Red Flags Flashcards
Prostate Cancer
- red flags symptoms
- initial investigations used in GP
Symptoms:
- visible haematuria
- erectile dysfunction
- lower urinary tract symptoms
Initial investigations: PSA, rectal examination
Breast Cancer
- red flags symptoms
- initial investigations used in GP
Symptoms:
- over 30 with an unexplained breast lump
- over 50 with nipple changes, discharge, retraction
- skin changes suggestive of cancer
- over 30 with axillary lymphadenopathy
Investigations at GP: breast examination
Lung Cancer
- red flags symptoms
- initial investigations used in GP
Symptoms:
- haemoptysis
- CXR suggestive of malignancy
- SOB, cough, fatigue, chest pain, persistent chest infections
- finger clubbing
- loss of appetite
- subclavicular or cervical lymphadenopathy
Ix: chest XR, FBC → platelets
Bowel Cancer
- red flags symptoms (for different ages)
- initial investigations used in GP
Symptoms:
- over 40 with unexplained weight loss and abdominal pain
- over 50 with unexplained PR bleeding
- over 60 with iron deficiency anaemia or changes in bowel habit or positive FOB
- under 50 with PR bleed AND abdo pain, or change in bowel habit or weight loss or iron deficiency anaemia
Ix: PR exam, FBC → anaemia
Oesophageal Cancer
- red flags symptoms
- initial investigations used in GP
Symptoms:
- dysphagia
- over 55 with weight loss and upper abdo pain, reflux or dyspepsia
- over 55 with treatment - resistant dyspepsia, upper abdo pain with anaemia
- raised platelets with nausea, vomiting, reflux or weight loss
- nausea or vomiting with weight loss, dyspepsia or upper abdominal pain
Ix: anaemia, raised platelets, OGD
Ovarian Cancer
- red flags symptoms
- initial investigations used in GP
Symptoms:
- ascities
- pelvic/abdominal mass
Ix: USS, Ca 125
Malignant Melanoma
- red flags symptoms
- initial investigations used in GP
Symptoms:
3 points or more on the weighted checklist:
- Major (2 points): change in size, change in shape, irregular colours
- Minor (1 point): inflammation, oozing, change in sensation, diameter >7mm
Ix: dermatoscopy
Bladder Cancer
- red flags symptoms (ages)
- initial investigations used in GP
Symptoms:
- over 45 with unexplained visible haematuria (without UTI) or recurrent visible haematuria after the infection was treated
- over 60 with non-visible haematuria and dysuria or raised WCC
Ix: FBC → raised WCC
Uterus Cancer
- red flags symptoms
- initial investigations used in GP
Sympotms:
- post-menopausal bleeding
- over 55 with vaginal discharge with thrombocytosis or haematuria
- over 55 with haematuria, anaemia, thrombocytosis OR high blood sugar levels
Ix: USS, FBC, HbA1C
A 46 year old lady comes to see you with a lump in the right breast.
List 3 potential signs on examination that would alert you to malignancy
- descrete hard lump with fixation (with or without skin tethering)
- unilateral bloody nipple discharge
- unilateral eczematous skin change not responding to treatment
- skin tethering/ peaud’ orange
- nipple distortion /znieksztalcenie/ or change of recent onset
- axillary lymphadenopathy
Risk factors for breast cancer
- Family Hx in 1st degree relative
- BRCA1 and BRCA2 → carry a very high risk but represent only <5% of cases
- Age → 2% in <35, 5% in <40
- the nulliparous or first child born >35 yo
- early menarche/ late menopause
- HRT → risk increases after >5 yrs duration and is significant with >10 yrs of use
- radiation to chest
- no having breast fed (it is considered to be protective)
A 46 year old lady comes to see you with a lump in the right breast.
What would you do as a GP? When might you consider referral?
- History and examination
- Refer using suspected cancer pathway if:
- aged >30 years with unexplained breast lump with or without pain
- aged >50 years with any of the following in one nipple only: discharge, retraction or other changes eg Pagets
Breast Cancer
- What would you do, to make a diagnosis, if you were a specialist in a breast clinic?
Triple assessment:
- clinical examination
- USS / mammo (mammogram detects 90% of cancers but less accurate in younger women)
- FNA/tissue diagnosis
What life and lifestyle risk factors are linked to lung cacner?
- Smoking
- Asbestos exposure
- COPD
- Previous history of cancer – esp head and neck
- Occupational: aluminium, iron and steel. Exposure to arsenic, beryllium, cadmium, nickel, chromium compounds, coal, diesel engine exhaust, hematitie mining, MOPP chemo, DXT, production of rubber, crystalline silica dust, sulphur mustard
Lung cancer
When would you consider making a referral using the cancer pathway for an appointment within 2 weeks?
- CXR findings suggestive of lung cancer
- Aged >40 yrs with unexplained haemoptysis
Name 3 symptoms or signs which would prompt you to consider requesting an urgent CXR (within 2 weeks) in individuals aged >40 years
- Persistent or recurrent chest infection
- Finger clubbing
- Supraclavicular or persistent cervical lymphadenopathy
- Chest signs consistent with lung cancer or pleural disease
- Thrombocytosis
Offer a CXR to those aged >40 with the following unexplained symptoms:
Cough, fatigue, SOB, chest pain, weight loss, appetite loss
- 1 of the above symptoms for smokers / asbestos exposure
- 2 of the above symptoms for never smokers
What alarm features would cause you to make a referral for an urgent direct endoscopy?
(symptom and range of age)
- Dysphagia
- Aged >55 yrs with: weight loss + any of: upper abdo pain/ reflux/ dyspepsia
What symptoms would prompt consideration of non-urgent direct access endoscopy?
age + symptoms
- Haematemesis – but clinical judgement used
- Aged >55 yrs with:
1) treatment resistant dyspepsia
2) upperabdo pain + anaemia
3) Raised platelets AND any of N /V /weight loss/reflux/dyspepsia/upper abdo pain
4) Nausea & vomiting AND any of weight loss/reflux/dyspepsia/upper abdo pain
What symptoms might make you suspicious of pancreatic cancer? (age ranges and symptoms)
- Jaundice in those aged >40 – refer using suspected cancer pathway
- Patients aged >60 years with weight loss AND any of:
Diarrhoea, back pain, abdominal pain, N/V, constipation, new-onset diabetes
Ix in pancreatic cancer
- CT scan
- USS if CT not available
*USS only images the head of the pancreas, CT images the whole pancreas and may detect other cancers
What is the main factor determining prognosis in malignant melanoma?
Breslow thickness
- measures in millimetres the distance between the upper layer of the epidermis and the deepest point of tumor penetration
- the thinner the melanoma, the better the chance of a cure
A 62 year old lady has had a “period type” post menopausal bleed.
List your differential diagnosis
- HRT
- Endometrial hyperplasia / carcinoma / polyps
- Uterine sarcoma (rare)
- Cervical carcinoma / polyps
- Vaginal, vulval, ovarian cancers
- Vaginal atrophy
- Non gynae causes
When to consider direct access USS in women aged >55? (gyn cancers)
Consider direct access USS in women aged >55 yrs
- with unexplained PV discharge presenting for the first time OR if thrombocytosis OR haematuria
- Visible haematuria AND any of anaemia/thrombocytosis/raised blood glucose
Ix performed in FastTract clinic for suspected endometrial/gyn cancer
- Transvaginal USS – including endometrial thickness
- Endometrial biopsy – for histology
- Hysteroscopy and biopsy
What’s the threshold for endometrial thickness in terms of likelihood of endometrial ca?
Threshold is 5mm
- >5mm → 7.3% likelihood of endometrial cancer
- <5mm has negstive predictive value of 98%
What patients (age ranges and symptoms) need 2ww referral for bowel cancer?
- Aged >40 with unexplained weight loss and abdo pain
- Aged >50 with unexplained rectal bleeding
- Aged >60 with iron deficiency anaemia OR change in bowel habit
- If positive FOB test
When to consider* 2ww bowel ca referral?
*symptoms/ages that not usually will straight away alert 2ww referral
- Rectal or abdominal mass
- Unexplained anal mass or ulceration
- <50 y & rectal bleeding PLUS abdo pain/changed bowel habit/weight loss/iron def anaemia
What would you consider to identify a patient’s fitness for a colonoscopy?
- MI in past 3/12
- Fitness for bowel prep (moviprep) at home
- Mobility - capable of climbing on to couch/lying flat / turning on side
- On anticoagulants / anti-platelets/ iron tablets
A 56 year old singer presents with 6 weeks of hoarseness
Differential diagnosis
- Benign laryngeal conditions – voice overuse, nodules, functional dysphonias
- Cancer of the larynx/ Other head and neck cancers eg lung Ca, lymphoma, thyroid Ca
- Laryngeal nerve palsy (CVA, Parkinsons, MND, Myaesthenia gravis)
- Infections – viral, bacterial staph/ strep, fungal or TB
- Endocrine – hypothyroid, acromegaly
- Congenital – glottis web, congenital cyst
- GORD
- Scarring (prolonged intubation or post radical radiotherapy/ surgery)
Main risk factors for laryngeal cancer
- Smoking
- Alcohol
- GORD
- HPV – Ca larynx
- Long term exposure to chemicals / fumes / pollutants
- What’s that sign? (name)
- name 2 specific cancers that may cause that picture
Clubbing
- Squamous Cell Carcinoma (bronchial carcinoma)
- Mesothelioma
- Name the Ix performed (picture)
- Name 4 possible causes
CT Brain – enhanced
- Cerebral metastases
- Lymphoma
- Cerebral abscesses (HIV/TB/Toxoplasmosis)
- Primary cerebral cancer
Koilonychia
- Iron deficiency anaemia (GI malignancy)
CT Abdomen
- Colonic adenocarcinoma
- Breast cancer
- Lung cancer
- Stomach/Pancreas
Virchows node / Troisiers Sign
- Gastric carcinoma
- Lung cancer
Cannonball mets
- RCC/Testicular cancer (seminoma)/Sarcoma/Colon cancer/Breast
- Ca Pancreas
- Cholangiocarcinoma
- Small bowel lymphoma
- Duodenal carcinoma
Barium Enema
- Colon adenocarcinoma
- Dukes Staging
Sclerotic Metastases
- Prostate carcinoma
Nipple Inversion
Ultrasound/Needle aspiration/Mammogram
Barium Meal
Linitis Plastica
- Thyroid cancer/Lymphoma/Lymphatic mets
- SVC obstruction
Name 3 malignant causes for haematuria
Prostate carcinoma/Transitional cell carcinoma/Renal cell carcinoma/Genital or Gynae cancers
Multiple Myeloma
Breast cancer/Bronchus/Prostate/Thyroid/Kidney
Name 4 causes for elevated PSA
- BPH
- Prostate cancer
- Prostatitis
- TURP
- Catheterisation
- Retention
Hepatocellular carcinoma
Cirrhosis due to:
- Alpha 1 antitrypsin def
- Haemachromatosis
- Alcohol
- PBC
- HBC/HCV
- OCP
- Anabolic Steroids
- Aflatoxins
- Parasites
Hypertrophic Osteoarthropathy
- Lung cancer (SCC)
- Chronic Liver disease
- Chronic Lung sepsis
Sx: Dull bone pain, swelling occasionally
Red flags for lower back pain
- age < 20 years or > 50 years
- history of previous malignancy
- night pain
- history of trauma
- systemically unwell e.g. weight loss, fever
