more Flashcards
SSC vs BCC
SCC is more painful and faster growing than BCC
most common lung cancer
adenocarcinoma - originates in peripheral lung tissue
features of squamous cell lung cancer
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.
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?
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).
how to uptitrtte pain relief
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)
Seizure meds in cancer
Leviteracitam - can take at home, Phenytoin/carbamazepine in hospital, Midazolam if near death
Gastric stasis and raised ICP drugs
metaclopramide, cyclizine
Brain mets
Visual changes, headaches, LOC, seizures
Steroids and PPI, analgesia, anti-emetics, radiotherapy
can’t drive
CURB 3 treatment for CAP in cancer patent
Check micro guide
IV co amox and oral clarithro cover as CURB3, co-codamol, fluids
EOLC anticipatory medications (for opioid naive)
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
secretions - death rattle usually indicate
72 hrs death.
important aspect of death
religion - roman catholic to see priest, make aware a pt could die on way home. What do you think patient would want.
cauda equina vs spinal cord compression
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.
radiotherapy for MSCC
one large fraction, or one small dose for pain, old guidelines said 5 doses over 5 days
rules re MSCC
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)
high dose steroids monitor
glucose
dysphagia from oesophageal cancer history
swallowing, fluids and solids, intake, regurgitation, coughing (aspiration), hoarseness, B symptoms
dexamethasone common consequence
thrush
PEG vs RIG
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
features of prescribing fentanyl patches
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 !
key points re empathy
- 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
bowel obstruction supportive Mx in inoperable patients
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)
nausea in cancer pt Dx
Hypercalcaemia, progression of disease, brain mets (movement related, less mentally sharp), gastric stasis, infection, anxiety, dehydration
hypercalcaemia of malignancy management
Give fluids, then 24hrs later give bisphosphonates (zolendronic acid), give anti emetic haloperidol
adjust zolendronic acid to eGFR
Ondansetron indications
chemo, post radiotherapy that has caught the bowel and caused serotonin release, laparotomy
haloperidol for
biochemical
hypercalcaemia levels
over 3.5 severe, 3-3.5 moderate, below 3 is mild
Fluids in hypercalcaemia
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
how to explain cancer progression
cancer has gotten bigger, cancer has spread,
oxycodone to morphine ratio
1.5 to 1
uptitrate on same principals no need to switch
pain in pancreatic cancer that is not responding to opioids can be
neuropathic - coeliac plexus pain
WHO pain ladder
anxiety and neuropathic pain medication
gabapentin and amitryptilline
sleep and neuropathic pain meds
amitryptilline
Longer acting benzo with neuropathic effect, for evening time
Clorazepam
severe neuropathic pain
nerve block
warning for starting dexamethasone on diabetic patient
will mess up their blood glucose
opioid toxicity Mx - resp depression and pinpoint pupils, low sats, check drug chart
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
opioid toxicity on chart example
oxycodone oral to sc, not halved
ALWAYS REMEMBER TO
ESCALATE TO SENIOR
most significant cervical cancer risk factors
HPV subtypes 16,18, 33 are carcinogenic and increase the risk of cervical cancer
breast cancer marker
CA 15-3
Pancreatic cancer marker
CA 19-9
lung cancer markers
neuron-specific enolase (NSE) or cytokeratin fragment (CYFRA) 21-1.
Ovarian and liver cancer markers respectively
CA125 and AFP
lung fibrosis chemo agent
bleomycin
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?
increase MST (morphine sulphate tablets) and refer for radiotherapy
colorectal cancer marker
CEA
cisplatin is associated with
Nephrotoxicity (the primary dose-limiting side effect), Ototoxicity, peripheral neuropathy, hypomagnesaemia
doxorubicin SE
cardiomyopathy
all anti metabolite chemos cause
myelosup
palliative patient with mild-mod renal impairment
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
when is buprenorphine used
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.
Human papilloma viruses 6 and 11 found on smear management
Human papilloma viruses 6 and 11 are non-carcinogenic and associated with genital warts
return to 3 yearly screening and discuss safe sex practice
chronic cough, absence of a smoking history and normal bronchoscopy,
suggests peripheral - adenocarcinoma
N and V palliative due to stasis
metaclopramide
Dopamine (D2) receptor antagonists should be used in palliative care for nausea and vomiting that is due to gastric dysmotility and stasis
renal impairment pain relief
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
resp secretions and bowel colic
Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide
A raised alpha-feto protein level excludes a
seminoma of testicle
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?
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.
painful mouth extra Mx as well as analgesia
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
Glycopyrronium bromide or Hyoscine hydrobromide or hyoscine butylbromide is generally used first-line to manage secretions in a palliative care setting
what form
subcut/IV
chemo nausea not helped by domperidone Mx
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).
Hiccups in palliative care -
chlorpromazine or haloperidol
morphine to diamorphine
divide by 3
