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EM Board exam > Oncology and Rheumatology > Flashcards

Oncology and Rheumatology Flashcards

1
Q

Spinal Cord Compression

Most common malignant causes (3)

Most common location

Dx pearl

Tx

A

–Big three are lung, breast and prostate (combined = 60%)

•60% thoracic, 30% lumbosacral, 10% cervical

CT/MRI (MRI of the whole spine is best)

high-dose steroids, pre-op, maybe radiation

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2
Q

Airway obstruction

Associated Cancers (4)

A

–Laryngeal CA

–Thyroid CA

–Lymphoma

–Metastatic lung CA

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3
Q

Cancer-Related Pericardial Effusion

Most common cancer types (3)

Other associated causes (3)

A
  • Most common cause is lung / breast cancer
  • Malignant melanoma has a special predilection for the heart

–Radiation

–Infection

–Chemotherapy

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4
Q

Pericardial Effusion

classic findings (6)

definition of associated eponym

A

–Hypotension / narrow pulse pressure

–Jugular venous distention

–Diminished heart sounds

–Pulsus paradoxus greater than 10 mmHg (an exaggeration of the normal physiologic response)

–Low QRS voltage

–Cardiomegaly on x-ray without evidence of CHF

Pulsus paradoxus: abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.

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5
Q

Superior Vena Cava Syndrome

most common malignant cause

Non-malignant etiologies

A

–Bronchogenic lung cancer (70%)

–Lymphoma (12%)

Non-malignant causes

–Goiter

–Pericardial constriction

–Thrombosis

–TB

–Radiation

–Central lines

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6
Q

Superior Vena Cava Syndrome

Tx - med(2), proc (2)

Less common sx

A

Steroids, diuretics, radiation if appropriate, SVC stenting

–ICP increase (may cause syncope [10%])

–Dyspnea (54%), cough (54%), hoarseness (17%)

–Papilledema

–Neck (63%) and upper chest vein congestion (53%)

–Facial plethora / telangiectasia (20%)

–Occasionally a palpable supraclavicular tumor mass

–Enlarged mediastinum on CXR

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7
Q

Cancer-Related Hypercalcemia

Prognosis

Mechanism (2), most common

Most common cancer types (2)

A

•10-30% of CA patients. Poor prognostic sign – 80% die within a year (median survival = 6 weeks)

Mechanism

–Tumor cells produce PTH-rP (PTH related protein) which mimics hyperparathyroidism ->increased bone resorption and renal calcium retention. This is most common cause (80%) Caused by any solid tumor. Squamous cell lung, breast most common causes.

–Osteolytic metastasis (lung and breast CA most common)

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8
Q

Hypercalcemia relationships

  • Calcium and albumin
  • Calcium and phosphate
  • Calcium and pH
A

•Calcium and albumin

–Most calcium is bound to albumin

–Low serum albumin = low serum calcium

–Biologically active calcium is the ionized unbound component

•Calcium and phosphate

–Inverse relationship: when one declines the other increases

•Calcium and pH

–Alkalosis causes a decrease in ionized calcium and an increase in bound calcium = functional hypocalcemia

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9
Q

Hypercalcemia

Tx (4)

A

Hydration with isotonic saline

–Loop diuretics – increase calcium excretion (thiazides decrease calcium excretion)

–Calcitonin (inhibits bone resorption and increases calcium excretion, onset 4-6 hours, duration of action 6-12 hours) / max lowering effect, 1-2mg/dl)

–Bisphosphonates – block osteoclastic bone resorption - takes 1-3 days for effect (pamidronate /zoledronic acid)

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10
Q

Short QT cause

A

hypercalcemia

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11
Q

Cancer-Related SIADH

Common causes

Mechanism

Associated findings (3)

Tx (3)

A
  • cancer of the brain, lung, pancreas, duodenum, thymus, prostate and lymphosarcoma (think of midline cancers)
  • Ectopic secretion of ADH (excess antidiuretic hormone will cause water retention)
  • Manifestations

–Hyponatremia / low osmolality / normovolemia

–Less than maximally dilute urine

–Excessive urinary sodium excretion

•Treatment

–Find and eliminate cause

–Fluid restriction

–Hypertonic saline if seizures or cardiac arrhythmias

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12
Q

Cancer-Related Hyperviscosity Syndrome

common causes (3)

etiology (2)

Sx and cause

Tx (3)

A
  • Usual causes - macroglobulinemia, multiple myeloma, CML
  • Due to marked increase in serum proteins (usually immune globulins) or WBCs
  • Symptoms due to sludging of blood flow and reduced perfusion and microthromboses
  • Fatigue, headache, anorexia and somnolence are early findings (sounds a lot like hypercalcemia)

Tx: hydration, phlebotomy and plasmapheresis

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13
Q

These sx might suggest:

–AMS

–Anemia

–Hypercalcemia

–Rouleaux formation on peripheral smear

–“Sausage-linked” retinal vessels on fundus exam

–Factitious hyponatremia

A

Cancer-Related Hyperviscosity
Syndrome

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14
Q
A

“Sausage-Linked” Retinal Vessels suggestive of hyerviscosity

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15
Q

Cancer-Related Adrenal Insufficiency

Cause

Precipitants

Sx cluster

Dx pearl

A
  • May occur from tumor that invades adrenals or adrenocortical suppression
  • May be precipitated by infection, dehydration, surgery, trauma
  • Consider in all cancer patients with fever, dehydration, hypotension and shock
  • Empirically treat steroid-dependent cancer pts who have the above findings /get cortisol level before empiric tx

Bottom line: Cancer pt on steroids with sepsis-like picture?

Think adrenal insufficiency!

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16
Q

This suggests:

  • Hypoglycemia
  • Hyponatremia
  • Hyperkalemia
  • Eosinophilia

Treatment

A

Cancer-Related Adrenal Insufficiency

•Patients without adrenal function need about 35-40mg of hydrocortisone per day (250-500mg as an emergency dose to treat adrenal insufficiency crisis)

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17
Q

Tumor Lysis Syndrome

Timing

Most common causes

Labs (4)

Sx

Dx pearl

A
  • 12-72 hrs post treatment
  • Blood-based cancers are particularly prone to causing TLS – non-Hodgkins lymphoma, acute or chronic lymphocytic or myelogenous leukemia / breast, testicular, small cell lung
  • Release of intracellular electrolytes with elevations of K (the most life-threatening component of TLS), Mg, PO4 and decreases of calcium (from combining with phosphorus and precipitating)

Sx: based on labs abls as above + Extensive DNA / RNA breakdown causes uric acid precipitation in the tubules and acute nephropathy

  • LDH elevations indicate extensive cell lysis
  • Manifestations – rapid onset and life-threatening
  • Dehydration and renal insufficiency predispose
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18
Q
A
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19
Q

Tumor Lysis Syndrome

Tx (3 categories)

A

Reduce PO4 – hydration and forced diuresis / oral phosphate binders (aluminum hydroxide) / hemodialysis

Reduce K – hydration, furosemide / aerosolized adrenergics / glucose-insulin infusions / oral potassium binders (sodium polystyrene – works very slowly)

Reduce uric acid: alkalinization of the urine, Allopurinol and Rasburicase

20
Q
A

Tumor Lysis Syndrome

Peaked Tws from hyperkalemia, uric acid crystals

21
Q

Joint Fluid Analysis

First 2 most useful tests

Cell count useful for

glucose low in

A

•Culture is 1st, gram stain, crystal exam, cell count, glucose

Cell count: inflammatory vs non (eg not a great test for septic vs gout etc)

> 50k typical for SA; < 2000 for non-inflammatory

septic arthritis and RA

22
Q

Septic Arthritis

most common cause overall and

newborn, children
sexually active adult
sickle cell
SLE

A

Staph aureus, #2 = Strep
newborn, children: staph, group B strep
sexually active adult: Neisseria gonorrhea, staph
sickle cell: salmonella
SLE: salmonella

23
Q

Septic arthritis

IVDU location and pathogens

joint prosthesis, pathogen by timing

A

•IVDU- often involves axial skeleton (ribs, vertebrae, sternoclavicular and SI joints), often Gram negatives & Pseudomonas

–Joint prosthesis – early after surg. = Staph / late = Gram neg

24
Q

Gout versus pseudo-gout
crystal type
the etiology
locations
who

A
25
Q

Gout vs. Pseudogout

crystal shape
x-ray findings
treatment

A

Gout: needle shaped; pseudogout: rhomboid

X-ray: pseudogout shows calcification of joint cartilages
NSAIDs, colchicine, steroids
for gout allopurinol (decreases uric acid production), probenecid (increases uric acid excretion)

26
Q
A

Chondrocalcinosis due to pseudogout

27
Q
A

Chondrocalcinosis due to pseudogout

28
Q

Gonococcal arthritis

epidemiology, timing

characteristic finding
diagnostic and tx pearl

A
  • More common in females (4:1)
  • Symptoms often start during menses
  • Begins with fever, chills, migratory tenosynovitis, arthritis (knee, ankle, wrist)
  • Characteristic rash in 2/3rds - hemorrhagic, necrotic pustules with surrounding erythema (usually occurs first on distal extremities)
  • Blood and joint cultures are frequently negative for GC
  • Treat empirically in young female patients with fever, migratory polyarthritis and polytendonitis
29
Q

fever, chills, migratory tenosynovitis, arthritis (knee, ankle, wrist)

young woman

rash

Dx = ?

A

Gonococcal Arthritis

30
Q

Antiphospholipid Syndrome
general definition
manifestations
treatment

A
  • A noninflammatory autoimmune syndrome generating antiphospholipid antibodies whose primary pathologic process is thrombosis (both arterial and venous) –occurs mostly in young women (age 30-40)
  • Multiple potential manifestations:

–Stroke / MI / retinal vessel thrombosis / PE / placental ischemia and recurring fetal loss

–Responsible for 15-20% of all DVTs under 50 and 1/3 of strokes in this age group

–Catastrophic APL syndrome:

•Sudden, diffuse vascular occlusion leading to multi-organ failure

Tx: lifelong warfarin

31
Q

Rheumatologic Arthritis Emergencies (3)

A

Septic arthritis: consider with mono articular flareup
Atlantoaxial subluxation: upper extremity symptoms
–Cricoarytenoid arthritis / symptoms often precipitated by laryngeal manipulation or infection / hoarseness, fullness in the throat or FB sensation / stridor – laryngoscopy can show laryngeal edema, reduced cord motility

32
Q
A

Atlantoaxial subluxation

33
Q

Rheumatologic Arthritis

treatment classes
treatment complications (2)
A

treatment classes (both –DMARDs, disease-modifying anti-rheumatic drugs) :

  • conventional (methotrexate) and Biologics (more selective), usually second line due to increased risk of complications

treatment complications: infection and cancer

34
Q

Rheumatoid factor negative spondyloarthropathies

ankylosing spondylitis features

A

Factor negative: ankylosing spondylitis, inflammatory bowel disease, psoriasis, reactive arthritis

ankylosing spondylitis features: –Is characterized by sacroiliac arthritis, arthritis and fusion of the spine (“bamboo spine”) / can have atlantoaxial subluxations (like RA) and spine fractures

35
Q

Reactive arthritis
definition
most common causes (three)

subtype with eponym triad

A

reactive arthritis (arthritis triggered by an infection

•Reactive arthritis can also be caused by cervicitis and other infections (including Salmonella and Shigella GI infections)

urethritis causing arthritis, conjunctivitis and uveitis = Reiter’s syndrome

36
Q
A

In closing spondylitis bamboo spine infusion of spinal processes

37
Q

Scleroderma
definition

complication and treatment

A

Definition:–A chronic systemic autoimmune disorder – can be limited to the hands, arms and face or diffuse involving multiple organs

Renal Crisis:

  • Usually within 4 yrs of diagnosis
  • Steroids implicated in precipitating
  • Classic cases – headache, malignant hypertension, elevated creatinine, microangiopathic anemia, thrombocytopenia
  • Diagnosis may be missed when malignant hypertension is not present (about 10% of cases)
  • Treatment of renal crisis: ACE-I, Immunosuppresants
38
Q

Raynaud’s disease/phenomenon

phenomenon versus disease

three criteria
attack progression

A

Raynaud’s “phenomenon” = Raynaud’s disease when there is an underlying cause (scleroderma, RA, SLE)

–Episodes precipitated by cold or emotion

–Symptoms are bilateral

–Symptoms for at least 2 years

–Minimal to no gangrene (skin only if present)

•Attacks are triphasic (white>blue>red)

39
Q
A

Raynauds

40
Q

Systemic Lupus Erythematosus

epidemiology
manifestation categories (9) (or spared organ systems)

Tx

A

•Multi-organ autoimmune disease / most are females (esp. African-Americans), age 16-55 / exacerbations and remissions are typical / runs in families

manifestations: almost every organ system except liver and spleen, full list below
TX: steroids in most cases

  1. Constitutional symptoms: fever, fatigue, malaise, anorexia
  2. Rheumatologic: can mimic RA, arthralgias (>90%), myalgias, tenosynovitis
  3. Dermatologic: butterfly facial rash (55-90%) / intermittent

•Discoid lupus: scaly, raised plaques primarily on face, head, neck; most patients with discoid lupus do not have SLE

  1. Renal: nephritis (persistent proteinuria), nephrotic syndrome, chronic renal failure
  2. Cardiac: pericarditis (20-30%), myocarditis, effusions, tamponade
  3. Pulmonary: pleural effusions, pleurisy, pulmonary infarcts, pneumonitis, cough, dyspnea
  4. GI: oral & nasal ulcerations, intestinal vasculitis, possible perforation/gangrene
  5. Hematologic: anemia, thrombocytopenia, auto-splenectomy, thrombosis (often due to antiphospholipid syndrome – can be catastrophic)
  6. Neurologic: seizures, strokes, psychosis (may be due to SLE or steroid treatment of SLE), migraines, neuropathy (neuro events often occur when SLE is active in other organs), transverse myelitis (due to thrombosis or CNS vasculitis – back pain, extremity neuro symptoms, bladder dysfunction, paralysis – MRI)
41
Q
A
42
Q

Rheumatic Fever

definition

diagnosis

A

Definition: autoimmune complication of group a beta hemolytic strep infection occurring 3 to 4 weeks after infection
diagnosis: two major or one major and two minor Jones criteria

43
Q

Jones crieria

for diagnosis of
major (5) criteria

A

To diagnose rheumatic fever

Major criteria:

–Migratory polyarthritis

–Carditis*

–Chorea* (rapid face and arm movements – late)

–Erythema marginatum*

–Subcutaneous nodules*(back of wrist, elbow, front of knees)

44
Q

Jones criteria, minor

A

•Minor criteria

–Fever

–Arthralgias

–Prior history of RF

–Prolonged PR interval

–Elevated acute phase reactants (CRP)

–Evidence of group A strep infection

45
Q

Rash name and association

A

Erythema marginatum

major criteria for rheumatic fever

46
Q
A

EM Board exam (18 decks)

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