HPM Flashcards
side effects of megestrol
adrenal insufficiency
venous thromboembolism
androgen insufficiency
what does MODS predict
predictor of mortality among ICU patients.
what variables does MODS use
physiological variables (PaO2/ FIO2, plt count, bilirubin, (heart rate*CVP)/SBP, GCS, serum creatinine)
what is most important parameter affecting mortality in MODS score
number of failing organs
what is the leading cause of death from blood transfusions
TRALI
prognosis of patients with HGb<3
median survival is 4-5 days
familial adenomatous polyposis- what cancers are associated with it
papillary thyroid cancer, adrenal carcinomas, central nervous system tumors
inherited pancreatic cancer= what also do they have increased risk of
2x likely to die of breast cancer
chances of developing breast cancer from Peutz-Jeughers
54%
hereditary conditions associated with increased risk of breast cancer
familial pancreatic cancer, cowden syndrome, peutx-jeghers syndrome, hereditary diffuse gastric cancer
how to notify patient’s family of death if they are not present
over phone if >1 hour away, otherwise wait for in person
how quickly should physicians tell family that a patient has died
important to get point out quickly- within 30 seconds to 2 mins of starting the conversation
how does having an additional child affect grief of parents
associated with recovering from grief of losing a child
what is best predictor of prognosis
functional status
pps 40%-> life expectancy <8 weeks
how to calculate intrathecal morphine dose from oral morphine dose
Morphine: 10mg IV = 1mg Epidural = 0.1mg Intrathecal (1/10 ratio; very hydrophilic)
which group has the lowest rates of hospice enrollment
asian and pacific islander
what receptors are in the GI tract that are affected by opioids
mu receptors
what type of opioid receptors are in the chemoreceptor trigger zone
mu opioids
what causes hypotension, rash, and pruritis with morphine use
histamine release
besides constipation, what is the other persisting effect of opioid use
miosis
what drugs can be used with buproprion
SSRIS/SNRIS as the bupropion counteracts sex side effects
what should you not take with bupropion
-MAOIS (wait 14 days or can cause htn)
-clozapine, theophylline, clomipramine because they lower seizure threshold
three risk factors most highly associated with decrease in global function in children after death of a parent
- lower socioeconomic status
2.pre-exisiing psych factors - presence of a depressed surviving patient
three mechanisms of methadone
- mu receptor agonist
- NMDA antagonist
- inhibitor of monoamine transmitter reuptake
TCA with best side effect profile
nortriptylline (also desipramine- secondary amines)
how do opioids affect respiratory depression
agonism of mu-opioid receptors in ventral medulla
when can children use number scale or visual analog scale for pain
> 8 years old when they can understand abstract concepts
when can the faces scale be used in kids
> 4 years old
how does buprenorphine work
mixed agonist-antagonist opioid receptor modulator with partial agonist at mu opioid receptors and opioid receptorlike receptors; antagonistic at kappa and delta opioid receptors
what medication interaction can dextromethorphan have
can cause serotonin syndrome
two central acting cough suppressants
opioids, gabapentin
what are the most common side effects of celiac plexus blocks
- diarrhea
- orthostatic hypotension (due to Inc parasympathatic tone, should volume resuscitate ahead of procedure)
can you have passive wishes for death in a normal grief reaction
yes, passive wishes are nomal, but more depression when it becomes SI and persistent
do all states have a next of kin rule
no
what is the most common cause of malignant cardiac effusion
lung cancer
where should intercostal nerve blocks be performed
under the rib to block nerve fibers associated with nociception
how to treat serotonin withdrawal
restart medication at prior dose and taper slowly
which herbal supplement has been shown to improve fatigue in patients with cancer
american ginseng
6-MAM is a unique metabolite of what substance
heroin
cisplatin- emetogenic risk
high
rituximab emetogenic risk
low
which anti-depressants don’t interact with tamoxifen
venlafaxine and desvenlafaxine
minimum age you can use the FACES scale
age 4
what is the prognosis of metastatic osteosarcoma
spread only to lungs- 40% survival rate
spread anywhere else- 5yr survival rate drops from 15-30%
what can be used for severe cases of xerostomia
pilocarpine
what is oral bioavailability of morphine
10-45%
is bereaving loss of loved one to suicide increased risk of causing suicide
yes
how does gabapentin work
a2-delta calcium channels and inhibits voltage-dependent sodium channels
-acts peripherally and centrally
peak plasma concentrations of gabapentin
2-3 hours
difference between opioid and opiate
opiate- from natural opium poppy plant
what does prognostic performance index predict
predicts 3 week survival estimates for terminally ill cancer patients receiving palliative care only (not cancer directed therapy)
what does the PPI incorporate
PPS + four symptoms (oral intake, dyspnea at rest/severity, edema, delirium)
what does HIV neuropathy most commonly involve
the bilateral lower extremities
most common cause of death in crest syndrome
pulmonary hypertension or acute renal failure
what opioid has no clinically active metabolites
methadone
what is hydrocodone’s active metabolite
hydromorphone
what percentage of people with chronic pain have MDD
15%, higher in pain clinicsw
what is the behavioral pain scale
pain scale for ventilated patients
what CBC findings are associated with poor prognosis is GBM
hgb<12
thrombocytosis
how do neonates metabolize morphine
protein binding is reduced and half life is increased
presentations of digoxin toxicity in elderly
nausea, anorexia, confusion
Most commonly used screen for complicated grief
inventory of complicated grief
cases in which dialysis should not be initiated
cirrhosis without possibility of tranpslant
metastatic cancer
severe CHF or endstage pulm disease
REMAP
REFRAME why status quo isn’t working
EXPECT emotion
MAP out what’s important
ALIGN with the patient’s values
PLAN to match values
what is the metabolite of cariprosodol
meprobomate
what are findings of complex regional pain syndrome
vasomotor (skin color changes)
sudomotor (swelling)
trophic (hair loss)
sensory (allodynia)
what type of pain is complex regional pain
sympathetically mediated pain
what pain scale can be used in neonates
CRIES
what pain scale can be used in2mos to 7yo
FLACC
what percentage of patients with chronic conditions have an affective disorder
20-25%
what is the youngest age someone can get a PCA
6yo
what medications induce metabolism of methadone (CYP450 inducers)
CRAP GPS
Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
CYP540 inhibitors that increase levels of methadone
SICKFACES.COM
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
lab findings in tumor lysis
hypocalcemia
hyperphosphatemia
do more asians or hispanics enroll in hospice
more hispanics than asians
what causes overflow incontinence
impaired detrusor contractility or obstruction
antidepressant that causes weight loss
bupropion
scale used to track complicated grief
clinical global impression scale for complicated grief
two mid acting BZDs
lorazepam and temazepam
long acting BZDs
clonazepam, diazepam, amd flurazpeam
short acting BZD
alprazolam
what are phase one and two of metabolism of opioids
- CYP450
- glucoronidation
what causes respiratory depression from opioids
agonism of mu opioid receptors in brainstem regions
most common cause of infant mortality
congenital causes
MCC death in babies 1mo to 1 year
SIDS
is SIDS more common in boys or girls
boys
mormon faith beliefs after death
soul released from physical body and then gets united with a perfect body
step 2 WHO ladder
weak opioid like codeine or tramadol
step 3 WHO ladder
strong opioid- morphine, methadone, fentanyl
step 4 WHO
nerve block, epidural, PCA, spinal stimulator
compare loperamide vs diphenoxylate
loperamide crosses BBB much less than diphenoxylate
mortality of white vs black vs hispanic men
black men live 8 years less than white men and 6 years less than hispanic men
can jehovah parents refuse blood transfusions for their children
not in life threatening situation
non-selective NSAID that poses highest CV risk
diclofenac
how many patients can be in GIP and respite for a hospice
total inpatient days of GIP and respite cannot exceed 20% of total medicare days
when does most recovery after stroke take place
3-6 months after
define potency
amount of medication required to produce effect of a given intensity
where does superior hypogastric plexus block help with
helps with pain associated with cervical, rectal, bladder, and prostate cancer
ecog 0
no performance restrictions
ecog 1
moderate physical endurance but no strenous exercise
ecog 3
limited self care but spend >50% sitting
ecog 2
all self care and <50% sitting
ecog 4
bed to chair bound
most common psychiatric illness that cancer pateint develops
adjustment disorder
chronic cough is most commonly seen in what condition
head and neck cancer
2. lung cancer
most common type of incontinence elderly
urge incontinence
safest pde5
sildenafil
two most common cancers that result in anxiety
lung cancer, melanoma
mortality rate for ARDS alone
25%
mortality of aki alone +sepsis
35%
mortality rate of multi organ failure caused by sepsis
40-75%
what is the discriminant function
identifies patients who are likely todie from alcohol hepatitis
maddrey discriminant >32 is associated with what
high short term mortality rate
most common type of delirium
mixed
what is the withdrawal syndrome of tramadol
restlessness, headache, insomnia, diarreha
onset of action of tramadol
1 hour
what percentage of patients are receiving hospice care at the time of their death
45% in gen populpation (47.5% in medicare)
what percentage of patients will die one week into hospice admission
about 1/3
what does the meld score predict
3 month mortality in patietns 12+ years old in patients with cirrhosis, acute alcohol hepatitis
what does child pugh score predict
mortality in patients with cirrhosis
at what age should you get screening ecg for tca
50
what should be checked in citalopram doses >40mg/day
ECG
requirements for continuous home care
- > 8 hours care (provided by nurse, homemaker, or hospice aide)
2.>50% hours spent by RN, LPN
most important prognostic indicator for colon cancer
stage at diagnosis
dyspnea- first medication
opioid (unless test says there is wheezing on exam)
when would clonazepam withdrawal occur
1-2 weeks after stopping due to half life
what is fica screening tool
presence of FAITH
Importance of spirituality
Community
interventions to address spiritual needs
drugs most commonly cause extrapyrimidal syndrome
haldol, fluphanezine
what muscle relaxant has structure similar to TCA
flexeril
how does tizanidine work
central alpha-2 adrenergic receptor agnoist
baclofen MOA
GABA agonist
mechanism of clonidine
alpha 2 adrenergic receptor agonist
most significant risk factor for developing depression in a cancer patient
prior history of depression
what is included in childs pugh
albumin, INR, bilirubin, degree of ascites, encephalopathy
what is prognosis of stage IV gastric cancer, HCC, colon adenocarcinoma if left untreated
6 months
what is prognosis of stage IV small cell lung cancer that is not treated
2 months
wwhat has a better prognosis- small cell vs non small cell
non-small cell
treatment of choice for pruritis of unknown cause
gabapentin or paroxetine
prognosis of malignant hypercalcemia
8 weeks
prognosis of malignant pericardial effusion
8 to 12 weeks
prognosis of carcinomatous meningitis
8 to 12 weeks
prognosis of brain cancer without XRT
4-8 weeks
prognosis of brain cancer with XRT
12-24 weeks.
how pain is transmitted
transmission
conduction
transduction
perception
modulation
what are c fibers
small, unmyelinated, slow-conducting
what are a-delta fibers
large, myelinated, fast-conducting
where does transmission occur
- injury site-> spinal cord
- spinal cord-> brain stem & thalamus
- thalamus-> cortex
age 2-6 understanding of death
death is reversible, death as punishment, wishful thinking
age 7-12 understanding of death
death is irreversible
normal ped BP
> 70/40+ (2xyear)
how to dose opioids <6mo age
lower by 25% of usual weight-based childhood dose
why is neonatal metabolism slower
-immature liver
-slow kidneys
-inc water to fat ratio
-high perfusion of tissues
-decr albumin
-decr ventilatory response
one year mortality rate of pts who start dialysis
41% if greater than 75yo
20% for everyone else
what is a clinically significant change on a 0-10 scale
2 points
what does gangion impar block treat
pelvicpain
most common cause of svc syndrome
nsclc-> small cell-> NHL
Ca 19-9
Pancreatic cancer or colon cance
Ca-125
Ovarian cancer
Cea
GI, cervical, lung, ovarian
Cd 117
GI stromal tumor and seminoma
Anti depressants for pruritis from ckd
sertraline, amitriptyline, and doxepin
What is the best antidepressant to use with tamoxifen
Venlafaxine
Antidepressants that inhibit CYP2D6 and prevent tamoxifen from being converted into its active form
fluoxetine, paroxetine, bupropion
FEV that can be used for hospice
FEV<30%
What serum-ascites albumin <1.1 means
Likely malignant, won’t respond to diuretics
Serum to ascites albumin ratio >1.1 suggestive of
Portal hypertension, responds well to diuretics
how common are stillbirths
1% of deaths
what causes decreased pain control after long-term opioid use
- increased neuronal activity in the dorsal horn
- sensitization of primary afferent neurons
- increased expression of substance P
C fibers
Small, unmyelinated, slow
What do C fibers conduct
Dull, pooorly localized pain
What type of pain do a fibers conduct
Sharp and localized pain
What role does lambic system play in pain
Emotional response
Reticular system and pain
Manages autonomic responses
