Which one of the following is associated with a high leucocyte alkaline phosphatase score?
Correct Answer A:
Leucocyte alkaline phosphatase Raised in:
Low in:
A 72-year-old woman is admitted with confusion and pallor. Her daughter reports that she has been getting more confused are tired for the past three months. Blood tests are reported as follows:
In light of the macrocytic anaemia some further tests are ordered:
What is the most appropriate management?
Correct Answer C: It is important in a patient who is also deficient in both vitamin B12 and folic acid to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord.
Macrocytic anaemia:
Macrocytic anaemia can be divided into causes associated with a megaloblastic bone marrow and those with a normoblastic bone marrow.
Megaloblastic causes:
Normoblastic causes:
Which one of the following statements regarding warfarin is correct?
Warfarin:
Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the formation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.
Indications:
Patients on warfarin are monitored using the INR (international normalized ration), the ratio of the prothrombin time for the patient over the normal prothrombin time. Warfarin has a long half-life and achieving a stable INR may take several days. There a variety of loading regimes and computer software is now often used to alter the dose.
Factors that may potentiate warfarin:
Side-effects:
Haemorrhage
A 71-year-old woman with metastatic breast cancer comes to surgery with her husband. She is known to have spinal metastases but her back pain is not controlled with a combination of paracetamol, diclofenac and (Morphine Sulphate) MST 30mg bd. Her husband reports she is using 10mg of oral morphine solution around 6-7 times a day for breakthrough pain. The palliative care team at the hospice tried using a bisphosphonate but this unfortunately resulted in persistent myalgia and arthralgia.
What is the most appropriate next step?
Correct Answer E: Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy.
Palliative care prescribing: pain:
NICE guidelines:
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.
Starting treatment:
SIGN guidelines:
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points:
Other points:
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