oncology medicine Flashcards by Derin King

in a patient with chronic kidney disease that develops nausea and headaches and retinal hemorrhages. this patient has developed a hypertensive crisis.

what is the most likely medication that can cause this adverse effect?

erythropoitien stimulating agents

*note a hypertensive response can also occur in the setting of a stroke, but there would be neurological findings

cerebral venous sinus thrombosis causes papilloedema not hemorrhages, and hypercoagulability risk factors eg OCP

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next step in management of a patient with TTP?

plasma exchange!!! + steroids and rituximabe.

TTP patients may not have all symptoms but blood smear will show shistiocytes!

note DIC is treated with cryoprecipitate

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GVHD is caused by activation of?

DONOR t lymphocytes

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why might hematocrit be raised in hereditary hemorrhagic telnagiectasia?

pulmonary AVMS -> Shunting -> chronic hypoxemia and digital clubbing

avms in liver -> hepatomegaly

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PET scan can be used to detected hodgkins lymphoma, however PET scan will also pool in healthy organs with high metabolic activity eg brain, kidneys, urinary bladder

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pancytopenia can be seen in acute myeloid leukemia. if DIC is present (prolonged PT/ApTT, hypofibrinogenemia) ->APML! . can present as a long nosebleed

raised ldh can be seen due to rbc destruction

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acute cholecystitis is a complication of hereditary spherocytosis!!! (anemia jaundice spleenomegaly) -> condition caused by genetic red blood cell defect

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how to prevent non febrile hemolytic transfusion reaction?

use a leukoreduced blood product

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CLL is diagnosed via?
not CLL may present with infection eg pneumonia

flow cytometry - note, immunophenotyping is a specific application of flow cytometry

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in Tumour lysis syndrome, what are the electrolyte/lab values?

hyperuricemia, hyperkalemia, hyperphosphatemia

and HYPO!! CALCEMIA -> due to phosphate binding. you get kidney stone precipitates

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66 yo man with back pain, normal calcium, raised alkphos, bony sclerosis of L1 on radiography. most likely diagnosis?

prostate cancer!! most likley cancer in a man.

causes osteoblastic lesion hence calcium is normal vs most other cancers that cause osteolytic lesions and raised calcium. note! osteoblastic lesion = increased whiteness on radiography

not pagets as it causes osteolytic or mixed lesions

not multiple myeloma which also cause osteolytic lesions on x ray = back patches/ moth eaten!! appearance

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A patient with signs of polycythemia vera and has now developed abdominal pain, ascites and hepatosplenomegaly. most likley complication?

next step in evaluation?

Budd chiarii syndrome

Abdominal doppler ultrasonography!!!!

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Two most common causes of microcytic anemia are iron deficiency and thalessemia AKA hemoglobin defect!!!

if a patient with microcytic anemia is supplemented with iron and doesnt improve symptoms, then they most likely have?

hemoglobin defect!!! (thalessemia)

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a patient with Heparin induced thrombocytopenia is also at risk of what complication? mechanism by which this occurs?

management of HIT?

venous and arterial thrombosis!! -> antibody mediated platelet aggregation!!!

discontinue heparin, start anticoagulants immediately

note risk of HIT is highest with unfractionated heparin!!!! not enoxaparin

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B12 deficiency in elderly is usually due to pernicious anemia. patients are at risk of what complicaiton?

gastric cancer

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before workup for protein S deficiency (a thrompophilia), what drug must be discontinued?

Warfarin!!

as it not only inhibits the synthesis of clotting factors, but also

the anticoagulants protein C and S

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PCV treatment = phlebotomy

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patient has TLS following chemo. most appropriate medication to give?

Rasburicase!!! - as it directly breaks down urate formation (+ IV Fluids!!!!)

rasbirucase is used in patients with hyperuricemia already or used post chemo in TLS as there would be hyperuricemia

NOTE: xanthine oxidase inhibitors (allopurinol, feboxostat) are only used as prophylaxis i.e BEFORE chemo. as it can only reduce urate formation.

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splenic infarction, most useful investigation to confirm diagnosis?

hemoglobin electrophoresis

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1st line treatment for chemotherapy induced nausea & vomiting?

serotonin receptor antagnosists!! = ondansetron

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patient with osteoarthritis taking naproxen and has microcytic anemia. most likely cause of anemia?

iron dediciency anemia!!

chronic blood loss due to nsaid associated gastropathy

in macrocytic anemia, folate supplementation is usally given to people with heavy alcohol use

cancer pain management?

up to 3/10 pain = paracetamol or nsaid. if inadequate = short acting opioid. patients not previously on opiodis should not be immediately started on long acting opioids due to risk of resp. depression

4/10 and above = short acting opioid!!! = oxycodone, morphine and if multiple daily doses -> long acting opioid eg ER morphine, fentanyl patch

radiation therapy can also be used for moderate to severe pain

32 YO man. microcytic anemia. blood smear shows target cells. RBC count on higher end. routine checkup thus asymptomatic

best treatment?

Reassurance!! -> most likely thalesemmia minor

not IDA as IDA can also cause target cells, but RBC count would not be elevated.

note microcytic anemia is often due to IDA or thalessemia.

multiple gunshot wounds to abdomen and surgical scars -> most likely splenectomy. -> risk of fulminant infection with encapuslated bacteria

tingling feet, headaches, blurry eyes, hepatosplenomgaly and lymphadenopathy. anemia. IgM spike on serum electrophoresis!! most likely diagnosis?

Waldenstroms Macroglobulinemia!!!! roleaux formation also seen here (headache, dinesss, blurry eyes, fundoscopy findings, tingling of legs. key cause outside B12 deficiency multiple myeloma= IgG, IgA light chains NOT MGUS as there are no end organ effects as seen here!!!

cytopenias (anemia, low platelet) spleenomegaly, recent infections, blood smear shows one leukocyte cell with hair projections most likely diagnosis?

hairy cell leukemia NOT CLL, as would have even more significant leukocytosis >100,000. lymphadenopathy and b symptoms would be present in CLL and peripheral blood smear will show smudge cells

treatment for hypercalcemia of malignancy and prevention of pathological fractures in cancer?

bisphosphonates!!! (zolendronic acid, pamidronate) -> they inhibit osteoclastic activity and stabilising bony tumours, reducing risk of pathologic fracture and malignant hypercalcemia

most DVTs occur in calf vein. However, most likely source of a Lower extremity DVT that embolises to the lungs is?

proximal deep leg veins -> femoral, popliteal, ileal

what is the mechanism for Von Willebrand disease?

impaired platelet endothelial binding!!! not decreased factor 8 production -> seen in hemophila A

b12 deficiency can also cause mild thrombocytopenia/leukemia

next step in management for suspected SVC?

chest xray!!! common causes are lung cancer and NHL

AML + pancytopenia = APML!!! Most likely complication? management?

consumptive coagulopathy!! -> high risk of catastrophic hemorrhage!! all trans retinoic acid!!

megaloblastic anemia can also be present with anisocytosis, poikilcytosis and basophilic stippling. lead poisoning causes basophilic stippling but MICROCYTIC anemia

if warfarin is not effective in DVT treatment -> management = Xa inhibitor eg apixaban

patient with BMI of 45, blood pressure 160/100, erectile dysfunction. raised hematocrit on blood count most likely diagnosis? and mechanism?

Obstructive sleep apnea!!!. snoring is not always recognized or reported. transient hypoxemia = increased EPO production!!!

Absence of CD55 in red cell membranes is seen in PNH. Hereditary spherocytosis has a high MCHC

in absence of clear provoking factors for DVT, all patients with a DVT first episode should be referred for?

age-appropriate cancer screening

a normal G6PD level assay does not rule out the condition as sensitivity is low in acute crises

patients with microcytic anemia and normal iron studies. next step in evaluation?

hemoglobin electrophoresis!!. you need to rule out hemoglobinopathies

patient has a "mechanical" heart valve. fatigue and dyspnea. complete blood count shows increased reticulocytes, low hematocrit and low platelets. hepatospleenomegaly. next step in management?

transthoracic echocardiogram!!! - assess valve function

patients with antiphospholipid antibodies (eg lupus anticoagulant) have prolonged PTT that fails to correct with mixing test

Chronic myeloid leukemia is marked by leukocytosis, basophilia and a shift towards early neutrophil precursors cells (promyelocytes, myelocytes)!! vs myeloBLASTS seen in AML and auer rods seen in AML how do you differentiate between CML and Leukemoid reaction?

LAP score -> leukocyte alkaline phosphatase score is low in CML!!! vs high in leukemoid reaction (in infection)

secondary causes of ITP?

hiv, hep c - testing recommended sle - ana antibody screen

how does scleroderma renal crisis present?

marked hypertension aki - proteinuria MAHA thrombocytopenia

moderate or high probability of DVT using modified wells score first step in management?

compression ultrasonography!!! -> only AFTER it has been confirmed do you start anticoagulation. low well score = d dimer

dark urine, signs of hemolytic anemia PLUS abdominal or cerebral venous thrombosis. most likely diagnosis?

PNH flow cytometry shows absent CD55 and CD59

hodgkins lymphoma carries a risk of secondary malignancy, and cardiovascular disease

chronic autoimmune diseases increases risk of non-hodgkin lymphoma - characterised by lymphadenopathy + b symptoms

patient with fever and pharyngitis, leukocytes 1,800 with neutrophils making 20% of this. patient on sulfasalzine for inflammatory bowel disease associated spondyloarthritis. most appropriate next step in management?

discontinue sulfasalazine patient has severe neutropenia. absolute neutrophil count <500. drug induced neutropenia most likely!!! - can manifest with oral mucositis and fever. clozapine, methimazole, Trimethoprim, PTU cause this. NOT EBV as neutrophils typically between 500 - 1500, and lymphadenopathy/spleenomegaly would be seen

hereditary hemachromatosis causes erectile dysfunction, skin pigmenting, diabetes, elevated liver enzymes. increased risk of what complication?

HCC