on what receptor

A

Serotonin 5HT3 receptor

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16
Q

What is agonal breathing?

A

When someone who is not getting enough oxygen is gasping for air?

17
Q

Signs and symptoms a patient may be entering last days or hours of life and likely to be dying?

A
  1. Reduced oral intake
  2. Difficulty swallowing
  3. Agonal breathing
  4. Overwhelming fatigue
  5. Fluctuating consciousness
  6. Confusion / delirium
  7. Reduced social interaction
18
Q

Late signs a patient may be entering last stages of life

A
  1. Mottled skin
  2. Cool extremities
  3. Irregular respiration (Cheyne-Stokes breathing)
  4. Respiratory secretions
19
Q

Converting from morphine modified release tablets to a continuous subcutaneous infusion?

A

Divide by 2

20
Q

Please describe common symptoms a patient may encounter when dying and what medications you might give to combat this?

A

1. Agitation –> Midazolam 2.5-5mg PRN 1hrly

2. Resp secretions –> Glycopyrronium (also hyoscine hydrobromide or hyscine butyl bromide) 200 micrograms PRN 1hrly

3. Nausea –> cyclizine, haloperidol, levomepromazine

4. Pain/ breathlessness –> 1/6th of total opioid dose in continuous sub cut infusion

5. Delirium –> haloperidol 0.5-1.5mg (max 10mg in 24 hrs)

21
Q

What information should be considered in an individualised care plan of a patient who is thought to be dying?

A
  1. Preferred place of care and death
  2. Preferences for symptom management, including anticipatory medications
  3. Any care needs after death
  4. Religious / spiritual needs
  5. Personal goals and wishes
  6. Resuscitation status
  7. Review of long term medications
  8. Physical needs
  9. Eating and drinking: hydration status
  10. Concerns regarding carers
22
Q

How would you verify a death:

A

Listen for a minimum of 5 minutes:

  1. No visible respiratory effort
  2. No palpable large pulses
  3. No response to painful stimuli
  4. Pupils fixed and dilated
  5. No audible heart or breath sounds
  6. Absence of corneal reflex
23
Q

Which patients should be discussed with the Coroner?

A
  • if unknown cause of death
  • death following an accident: road, work, inpatient
  • not seen within last 28 days
  • post operative death
  • any suggestion of neglect, poor care
  • death in detention - custody, prison
  • industrial illness e.g. mesothelioma
  • suicide
24
Q

Death confirmation assessment notes

A
  • Identify confirmed from wrist band
  • Patient in bed , eyes closed, no signs of life or respiratory effort
  • no palpable carotid pulse for 5 minutes
  • no heart of respiratory sounds for 5 minutes
  • pupils fixed or dilated
  • no corneal reflex
  • no response to supra-orbital pressure
  • no concerns
25
Q

Differential diagnoses for lump in neck:

A

Vascular: carotid body tumour

Infective: reactive lymphadenopathy, sialadenitis

Trauma: haematoma

Autoimmune: Grave’s disease

Neoplasm: Lymphoma, H&N ca. , salivary gland tumour, lipoma, malignant skin cancer

Congenital: cystic hygroma, thyroglossal cyst, branchial cyst, dermoid cyst

26
Q

What type of cell is present in Hodgkin lymphoma?

A

Reed Sternberg cells

27
Q

Which symptom is often diagnostic for Hodgkin Lymphoma:

A

Summary of symptoms
1. High temperature
2. Heavy drenching night sweats
3. Weight loss
4. Fatigue
5. Painless swollen lymph nodes: armpit, neck and groin
6. Splenomegaly
7. cough or breathlessness

Key symptoms
- PEL EBSTEIN FEVER
——> high fevers one to two weeks alternating with an afebrile period of around 1 week

28
Q

What bloods and histological investigations may aid in the diagnosis of Hodgkin Lymphoma?

A
  1. FBC —>
    a. Anaemia? (anaemia of chronic disease, autoimmune haemolytic anaemia)
    b. Thrombocytopenia (bone marrow involvement, ITP or splenomegaly)
    c. Neutropenia
    d. Lymphopenia
    e. Eosinophilia
  2. Hypercalcaemia (unusual)
    a. vit D secretion by Hodgkin Reed Sternberg cells.
  3. Biopsy + histology
    a. Cell surface markers diagnostic:
    1. CD30+
    2. CD15+
    3. CD20-
29
Q

Key imaging in Hodgkin Lymphoma and clinical significance

A
  1. X-Ray
    –> symptoms: SOB, chest pain and cough
  2. USS
    –> for cervical or supraclavicular lymph nodes
    –> guide core biopsies
    –> assess spleen size
  3. CT Staging
    –> to guide biopsy
    –> staging of Hodgkin lymphoma
  4. PET scan
    –> for more accurate staging
    –> patients assessed with PET after 2 cycles of chemo to guide further tx
30
Q

Summarise treatment modalities for Hodgkin Lymphoma

A

1. Radiotherapy
- early disease
- tx for superior vena cava obstruction

2. Chemotherapy
- ABVD
- if still PET positive after 2 cycles —> BEACOPP

3. Chemo-immuno
- Brentuximab Vedotin
(anti-CD30 conjugate)
- if pt resistant to chemo OR replapse

4. Immuno
- PDL1 inhibitor
- Nivolumab

5. Transplant
- Autologous w/ high dose chemo
- allogenic from donor

31
Q

Acute complications of Hodgkin lymphoma due to treatment

A
  1. Neuropathy
  2. Constipation (Vinblastine)
  3. Pulmonary toxicity (bleomycin –> lung fibrosis)
32
Q

Late complications of Hodgkin lymphoma

A
  1. Secondary malignancies
    • acute myeloid leukaemia and other haematological malignancies
  2. Cardiovascular disease
    • Coronary artery disease, arrhythmias, cardiomyopathy and peripheral vascular disease
  3. Pulmonary dysfunction
    • pulmonary fibrosis, bronchiectasis and recurrent chest infections
  4. Endocrine dysfunction
    • hypothyroidism, diabetes mellitus
  5. Fertility and pregnancy
    • gonadal dysfunction with alkylating agents and radiotherapy to pelvic area.
    1. IVF may be required in young females
  6. Neuromuscular complications
    • neuropathy and muscular atrophy
      — vinblastine and brentuximab
  7. Psychological issues
    • impaired quality of life
    • various mental health issues
33
Q

Further investigations for suspected breast cancer

A
  1. Grade and receptor status of the breast cancer
    1. oestrogen receptor
    2. progesterone receptor
    3. HER2
  2. Staging CT scan and bone scan
  3. ECG and cardiac ECHO
    1. any cardiac issues that may influence treatment
  4. Grading determined with pathologist
  5. Staging via TNM system
34
Q

Treatment summary for breast cancer

A

1. Neoadjuvant
- shrink tumour before surgery

2. Adjuvant
- Tx AFTER surgery
—> ANTHRACYCLINE & TAXANE
—–> 2-3 week cycles

3. Radiotherapy
- chest wall / breast
- given in fractions
- damages DNA

4. Hormone
- tamoxifen
- anastrozole (post menopausal)

5. Trastuzumab
- herceptin

6. Palliative

35
Q

What is given in Adjuvant treatment for breast cancer to prevent neutropenic sepsis?

A

anthracycline and a taxane (cycles ever 2-3 weeks)
- G-CSF (growth factor) given to prevent neutropenic sepsis.

36
Q

What scoring system is used to see who would benefit from adjuvant breast cancer treatment?

A

ONCOTYPE DX score

PREDICT score

37
Q

Types of benign breast lumps

A
  • Fibroadenoma
  • papilloma
  • adenoma
  • lipoma
  • phyllodes tumour

Y4 - Finals Edition (40 decks)

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