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Symptoms 2 > Unintentional Wt loss > Flashcards

Unintentional Wt loss Flashcards

1
Q

Mr. M is a 35 year male who comes in for evaluation of weight loss. He reports that, in the last 6 months, his weight has gone from 165 lbs to 130 lbs. What questions do you want to follow up with?

A

Was it intentional?

Sexual histroy

Associated symptoms

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2
Q

Unintentional: changes in eating/diet/exercise/stressors: no new meds, NC to eating habits, NC to exercise but has felt more tired. No big stressors.
NC to bowel movements
Sexual history; homosexual monogomous sexual history, no condoms, believes partner is monogomous. No recent travel.
Has had some fevers/chills/nightsweats. No other overall symptoms other then fatigue and maliase. NC to urination. No alcohol/tobaccor/illlicit drugs and negative family hx for cancer

Gen: no acute distress, thin with temporal wasting

HEENT: no scleral icterus, no oral thrush or oral ulcers, no thyromegaly, nl dentition

Lymph: bl enlarged cervical lymph nodes

Heart: regular rate, no murmurs appreciated, no lower extremity edema

Lungs: clear to auscultation bl

Abdomen: soft, non tender, no distended, nl bowel sounds

Skin: no rashes

DDx along with the pt history

A

Cardiac: heart failure, endocarditis Pulmonary: COPD, TB

GI: esophageal disorders, malignancy, peptic ulcer, gastric outlet obstruction, inflammatory bowel disease, mesenteric ischemia, celiac sprue, lactose intolerance, bacterial overgrowth, pancreatic disorders, infectious diarrhea

Renal: uremia, hypercalcemia
Endocrine: adrenal insufficency, hyperthyroidism, diabetes mellitus Heme/onc: malignancy
Infectious: endocarditis, tuberculosis, HIV, infectious diarrhea Psych: depression, anxiety

Rheum: systemic lupus erythematous, polymyalgia rheumatica, temporal arteritis, rheumatic arthritis

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3
Q

Pt with unintential wt loss of 35 lbs + history + PE

What are top three DDx?

A
  1. HIV; night sweats, unprotected anal sex, associated symptoms
  2. Malignancy: lymphoma or leukemia
  3. Hyperthyroidism (but not tachycardic and no skin changes)
  4. Autoimmune disease (lack of associated symptoms makes less likely)
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4
Q

What test would you order to further evaluate your patient (the one you suspect has HIV)?

A
  • CBC and differential normal
  • Complete metabolic profile with normal renal and liver function
  • TSH normal
  • HIV Ab positive
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5
Q

You inform the patient of his HIV diagnosis and begin to work up his disease. He has a CD4 T cell count of 135 and his viral load is 154,990 copies.Why would you want to start therapy?

A

Because of the low T cell count, you recommend treatment.

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6
Q

start treatment to decrease viral load to decrease transmission
At under 200 we worry about

A

PCP and other opportunistic infections: TMP-SMX and possibly macrolide coverage

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7
Q

When starting HIV regimen, how many drugs do we use, how many classes

A

Use at least 2 classes and at least 3 drugs and we do so to keep viral replication LOW (From reverse transcriptase) which is very prone to acquire mutations to avoid drug targeting

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8
Q

Key for HIV regimens

A

3 or more drugs ≥ 2 drug classes

Stop viral replication –to prevent mutations that can lead to resistance

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9
Q

What other factors should you consider when selecting the initial drug regimen to treat this patient’s HIV?

A

Check allergies, look for other medications he is on (drug-drug interactions)
Liver and kidney fnx
What is HIS viral resistance profile; culture drug and test

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10
Q

What do you need to consider when creating an HIV regimen

A

• Viral resistance profile

• Factors to enhance compliance
– Dosing frequency, pill burden, combination products

– Tolerable side effects – Cost

  • OtherRx:drug-druginteractions
  • Co-morbidconditions
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11
Q

Examples of 2NTRIs + integrase inhibitor

A

2 NRTIs + integrase inhibitor (____-tegravir)

– Tenofovir + emtricitabine + raltegravir

– Tenofovir + emtricitabine + dolutegravir

– Abacavir + lamivudine + dolutegravir

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12
Q

HIV regimen of 2NTRIs + navirs + booster

A

2 NRTIs + PI (____-navir) + booster

– Tenofovir + emtricitabine + darunavir + ritonavir

– Tenofovir + emtricitabine + atazanavir + ritonavir

– Abacavir + lamivudine + darunavir + ritonavir (or cobicistat)

– Tenofovir + emtricitabine + lopinavir + ritonavir

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13
Q

Example of 2 NRTIs + NNRTI

A

– Tenofovir + emtricitabine + efavirenz

– Tenofovir + emtricitabine + rilpivirine

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14
Q

What HIV drug has HLA-B*5701 status:

A

abacavir

– Assoc. with potentially fatal hypersensitivity reactions

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15
Q

• Co-morbid conditions associated with PI’s:

A
  • Diabetes (PI’s block GLUT4 glucose uptake & can decrease glucose sensing by beta cells)
  • hyperlipidemia, CV disease
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16
Q

______is strong inhibitor of CYP3A

A

Ritonavir

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17
Q

Which of the following may be of concern in patients with a history of psychiatric illness?

  1. Maraviroc
  2. Zidovudine
  3. Efavirenz
  4. Raltegravir
  5. None of the above
A

Efavirenz

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18
Q

– High incidence of CNS and psychiatric symptoms, possibility for suicide ideation

A

Efavirenz

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19
Q

Side effects of Zidovudine and drug interactions

A
  • Bone marrow suppression
  • Drug interactions: glucuronyltransferase
  • Myopathy
  • Lactic acidosis, hepatic steatosis
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20
Q

Side effects of Raltegravir

A

• myopathy, CK elevations, some hypersensitivities

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21
Q

Pt stops taking HIV regimen, experiences weight loss and difficulty swallowing. Whats going on?

A

Oral candidiasis

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22
Q

What is the most effective mechanism to prevent opportunistic infections in HIV patients?

A

Effective HIV regimen

23
Q

Pt has high viral load and low CD4 count, has oral candidiasis, what is the recommended tx

A

Oral azoles: fluconazole best bet
Pill you need to make sure there is systemic distribution; in immunosuppresed this is helpful for more thorough distribution of drug

Examples of common initial treatment for oral Candida

fluconazole (pill, oral) clotrimazole (oral troche) nystatin (oral suspension)

24
Q

What drug interactions are we concerned about when tx patients with HIV with antifungals

A

work by inhibiting fungal P450s

They also inhibit human CYP3A and CYP2C9

NRTIs do not have significant CYP interactions

PI’s are metabolized by CYP3A: -conazole antifungals can increase PI levels

But he is already on ritonavir as a deliberate CYP3A inhibitor

25
Q

Key interactions of NNRTIs and Maraviroc with CYP3A

A

While not pertinent to this patient, NNRTIs and maraviroc have CYP3A links

Maraviroc: CYP3A substrate
NNRTIs can inhibit and induce CYP3A and other CYPs

26
Q

options to treat candida glabrata

A

oral options: itraconazole, voriconazole, posaconazole

IV:
caspofungin, anidulafungin, micafungin (amphotericin B)

27
Q

What do you need to do when starting a patient back on an HIV regemin who has a history of lack of compliance to medications?

A

He may have developed resistance secondary to his many missed doses

• Check for mutations which preclude resistance to certain medications

– Genotype

28
Q

55 year old otherwise healthy male who for the last two months has experienced weight loss. He states his usual weight is 180 lbs and his weight is now 160lbs. Upon further questioning the patient voices increase in urination (all day) and feels thirsty all day as well. He drinks 6-8 glasses of water everyday. What is concerning about his weight loss?

A

more then 10% loss unintentionally in short amount of time
check metabolic panel

29
Q

Physical Exam
VS 110/75 HR 90x’ Sats 98% RA Temp 97.5

Height 175cm Weight 155 lbs
AAOx3, pleasant, hydrated, NAD HEENT PERLA, No nasal or oral masses, NECK No Masses, No JVD

CHEST CTA
CV rrr no murmurs
ABD soft, mild tender on epigastrium
Ext Mild edema and erythema right calf, LLE wnl Neuro intact
SKIN no rashes

What is most concerning about this PE? What test would you order?

A

The right calf pain is pretty concerning.

Order a D-Dimer to check for DVT

(this does not solve the mild/tender epigastrium)

30
Q

Pt hs significant unintentional weight loss and R calf pain and erythema. He has mild epigastric pain and increased thirst and urinary freuqency. His blood glucose is 360 with no history of diabetes. His D-dimer is + for right calf DVT. What test woud you order next?

A

Get a CT of chest and abdomen and look into Serum CA 19-9 to check for pancrease function

31
Q

The patient was started on treatment for DVT and diabetes. He experienced over the following month increasing band like epigastric pain. A CT scan of the chest abdomen and Pelvis revealed a large head of the pancreas mass encasing the Superior mesenteric artery and 4 liver metastasis (largest 3cm) were noted. Serum CA 19-9 was 6500

Which of the following tests is going to provide you with the most information?

A. ERCP

B. MRCP

C. ENDOSCOPIC ULTRASOUND

D. LIVER METASTASIS BIOPSY

E. CHOLESCYSTECTOMY

A

D. LIVER METASTASIS BIOPSY

32
Q

A type of pancreatic cancer associated with flushing and diarrhea is:

A. Adenocarcinoma
B. Acinar type Pancreatic cancer
C. Neuroendocrine tumor
D. Adenosquamous Carcinoma
E. Gastrointestinal stromal tumor of pancreas

A

C. Neuroendocrine tumor

33
Q

Migratory thrombophlebitis is most commonly seen in the following cancers:

A. Small cell Lung cancer and Pancreatic cancer

B. Gastric Cancer and Pancreatic Cancer
C. Gastrointestinal stromal tumor and Colon Ca

D. Non Small Cell Lung Ca and Pancreatic Ca

E. Insulinoma and Head and neck Cancer

A

B. Gastric Cancer and Pancreatic Cancer

34
Q

The following are known risk factors for Pancreatic Cancer:

A. Lynch Syndrome
B. Diabetes Mellitus
C. Peutz Jeghers Syndrome
D. BRCA Hereditary breast cancer

E. All of the above

A

E. All of the above

35
Q

Clinical signs of pancreatic cancer include:

A. Virchow’s node
B. Sister Mary Joseph’s node

C. Trousseau’s sign
D. Jaundice
E. All of the above

A

D. Jaundice

36
Q

Treatment administered after surgical resection for pancreatic cancer is called:

A. Adjuvant treatment
B. Neoadjuvant Treatment

C. Definitive treatment
D. Palliative treatment
E. Alternative treatment

A

A. Adjuvant treatment

37
Q

A drop in Ca 19-9 is considered a marker for improved survival in pancreatic adenocarcinoma.

A. True

B. False

A

A. True

38
Q

Metastatic Pancreatic Adenocarcinoma

  • Proposed treatment_____ chemotherapy.
  • Overall survival for best first line therapy is ____
A

FOLFIRINOX

11.1 months

39
Q

What is an alternative therapy to FOLIFOX for pancreatic cancer?

A

Gemcitabine in combination with nab-paclitaxel is a reasonable alternative for poor performance status patients or second line therapy

• Median survival with Gemcitabine nab paclitaxel is 8.5 months.

40
Q

Drugs approved for pancreatic cancer

A

Paclitaxel (albumin- stabilized)

5-fluorouracil

Erlotinib

Everolimus

Gemcitabine

Mitomycin C

Sunitinib

41
Q

A patient is being treated with a combination of drugs for pancreatic cancer. Her recent labs show these serum abnormalities:
creatinine: 5.5 (normal 0.5–1.2 mg/dL)
BUN: 45 (normal 6–20 mg/dL)
Mg2+: 0.2 (normal 1.5–2.0 mM)
Which of these drugs is most likely responsible?

Cisplatin

Gemcitabine

5-FU

Erlotinib

Paclitaxel

A

Cisplatin is BAD for kidneys!

42
Q

What effect does Erlotinib, 5-FU, Gemcitabine and Paclitaxel have on the kidneys?

A

Low incidence of renal toxicity: Erlotinib, 5-FU

Lower incidence renal effects (≤12%), but no magnesium effects
– Gemcitabine, paclitaxel

43
Q

Identify two reasons for giving leucovorin in anti-neoplastic therapy.

A

Rescue normal cells from methotrexate

Enhance the effectiveness of 5-FU

44
Q

As predicted from their mechanisms of action, which of the following drugs for pancreatic cancer primarily target the S phase of the cell cycle?
Can select multiple answers

  1. Paclitaxel
  2. Erlotinib
  3. Cisplatin
  4. Gemcitabine
  5. 5-FU
A
  1. Gemcitabine
  2. 5-FU
45
Q

What drug is this describing?

– Pyrimidine analog, S-phase targeting

– F-dUMP inhibits thymidylate synthase

A

5-FU

46
Q

What is the mechanism of actiong of Gemcitabine

A

– Dilfuorocytidine analog

– Gemcitabine tri-P competes for dCTP for DNA incorporation

– Gemcitabine di-P inhibits ribonucleotide reductase

47
Q

– Late G2 (G2/M)

– Enhances assembly & stability of microtubules

A

Paclitaxel

48
Q

– Cycle-specific phase-non- specific

– Platinum coordination complex –> DNA crosslinks

– Inhibits thioredoxin reductase

A

Cisplatin

49
Q

MOA of Erlotinib

A

– Cell cycle arrest (in G1)

– Inhibits tyrosine kinase of EGFR, blocking growth promoting signal

50
Q

A patient being treated for pancreatic cancer develops peripheal neuropathy. Which of the following drugs are most likely to cause this adverse effect.
Can select multiple answers

  1. 5-FU
  2. Paclitaxel
  3. Cisplatin
  4. Gemcitabine
  5. Oxaliplatin
  6. Irinotecan
A

Paclitaxel

Cisplatin

Oxaliplatin

51
Q

Compare and contrast Paclitaxel to Albumin-stabilized paclitaxel

A

Paclitaxel
– Highly hydrophobic
– Traditionally given with a detergent (Cremaphor)

• Severe hypersensitivity reactions – Poor drug distribution/penetration

Albumin-stabilized paclitaxel – No detergent needed

  • Avoids hypersensitivity reactions – Improved tissue/tumor penetration
  • Improved antitumor effects
52
Q
  • Topoisomerase inhibitor
  • Blocks re-ligation of DNA strand breaks (during replication)

– S-phase

A

Irinotecan

53
Q

Most common side effects of Irinotecan

A

– Myelosuppression (98%, dose-limiting) – Alopecia (60%)
– Nausea, diarrhea, vomiting, fever

Symptoms 2 (11 decks)

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