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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
which cancer drugs are given by a GP
aromatase inhibitors tamoxifen GnRH analogues
26
How is goserelin given for prostate cancer
Subcut depot 3 monthly | need cytperotone or BICALUTAMIDE for cover at first
27
Usual timing for neutropenic sepsis
1 week after chemo
28
What is the gold standards framework
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
29
when do you refer to coroner
``` 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 ```
30
which are the only drugs that need an end date on drug chart
steroids and antibiotics
31
how is morphine metabolised
Into M3G (inactive) and M6G (Active)
32
how is morphine excreted
renal (hence be careful in low GFR)
33
How are you 'careful' with morphine in low GFR
``` >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) ```
34
Middle of the night anti-emetic choice
Central? Cyclizine Peripheral? Metoclopromide Unsure? Metoclopromide
35
Which laxatives for morphone
Docusate (soften) AND Senna (stimulate)
36
why is lactulose not great in palliative setting
It is sweet, causing fermentation, bloating and flatus
37
Is Movicol/Laxido any good?
Yes, it is a mix of softner and stimulant just like the ideal combo BUT this means you can't titrate for their poopens
38
You were prescribing Oramorph 4 hourly but want to switch to give Zomorph at noon. When should you give the last dose of Oramorph
Also noon. give alongside MR dose as it will take time to kick in.
39
How often do you need to change syringe driver site
Every 3 days
40
Dose change when changing from oral to subcut?
Half it baby
41
oxycodone versus morphine potency?
O is 2x M M--> O (1/2 the morphine to get oral oxycodone) if subcut half again
42
when do you switch to oxycodone from morphine
No pain control + toxicity SEs
43
LDH is a cancer marker of
Lymphoma, melanoma, germ cell tumour
44
CUP versus malignancy unknown origin
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....
45
which are the only cancers you can cure with chemo alone
Testicular cancer leukaemia lymphoma
46
don't ever take blood from someones arm if they have had a........ (breast cancer thing)
Axillary node clearance
47
palliative vs best supportive care
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
48
Can F1 sign DNACPR
No, but F2 can
49
Adjuvant chemotherapy in breast cancer, what is it's purpose?
NOT to help cure (the surgery is the bit that is doing that) It is to REDUCE CHANCE OF RECURRENCE
50
Non pharmacological treatments for breathlessness at the end of life
Fans Prolong exhale Anxiety management Exercise
51
Drug to reduce sense of breathlessness
2.5mg Oramorph | Benzodiazepine if in panic attack
52
Drug for cough in general - wet cough - dru cough
Morphine - wet = aid to expectorate with saline neb, PT, mucolytic - dry = can add dry linctus
53
Drug for secretions
Hyoscine butylbromide (hydro from passed, butyl from lecture, neither from happy app)
54
Electron versus photon radiotherapy uses
Electro = better for superficial tumours | Photon (i.e. Xray) = better for deep tumours
55
Skin sparing in radiotherapy?
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
Spinal cord compression radiotherapy or surgery timeline
ASApP but within 48 hours
57
why is proton radiotherapy good
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
Why do you have to do a whole spine MRI in cord compression
1/3rd have multiple sites
59
PR examination if on chemo?
Try to avoid due to risk of sepsis
60
most common GI symptom
xerostomia (dry mouth)
61
when is metoclopromide most effective
given before mealtimes
62
suppository laxatives? (2)
Glycerine (softner) | Bisacodyl (stimulant)
63
Can you use metoclopromide in bowel obstuction
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
What drugs do you give for complete obstructin
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
Performance status?
``` 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
MASCC index?
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
When can you de-escalate IV tazocin in neutopaenic sepsis
after 24 hours of being afebrile and when not neutropenic anymore
68
signs if cord compression is above versus below L1
above you get UMN signs below you get LMN signs bilat sensory loss always
69
how does dex make you feel
energised (so must give it in the morning) obvs if emergency then dw
70
how do you elicit pembertons sign
lift arms for 1 min and you go red, jvp and resp distress
71
when do you give fentanyl instead of morphine
eGFR <30 ya bish
72
opioid side effects
transient: - nausea - drowsiness - pruritis - respiratory depression persistent: - constipation - prescribe all patients on strong opioids with laxatives - dependence
73
breakthrough dose of morphine
1/6th of daily dose (24hrs) of morphine
74
what should all patients be put on with an opioid
laxative
75
prefered opioid for palliative care patients if mild-moderate renal impairment
oxycodone
76
prefered opioid for palliative care patients if severe renal impairment
alfentanil, buprenorphine and fentanyl preferred
77
codeine/ tramadol : morphine ratio
10:1 | if on 240mg of codeine/tramadol if you want to change to morphine divide by 10
78
continuous anti-emetic first line
1st line: cyclizine levopromazine metoclopramide CI in bowel obstruction
79
mx for n+v secondary to opioid use/ hypercalcaemia/chemo
haloperidol
80
opioid toxicity mx
naloxone
81
oral morphine to fentanyl patch
divide by 3.6
82
oral morphine to buprenorphine patch
divide by 2
83
mx for agitaion and confusion
first choice: haloperidol | other options: chlorpromazine, levomepromazine
84
mx agitation for terminal phase of illness
s/c midazolam
85
headaches caused by raised ICP due to brain tumour | mx
dexamethasone
86
pain from metastatic spinal cord compression
dexamethasone
87
relieving mx for metastatic bone pain
analgesia bisphosphonates radiotherapy
88
nausea and vomiting that is due to gastric dysmotility and stasis
metoclopramide
89
bowel colic mx
Bowel colic: hyoscine BUTYLbromide
90
respiratory secretions
hyoscine HYDRObromide
91
oral morphine to s/c diamorphine
divide by 3
92
hiccups in palliative care
chlorpromazine or haloperidol
93
vincristine side effect - chemo
peripheral neuropathy
94
doxorubicin side effect - chemo
cardiomyopathy used in lymphoma
95
Gardners syndrome
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
amsterdam criteria
``` for HNPCC three or more family members with colorectal cancer spanning two generations one or more colon cancers < 50yrs FAP excluded ```
97
lynch syndrome
autosomal dominant colonic + endometrial cancer at young age HNPCC
98
BRCA 1 and 2
BRCA 1: chromosome 17 BRCA 2: chromosome 13 breast cancer ovarian cancer BRCA 2 associated with prostate cancer in men
99
Li-Fraumeni syndrome
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
CEA (carcinoembryonic antigen) tumour marker
colorectal cancer
101
CA 125
ovarian cancer
102
CA 15-3
breast cancer
103
CA 19-9
pancreatic cancer
104
PSA
prostatic carcinoma
105
AFP (alpha-feto protein)
hepatocellular carcinoma | teratoma
106
S-100 tumour marker
melanoma | schwannomas
107
bombesin tumour marker
small cell lung cancer gastric cancer neuroblastoma
108
``` lung cancer sudden onset: blurring of vision SOB headache bulging veins on forehead papiloedema pemberton sign +ve diagnosis + mx ```
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
pathological fractures/ bone pain hypercalcaemia raised ALP
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
bone cancer of long bones of a child/young adult
osteosarcoma | often presents with pathalogical fractures in long bones
111
cyclophosphamide chemo drug side effect
used to treat lymphoma and other haematological conditions haemorrhagic cystitis
112
Docetaxel side effect - chemo
neutropenia used for breast and lung cancers
113
bleomycin side effect - chemo
pulmonary fibrosis used for lymphoma
114
detecting disease recurrence in testicular teratoma
AFP (teratoma) + B-HCG (testicular carcinoma)
115
N+V due to chemo mx
low risk for N+v: metoclopramide high risk: 5HT3 receptor antagonist - ondansetron
116
most common site of bone mets
spine
117
HPV 16 and 18 and 33
cervical cancer infected cells may become koilocytes
118
HPV 6 and 11
genital warts non-carcinogenic if found on cervical smear refer back to normal recall and encourge safe sex practice
119
screening when a patient has been treated for CIN - cervical dyskaryosis
screening increased to yearly for 10yrs
120
rise in calcitonin | which type of thyroid cancer
medullary thyroid cancer produces calcitonin as originates from parafollicular cells
121
suspected neoplastic spinal cord compression ix
urgent MRI of whole spine
122
lung cancer with the strongest association to smoking
squamous cell carcinoma more commonly found near large airways
123
lung cancer positions based on type
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
methotrexate side effects
myelosuppression liver fibrosis oral mucositis
125
cisplatin side effects
hypomagnesaemia
126
what does PET scan demonstrate
glucose uptake | to determine whether lesions are metabolically active
127
woman with abdominal malignancy of unknown primary
CA125 should form part of diagnostic work-up as ovarian cancer often presents with non-specific abdo symptoms
128
lytic bone lesions ix
myeloma screen
129
germ cell tumours ix
testicular USS
130
MEN II (multiple endocrine neoplasia II) associated with what thyroid cancer
medullary thyroid cancer - presenting feature of neck swelling associated with phaeochromocytomas (adrenal gland cancer)
131
sinusitis + situs inversus + bronchiectasis
kartagener syndrome ciliary dyskinesia situs inversus: organ on wrong side of body (heart, liver)

3rd year medicine (31 decks)

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