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1
Q

SSC vs BCC

A

SCC is more painful and faster growing than BCC

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2
Q

most common lung cancer

A

adenocarcinoma - originates in peripheral lung tissue

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3
Q

features of squamous cell lung cancer

A

Squamous cell carcinoma
Squamous-cell lung cancer is the second most common sub-type of lung cancer. The vast majority of people with this type of lung cancer have a smoking history. The tumour may produce parathyroid hormone-related peptide (PTHrp), resulting in hypercalcaemia.

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4
Q

A 76-year-old male is admitted to hospital by ambulance following a fall. He reports reaching up into the cupboard in his kitchen before falling backwards over a stool onto his back. X-rays demonstrate a burst fracture in the lumbar spine, and subsequent MRI confirms compression of the spine at the L1 level.
Which of the following examination findings is most consistent with this presentation?

A

Absent ankle jerk reflexes with upward plantar response

This patient is likely suffering from a conus medullaris syndrome caused by spinal cord compression at the end of the cord just as it tapers from a cord-like structure (upper motor neurons) to peripheral nerves exiting the spine (lower motor neurons). In most patients, this is found at the L1 level. The syndrome presents with a mixture of upper and lower motor neuron signs. It is one of the rare causes of loss of ankle jerk reflexes (lower motor neuron signs) with upward plantar responses (upper motor neuron signs).

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5
Q

how to uptitrtte pain relief

A

add up overall dose of BD plus PRN, then do half that for BD and 1/6 of that for PRN dose. (round PRN to multiple of 5, round down)

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6
Q

Seizure meds in cancer

A

Leviteracitam - can take at home, Phenytoin/carbamazepine in hospital, Midazolam if near death

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7
Q

Gastric stasis and raised ICP drugs

A

metaclopramide, cyclizine

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8
Q

Brain mets

A

Visual changes, headaches, LOC, seizures

Steroids and PPI, analgesia, anti-emetics, radiotherapy

can’t drive

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9
Q

CURB 3 treatment for CAP in cancer patent

A

Check micro guide

IV co amox and oral clarithro cover as CURB3, co-codamol, fluids

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10
Q

EOLC anticipatory medications (for opioid naive)

A

morphine 2.5-5mg s/c PRN for pain and dyspnea, glycopyrronium 200mcg s/c PRN, midazolam 2.5-5mg s/c PRN for anxiety/agitation, Levomepromazine 2.5-5mg s/c PRN for anxiety/agitation/nausea

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11
Q

secretions - death rattle usually indicate

A

72 hrs death.

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12
Q

important aspect of death

A

religion - roman catholic to see priest, make aware a pt could die on way home. What do you think patient would want.

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13
Q

cauda equina vs spinal cord compression

A

Spinal cord compression is more likely to be thoracic with neurology in the upper limbs with bladder & bowel changes being a very late sign. Whereas in cauda equina, the lower limbs are classically affected with earlier bladder & bowel dysfunction and saddle anaesthesia.

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14
Q

radiotherapy for MSCC

A

one large fraction, or one small dose for pain, old guidelines said 5 doses over 5 days

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15
Q

rules re MSCC

A

MRI within 1 hour of presentation, radiotherapy within 1 hour of MRI

complete bed rest until spine is stable - so give catheter (e.g. myeloma could sever spine)

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16
Q

high dose steroids monitor

A

glucose

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17
Q

dysphagia from oesophageal cancer history

A

swallowing, fluids and solids, intake, regurgitation, coughing (aspiration), hoarseness, B symptoms

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18
Q

dexamethasone common consequence

A

thrush

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19
Q

PEG vs RIG

A

Percutaneous Endoscopic Gastrostomy vs Radiologically Inserted Gastrostomy

PEG need to be able to get endoscope down to stomach, RIG just needs fine bore tube down to inflate stomach and then RIG inserted from outside

RIG has higher risk of tube dislodging, infection or adverse event

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20
Q

features of prescribing fentanyl patches

A

Takes 12-24 hours to work, so give some modified release zomorph. Allow PRN oramorph on top.

calculate overall dose of morphine they are TAKING not just prescribed. Divide by 3.6, give as x microgram/hr patch

The patches are designed to deliver approximately 12, 25, 50, 75, and 100 mcg/h fentanyl. Round down !

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21
Q

key points re empathy

A
  • Use statements not relating to you (not I am sorry, or I wish it was better news, more that this will be hard news for you to hear, this is not the news you were hoping for)
  • Ask who they want there, if they are happy to discuss. Make warning shot connected, so relate to symptoms, then say unfortunately not good news, then say are they comfortable to discuss the results now, then say what it is
  • Empathy not sympathy: I can see you are devastated, I can appreciate this is shocking, I can only imagine how hard this is
  • Silences
  • Use what patients knows as much as possible (PERCEPTION), try and get them to put 2 and 2 together (e.g. what are you particularly concerned about, we have found something on the scans that would explain your symptoms you’ve been telling me about, it is not good news, do you want someone with you etc)
  • Use less words, keep relating it back to patient
  • Don’t use minimising language such as this must be quite a shock, just say this must be a huge shock
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22
Q

bowel obstruction supportive Mx in inoperable patients

A

NG and IV fluids, rest bowel and decompress. Limit oral intake NBM. (Venting gastrostomies).

Stop pro kinetic if on metaclopramide, start cyclizine

Give morphine

Dexamethasone for oedema around tumours s/c

Hyosine butyl bromide (buscopan) reduces colicky pain and secretions

ocreotide: somatostatin analogue, reduces volume of secretions

(if wants palliative chemo, will need TPN via large line)

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23
Q

nausea in cancer pt Dx

A

Hypercalcaemia, progression of disease, brain mets (movement related, less mentally sharp), gastric stasis, infection, anxiety, dehydration

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24
Q

hypercalcaemia of malignancy management

A

Give fluids, then 24hrs later give bisphosphonates (zolendronic acid), give anti emetic haloperidol

adjust zolendronic acid to eGFR

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25
Q

Ondansetron indications

A

chemo, post radiotherapy that has caught the bowel and caused serotonin release, laparotomy

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26
Q

haloperidol for

A

biochemical

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27
Q

hypercalcaemia levels

A

over 3.5 severe, 3-3.5 moderate, below 3 is mild

28
Q

Fluids in hypercalcaemia

A

At least 3L over 24 hours (125ml/hour), 4-5L if symptomatic. Bags only come as 1L so write 4 bags, then in time to run put per hour. IV sodium chloride

29
Q

how to explain cancer progression

A

cancer has gotten bigger, cancer has spread,

30
Q

oxycodone to morphine ratio

A

1.5 to 1

uptitrate on same principals no need to switch

31
Q

pain in pancreatic cancer that is not responding to opioids can be

A

neuropathic - coeliac plexus pain

32
Q

WHO pain ladder

A
33
Q

anxiety and neuropathic pain medication

A

gabapentin and amitryptilline

34
Q

sleep and neuropathic pain meds

A

amitryptilline

35
Q

Longer acting benzo with neuropathic effect, for evening time

A

Clorazepam

36
Q

severe neuropathic pain

A

nerve block

37
Q

warning for starting dexamethasone on diabetic patient

A

will mess up their blood glucose

38
Q

opioid toxicity Mx - resp depression and pinpoint pupils, low sats, check drug chart

A

Initial anagement: STOP syringe driver (takes 4 hours to kick in). If resp rate continues to fall then you would give naloxone

Severe: Initial treatment consists of ensuring adequate ventilation and consideration of the opioid antagonist naloxone. Patients should be monitored for re-sedation and antidote dose repeated if necessary.

differential is sepsis, or AKI causing opioid accumulation

39
Q

opioid toxicity on chart example

A

oxycodone oral to sc, not halved

40
Q

ALWAYS REMEMBER TO

A

ESCALATE TO SENIOR

41
Q

most significant cervical cancer risk factors

A

HPV subtypes 16,18, 33 are carcinogenic and increase the risk of cervical cancer

42
Q

breast cancer marker

A

CA 15-3

43
Q

Pancreatic cancer marker

A

CA 19-9

44
Q

lung cancer markers

A

neuron-specific enolase (NSE) or cytokeratin fragment (CYFRA) 21-1.

45
Q

Ovarian and liver cancer markers respectively

A

CA125 and AFP

46
Q

lung fibrosis chemo agent

A

bleomycin

47
Q

A 71-year-old woman with metastatic breast cancer comes to surgery with her husband. She is known to have bone metastases in her pelvis and ribs but her pain is not controlled with a combination of paracetamol, diclofenac and MST 30mg bd. Her husband reports she is using 10mg of oral morphine solution around 6-7 times a day for breakthrough pain. The palliative care team at the hospice tried using a bisphosphonate but this unfortunately resulted in persistent myalgia and arthralgia. What is the most appropriate next step?

A

increase MST (morphine sulphate tablets) and refer for radiotherapy

48
Q

colorectal cancer marker

A

CEA

49
Q

cisplatin is associated with

A

Nephrotoxicity (the primary dose-limiting side effect), Ototoxicity, peripheral neuropathy, hypomagnesaemia

50
Q

doxorubicin SE

A

cardiomyopathy

51
Q

all anti metabolite chemos cause

A

myelosup

52
Q

palliative patient with mild-mod renal impairment

A

Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

53
Q

when is buprenorphine used

A

This medication can only be used on expert advice to treat moderate to severe chronic pain unresponsive to non-opioid analgesics in opioid-naive patients. In these situations, it is usually administered in the form of a patch, making it a much less desirable form of analgesia, as it is difficult to titrate. Even if it can be used in patients with renal impairment, this patient has no contraindication for the usage of oxycodone, making this option incorrect.

54
Q

Human papilloma viruses 6 and 11 found on smear management

A

Human papilloma viruses 6 and 11 are non-carcinogenic and associated with genital warts

return to 3 yearly screening and discuss safe sex practice

55
Q

chronic cough, absence of a smoking history and normal bronchoscopy,

A

suggests peripheral - adenocarcinoma

56
Q

N and V palliative due to stasis

A

metaclopramide

Dopamine (D2) receptor antagonists should be used in palliative care for nausea and vomiting that is due to gastric dysmotility and stasis

57
Q

renal impairment pain relief

A

Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment, as they are not renally excreted and therefore are less likely to cause toxicity than morphine

58
Q

resp secretions and bowel colic

A

Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide

59
Q

A raised alpha-feto protein level excludes a

A

seminoma of testicle

60
Q

A 68-year-old woman has presented with painless jaundice. On examination there is a palpable gallbladder. A cancer blocking the common bile duct is suspected. Blood is taken in order to screen for serum tumour markers.

Which of the following tumour markers is the most relevant to the most likely diagnosis?

A

The correct answer is CA19-9. CA19-9 is the most specific and sensitive tumour marker for pancreatic adenocarcinoma, which is the most likely diagnosis in this clinical scenario. The combination of painless jaundice and a palpable gallbladder (Courvoisier’s sign) is highly suggestive of a pancreatic head tumour causing obstruction of the common bile duct.

61
Q

painful mouth extra Mx as well as analgesia

A

Benzydamine hydrochloride mouthwash or spray may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life

62
Q

Glycopyrronium bromide or Hyoscine hydrobromide or hyoscine butylbromide is generally used first-line to manage secretions in a palliative care setting

what form

A

subcut/IV

63
Q

chemo nausea not helped by domperidone Mx

A

The correct answer is to add a 5HT3 antagonist. This class of drugs, which includes ondansetron and granisetron, are highly effective against chemotherapy-induced nausea and vomiting (CINV).

64
Q

Hiccups in palliative care -

A

chlorpromazine or haloperidol

65
Q

morphine to diamorphine

A

divide by 3

66
Q
A

Y4 pqs cancer (3 decks)

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