MBChB Clinical Scenarios

Show Learning Points most relevant to Phase 1:

Hypercalcaemia and back pain

Clinical Discipline(s)/Organ System(s)
Clinical Biochemistry, Haematology, Palliative Medicine, Oncology, Musculoskeletal System

Progress Test Topic(s)
Blood and lymph, Homeostasis

Description

A 62 year old woman sees her GP because of worsening lower back pain for the last 2 months. She has tried paracetamol and codeine, with no improvement in pain control. She has lost weight, lost her appetite and has been constipated for the last 3 weeks. Past medical history includes breast cancer treated with mastectomy 2 years ago. She is an ex-smoker with a 40 pack-year history of smoking. A blood test shows an elevated creatinine of 168 µmol/L (normal at 62 µmol/L 6 months ago), elevated adjusted calcium of 2.9 mmol/L and a normal full blood count. The serum IgG is elevated at 31 g/L.

Progress Test-Type Questions: Question 1 | Question 2

Applied Science for Medicine
   - Calcium absorption and homeostasis; transportation of calcium in serum with binding to albumin
   - Pathophysiological mechanism of hypercalcaemia
   - Molecular structure, production and role of immunoglobulins
   - Science of protein electrophoresis and differentiating polyclonal from monoclonal increases in immunoglobulins
   - Concept of paraneoplastic syndrome
   - Pharmacology of opiates such as morphine

Clinical and Communication Skills
   - History from a patient with suspected malignancy; identify 'red flags' and 'yellow flags'(psychosocial indicators) of back pain; symptoms of hypercalcaemia
   - Examination of a patient with a suspected malignancy; signs of cauda equina syndrome and spinal cord compression
   - Interpretation of calcium, phosphate, 25-hydroxyvitamin D, and parathyroid hormone (PTH) level
   - Causes of hypercalcaemia
   - Common primary cancers that metastasise to bone
   - Classification of plasma cell neoplasms; distinguishing monoclonal gammopathy of undetermined significance (MGUS) from myeloma; interpretation of protein electrophoresis; importance of assessment for end-organ damage in myeloma
   - Complications of hypercalcaemia
   - Management of hypercalcaemia; outline the management of myeloma
   - Pharmacological and non-pharmacological management of pain including in palliative care, conversion of opioids between oral and parenteral formulations; use of opioids in renal impairment

Personal and Professional Skills
   - Delivering life-changing news
   - Role of palliative care and community hospice
   - Equipoise and enrolling patients in research

Hauora Māori
- Differing risk profiles for cancer in Māori compared with non-Māori in New Zealand
- Barriers to health screening programmes for Māori (and other disadvantaged populations)

Population Health
- Epidemiology of cancer and its impact on the society
- Environmental and lifestyle risk factors for various cancers

Conditions to be considered relating to this scenario

Common
myeloma, osteolytic metastases (particularly breast and lung cancer), PTH-related peptide secreting tumour (particularly breast and lung cancer), hyperparathyroidism

Less common but 'important not to miss'
chronic renal failure, hypercalcaemia secondary to medication (thiazide and lithium toxicity), vitamin D toxicity, hyperthyroidism, sarcoidosis

Uncommon
adrenal insufficiency, immobilisation, parenteral nutrition, 1-hydroxylase expressing haematological malignancies