Med D CBLs Flashcards by Andrea Jayawardena

Red flags for spinal cord compression

Red flags

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

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Management of Spinal cord compression

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

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

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Side effects of opioids

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

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Signs of opioid toxicity

Drowsiness
Hallucinations
Confusion
Pin point pupils
Vomiting
Respiratory depression
myoclonus (involuntary jerking)

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

1.5x more potent

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Indications for continuous subcutaneous infusion

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

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How much stronger is oxycodone injection than oxycodone liquid:

2x more potent

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

GFR < 30

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

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Managing constipation in palliative care patients

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

Assess potential causes
Carry out IX and infection screen
Consider antiemetics
—-> SUBCUT METOCLOPRAMIDE
———> cyclizine may help but might be constipating

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

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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Cyclizine acts on what receptor

HISTAMINE H1

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Haloperidol acts on what receptor

Dopamine D2 receptor

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Odansetron acts on what receptor

Serotonin 5HT3 receptor

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What is agonal breathing?

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

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

Reduced oral intake
Difficulty swallowing
Agonal breathing
Overwhelming fatigue
Fluctuating consciousness
Confusion / delirium
Reduced social interaction

Late signs a patient may be entering last stages of life

Mottled skin
Cool extremities
Irregular respiration (Cheyne-Stokes breathing)
Respiratory secretions

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

Divide by 2

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

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)

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

Preferred place of care and death
Preferences for symptom management, including anticipatory medications
Any care needs after death
Religious / spiritual needs
Personal goals and wishes
Resuscitation status
Review of long term medications
Physical needs
Eating and drinking: hydration status
Concerns regarding carers

How would you verify a death:

Listen for a minimum of 5 minutes:

No visible respiratory effort
No palpable large pulses
No response to painful stimuli
Pupils fixed and dilated
No audible heart or breath sounds
Absence of corneal reflex

Which patients should be discussed with the Coroner?

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

Death confirmation assessment notes

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

Differential diagnoses for lump in neck:

**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

What type of cell is present in Hodgkin lymphoma?

Reed Sternberg cells

Which symptom is often diagnostic for Hodgkin Lymphoma:

**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

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

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-

Key imaging in Hodgkin Lymphoma and clinical significance

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

Summarise treatment modalities for Hodgkin Lymphoma

**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

Acute complications of Hodgkin lymphoma due to treatment

1. Neuropathy 2. Constipation (Vinblastine) 3. Pulmonary toxicity (bleomycin --> lung fibrosis)

Late complications of Hodgkin lymphoma

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. 2. 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

Further investigations for suspected breast cancer

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**

Treatment summary for breast cancer

**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**

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

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

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

**ONCOTYPE DX score** **PREDICT score**

Types of benign breast lumps

- Fibroadenoma - papilloma - adenoma - lipoma - phyllodes tumour