MFE, Oncology & Palliative Care Flashcards
Confirmation of death checklist?
Check patient ID
Look for respiratory effort
Check for verbal response
Check for pain response
Assess pupillary reflexes
Palpate carotid artery (> 1 min)
Listen for heart sounds (> 1 min)
Listen for lung sounds (> 1 min)
“Just in case” medicines and indications?
Morphine sulphate (pain, breathlessness)
Midazolam (agitation, anxiety, breathlessness)
Hyoscine butylbromide (respiratory secretions)
Levomepromazine (N&V)
Pain management ladder?
Mild = paracetamol or NSAID (+ adjuvant)
Moderate = weak opioid + above
Severe = change weak to strong opioid
Weak vs strong opioids?
Weak = codeine, tramadol
Strong = morphine, oxycodone, fentanyl, alfentanil, methadone, buprenorphine
Opioids used in mild-moderate vs severe renal impairment?
Mild-moderate (eGFR < 90) = oxycodone
Severe (eGFR < 30) = alfentanil, fentanyl, buprenorphine
Adjuvant pain medications?
Anticonvulsants e.g. gabapentin
Antidepressants e.g. amitriptyline
Corticosteroids e.g. dexamethasone
Local anaesthetics e.g. lidocaine
Bisphosphonates e.g. zoledronic acid
Breakthrough opioid and oral to subcut morphine calculations?
Breakthrough opioid = 1/6th-1-10th of 24 hour dose
Oral to subcut morphine = divide by 2
How much should an opioid dose be increased each day if required?
30-50%
Morphine is an agonist of which opioid receptor?
Mu (µ) receptor
Signs of opioid toxicity vs withdrawal?
Toxicity = bradycardia, hypotension, hypothermia, sedation, coma, miosis
Withdrawal = tachycardia, diaphoresis, agitation, sneezing/yawning, mydriasis
List some oncological emergencies?
Hypercalcaemia
Cord compression
SVC obstruction
Tumour lysis syndrome
Neutropenic sepsis
Features and management of hypercalcaemia?
Bone pain
Kidney stones
N&V, constipation
Fatigue, depression, confusion
Management = IV fluids (1st line), IV bisphosphonate (2nd line)
Features, investigation and management of malignant spinal cord compression?
Back pain
Leg weakness
Incontinence
Sensory changes
Investigation = whole spine MRI < 24 hours
Management = dexamethasone, analgesia, radiotherapy or surgical decompression (if appropriate)
Main 3 cancers which cause bone metastases?
Prostate
Breast
Lung
Most common sites of bone metastases?
Spine (most common)
Pelvis
Ribs
Skull
Long bones
Management options for metastatic bone pain?
Strong opioids e.g. morphine
Bisphosphonates
Radiotherapy
Features, investigation and management of SVCO?
Breathlessness
Swelling of face/neck/arms
Pemberton’s +ve
Headache
Raised JVP
Visual changes
Investigation = CT chest
Management = dexamethasone, analgesia, radiotherapy or endovascular stenting (if appropriate)
Condition which puts patients most at risk of tumour lysis syndrome?
Haematological malignancy e.g. Burkitt’s lymphoma
Features and management of tumour lysis syndrome?
Myalgia
N&V
Fatigue
Heart palpitations
Urinary disturbance
Management = allopurinol, rasburicase
Biochemical features of tumour lysis syndrome and why?
Hyperkalaemia (from tumour cells)
Hyperphosphataemia (from tumour cells)
Hypocalcaemia (↑ PO = ↓ Ca)
Hyperuricaemia (purine catabolism of nucleic acids produces uric acid)
What is the most common pathway for AKI in tumour lysis syndrome?
- High levels of serum PO bind Ca to form CaPO crystals
- Crystals injure or obstruct tubules
- Reduced urine output
Diagnostic criteria for neutropenic sepsis?
Temperature > 38.5 or 2 readings over 38 + neutrophils < 0.5 (or predicted to be < 0.5 in next 48 hours)
Empirical treatment for neutropenic sepsis?
IV tazobactam + piperacillin (tazocin)
Screening tool for delirium and contents?
4-AT:
Alertness
Age/DOB/time/place
Months of the year backwards
Acute change or fluctuating course
What is delirium? List some causes.
Acute state of confusion:
Pain
Infection
Electrolyte/metabolic
Constipation
Medications
Drug withdrawal
Change of environment
Drug choices for agitation in delirium?
Haloperidol or olanzapine
Examples of bulk forming, stool softening, osmotic and stimulant laxatives?
Bulk-forming = fybogel (ispagala husk), methycellulose
Stool softening = docusate
Osmotic = lactulose
Stimulant = senna, dulcolax (bisacodyl)
Factors favouring delirium over dementia?
Acute onset
Fluctuating symptoms
Impaired consciousness
Poor attention span
Tools for elderly patient medication reviews?
STOPP and START criteria
What causes stress, urge, mixed, overflow and functional urinary incontinence?
Stress = increased abdominal pressure
Urge = detrusor overactivity
Mixed = stress + urge physiology
Overflow = blockage or detrusor underactivity
Functional = can’t get to toilet in time (bladder healthy)
Investigations for urinary incontinence?
Bladder diary
Urine dipstick
Post-void USS
Management of stress incontinence?
1st line = lifestyle changes, pelvic floor exercises
2nd line = duloxetine
3rd line = mid-urethral sling
Management of urge incontinence?
1st line = lifestyles changes, pelvic floor exercises, bladder training
2nd line = tolterodine, solfenacin, oxybutynin (1st line), mirabegron (2nd line)
Adjuvant for post-menopausal women with urinary incontinence?
Intravaginal oestrogen
Most common cause of dementia?
Alzheimer’s disease
Pathology of Alzheimer’s?
- Widespread cerebral atrophy
- ACh deficit from neuronal loss
- Beta-amyloid plaques
- Tau protein (microtubule-associated protein in neurons) aggregates to form neurofibrillary tangles
Areas of brain most affected by atrophy in Alzheimer’s?
Cortex
Hippocampus
Mutations associated with early-onset Alzheimer’s?
Amyloid precursor protein (APP)
Presenilin 1 (PSEN1)
Presenilin 2 (PSEN2)
Mutation associated with late-onset Alzheimer’s?
ApoE4
Drug options for Alzheimer’s?
1st line = cholinesterase inhibitor (donepezil, galantamine, rivastigimine)
2nd line = memantine
Memantine mechanism of action?
NMDA-receptor antagonist
Prevents glutamate excitotoxicity (causes neuronal cell death)
Investigations for dementia?
Cognitive assessment e.g. MMSE, Addenbrooke’s (ACE-III)
Blood tests
Head CT
Features of vascular dementia?
Cognitive deterioration (stepwise)
Evidence of vessel disease
Focal neurological signs
Features of Lewy body dementia?
Cognitive deterioration (fluctuating)
Visual hallucinations
REM sleep disorder
Parkinsonism
Main protein in Lewy bodies?
Alpha synuclein
Types of Lewy body dementia (LBD) and how to distinguish them?
Parkinson’s disease dementia = dementia presents > 1 year after motor symptoms
Dementia with Lewy bodies = dementia presents before, at the same time or < 1 year after motor symptoms
Features of Alzheimer’s disease?
4 As:
Amnesia (short-term before long-term)
Aphasia (communication problem)
Agnosia (poor recognition)
Apraxia (loss of motor control)
Key features of frontotemporal dementia (Pick’s disease)?
Early personality and speech changes
BRCA gene risks in men vs women?
BRCA 1 and 2 in women increases risk of breast and ovarian cancer
BRCA 2 mutation in men increases risk of prostate cancer
Cancer linked to CA 125, CA 19-9, CA 15-3, PSA, AFP, S-100 and CEA?
CA 125 = ovarian
CA 19-9 = pancreatic
CA 15-3 = breast
PSA = prostate
AFP = germ cell tumour, hepatocellular carcinoma
S-100 = melanoma, schwannoma
CEA = colorectal cancer
Antiemetics used for reduced gastric motility?
Metaclopramide
Domperidone
Antiemetics used post-chemotherapy?
Ondansetron
Haloperidol
Levomepromazine
Antiemetics used in raised ICP?
Cyclizine
Dexamethasone
Antiemetic for vestibular N&V?
Cyclizine
Side effects of bleomycin, doxorubicin, vincristine, cyclophosphamide and cisplatin?
Bleomycin = lung fibrosis
Doxorubicin = cardiotoxic
Vincristine = peripheral neuropathy
Cyclophosphamide = haemorrhagic cystitis, transitional cell carcinoma
Cisplatin = peripheral neuropathy, ototoxicity
