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Ok, cool. Let's get started. So my name is Simi. I am an fy one doctor currently working at Broomfield Hospital in Chelmsford. I am going to be delivering the final lecturer, series talk on oncology and palliative care. Just to check. Can someone let me know if the slides are visible to you? Yeah, it's working. Ok, perfect, cool. So uh I think oncology and palliative care are both very important specialties. I know in final year you guys get like very little time in terms of placement time with those specialties. I think I only got like two weeks but it's enough to give you a flavor of what those specialties are like. And I think that was the driving force that owed me to choose it for my elective. So I did my elective in pediatric palliative care and specifically with hematology, oncology patients. And I think that there is a level of communication skills that you need in these specialties that is just unrivaled in anything else. And you really see the art of medicine at work there, which is why I was very passionate about it. But like obviously you guys have exams to pass So I've tried to keep everything quite tight in this presentation and map them to the learning objectives that visi sent me. Um So hopefully this will be high yield stuff for you guys. So let's get started. There's quite a few slides to get through. Um So forgive me, if I'm going a bit fast, please do not hesitate to ask any questions in the chat or interrupt me if needed. Ok. So just to give an overview of what we will be talking about. So first of all, we are going to go through some of the key cancers, there will be quite a bit of overlap here from your general revision of the other specialties. And we will go through some key stuff like the two week wait referral pathways, different cancer markers, like the very buzzword stuff that you will find on pos med and the question banks, then we will go through the principles of cancer management. So there are different kinds of therapies and the side effects will then go into oncological emergencies, which is actually quite useful for your cases as well to think about the different presentations and how you would manage them, particularly investigations of management. Then we will have a chat about palliative care, what it is and how it might be different from end of life care. And then we will talk about prescribing at the end of life, which is quite a quite a common thing to come. Up in your exams and in the PSA as well, actually. Ok, so we're going to start off with an SBI don't know if you guys got a chance to look at the ment code, which is back here. I can also put it in the team's chat, uh, which I'll do now, uh, any chance you can put that code in the chat, um, for some trouble. Thank you. Oh, so I'm gonna start that and we'll see how it goes. If the mentee doesn't work guys, we will not worry about it too much, but it will, it will be good if we can get it to work. OK? About three people. I'll give it 30 more seconds and then we'll begin if anyone's still joining. OK. Nice. We've got four full house. All right. So let's get back to that SBA. Uh oh, I really wish I hadn't. Hopefully you guys didn't see that. Um But which one of these is most associated with raised levels of ca 125. So this is one of those like buzzword, just match the tumor marker to the right cancer kind of questions, which actually makes up a lot of the question bank, sadly. And yeah, give that one a go, I'll open that on the now get a chance to vote. Hopefully you did. But OK, so yes, the answer was ovarian cancer, which I sadly, order revealed a bit too early. But the, it's nothing too technical going on here. There is just a list of tumor markers that you will most associate with certain cancers. So it's really important to look at the wording of these questions actually, because ca 125 for example, is actually something that you can see raised in other types of cancer as well like breast cancer, but it will be very clearly one cancer that these markers are most associated with. In this case, it's like an epithelial type of ovarian cancer. Some other tumor markers I've listed over here. One is carcino embryonic antigen, which isn't so much used for diagnosis of colorectal cancer, but more to track how we are doing with the management of colorectal cancer. You've got ca 15 3 for breast cancer. Now that one actually isn't used that much in the actual treatment and management of breast cancer just because the marker isn't particularly sensitive or specific. And there are better ways to do that with breast cancer. But still, it's something that you guys need to learn alpha fetoprotein for hepatocellular carcinoma. And that is also something which is associated with multiple types of cancer. So I think testicular cancer and like germ cell cancer, it's also associated with but particularly bad cellular. And then you've got ca 99 which is your classic pancreatic cancer marker. Now, it can be a bit tricky to learn these. And sadly, there's a lot of stuff in med which is just like rote learning. Um I don't know if you guys are on medical Tik Tok and stuff like that, but people have proposed funny ways of remembering it. So for example, with C 15 3, you can turn to three sideways and it looks like a pair of breasts. Therefore, breast cancer with AFP, if you write the F and the P like really close together, then it sort of looks like the two lobes of the liver close together. Um And C 99 you've turned the nine around like on its side. And that also looks like a pancreas. There are varying degrees of effectiveness with these techniques. Ultimately, some of these, you may just have to learn. But yes, so that's that I've written some summaries of each of the key cancers on these slides. I'm not going to go through them all in too much detail, but I think it's useful for us to just have on there and you can screenshot them and then look at them later in the recording as well. But some key things I'll just go through. So with esophageal cancer, you mainly want to think about your risk factors. So if you've got really persistent reflux and that's caused and you've got Barrett's disease going on, you've got metaplasia that really predisposes you as a smoking. And the key key investigation, there is going to be an software, sorry, an ogd and biopsy in lung cancer, you want to remember the different types of lung cancer. And honestly, the best way to do it is just spam the past questions on this. But each thing is associated with different presentations and patterns if they are asking about non smokers. So you will get a typical spa, which is like a 40 year old who was recently diagnosed with lung cancer, never smoked, no smoking history. Then you are looking for adenocarcinoma in particular. Another thing about lung cancer is people always think smoking, but think about other risk factors as well like asbestos exposure good and then with breast cancer. So with risk factors, you want to think about estrogen exposure. So that's a big one. So when we've got early menarche and late menopause, that means the level, the length of time that you were exposed to estrogen is longer in your lifetime. And therefore the risk increases because estrogen is basically stimulating cell division and growth. And if you've got a really long period of that, you've got more opportunity for errors to arise basically. So I just think that with that and BRCA genes, you guys may have heard of. It is also quite linked to, I think ovarian cancers as well. BRCA is basically a tumor suppressor gene. And when you've got mutations in it, it will stop suppressing tumors basically, which is why BRCA is very associated with breast and ovarian cancer. When it comes to presentation, there's very classical symptoms associated with breast cancer. You are mainly thinking about like skin changes like pure derange is a very classical one. You also want to think about discharge, particularly body discharge. And the way you work up concerns about breast cancer is with something called triple assessment. So if you guys have had your breast week, you will be in these breast clinics where basically they move them, shuttle them through these three different stations. Basically where you have a breast examination done by the registrar or the consultant who will pick up any presenting signs or symptoms, you will then get imaging done. So that will be an ultrasound scan in patients who are less than 40 that has to do with people less than 40 having more dense breast tissue. And therefore, it's better to do an ultrasound scan for that and a mammogram for people who are over 40. And then the third thing is a biopsy and you combine all of the findings from those results and you then make an assessment of whether you have breast cancer, whether you are likely to have breast cancer and how you want to pune it further in terms of treatment of breast cancer. So that's a lot of the time tailored to the receptor profile you have. So with some people's breast cancers, there will be estrogen receptor positives, some will be progesterone receptors, some will be both, some will have like her two receptor positives. And basically that will determine which treatment you use again. These are things like you will have to learn. I haven't gone in too much detail because it's more of a surgical topic. But you will basically match estrogen receptor modulators to the er positive ones, for example. Yes. So you guys need to think about whether they are post menopausal or pre menopausal and whether there are certain receptor positive in their breast cancer and then the treatment will be tailored from there. Yeah, cool. So now we've got another spa about one of our key cancers and this is looking at referral pathways and referral criteria. So let me open up the mentee. This one. Are you guys able to access the mentee? Yeah, but it says you didn't vote in time. Uh I see. OK. Mm Tell you guys what I think let's leave the to you because it's being a bit tricky if that's OK with you. Um Yeah, of course. Yeah. OK, cool, cool. Um But yeah, so guys have a think about this question. Um It is a bit mean because it's one of those where like either you know, the referral criteria or you don't but but hazard a guess. Um and then we'll discuss it in a little bit. We have ac in the chart. OK. No. OK. Nice. So hopefully everyone has had an opportunity to have a read and have a think. So whoever puts you in the chat? Well done, you are correct. So the two week wait criteria for colorectal cancer are listed over there. So it's a bit annoying because you need to combine age and like symptoms basically. So it's one of those that, yeah, just understand. It gets to the bottom of it. Um One thing that is useful when the questions are put you in a GP setting. It's not the case with this one, but in general is when you are uncertain. Oh, has there been bleeding in the stool? And in those situations, especially when you are in a GP setting, you want to ask for a fit test which detects hemoglobin in the stool. So that's one thing to keep in mind. But otherwise, in terms of getting this right, it's all about whether you can keep the flow criteria in your head. OK. Nice. So again, a nice summary slide for you guys with the different types of key cancers. So we've got risk factors again. So for colorectal cancer, you are thinking about genetic syndromes as well. So FAP and then something called Lynch syndrome which predisposes you with colorectal cancer. You often think about older people and bleeding in the stool as the very key feature of it. But you also want to consider it if you are detecting iron deficiency anemia and just as a sign of that and also any kind of weight loss or systemic features, as would be the case with most cancers. And then strep bovis is like a very strong association with colorectal cancer. So, if you guys were seeing strep bovis, again, it should flag up in your head that you should be thinking about colorectal cancer, prostate cancer. So you'll just have to do prostate cancer to death when it comes to revising urology. But I've summarized a little bit over there psa very important to understand. You've got. The first line investigation is a multiparametric MRI of the prostate and prostate cancer is also one that is very highly associated with bony Mets. So yeah, that's also something to be aware of hepato cellular carcinoma. So with liver cancers, most of the time, if you've got cancer in your liver, it's to do with metastases rather than like a primary cancer. But you can, you can still get primary pa cellular carcinoma. The key thing to think about is whether the right upper quadrant mass or the liver that you are feeling is enlarged. And if they have the symptoms, consistent with liver cancer, the reason is that you have people with endstage liver disease or liver cirrhosis and with liver cirrhosis, the liver often shrinks up. But at the same time, cirrhosis can be a risk factor for cancer. So if you've got a large mass, but where you are expecting cirrhosis, that's pointing you towards paci carcinoma and gastric cancer. So, the most typical spa thing that you are going to encounter is this idea of signet ring cells on histology where you just have like a, a collection of burly pigment at the top of the cell on the images that you guys will see which really resembles signet ring. Uh And Brooke has not everyone should know that based on like third year abdominal examination like memorization. Uh Yeah, cool. Um We've also got all these uh just in the interest of time. I'm gonna skip over this because we've got a lot more to do Uh but feel free to go through this in your own time. OK. Now we are going to think about toxicity with chemotherapy agents. Um So this is asking which one is most associated with lung fibrosis. So again, like I said, rote learning stuff is very common in med. And this is another one of those, I'll give you guys a tip on how to remember all of these in a second. But for now, just have a read and give it a go in your head. Cool. So again, this is one that you can have your gas out but like either you know it or you don't. Um So the answer was Bleomycin, which is e and yes, there is quite a few side effects and toxicity symptoms to learn when it comes to the cytotoxic agents. It does actually come up quite a bit. So again, II would recommend learning these, the best way that I found to learn these is to draw a diagram of a toxicity bear. So maybe you guys have encountered these like an flash cards that are floating around or whatever, but this is what you get with the toxicity bear. The idea is that the first letter of each side is toxic agent. You draw on to the part of the bear that is being infected. So just to go through it. So with asparagine, you are thinking about some neurotoxicity and you are drawing that as like a hat that's going directly over the head, which should help you remember to think about up there, neuro CISplatin. So CISplatin, you draw the c for the ears and also the kidneys. So hopefully the shape makes sense in both those places to you. And that's to signify autotoxicity and nephrotoxicity. Then we've got vinCRIStine. So the bees we draw for the arms and legs of the bear and that's to do with the peripheries, peripheral neuropathy bleomycin as we just said, lung fibrosis. So we are drawing our lungs in our chest in like a mirror image kind of shape. I know that one lung has two lobes, the other one is meant to have three. But yeah, just deal with it and then DOXOrubicin for the heart cardiotoxicity, the Greek letter I, which is annoying that there can be a better way to remember that. But hopefully, you know your Greek letters that's for bladder toxicity and methotrexate for the feets. I can't quite remember what that one is for I think. And then you draw the MS on the kidneys as well. I think where the pelvis is meant to be um to indicate uh nephrotoxicity. Cool. Ok. So now we'll talk about cancer treatment. So these are three or two major terms that you will keep seeing where they will be like, oh, they were given neoadjuvant or adjuvant chemotherapy or radiation. So, with new adjuvants, what we are talking about is giving therapy prior to surgery to reduce tumor size. So with radiation, you would give that to help the surgeons out when they eventually decide to resect the tumor. Because if you've got a smaller tumor, it's a lot easier to access and get rid of on go. Adjuvant is when you've done the surgery and you are worried about just like the lingering cancerous cells. So for that, you would do adjuvant treatment treatment only is where you are not thinking about surgery playing a role, you are just aiming to treat and aiming to eliminate. So very worthwhile learning about how the different therapies work. So chemotherapy, it's cytotoxic. The idea is it's like tackling cell division and growth and disrupting that and oftentimes it will be systemic and therefore affecting healthy cells as well as well as the cancer cells that you are trying to get to. And with chemotherapy for side effects, just think about what cells have the most rapid turnover in order to figure out which ones would be affected. So a lot of times most times you will get hair loss and that's you would like how hair cells are very fast growing. You will also think about the lining of your bowel. Um So that's why you get bowel disturbance mucositis. Similar concept in radiotherapy, you are basically beaming radiation or exposing different parts of the body to radiation depending on the type of radiotherapy you are using to break the DNA in cells and therefore prevent them from multiplying. So in order to do that, what radiotherapy units do is they will very specifically map the areas that you are going to deliver that radiation to especially when it comes to beaming radiotherapy. And you are trying to maximize the area of cancer that you are trying to target and minimize the exposure to radiation of the healthy, healthy structures around it. Um Now, in order to remember the side effects, just think about what, depending on where the radiation is hitting, what kind of inflammation and problems are going to take place around those structures. So for example, with esophageal, you want to think about the yes, with lung cancer and you want to think of that in relation to the esophagus and mucositis and similarly with other parts of the body immunotherapy. So with immunotherapy, you're basically charging up the immune system to attack the tumor cells and that often leads to a high level of inflammation that goes on. And so the side effects are all to do with hyper inflammation basically. So you get all the different itis reactions like colitis and thyroiditis. Yeah. So that's just three in a nutshell. Ok. So this is moving on to oncological emergencies now. So we've got a 28 year old inpatient receiving chemotherapy for a new diagnosis of AML. They have a severe sore throat that began this morning. There is no shortness of breath, cough, chest pain or any other infective symptoms. They've been taking paracetamol for headaches, bloods from this morning show a low hb, a low platelet count and also a low neutrophil count. The observations including his temperature are all stable. What is the most appropriate next step in management? So, uh, if you guys have a think about that, you can put your answer in the chat if you'd like to, I'll give you, ah, three seconds to think through. Ok, cool. So, uh, moving on to the answer. So I think it's quite a tricky tricky question and it's one of those multi step ones where you are trying to figure out what is actually the underlying diagnosis here. And then what are we doing about it? I think the key thing that throws you off here is that the temperature is stable and you've got this pancytopenic picture. So this is a very common oncological emergency that you will see in people getting chemo, which is called neutropenic sepsis and neutropenic sepsis is where you've got chemotherapy, basically causing immunosuppression in your body and this is particularly felt in this window of time called Nadir, which is about, I think 7 to 14 days post chemotherapy where your immunosuppression is at its highest level. And therefore your susceptibility to infection is at the highest level. Now because you've got neutropenia and you've got a suppressed immune system. You are really worried about any kind of small infection and anything can lead to sepsis really. So you want to be super on top of it, you want to be monitoring and be able to tell immediately if something like that happens, which is why a lot of doctors you will see will be very hesitant to prescribe antipyretic drugs like paracetamol for these patients because they don't want to mask any fevers, which could be a really good telltale sign. So we've got neutropenic sepsis going on here. Then next step is to think about what you are going to do in a case of neutropenic sepsis. So the key thing with sepsis in general is to make sure you have antibiotics in that first golden hour period, that's really, really important. However, before you give the antibiotics, it's also really important that you get blood cultures, which is what the answer is. Um And the reason that you need to do blood cultures before the antibiotics is you want to, there needs to be a purpose to having the blood cultures. And if you've got antibiotics already slid in, then you are not going to be able to tell what is actually going on. And therefore you won't be able to target your therapy. Antibiotic therapy later on if you would like to. So the key thing is blood cultures first and then antibiotics with the antibiotics you give um the initial ones you will give will be very empirical. So I think I have a slide on neutropenic sepsis. So I'll wait to talk about that then. But essentially with neutropenic sepsis, you want to give a combination of piperacillin and tazobactam, which is 4.5 g IV QDS. It's also known as Tazocin. It's like very empirical treatment and it only exists as IV treatment. So it doesn't exist as oral treatment, which is why it's important to give it IV. So just looking at the slides. So yes, we talked about nadir neutrophil counts. So to be classified as neutropenic sepsis, it varies depending on the center. But a lot of sensors use less than 0.5 others will use less than one. I think in this case, it was 0.7. But you can clearly see that there is pancytopenia going on there. So you should definitely be thinking about neutropenic sepsis and the 7 to 14 day period that I mentioned that is that is true in terms of like that's when the s are at their lowest. But you should suspect it in patients all the way up to six weeks after having received chemo. Um Yes. So in terms of presentation, so as with this patient, you may not have specific focus, focuses of infection or signs to do with focuses of infection, but you will have more generalized signss. I think it depends. So I'm doing an audit in our pediatric ward right now about neutropenic sepsis. And you will see the presentations vary significantly. You are always looking for those systemic signs like fever, weight loss, lethargy and also like deranged obs like tachycardia, tachypnea and hypertension. Oh, sorry, the weight loss and that's more to do with the cancer with sepsis. You were thinking about p tachycardia, tachypnea, hypertension and with that, you may get things like thigh pain or sometimes vomiting. It will vary a lot. But you are looking for those systemic signs that are a characteristic of sepsis. You want when it comes to investigations in sepsis six and management, this is very important for your cases to just be able to rattle this off immediately. When it comes to the cases of sepsis, you want your full septic screen, which includes blood cultures, urine cultures, chest X ray. And remember the lactate from the BVG, the lactate is a really good way of determining the level of unwellness and the level of escalation you need to do. So if it's a very high lactate, you may want to consider involving ICU and then with the sepsis six, I'm sure you guys know what a ESIs six is by now. But you want to make sure you do that, uh puberty, needle time. That means when you get the antibiotics in that needs to be under one hour. And then if that initial tazocin doesn't do the job, you then want to escalate. But that's beyond the scope of what we need to know. And GCSF. So there is something called grain, which is also known as GCSF. So granulite stimulating factor and that's given to patients to boost their immune response at a time where they are very immunosuppressed. So that's given to help them along. And then you also want to give supportive care in general, which is symptomatic management and also fluids like keep them hydrated, managing any B thing, that kind of thing. Cool next SBA. So this is also to do with one of the oncological emergencies. So give this a read and then, yeah, then we will discuss, ok. Um I can't see the chat so I can't tell if anyone has hazarded a guess as to what the answer is. But this is a very typical presentation of something called superior vena cava obstruction or sp and the key signs of what's going on here is puffiness of the upper extremities. So, congestion and edema of the upper extremities, severe headaches. So again, just thinking about something that's causing blockage and causing that congestion, upwards of the vena cava and descended veins as well. So in terms of the key etiology that you guys need to learn. The key one in this case is going to be lung cancer. And more specifically, we are thinking about small cell lung cancer as the commonest cause. And you get that when the cancer is situated in the right upper lobe um of the lung, I think I've got a picture of it here. So when you have the tumor in that position, just think anatomically, it's going to be compressing the SVCO and therefore you have a blockage of the brachiocephalic vein. And therefore, you won't have like drainage of all of the fluid and blood that's coming from the upper extremities, which is why it all gets backed up and you get those characteristic symptoms as you can see there. Cool. So, uh yeah, so the upper extremity signs is accentuated really well by something called Pemberton's sign. And that's basically where you lift the arms to the sides of the patient's head as is being done in this picture on the right. And then that leads to really like visual redness and congestion of the head. So that's very important to remember in terms of key signs. So you get mediastinal widening on chest X ray and CT and to manage it. What you do is you basically try and reduce the level of inflammation there by giving dexamethasone and therefore trying to ease off the pressure on the vein. But ultimately, you need to actually get to the bottom of the problem, which is the actual cancer itself so that you are going to do with chemo and radiotherapy. You do also get stents which go in and try and open up the vein again and that's made for symptomatic relief. But it's quite a bad prognosis. I believe if you have SVCO Cool. Moving on to the next question. Uh, so a 37 year old female with a history of AML was discharged three days ago following her first cycle of chemotherapy presents to GP with nausea, vomiting, diarrhea, she denies dyspnea, cough and back pain but has not opened her bladder in the last 24 hours. GP checks her discharge letter and realizes she was not prescribed any supportive medication prior to the onset of chemotherapy. Uh in terms of her obs, she just has tachycardia, uh normal FBC you and these pending what a single most likely diagnosis. So I have to think the main thing that I would point you guys towards is the fact that the UNS are pending paper. Let's get to the answer in the interest of time. So, in this situation, we have a lot of like vague symptoms. Um basically, uh and the cause of them is electrolyte derangement and electrolyte derangement is something you get in tumor lysis syndrome. The key things you get is um raised potassium, raised phosphates, raised uric acid and low calcium. So that combination of electrolyte derangement is very characteristic you would probably get a lot of spas that show that electrolyte. I didn't want to do that for this one because it becomes quite obvious. But it's very typical for it to happen in patients who have just had the first cycle of chemotherapy where their body is not used to it. And all of a sudden it gets exposed and you get a huge release of all of these things. When the tumor lss, the commonest ones are al and AML and the ECG you are doing that because of the hyperkalaemia. You are trying to detect any life threatening arrhythmias. So once you know, someone has tuberis or you identify the high potassium, you always need to do an ECG in terms of supportive medications. So we were talking about allopurinol and rasburicase. So these are two medications that are typically given like an anticipatory to prevent the complications of tumor lysis. The way they work really is they block the build up of uric acid by disrupting the formation of uric acid. So that was another clue, the way to manage it mainly is through hydration. Um, so you obviously have your prophylactic medication that we talked about. But then, yeah, that's mainly it. And then haemodialysis, you're going to do that once you're worried about like real damage to the kidneys. Yeah. Ok. Cool. And this is just to show what's going on there. So the reason people think, oh, why is calcium low because you are lying, the tumor cells, therefore, you get a release of things, right. Um True. But the release of phosphorus is the most significant thing um when it comes to the calcium levels. So the phosphorus that is released will bind to the calcium that's floating around and therefore you'll get calcium phosphate and the free calcium will be lowered. And over there, you can see the allopurinol and rasburicase will disrupt different parts. Sorry, allopurinol will disrupt the formation of uric acid and rasburicase will decrease the uric acid. It's been general, you said the other another key oncological emergency, metastatic spinal cord compression. So the most classic sign you'll get with this is back pain. Um When you get back pain in a constipation, just think of metastatic spinal cord compression and you can also get bowel and bladder dysfunction and you want to get a full spine MRI in less than 24 hours because just because you identified one metastases that it's very probable that there's more going on. So you want to detect all of those cool. And then again, you want to give dexamethasone to treat, to again, ease off the pressure that is being placed on the structures, the spine from the tumor. Another thing that's very key. I think in your pieces, exam if this comes up is you want to talk about something called spinal precautions where you'll get the patient to be flat and stable and possibly put them in a brace. Um So important to mention that and then when it comes to management. So you really want to refer over to neurosurgery or clinical oncology with neurosurgery. You are asking them to see if they want to operate. It's very rare that they would want to do that with clinical oncology. You are basically figuring out what we are doing for radiotherapy, which is something that happens a lot often with this. OK. Cool. Next question. So I'll give you guys some time to have a read and then we'll go through it. OK. Cool. So what we've got in this situation is um very classical uh symptoms of uh hypercalcemia. And we want to treat that hypercalcemia and the best way to do. And the reason I say a classical signs for hypercalcemia is we are thinking about the stones, bones, Crohn's psychiatric overtones, which I've put a little graphic over there. And the calcium in that question was clearly very raised. It was at 3.1 and that's going to give you all of those very classical hypercalcemia symptoms. You want to treat the hypercalcaemia and you can do that in multiple ways. So, prednisoLONE for example, can be used. But the first course you would take is to give fluid and particularly sodium chloride is 500 mL cool. So with hypercalcemia, key ecg findings to remember showing QT interval. Now, calcium is obviously linked to parathyroid hormone. So in squamous cell lung cancer, you can get a PTH producing tumor. In which case, you're thinking of that as a cause as well. Myeloma where you've got release of calcium from the bones from osteolysis. You are also thinking that and bisphosphonates you can, you can do. But with bisphosphonates, the problem is you can't really use that in situations where Egfr is low and I believe in this one. Yes, we said Egfr was 15 and so it would not have been appropriate for anyone who chose, uh, bisphosphonates. Ok. Uh Other oncological emergency bowel obstruction, you guys know how to deal with bowel obstruction, just classic, like nil by mouth dri and suck and see what surgery you have to say. You're going to ask for an abdominal X ray and a CT abdomen. Um, cool, nothing more to say about that. Ok. So now we're thinking about, um, are end of life prescribing and symptom management prescribing. So, have a look at this question. Um We'll go through what the key rules are when it comes to doing these prescriptions. But I think it will be useful for you guys to give this a go first. Ok. So what we've got here is, uh, basically a question to do with PRN prescriptions. Prn prescriptions is quite straightforward. You do calculate it by looking at the total daily dose of morphine that has been given and then you want to divide that by 1/6. So in this case, we've got 30 mg twice daily. And that gives you 60 mg in a 24 hour period. And in order to get PRN you divide that by six, which is 10. And then it's just a matter of choosing between immediate release and modified release. So when you think about it, the whole point of PRN is that you get immediate relief. So you want to go for the immediate release and therefore a a cool um that's how do appearance. Um and this spa is more to do with morphine conversions. So give this a go and then uh ii know it can be quite daunting to like trial questions like these until you understand what's going on. But hazard a guess and then we'll go through some of the key rules. OK? So we've got a patient who has metastatic prostate cancer. They have uncontrolled pain. So they are constantly running out of their pain medications. They are taking 5 to 6 doses of their oral morphine over the course of a day, which is useful each time they take it, but each dose really only gives them relief for a small amount of time. So they are having to take it over and over and over and that's not particularly sustainable. So we need to converse it or into a more sustainable dosage. So this is where modified release becomes really effective and useful. So in order to calculate his needs, we are going to want to give him his total daily regime. And we're also going to want to think about what the relevant prn for his breakthrough pain will be, which as we just talked about was 1/6 of the total. So in order to work out what the total is, we just look at how many doses he's taking in the day. So it's saying he's in order to get through the day, he needs 5 to 6, it's better to go for the higher number just because we don't want to be in a situation where we are still underdosing him. So we'll go for six and then we know each dose is five mg. So you do six times five which is 30. So you've got 30 mg that he is taking in a day and modified release. The function of it is that you don't need to take it like loads and loads of times. So you typically give it BD. So you want to give the modified release BD. Therefore, divide that 30 mg by two because we are not conversing the morphine sulfate into any other kind of opioid. You are just keeping as morphine sulfate just making it modified release. So you've got 15 mg as 30 divided by two and then the 1/6 PRN is 30 divided by six. So we are going to go for 15 mg of modified release and five mg PRN. So answer is a uh this is um a graphic just to show you different conversions. I wouldn't worry too much about like learning all of these. I think like the the key stuff is converting oral morphine to IV and subcut, which is times by 0.5 you will be able to, the times that you really need to think about. This is your PSA and at that time, you will have access to the PNF. There is a great page called prescribing at the end of life. So you want to prescribe for palliative care. One of the two, you want to just go on that page and it has great tables which break down everything and show you what the conversion ratios are so good. So that's why uh we have answer a um the reason you wouldn't go for the other ones. So the fentaNYL patch one over there. So 12.5 mg per hour, if you did the maths and you did that 24 and then you did this conversion of 0.05 as a multiplication factor, you would get a dose of morphine equivalent dose of morphine. That is too much. It's 45 mg and we don't need that much because this guy is able to get by albeit very inefficiently with currently on six doses. So we don't want to do that. So, and then traMADol, traMADol is basically like a weaker form of opioid um than morphine sulfate. And if you've got a situation where his pain is being uncontrolled on, on his given type of morphine, sulfate you. Yeah, you don't want to change his opioid type. Um and and make it a weaker opioid cool. And then uh got another SBA I, yes, I think this is to do with uh fine. OK. This is one of the other key presentations to manage. Sorry, I didn't realize all of the questions would be coming up first before the summary slides but have a go at this guys and then we will have a good, nice long talk about all of the key symptoms at the end of life and how to manage them. Ok. So um I realize it's gone eight o'clock. So let's just speed through this. So we've got a situation where you have some respiratory secretions going on and for respiratory secretions, the key ones you want to use key medications are glycopyrronium and hyoscine fil bromides. However, it's useful to know specific doses. It is, it is quite harsh most of the time you don't need to know exact doses. But I think it's worth just memorizing the key ones, especially when it comes to going into your paces, especially for the key end of life symptoms that you are trying to manage. So in this case, it's between glycopyrronium, bromide and hyoscine butylbromide and you're going to go with glycopyrronium because the dosage is correct. Um So with respect to secretions, it's quite, you get it quite often, it doesn't actually distress the patient as much as it distresses the family. So it's called a death rattle because of how awful it sounds. And yeah, if it's something that is causing distress, it's worth treating. So yeah, we've got that um ok, just to go through um palliative care versus end of life care just as concepts really quickly, palliative care. I always think of it as like the larger bubble within which end of life care is included with palliative care. You're basically thinking about any kind of care that improves the quality of life of patients that are living with life limiting illness or terminal illness. So where you know, there is a significant decrease in the quality of their life or the l of their life and you need to give them relief and that relief can take many forms. It's symptomatic in the ways that we've just been discussing with the question so far. But it's also psychosocial and spiritual as well. So very important to make that distinction end of life cares when you can clearly identify and flag. Ok. I think this patient is very likely to pass in the next 12 months. It's a hard thing to pin down as to whether yes, they are definitely going to pass soon. And I think as you get closer and closer to the time of death, you can make a more accurate prognosis. But it's still useful because if you are able to identify that early enough, then you can take action and improve their, improve the planning process and your management with the ultimate and destination in mind spine. These are ok. So these are the key signs and symptoms of dying guys. There are lots of signs and symptoms and the BNF page on end of life prescribing really does a great job going through each of those. The main ones that you need to know for your exams are the four at the top there. The common symptoms, agitation, pain, excessive secretions, nausea, and vomiting. So we've talked quite a bit about pain and excessive secretions based on the spas. Let's also just talk about the other ones and we will do that in the context of syringe drivers. So, syringe drivers is really important for you guys to understand as well. They are basically machines that enable a continuous delivery of medication. And this really helps people at the end of their life because instead of having to worry about the scheduling of medication and constantly be disturbed at a point where perhaps you weren't even capable of taking oral medication. In that way, you just have a continuous stream of medication through a subcu injection. And these are the key medications you would use in each. So for agitation, you're thinking about midazolam, haloperidol pain opioids as we've discussed and nausea, vomiting, you think about cyclizine, metoclopramide, haloperidol. Remember the key hazards when it comes to using metoclopramide and cyclizine So for example, cyclizine, I think you, it can cause highs in young women. So you want to be careful about prescribing that. And do you also want to think about allopurinol in relation to Parkinson's? Ok. So we've talked about, we've basically touched on opioid prescribing, but when it comes to pain prescribing in general, you want to follow something called the pain ladder. And what that is, is basically step ups of the level of pain. So if someone is presenting with very, very severe pain, the best thing honestly to do is to go higher up on the ladder and then step down. Other times when people are, are in a fair bit of pain. And you think, ok, fine, maybe one first run will solve it I process or ibuprofen. Um then you should start there and then see if you need to work up. But it's very much a clinical assessment at the time. Key things to remember for prescribing is don't prescribe Cocodamol and paracetamol. You also with Cocodamol, you have the paracetamol in there as well. That's something that people often get wrong. And then you've got weak opioids, strong opioids like we touched on before. So key to make those distinctions. Uh and then uh these are some of the key rules. So 1/6 of the daily dose for PRN um and side effects of morphine are very important to know. So, constipation, nausea and vomiting, drowsiness, confusion. So oftentimes like when people get prescribed morphine, there are other things that are prescribed with it, co prescribed. So, antiemetics and laxatives based on the constipation and the vomiting and some people even do Pr and naloxone. That's because of the possible respiratory depression and to people who are particularly sensitive to opioids, you may want to think about doing that. But again, I don't think that will count on your exams that much nausea and vomiting. These are the key key um medications to use there. Uh Mesopram, as I was mentioning before, you want to think about that in relation to uh Parkinson's and bowel obstruction. So it's prokinetic. So you don't want to be prokinetic in a situation where you've got an obstruction because that could cause perforation in Parkinson's. You've got dopaminergic, it's a D2 antagonist and in a case where you don't have enough dopamine in your system anyway, you don't want to be messing with that basically. Um Cool. So that's that should run everything, run through everything you need guys. Sorry, it's a bit rushed. I was quite aware of time and I know people want to get away and into their even, but everything is their own, feel free to go through it and review the key, key information on there. Most important is your ability to recognize and treat oncological emergencies. Just go through loads of presentations of that, whether it's with paces cases or with spas. Always remember like your at approach fourth rote learning de annoying stuff like tumor markers as we were going through before and two week weight pathways, side effects and toxicity is important. And with palliative care, the key thing is just all those common symptoms, there are four common symptoms that you need to know how to prescribe against. And yeah, hopefully that was useful for you guys and as relevant uh as possible. Thank you. Cool. A any questions that anyone has and if not, we can wrap up? Thank you. Do you wanna put the feedback form on? Yes, I do. Um Yeah, guys, if you can, please please bounce that feedback form, I'd be very grateful. Um You learn very quickly when you start f one like how important having like a good teaching portfolio is whether that's just like to progress through the foundation years or? Um Yeah, also just think about like your actual specialty applications later on. Um If anyone has any questions about uh foundation years or you know, this lecture in general, feel free to email me the my email address was at the start. Um And yeah, hopefully you guys have a nice rest of your day.