Oncological Histories & Breaking Bad News

Question 1

When taking a haematological history, alongside you your usual structure/components of history taking, what else should you include?

Answer 1

• B symptoms: fever, night sweats, weight loss >10% 6 months
• Myeloma symptoms: hypercalcaemia, renal failure, anaemia, bleeding & bruising, bone pain, infections, hyperviscosity
• Anaemia symptoms: fatigue, SOB, reduced exercise tolerance, light-headedness, palpitations, pallor
• Thrombocytopenia: bleeding (e.g. epistaxis, gums etc…), bruising, joint swelling
• Leucopenia: frequent infections, infections last longer, unusual infections
• Hyperviscosity: neuropathy, epistaxis, blurred or double vision, headaches, VTE symptoms
• Lumps/bumps: lumps anywhere, painful, abdo pain (splenomegaly)
• Rashes

PMH/Past Surgical HX/FH

• Transfusions & any reactions
• Transplants
• Ask specifically about haematological conditions

Question 2

When taking an oncological history, alongside you your usual structure/components of history taking, what else should you include?

Answer 2

• Systemic symptoms: weight loss, fatigue
• Specific question related to presenting complaint
• FH of cancers (for some age of cancer is important)
• Risk factors (vary for different cancers)
• Lumps bumps: if any lymph node spread
• Questions to gauge performance status (as this is factor in deciding treatment)
• Focus on impact on life “holistic history”

FINISH AFTER BEDSIDE TEACHING

Question 3

What framework can you use for breaking bad news?

Describe each section

Answer 3

• Setting up the interview: appropriate place, privacy, appropriate people present, phones on silent, someone hold bleep
• Perception of pt: find out what they know so far, what they think is going on, what they are worried about, what they are expecting today (basically ICE)
• Invitation to break bad news: is the time okay, do they want someone present
• Knowledge: give warning shot, small chunks, pauses, assess how much pt wants to know
• Emotions & empathy: acknowledge their emotions & show empathy, avoid “I understand” use phrases such as “I can see that”, “I hear that”
• Strategy & summary: propose a strategy, assess response, be open to questions, agree a plan, summarise, decide next meeting/point of contact

Question 4

Outline how to examine a lump/what to look for

*NOTE: focusing on neck lump here but can apply to all lumps

Answer 4

• Site
  
  • Midline:
    
    • Does it move when swallow → thyroid & thyroglossal cysts
    • Does it move when protrude tongue → thyroglossal cyst
• Size
• Shape (regular or irregular)
• Consistency (soft→cyst, hard→malignancy, rubbery→lymph node)
• Fluctuance (fluctuant→cyst)
• Mobility (asking to turn head whilst palpating can help you determine this)
• Temperature (warm→inflammatory/infective)
• Overlying skin changes (erythema, punctum)
• Tenderness (tender→inflammatory/infective)
• Pulsatility & vascular bruit (may suggest carotid artery aneurysm)