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3rd year medicine > Pall/Onc Lectures > Flashcards

Pall/Onc Lectures Flashcards

1
Q

how long does oramoprh take to work and how long does it last

Hence what is the frequency for Oramorph is given regularly

A

Takes 20-30mins to work
Lasts about 4 hours

Hence continuous Oramorph is given 4 hourly (also BD long acting)

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2
Q

What are some adjuvant analgesics and which is the best one

A

Amytryptiline, gabapentin, pregabalin and some anticonvulsants are adjuvants.

Amitriptyline is probably the best one

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3
Q

What type of myoclonus is opioid toxicity (compared to asterixis)

A

It is a FLEXOR myoclonus (throw tea on yourself) as opposed to asterixis which is a negative extensor myoclonus.

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4
Q

Best drug for vivid dreams on opioids

A

Haloperidol 0.5mg. But be careful as vivid dreams is the first step towards hallucinations and opioid toxicity

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5
Q

Does drowsiness and ‘slowness’ last forever if on opioids?

A

No, return to normal after about 5 days

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6
Q

Neoadjuvant versus adjuvant

A

Neo is BEFORE
adjuvant is after
both increase effectiveness of the main treatment

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7
Q

Why is proton beam radiotherapy better than X-ray radiotherapy

A

Because you spare the tissue BEHIND the tumour. Proton beams stop at the target and X-rays go straight through. Physics-y reason why dw

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8
Q

How does radiotherapy cause cell death

A

Creates photoelectrons that damages DNA, causing cell to apoptose. This causes cell death in hours/days/months but also causes increase in cancer in long years time

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9
Q

Why is radiotherapy treatment more effective on cancer cells

A

They have a decreased ability to repair themselves as they replicate much quicker

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10
Q

Why do you give many doses of chemo or radio across a number of weeks? (1)

A
  1. So that you hit the cancer cells in a variety of cell cycle points. Good as cells are more vulnerable in different stages
  2. So that normal cells have time to repair themselves between doses (remember Ca cells not as good at this)
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11
Q

acute SE of radiotherapy

A

Hair loss
Mucositis
Sunburn like rash
Pneumonitis

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12
Q

How can you treatment pneumonitis as acute radio SE

A

prednisolone

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13
Q

long term SE of radiotherapy

A 
telangectasia
lymphedema
fibroses organs (liver, lung)
secondary carcinogenesis
germ cell mutations causing mutations in future generations
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14
Q

How might the chemo TIMINGS be different in palliative versus curative (HINT HINT)

A 
Palliative = single chemo use
Curative = multiple chemos use (so more toxicity)
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15
Q

Chemo acute SE

A

nausea and vomiting
hair loss
mucositis
bone marrow suppression

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16
Q

When do you treat for neutropenic sepsis

A

Whenever there is a temperature above 38 degrees if recently on chemo. 4g tazocin IV

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17
Q

Chemo long term SE

A

chemo brain (10% have permanent long term MCI)
sterility
neuropathy in HANDS and FEET
renal failure

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18
Q

what is CAR-T

A

you take you antigens off the tumour cells and train your normal white cells to target the abnormal antigens and they re-infuse those T cells back in to you. Works very very well but costs about £250k. Can get massive cytokine release and cause ITU admission etc. most useful in non-solid tumours (leukaemia/lymphomas)

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19
Q

Ipilimumab and nivolimumab are examples of

A

checkpoint inhibitors in breast cancer

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20
Q

How do checkpoint inhibitors work

A

T-cells are an important part of our immune system which help destroy cancer cells. Some cancer cells make high levels of proteins that turn T-cells off. Checkpoint inhibitors block this process and reactivate and increase the body’s own T-cell population, enhancing the immune systems own ability to recognise and fight cancer cells.

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21
Q

SEs of checkpoint inhibitors and most common one

A

Any autoimmune disease you’ve ever heard of, you can get when on immunotherapy. Immune colitis is the most common. They can happen any time.

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22
Q

why does herceptin need cardiac moniotirng

A

because cardiac myocytes overexposes HER2 and so herceptin affects

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23
Q

What % of people on immune checkpoint inhibitors will have to be admitted for SEs

A

60%!!!

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24
Q

Tx of colitis from immunotherapy

A

prednisolone and tacrolimus

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25
Q

which cancer drugs are given by a GP

A

aromatase inhibitors
tamoxifen
GnRH analogues

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26
Q

How is goserelin given for prostate cancer

A

Subcut depot 3 monthly

need cytperotone or BICALUTAMIDE for cover at first

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27
Q

Usual timing for neutropenic sepsis

A

1 week after chemo

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28
Q

What is the gold standards framework

A

Basically good palliative care:

Aims to support palliative care patients in their own home
Start identifying patients early on and asses their needs
Make sure important medicines are available in advance

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29
Q

when do you refer to coroner

A 
o	Cause of death not known
o	Not seen doctor in 14 days
o	It was an accident
o	Patient may have had an industrial related disease
o	Death was violent or suspicious 
o	Evidence of neglect
o	Suicide
o	Death during or after an operation
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30
Q

which are the only drugs that need an end date on drug chart

A

steroids and antibiotics

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31
Q

how is morphine metabolised

A

Into M3G (inactive) and M6G (Active)

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32
Q

how is morphine excreted

A

renal (hence be careful in low GFR)

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33
Q

How are you ‘careful’ with morphine in low GFR

A 
>60 = no worries huh
30-60 = use 5mg instead of normal 10mg 4 hourly dose (6,10,2,6,10,2)
<30 = use fentanyl instead (or or buprenorphine or oxycodone)
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34
Q

Middle of the night anti-emetic choice

A

Central? Cyclizine
Peripheral? Metoclopromide
Unsure? Metoclopromide

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35
Q

Which laxatives for morphone

A

Docusate (soften) AND Senna (stimulate)

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36
Q

why is lactulose not great in palliative setting

A

It is sweet, causing fermentation, bloating and flatus

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37
Q

Is Movicol/Laxido any good?

A

Yes, it is a mix of softner and stimulant just like the ideal combo
BUT
this means you can’t titrate for their poopens

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38
Q

You were prescribing Oramorph 4 hourly but want to switch to give Zomorph at noon. When should you give the last dose of Oramorph

A

Also noon. give alongside MR dose as it will take time to kick in.

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39
Q

How often do you need to change syringe driver site

A

Every 3 days

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40
Q

Dose change when changing from oral to subcut?

A

Half it baby

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41
Q

oxycodone versus morphine potency?

A

O is 2x M
M–> O (1/2 the morphine to get oral oxycodone)

if subcut half again

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42
Q

when do you switch to oxycodone from morphine

A

No pain control + toxicity SEs

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43
Q

LDH is a cancer marker of

A

Lymphoma, melanoma, germ cell tumour

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44
Q

CUP versus malignancy unknown origin

A

Malignancy of unknown origin = you’ve diagnosed metastatic cancer but don’t know where the primary is yet as you haven’t done full investigations (relatively common)

CUP is an actual diagnosis = cancer of unknown primary. Even when you’ve done all the investigations you wanted to, you still don’t know where the primary is.

Remember at a certain point you stop caring where the primary is….

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45
Q

which are the only cancers you can cure with chemo alone

A

Testicular cancer
leukaemia
lymphoma

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46
Q

don’t ever take blood from someones arm if they have had a…….. (breast cancer thing)

A

Axillary node clearance

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47
Q

palliative vs best supportive care

A

Palliative is to improve length or quality of life, not curative. Can be decade long. Don’t jump to DNACPR

Best supportive care is probably at the end of life and trying to make them comfortable

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48
Q

Can F1 sign DNACPR

A

No, but F2 can

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49
Q

Adjuvant chemotherapy in breast cancer, what is it’s purpose?

A

NOT to help cure (the surgery is the bit that is doing that)

It is to REDUCE CHANCE OF RECURRENCE

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50
Q

Non pharmacological treatments for breathlessness at the end of life

A

Fans
Prolong exhale
Anxiety management
Exercise

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51
Q

Drug to reduce sense of breathlessness

A

2.5mg Oramorph

Benzodiazepine if in panic attack

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52
Q

Drug for cough in general

  • wet cough
  • dru cough
A

Morphine

  • wet = aid to expectorate with saline neb, PT, mucolytic
  • dry = can add dry linctus
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53
Q

Drug for secretions

A

Hyoscine butylbromide (hydro from passed, butyl from lecture, neither from happy app)

54
Q

Electron versus photon radiotherapy uses

A

Electro = better for superficial tumours

Photon (i.e. Xray) = better for deep tumours

55
Q

Skin sparing in radiotherapy?

A

In high energy radiotherapy, the photons are at such high energy that they only star t depositing energy at a depth of 1.5cm below the skin

56
Q

Spinal cord compression radiotherapy or surgery timeline

A

ASApP but within 48 hours

57
Q

why is proton radiotherapy good

A

It protects normal structures that will be deeper than the tumour. Protons are closer to alpha radiation than beta or gamma) and so it delivers it energy in superficial layers (poor penetrance)

58
Q

Why do you have to do a whole spine MRI in cord compression

A

1/3rd have multiple sites

59
Q

PR examination if on chemo?

A

Try to avoid due to risk of sepsis

60
Q

most common GI symptom

A

xerostomia (dry mouth)

61
Q

when is metoclopromide most effective

A

given before mealtimes

62
Q

suppository laxatives? (2)

A

Glycerine (softner)

Bisacodyl (stimulant)

63
Q

Can you use metoclopromide in bowel obstuction

A

In complete obstruction (i.e. colic present) then it is CI

In subacute obstruction (i.e. NO COLIC PRESENT) it is actually the treatment of choice alongside a softner like docusate

64
Q

What drugs do you give for complete obstructin

A

hyoscine bytlbromide (buscopan) for antispasmodic against colic pain
opioids for pain
anti-secretory medication or it’ll build up (hyoscine or ocreotide)

some sort of surgical procedure

65
Q

Performance status?

A 
o	0 = completely independent
1 = only manage light work
2 = independent but about 50% resting
3 = more dependent with >50% resting
4 = completely bed bound
66
Q

MASCC index?

A

MASCC index can identify low-risk febrile neutropaenic patients who can be managed at home

It is a score out of 26. If you score 22 or more then you are LOW risk and can be managed as outpatient.

Features that make you low risk are:

  • normotension
  • solid tumour
  • <60
  • low disease burden
  • presenting as an outpatient
  • not having COPD
67
Q

When can you de-escalate IV tazocin in neutopaenic sepsis

A

after 24 hours of being afebrile and when not neutropenic anymore

68
Q

signs if cord compression is above versus below L1

A

above you get UMN signs
below you get LMN signs

bilat sensory loss always

69
Q

how does dex make you feel

A

energised (so must give it in the morning)

obvs if emergency then dw

70
Q

how do you elicit pembertons sign

A

lift arms for 1 min and you go red, jvp and resp distress

71
Q

when do you give fentanyl instead of morphine

A

eGFR <30 ya bish

72
Q

opioid side effects

A

transient:

  • nausea
  • drowsiness
  • pruritis
  • respiratory depression

persistent:

  • constipation - prescribe all patients on strong opioids with laxatives
  • dependence
73
Q

breakthrough dose of morphine

A

1/6th of daily dose (24hrs) of morphine

74
Q

what should all patients be put on with an opioid

A

laxative

75
Q

prefered opioid for palliative care patients if mild-moderate renal impairment

A

oxycodone

76
Q

prefered opioid for palliative care patients if severe renal impairment

A

alfentanil, buprenorphine and fentanyl preferred

77
Q

codeine/ tramadol : morphine ratio

A

10:1

if on 240mg of codeine/tramadol if you want to change to morphine divide by 10

78
Q

continuous anti-emetic first line

A

1st line: cyclizine
levopromazine
metoclopramide CI in bowel obstruction

79
Q

mx for n+v secondary to opioid use/ hypercalcaemia/chemo

A

haloperidol

80
Q

opioid toxicity mx

A

naloxone

81
Q

oral morphine to fentanyl patch

A

divide by 3.6

82
Q

oral morphine to buprenorphine patch

A

divide by 2

83
Q

mx for agitaion and confusion

A

first choice: haloperidol

other options: chlorpromazine, levomepromazine

84
Q

mx agitation for terminal phase of illness

A

s/c midazolam

85
Q

headaches caused by raised ICP due to brain tumour

mx

A

dexamethasone

86
Q

pain from metastatic spinal cord compression

A

dexamethasone

87
Q

relieving mx for metastatic bone pain

A

analgesia
bisphosphonates
radiotherapy

88
Q

nausea and vomiting that is due to gastric dysmotility and stasis

A

metoclopramide

89
Q

bowel colic mx

A

Bowel colic: hyoscine BUTYLbromide

90
Q

respiratory secretions

A

hyoscine HYDRObromide

91
Q

oral morphine to s/c diamorphine

A

divide by 3

92
Q

hiccups in palliative care

A

chlorpromazine or haloperidol

93
Q

vincristine side effect - chemo

A

peripheral neuropathy

94
Q

doxorubicin side effect - chemo

A

cardiomyopathy

used in lymphoma

95
Q

Gardners syndrome

A

subtype of familial adenomatous polyposis (FAP)
autosomal dominant
multiple colonic polyps
extra colonic diseases: skull osteoma, thyroid cancer, epidermoid cysts
desmoid tumours (connective tissue) in 15%
APC gene mutation on chromosome 5
undergo colectomy to remove risk of colorectal cancer

96
Q

amsterdam criteria

A 
for HNPCC
three or more family members with colorectal cancer 
spanning two generations 
one or more colon cancers < 50yrs 
FAP excluded
97
Q

lynch syndrome

A

autosomal dominant
colonic + endometrial cancer at young age
HNPCC

98
Q

BRCA 1 and 2

A

BRCA 1: chromosome 17
BRCA 2: chromosome 13

breast cancer
ovarian cancer

BRCA 2 associated with prostate cancer in men

99
Q

Li-Fraumeni syndrome

A

autosomal dominant
mutation to p53 tumour suppressor gene
sarcomas and leukaemias

diagnosis:
sarcoma <45yrs
first degree relative with any cancer <45yrs + another family member with malignancy <45yrs or sarcoma at any age

100
Q

CEA (carcinoembryonic antigen) tumour marker

A

colorectal cancer

101
Q

CA 125

A

ovarian cancer

102
Q

CA 15-3

A

breast cancer

103
Q

CA 19-9

A

pancreatic cancer

104
Q

PSA

A

prostatic carcinoma

105
Q

AFP (alpha-feto protein)

A

hepatocellular carcinoma

teratoma

106
Q

S-100 tumour marker

A

melanoma

schwannomas

107
Q

bombesin tumour marker

A

small cell lung cancer
gastric cancer
neuroblastoma

108
Q 
lung cancer
sudden onset:
blurring of vision 
SOB 
headache
bulging veins on forehead
papiloedema 
pemberton sign +ve 
diagnosis + mx
A

SVC obstruction due to tumour

ONCOLOGICAL EMERGENCY

pemberton sign: light arms above head –> red face, cyanosis, worsening SOB = SVC obstruction

most associated with lung cancer (small cell), and lymphoma

Mx: dexamethasone to reduce swelling of tumour
then either stent or radio/chemotherapy

109
Q

pathological fractures/ bone pain

hypercalcaemia
raised ALP

A

bone mets

prostate cancer most common bone met
prostate cancer mets typically has sclerotic appearance on x-ray

breast and lung also mets to the bone

110
Q

bone cancer of long bones of a child/young adult

A

osteosarcoma

often presents with pathalogical fractures in long bones

111
Q

cyclophosphamide chemo drug side effect

A

used to treat lymphoma and other haematological conditions

haemorrhagic cystitis

112
Q

Docetaxel side effect - chemo

A

neutropenia

used for breast and lung cancers

113
Q

bleomycin side effect - chemo

A

pulmonary fibrosis

used for lymphoma

114
Q

detecting disease recurrence in testicular teratoma

A

AFP (teratoma) + B-HCG (testicular carcinoma)

115
Q

N+V due to chemo mx

A

low risk for N+v: metoclopramide

high risk: 5HT3 receptor antagonist - ondansetron

116
Q

most common site of bone mets

A

spine

117
Q

HPV 16 and 18 and 33

A

cervical cancer

infected cells may become koilocytes

118
Q

HPV 6 and 11

A

genital warts
non-carcinogenic

if found on cervical smear refer back to normal recall and encourge safe sex practice

119
Q

screening when a patient has been treated for CIN - cervical dyskaryosis

A

screening increased to yearly for 10yrs

120
Q

rise in calcitonin

which type of thyroid cancer

A

medullary thyroid cancer

produces calcitonin as originates from parafollicular cells

121
Q

suspected neoplastic spinal cord compression ix

A

urgent MRI of whole spine

122
Q

lung cancer with the strongest association to smoking

A

squamous cell carcinoma

more commonly found near large airways

123
Q

lung cancer positions based on type

A

small cell: near large airways
- associates with para-neoplastic syndrome and mets early

non-small cell:

  • adenocarcinoma: peripheral, not associated with smoking
  • squamous: near large airways
  • large cell: diagnosis of exclusion
124
Q

methotrexate side effects

A

myelosuppression
liver fibrosis
oral mucositis

125
Q

cisplatin side effects

A

hypomagnesaemia

126
Q

what does PET scan demonstrate

A

glucose uptake

to determine whether lesions are metabolically active

127
Q

woman with abdominal malignancy of unknown primary

A

CA125 should form part of diagnostic work-up as ovarian cancer often presents with non-specific abdo symptoms

128
Q

lytic bone lesions ix

A

myeloma screen

129
Q

germ cell tumours ix

A

testicular USS

130
Q

MEN II (multiple endocrine neoplasia II) associated with what thyroid cancer

A

medullary thyroid cancer - presenting feature of neck swelling

associated with phaeochromocytomas (adrenal gland cancer)

131
Q

sinusitis + situs inversus + bronchiectasis

A

kartagener syndrome
ciliary dyskinesia
situs inversus: organ on wrong side of body (heart, liver)

3rd year medicine (31 decks)

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