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HPM Questions Flashcards

1
Q

What are the components of Total Pain?

A

Physical, Psychological, Social, and Spiritual

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2
Q

What is acute pain?

A

Occurs suddenly due to illness, injury, or surgery, that is generally short-lived that resolves as the acute illness heals

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3
Q

What is chronic pain?

A

Pain that lasts longer than the expected healing process (3 months for IASP), and that affects a person’s activities of daily living

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4
Q

What is nociceptive pain?

A

Arises from actual or threatened damage to non-neural tissues due to activation of nociceptors

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5
Q

What are common symptoms of somatic nociceptive pain?

A

Arises from bone, joint, muscle, skin, or connective tissue that is well-localized, aching, and throbbing

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6
Q

What are common cymptoms of visceral nociceptive pain?

A

Arsises from visceral organs (such as the GI tract), that is aching if related to capsular pain or poorly localized cramping if due to hollow viscus organ pain

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7
Q

What are the stages of nociceptive pain?

A

Transduction -> Conduction -> Transmission -> Perception -> Modulation

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8
Q

What are the characteristics of pain conducted by C-fibers?

A

C-fibers are small, unmyelinated, slow-conducting fibers that transmit dull, poorly localized, diffuse, burning/aching pain, and are sensitive to mechanical, thermal, or chemical stimuli

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9
Q

What are the characteristics of pain conducted by A-delta fibers?

A

A-delta fibers are large, myelinated, fast-conducting fibers that transmit well-localized, sharp pain, and are sensitive to mechanical and thermal stimuli

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10
Q

What are the characteristics of pain conducted by A-beta fibers?

A

A-beta fibers conduct non-noxious input (i.e., touch), and do not transmit pain signals

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11
Q

Which of the stages of nociceptive pain is not responsive to drug therapy?

A

Perception

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12
Q

What is an example of transduction of pain?

A

Nociceptors translate physical stimulus into an electrical signal and action potential

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13
Q

What is an example of conduction of pain?

A

Pain impulse traveling up or up to the spinal cord

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14
Q

What is an example of transmission of pain?

A

Transfer of an action potential from one neuron to the next

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15
Q

What is an example of perception of pain?

A

The conscious experience of pain

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16
Q

What is an example of modulation of pain?

A

Inhibiting descending pain impulses

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17
Q

What medications help reduce the transduction of pain signals?

A

NSAIDs, anticonvulsants, Capsaicin, Lidocaine, and TCAs

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18
Q

What medications help reduce the conduction/transmission of pain signals?

A

Opioids (endogenous and exogenous), Gabapentin, Pregabalin, Ketamine, and anticonvulsants

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19
Q

What medications help reduce the perception of pain signals?

A

None

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20
Q

What interventions help reduce the perception of pain signals?

A

Relaxation and guided imagery

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21
Q

What medications help reduce modulation of pain signals?

A

Opioids, Tramadol, Tapentadol, TCAs, SNRIs, and Baclofen

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22
Q

What processes lead to the development of neuropathic pain?

A

Abnormal nerve regeneration, increased expression of membrane sodium channels, disinhibition of the modulatory process, or decreased expression of mu-opioid receptors

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23
Q

What is allodynia?

A

Pain from a non-painful stimulus, such as touch

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24
Q

What pain assessment tool has been validated for patients with advanced dementia?

A

PAINAD – a 5 item observational tool

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25
Q

How long must pain be present in a day for it to be classified as persistent pain?

A

12 out of 24 hours in a day

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26
Q

What is the preferred route of administration for medications for most patients?

A

Oral

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27
Q

What are the FDA guidelines to starting transdermal Fentanyl in patients?

A

Patients must be receiving and tolerating at least 60mg of oral Morphine equivalents per day for no less than 7 days (1 week)

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28
Q

What is the maximum daily dose of Acetaminophen recommended by the FDA?

A

4 grams

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29
Q

What opiate should you avoid due to it being a strong CNS irritant with dysphoria, irritability, tremors, myoclonus, and seizures?

A

Meperidine (Demerol)

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30
Q

If a patient has a neurolytic procedure performed, when might they have return of pain sensation secondary to nerve regeneration?

A

3 to 6 months

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31
Q

What kind of nerve blocks help with visceral pain?

A

Sympathetic nerve blocks

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32
Q

What kind of nerve blocks help with focal pain?

A

Somatic nerve blocks

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33
Q

What are the main types of sympathetic nerve blocks?

A 
Celiac plexus
Lumbar
Superior hypogastric
Stellate ganglion
Ganglion impars
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34
Q

What are the main types of somatic blocks?

A

Brachial plexus
Gasserian
Paravertebral
Epidural/Intrathecal

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35
Q

What is the indication for a superior hypogastric plexus block?

A

Visceral pelvic pain that is refractory to medical management

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36
Q

For what cancer type is a neurolytic procedure a first-line therapy for pain?

A

Upper abdominal cancers (i.e., pancreatic cancer)

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37
Q

What neurolytic intervention is indicated for pancreatic cancer?

A

Celiac plexus block

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38
Q

What are the side effects associated with a celiac plexus block?

A

Orthostasis and diarrhea

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39
Q

What kind of nerve block is indicated for chest wall pain (e.g., breast cancer pain or rib metastases)?

A

Intercostal

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40
Q

What kind of nerve block is indicated for unilateral leg pain?

A

Lumbar subarachnoid

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41
Q

What is another kind of nerve block indicated for pelvic pain?

A

Phenol saddle

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42
Q

What is another kind of nerve block indicated for chronic pelvic pain (e.g., interstitial cystitis)?

A

Pudendal nerve

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43
Q

What is complex regional pain syndrome?

A

Regional pain that is associated with focal autonomic dysfunction

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44
Q

What kind of nerve block is indicated for spinal facet joint pain (e.g., malignant vertebral compression fractures)?

A

Medial branch of the primary dorsal ramus

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45
Q

When are nerve blocks for trigeminal neuralgia indicated?

A

As a last resort

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46
Q

What nerve block has the lowest risk for adverse effects when treating

A

Gasserian ganglion block

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47
Q

What is the life expectancy patients should generally have if they are being referred for an epidural catheter for pain management?

A

Days to weeks

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48
Q

What is a major risk of epidural catheter placement?

A

Catheter fibrosis

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49
Q

What is the life expectancy patients should generally have if they are being referred for an intrathecal catheter for pain management?

A

Weeks to months

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50
Q

How much oral morphine daily dose equivalents must a patient be taking before being referred for an intrathecal catheter for pain management?

A

Greater than or equal to 100mg

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51
Q

What medications can be used in neuraxial pain management?

A

Opiates - Morphine, Hydromorphone, Fentanyl

Non-Opiates - Bupivacaine, Clonidine, Ziconotide, Baclofen

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52
Q

What are the common side effects seen with Bupivacaine neuraxial pain management?

A

Urinary retention, paresthesias, lower extremity weakness, gait impairment, and orthostatic hypotension

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53
Q

What is the most common side effect seen with Ziconotide neuraxial pain management?

A

Psychosis

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54
Q

What is the most emergent complication of an intrathecal pain pump?

A

Spinal cord and/or nerve injury

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55
Q

What are common non-emergent complications of intrathecal pain pumps?

A

CSF leaks, infection, migration, release of large concentrations of drug, and/or granulomas

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56
Q

What are the conversion ratios for Morphine?

A 
PO = 30mg
IV = 10mg
Epidural = 1mg
Intrathecal = 0.1mg
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57
Q

What are the conversion ratios for Hydromorphone?

A 
PO = 7.5mg
IV = 1.5mg
Epidural = 0.2mg
Intrathecal = 0.04mg
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58
Q

What are the conversion ratios for Fentanyl?

A 
IV = 100mcg
Epidural = 33mcg
Intrathecal = 6-10mcg
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59
Q

When are vertebroplasty and/or kyphoplasty indicated?

A

Used for symptomatic compression fractures to reduce pain and stabilize the fracture, most often showing pain relief in cancer patients

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60
Q

What are the contraindications to vertebroplasty and/or kyphoplasty?

A
  1. ) Epidural disease
  2. ) Neurologic damage related to the fracture
  3. ) Fracture with bone fragments extending into the spinal cord
  4. ) Infection
  5. ) Hypercoagulable state
  6. ) Severe cardiopulmonary disease
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61
Q

How long after radiation therapy do patients typically experience pain relief?

A

2 to 4 weeks

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62
Q

What is a rhizotomy?

A

A surgical procedure to sever the nerve roots of a spinal cord

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63
Q

What is a cordotomy?

A

A surgical procedure that disables selected pain-conducting tracts in the spinal cord to achieve pain control

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64
Q

When is a cordotomy indicated?

A

Severe, uncontrolled, refractory cancer pain

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65
Q

What is the primary use for Ketamine?

A

Refractory neuropathic pain

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66
Q

What is a growing use for Ketamine?

A

Refractory depression

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67
Q

What are the most common side effects of Ketamine?

A

Vivid dreams, hallucinations, floating sensations, and visual-spatial disorders

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68
Q

What is a rare side effect seen with Ketamine abuse?

A

Ulcerative cystitis

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69
Q

What medication should you use if there are psychogenic side effects seen while administering Ketamine?

A

Lorazepam

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70
Q

What is the preferred steroid to use in cancer pain management?

A

Dexamethasone

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71
Q

Why is Dexamethasone the preferred steroid to use in cancer pain?

A

Low mineralocorticoid effect

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72
Q

Other than pain, when might a provider consider steroids for symptom control?

A

End-of-life fatigue, anorexia, and nausea

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73
Q

What is the primary indication for topical lidocaine?

A

Post-herpetic neuralgia

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74
Q

For which disease processes has acupuncture been shown to have promising benefits?

A

Chemotherapy-induced neuropathy and post-thoracotomy pain

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75
Q

Which pain disease state does Cognitive Behavioral Therapy best treat?

A

Chronic pain

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76
Q

What are known contraindications for acupuncture?

A

An active infection or known malignancy at the site of needle insertion

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77
Q

What are the known indications for St. John’s Wort?

A

Depression and auto-inflammation

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78
Q

What are the side effects of St. John’s Wort?

A
  1. ) Interferes with the metabolism of opiates
  2. ) Blood thinner
  3. ) Increased risk of serotonin syndrome
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79
Q

What drug is ginger known to interact with?

A

Coumadin (Warfarin)

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80
Q

What is the most prevalent symptom in palliative care?

A

Fatigue

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81
Q

What is the definition of fatigue?

A

Extreme tiredness, typically resulting from mental/physical exertion

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82
Q

What other diagnoses should be considered when patients present with fatigue?

A

Depression, hypoactive delirium, weakness, or demoralization

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83
Q

What has been shown to improve cancer-related fatigue in particular individuals?

A

Exercise

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84
Q

What is the most likely cause of cancer-related fatigue?

A

Elevation of pro-inflammatory cytokines such as TNF-alpha, IL-1, and IL-6

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85
Q

What are common risk factors for cancer-related fatigue?

A

Unmarried, lower household income, medical comorbidities, poor nutritional issues, deconditioning, polypharmacy

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86
Q

What two factors are not consistently associated with cancer-related fatigue?

A
  1. ) Type of treatment

2. ) Dose intensity

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87
Q

What is the dosing for Methylphenidate for cancer-related fatigue?

A

Start at 5mg BID

Max of 40mg/day

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88
Q

What is the dosing for Modafinil for cancer-related fatigue?

A

200mg/day

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89
Q

What is the dosing for Dexamethasone for cancer-related fatigue?

A

8mg, typically divided into BID dosing

This is the medication of choice for fatigue at end-of-life

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90
Q

What patients are candidates for testosterone supplementation for fatigue?

A

HIV, ESRD, and COPD

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91
Q

What are the side effects for Megestrol?

A

Edema, thromboembolic events, increased mortality

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92
Q

What is a known independent risk factor for mortality?

A

Delirium

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93
Q

How often can delirium be reversed?

A

50%

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94
Q

What are the symptoms of hypoactive delirium?

A

Psychomotor retardation
Withdrawal/Apathy
Inattentive
Lethargy

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95
Q

What are the symptoms of hyperactive delirium?

A

Psychomotor agitation
Aggression
Hypervigilance
Sympathetic hyperactivity

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96
Q

What is the key difference between delirium and dementia?

A

Attention is impaired in delirium whereas it the patient is confused but does not have impaired attention in dementia

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97
Q

What are life-threatening causes of delirium?

A

Hypoxia, hyperglycemia, hypertension, Wernicke’s encephalopathy, intracranial hemorrhage, meningitis/encephalitis, or poisoning

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98
Q

What is a severe side effect of antipsychotics used to treat delirium?

A

Neuroleptic malignant syndrome

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99
Q

What is the FDA Black Box Warning for antipsychotics used to treat delirium?

A

Sudden death in elderly patients with dementia

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100
Q

What is the first-line therapy for delirium?

A

Medical evaluation leading to treating the underlying cause

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101
Q

What is a strong contraindication for using Haloperidol?

A

QTc above 450msec, or if it increases by 25% while on Haloperidol

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102
Q

What antipsychotics are known to potentiate delirium through their anticholinergic side effects?

A

Chlorpromazine and Olanzapine

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103
Q

What is the safest antipsychotic to use in patients with Lewy-body dementia?

A

Quetiapine

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104
Q

What are the symptoms associated with xerostomia?

A

Malodorous breath, altered taste, difficulty chewing/swallowing, tooth decay, gum disease

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105
Q

When should you use sialagogues for patients with xerostomia?

A

If prognosis is greater than 3 to 6 months

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106
Q

What is a common under-reported cause of insomnia?

A

Restless leg syndrome

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107
Q

What is the first-line therapy for the treatment of insomnia?

A

Behavioral therapy

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108
Q

What are the CDC recommendations for the treatment of insomnia?

A
  1. ) Consistent bed time
  2. ) Quiet, dark, relaxing bedroom
  3. ) No electronic media devices
  4. ) No meals or alcohol before bed
  5. ) Exercise during the day
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109
Q

What medications used commonly for insomnia cause an increased risk for accidental opiate overdose?

A

Zolpidem (Ambien)

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110
Q

What is the first-line therapy for opioid-induced pruritis?

A

Rotation

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111
Q

What is the second-line therapy for opioid-induced pruritis?

A

Sertraline, Paroxetine, or Mirtazapine

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112
Q

What is the treatment of choice for opioid-induced pruritis secondary to neuraxially-administered opiates?

A

Ondansetron

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113
Q

What are effective medications for pruritis associated with HIV?

A

Indomethicin

Doxepin

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114
Q

What are effective medications for pruritis associated with chronic kidney disease?

A

Gabapentin
Pregabalin
Mirtazapine
Dronabinol

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115
Q

What are effective medications for pruritis associated with hepatic disease?

A

Rifampin
Sertraline
Mirtazapine
Dronabinol

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116
Q

What are effective medications for pruritis associated with inflammatory dermatoses?

A

Steroids

Immunosuppressants

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117
Q

What are the characteristics of a stage I wound?

A

Intact skin with non-blanchable redness of a localized area, usually over a bony prominence

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118
Q

What are the characteristics of a stage II wound?

A

Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without sloughing

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119
Q

What are the characteristics of a stage III wound?

A

Full thickness tissue loss, with visible subcutaneous fat but nonvisible bone/tendon/muscle

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120
Q

What are the characteristics of a stage IV wound?

A

Full thickness tissue loss with exposed bone/tendon/muscle

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121
Q

Generally, what should the maximum PPS level be for patients who are referred for hospice (or declared terminal)?

A

30%

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122
Q

What are the PPS breakdowns for ambulation?

A 
80-100% - full
60-70% - reduced
40-50% - mainly site/lie
10-30% - totally bed bound
0% - death
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123
Q

What are the PPS breakdowns for activity and evidence of disease?

A

100% - normal activity with no evidence of disease
90% - normal activity with some evidence of disease
80% - normal activity with effort
70% - abnormal work with significant disease
60% - unable to house work
50% - unable to any work
40% - unable to most activity
10-30% - unable to do any activity
0% - death

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124
Q

What are the PPS breakdowns for self-care?

A 
70-100% - full
60% - occasional assistance needed
50% - considerable assistance needed
40% - mainly assistance
10-30% - total care
0% - death
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125
Q

What are the PPS breakdowns for intake?

A 
90-100% - normal
30-80% - normal or reduced
20% - minimal to sips
10% - mouth care only
0% - death
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126
Q

What are the PPS breakdowns for conscious level?

A

70-100% - full
50-60% - full or confusion
20-50% - full or drowsy with or without confusion
10% - drowsy or coma with or without confusion
0% - death

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127
Q

What time period is defined as the active phase of dying?

A

48 hours prior to death

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128
Q

What are the findings seen in the early stages of dying?

A 
Bed bound
Loss of interest and ability in drinking/eating
Cognitive changes
Increased sedation
Delirium
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129
Q

What are the findings seen in the late stages of dying?

A 
Loss of swallowing reflex
Death rattle
Coma
Fever
Altered respiratory pattern
Skin color changes
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130
Q

What is the chance of CPR survival to ultimate discharge in terminally ill patients?

A

0%

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131
Q

What medication is the first-choice for hyperactive terminal delirium?

A

Benzodiazepines such as Lorazepam or Midazolam

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132
Q

What is the first line treatment for death rattle?

A

Repositioning

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133
Q

How long until death is likely in a fair-skinned patient who develops lower extremity mottling at the end of life?

A

Hours

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134
Q

What kind of nerve block might be recommended for an individual with severe pelvic pain secondary to malignancy and external beam radiation?

A

Superior hypogastric block
Ganglion impars block (rectum)
Phenol saddle block

135
Q

For what patients is duloxetine a more appropriate starting medication than gabapentin?

A

Patients with heart failure (fluid retention), a history of falls, and depression

136
Q

What is the most likely adverse effect seen with high doses of Ketamine?

A

Psychomimetic reactions

137
Q

What medications are indicated to treat complex regional pain syndrome?

A

Bisphosphonates

Ketamine

138
Q

What non-pharmacologic intervention has the best evidence to support its use in pain management?

A

Cognitive-behavioral therapy

139
Q

What is the difference between sarcopenia and cachexia?

A

Sarcopenia is age-related, whereas cachexia is illness-related

140
Q

What is the definition of cachexia?

A

Weight loss greater than 5% over 6 months

141
Q

If a patient has anorexia, dyspepsia, nausea, bloating, and early satiety, what medications would you prescribe?

A
  1. ) Metoclopramide

2. ) Erythromycin

142
Q

If a patient has AIDS, fatigue, nausea, pain, and anorexia, what medication would you prescribe?

A

Dronabinol

143
Q

If a patient has cancer, fatigue, nausea, pain, and anorexia, what medication would you prescribe?

A

Dexamethasone

144
Q

If a patient has insomnia, anxiety, depression, and anorexia, what medications would you prescribe?

A
  1. ) Mirtazapine
  2. ) Olanzapine
  3. ) Methylphenidate
145
Q

What appetite stimulant has the best evidence to support its use in an individual who would live weeks to months?

A

Megestrol Acetate

146
Q

What kind of weight do people put on when they take Megestrol Acetate?

A

Fat and fluid – not muscle

147
Q

What are the risks of using Megestrol Acetate?

A

Increased risk of DVT, muscle catabolism, adrenal suppression, and hypogonadism

148
Q

What receptors are important to target for vestibular-related vomiting?

A

Acetylcholine

Histamine

149
Q

What receptors are important to target for chemoreceptor trigger zone related vomiting?

A

Dopamine
Serotonin
Neurokinin

150
Q

What receptors are important to target for peripherally related vomiting?

A

Serotonin

Mechanoreceptors in the intestine

151
Q

How does Metoclopramide work?

A

At low doses – Dopamine receptors in GI tract

At high doses – Serotonin receptors in brain

152
Q

How can Metoclopramide be administered?

A

PO, IV, SQ

153
Q

How does Haloperidol work?

A

Dopamine

154
Q

How can Haloperidol be administered?

A

PO, IV, IM, SQ

155
Q

How does Prochlorperazine work?

A

Dopamine

156
Q

How can Prochlorperazine be administered?

A

PO, PR

157
Q

How does Chlorpromazine work?

A

Dopamine

158
Q

How can Chlorpromazine be administered?

A

PO, IV, IM, PR

159
Q

How does Promethazine work?

A

Histamine, Acetylcholine, and Dopamine

160
Q

How can Promethazine be administered?

A

PO, PR

161
Q

How does Olanzapine work?

A

Dopamine, Serotonin, and Acetylcholine

162
Q

How can Olanzapine be administered?

A

PO, SQ

163
Q

How does Mirtazapine work?

A

Serotonin

164
Q

How can Mirtazapine be administered?

A

PO

165
Q

What is a well known side effect of Ondansetron?

A

Constipation

166
Q

What are two cannabinoid-receptor agonists that are FDA approved for chemotherapy-induced nausea and vomiting?

A

Dronabinol

Nabilone

167
Q

What are the two agents you should not use in opioid induced constipation?

A

Docusate and bulk-forming agents

168
Q

What are two newer agents introduced for opioid-induced constipation?

A

Lubiprostone and Linaclotide

169
Q

For what patients is Naloxegol indicated?

A

Opioid-induced constipation in non-cancer patients on chronic opiates

170
Q

What is the mechanism of action of Lubiprostone?

A

Selective chloride channel activator in the small intestine

171
Q

What is one unique fact about Lubiprostone?

A

Seemingly ineffective for Methadone-induced constipation

172
Q

What services does Medicare Part A cover?

A

Hospitalization
Skilled Nursing
Home Health
Hospice

173
Q

What services does Medicare Part B cover?

A

Outpatient payment to providers

DME

174
Q

What is Medicare Part C?

A

Medicare Advantage – minimum Medicare services for a fixed monthly payment with narrow networks; hospice is included

175
Q

What does Medicare Part D cover?

A

Pharmacy

176
Q

What Palliative Performance Scale score is associated with a prognosis of 6 months or less?

A

70% or less

177
Q

What ECOG score is associated with a prognosis of 6 months or less?

A

2 or more

178
Q

What are the Medicare hospice eligibility requirements?

A
  1. ) Entitled to Medicare Part A
  2. ) Certified as being terminally ill
  3. ) Certified to have a prognosis of 6 months or less
179
Q

What are the election periods of hospice?

A

An initial 90-day period
A subsequent 90-day period
An unlimited number of 60-day periods

180
Q

What are the core services required for hospice?

A

Physician
Nurse
Social services
Counseling (bereavement, dietary, and spiritual)

181
Q

What are the four levels of hospice care?

A

Routine home care
Continuous home care
Inpatient respite care
General inpatient care

182
Q

What are the daily payments made by Medicare for routine home care level of care?

A

Day 1 to 60 – $189.97

Day 61+ – $148.41

183
Q

What are the requirements for continuous home care?

A

Minimum of 8 hours of direct care in a 24 hour period, more than 50% of which is provided by a licensed nurse

184
Q

What is the per diem rate for continuous home care under Medicare?

A

$957.08

185
Q

How often can the respite care benefit be accessed under Medicare?

A

Accessed occasionally and potentially more than once in a benefit period, but not for more than 5 consecutive days

186
Q

What is the per diem rate for respite level of care under Medicare?

A

$169.36

187
Q

What is the per diem rate for general inpatient care under Medicare?

A

$728.83

188
Q

What are the reasons for discharge from hospice?

A
  1. ) Patient moves to a new area
  2. ) Patient is no longer terminally ill
  3. ) Ability of hospice to operate is seriously impaired by the person(s) in the home
189
Q

When must narratives and certifications be completed for recertification?

A

No earlier than 15 days prior to the start of the benefit period

190
Q

When must the face-to-face encounters be completed for recertification?

A

No earlier than 30 days prior to the start of the benefit period

191
Q

Who must do the hospice face-to-face encounter?

A

Hospice physician or Hospice Nurse Practitioner that is employed by the hospice

192
Q

What patient-centered factors lead to patients being less likely to enroll into hospice?

A
  1. ) African-American ethnicity

2. ) Fee-for-service Medicare

193
Q

What are the predictors for a good survival outcome of an acute spinal cord compression secondary to cancer?

A 
Ambulatory
Single metastasis
No visceral metastases
Radiosensitive cancer
Quickly engaging therapy
194
Q

What kinds of cancers typically metastasize to the thoracic spine?

A

Breast and lung

195
Q

What kinds of cancers typically metastasize to the lubmosacral spine?

A

Colon and pelvic cancers

196
Q

What is the gold standard imaging study to evaluate for cord compression?

A

MRI of the entire spine

197
Q

What is the recommended dose of Dexamethasone for cord compression?

A

10mg IV bolus followed by 4mg IV/PO 4 times a day with a 2 week taper
High dose is NOT necessary

198
Q

For spinal compression, when is radiation alone indicated?

A 
No spinal compression/instability
Prior spinal decompression
Subclinical cord compression
Known radiosensitive tumor
Poor surgical candidate
Multiple areas of compression
199
Q

For spinal compression, when is neurosurgery with post-operative radiation indicated?

A

Spinal instability (needs neurosurgical evaluation)
Previous radiation to area limiting the dose
Disease progression despite radiation
Radioresistant tumor
Good baseline performance status
Lost ambulation within past 48 hours
Single area of compression

200
Q

What is a key difference in outcomes in radiation alone versus combined with surgery for spinal cord compression?

A

Radiation alone will improve pain but will not restore function in individuals who have paralysis

201
Q

What is the standard of care for hemoptysis associated with lung cancer?

A

Palliative radiotherapy after a sentinel bleed

202
Q

What is the standard of care for bleeding associated with high-risk head and neck cancer?

A

Endovascular stenting of the carotid after a sentinel bleed

203
Q

What is the most common life-threatening metabolic disorder in cancer patients?

A

Hypercalcemia

204
Q

What is the mechanism of hypercalcemia in patients with breast cancer, myelomas, or lymphomas?

A

Osteolytic masses that cause an increase in bone resorption

205
Q

What is the mechanism of hypercalcemia in patients with renal cell, ovarian, endometrial, or HIV-associated cancers?

A

Increase in PTHrP leading to increased bone resorption and decreased renal clearance of calcium

206
Q

What is the mechanism of hypercalcemia in patients with Hodgkin and non-Hodgkin lymphomas?

A

Increased Calcitriol production leading to increased enteral calcium absorption and decreased renal clearance of calcium

207
Q

What are the symptoms of hypercalcemia?

A

Hypovolemia, constipation, arrythmia, delirium, and lethargy

208
Q

What is the primary treatment for patients with hypercalcemia?

A

Volume resuscitation (200-500mL/hour)

209
Q

What is the primary medication intervention for hypercalcemia?

A

Parenteral Bisphosphonates (Pamidronate or Zoledronic Acid)

210
Q

What is the indication for Denosumab?

A

Bisphosphonate-refractory hypercalcemia

211
Q

What is the emergent presenting symptoms of SVC syndrome?

A

Stridor, confusion, AKI, or syncope

212
Q

What is the treatment for emergent SVC?

A

Endovascular stenting with steroids followed by radiation

213
Q

What is the mainstay of treatment for SVC syndrome?

A

Radiation with steroids

214
Q

What is the standard treatment of increased intracranial pressure?

A

Steroids (Dexamethasone)

215
Q

What is the standard of care in preventing a pathologic fracture in patients with known bony metastases?

A

Bisphosphonates (IV more than PO)

216
Q

What is always an acceptable answer to treating dyspnea?

A

Treat any reversible cause, if possible

217
Q

What is an effective treatment for dyspnea releated to COPD?

A

Pulmonary rehabilitation

218
Q

What is the first-line medication therapy for dyspnea?

A

Opiates

219
Q

What is the standard treatment for a COPD exacerbation?

A

Bronchodilators and steroids

220
Q

What is an effective opioid-based strategy for managing refractory dyspnea?

A

MSER 10mg once daily, titrated weekly to a maximum of 30mg once daily

221
Q

What is pulmonary rehabilitation for COPD?

A

PT and RT focused outpatient exercise and behavioral modification to improve walk distance and dyspnea

222
Q

What is the median survival for an individual who develops a malignant pleural effusion?

A

4-6 months

223
Q

How often do you need to treat asymptomatic pleural effusions?

A

Never

224
Q

What is the indication for a thoracentesis?

A

A malignant pleural effusion with a short life expectancy

225
Q

What is the most effective drug for cough?

A

Opiates

226
Q

What is the medication indicated for radiation- or chemotherapy-induced pneumonitis?

A

Erlotinib

227
Q

What is an accepted therapy for radiation-induced pneumonitis?

A

Steroids – Prednisone 60mg tapered slowly over months

228
Q

What are the symptoms of radiation pneumonitis?

A

Dry cough, dyspnea, and pleuritic pain

229
Q

What are the two most common DSM5 anxiety disorders at the end of life?

A

Generalized Anxiety Disorder

Anxiety secondary to a medical condition

230
Q

What antidepressant medications should you avoid?

A

Paroxetine – anti-cholinergic symptoms
Venlafaxine – withdrawal symptoms
Bupropion – lowers seizure threshold

231
Q

What antidepressant helps with both sleep (at low doses) and appetite?

A

Mirtazapine

232
Q

What class of medications could be helpful for depression if the patient also has co-morbid pain or hot flashes?

A

SNRIs

233
Q

What is the most effective antidepressant to use with Tamoxifen?

A

Venlafaxine

Sertraline and Citalopram are other options

234
Q

What is the interaction with antidepressants and Tamoxifen?

A

There is a potential that it decreases the conversion of Tamoxifen to its active metabolite

235
Q

What classes of medications are the best at helping the overall symptoms of PTSD?

A

SSRIs and SNRIs

236
Q

What medications are helpful for PTSD associated nightmares?

A

Prazosin or Topiramate

237
Q

What is the relationship between antipsychotics and smoking?

A

Smoking causes a decrease in antipsychotic drug levels

238
Q

What are the Cluster A personality types?

A

– Weird –

Paranoid, Schizoid, Shizotypal

239
Q

What are the Cluster B personality types?

A

– Wild –

Narcissistic, Histrionic, Borderline, Antisocial

240
Q

What are the Cluster C personality types?

A

– Worried –

Avoidant, Dependent, Obsessive-Compulsive

241
Q

What is the difference between grief, mourning, and bereavement?

A

Grief – inward feelings
Mourning – outward expression
Bereavement – time for grief and mourning

242
Q

What are the risk factors for complicated grief?

A

History of depression/anxiety, dependent relationships, kinship relationships, neglect in childhood, poor parental bonding, separation anxiety in childhood, alack of preparation of death, and loss of a child

243
Q

What is the first basic HPM intervention?

A

Address physical symptoms/concerns

244
Q

What is the second basic HPM intervention?

A

Address psychosocial concerns

245
Q

What are the components of the second basic HPM intervention?

A 
Physical symptoms
Emotive symptoms
Autonomy related issues
Communication
Economic burden
Transcendent issues
246
Q

What is the third basic HPM intervention?

A

Communicate effectively

247
Q

What is the fourth basic HPM intervention?

A

Provide an empathic presence

248
Q

What is the fifth basic HPM intervention?

A

Foster hope

249
Q

What is a very common cause of benign acute hiccups?

A

GERD

250
Q

What is a common medication cause of hiccups?

A

Dexamethasone

251
Q

What is a common medication used to treat hiccups?

A

Proton-pump inhibitor to treat GERD

252
Q

What are other medication treatments for refractory hiccups?

A

Chlorpromazine (dopaminergic)
Haloperidol (dopaminergic)
Metoclopramide (dopaminergic)
Baclofen (caution in renal failure)

253
Q

What is the best treatment for worsening dementia-related behaviors?

A

Non-pharmacologic interventions such as creating a care plan around improving the environment around the individual

254
Q

What are several common medication causes of dysphagia?

A

NSAIDS
Antibiotics
Anticholinergics
Bisphosphonates

255
Q

What is the most common complication of transjugular intrahepatic portosystemic shunting (TIPS)?

A

Encephalopathy

256
Q

What is one of the most constipating anti-hypertensive medications?

A

Verapamil

257
Q

What herbal extract is associated with progressive liver failure?

A

Kava extract

258
Q

In addition to starting Dexamethasone, what two consultants should be called shortly after a patient is admitted with a spinal cord compression?

A

Neurosurgery and Radiation Oncology

259
Q

What medication is indicated to treat restless leg syndrome?

A

Pramipexole

Benzodiazepines are an appropriate second-line therapy

260
Q

What medications (in order) are often effective for cholestatic pruritis?

A
  1. ) Cholestyramine
  2. ) Rifampin
  3. ) Naltrexone
261
Q

What medication is often effective for uremic pruritis?

A

Gabapentin

262
Q

What antidepressant is a long-acting medication with a long half-life and comes as a liquid?

A

Fluoxetine

263
Q

What opioid preparation is the least constipating?

A

Fentanyl patch (by approximately 50%)

264
Q

What is the average total daily dose of Dexamethasone for cord compression?

A

15-30mg/day

265
Q

What do toddlers (0-2 years) understand about death?

A

No conceptualization

266
Q

What do children aged 3-5 years understand about death?

A

Cannot perceive universality of death

Do not understand irreversible nature of death

267
Q

What do children aged 5-10 years understand about death?

A

Death is irreversible and final
Can escape death if they do not talk about it
Magical thinking

268
Q

What do children aged 10-13 years understand about death?

A

Understand that death is universal
Pre-occupied with death
Psychosomatization of feelings around death

269
Q

What do children aged 13-18 years understand about death?

A

Risk of impaired grief if death occurs in adolescence

“Death is not fair”

270
Q

What interventions are helpful for children aged 0-2 with grief responses?

A

Cuddling

Simple music

271
Q

What are the typical grief responses for a child aged 3-4 years?

A

Intense but brief

Asks questions repeatedly

272
Q

What interventions are helpful for children aged 3-4 with grief responses?

A

Play therapy

273
Q

What interventions are helpful for children aged 5-9 with grief responses?

A

Answer questions honestly

Help with memorials/goodbyes

274
Q

What is the general trend of the Karnofsky scale?

A

Normal (100) Dead (0)

50 – considerable assistance with frequent medical care

275
Q

What is the general trend of the Palliative Performance Scale?

A

Normal (100) Dead (0)

276
Q

What is the general trend of the ECOG scale?

A

Normal (0) Dead (5)

3 - limited self-care or bed-to-chair less than 50% of waking hours

277
Q

What is the life expectancy of an individual who develops malignant hypercalcemia?

A

8 weeks

278
Q

What is the life expectancy of an individual who develops a malignant pericardial effusion?

A

8 to 12 weeks

279
Q

What is the life expectancy of an individual who develops carcinomatous meningitis?

A

8 to 12 weeks

280
Q

What is the life expectancy of an individual who develops multiple brain metastases?

A

4 to 8 weeks without radiation therapy

12 to 24 weeks with radiation therapy

281
Q

What is the New York Heart Association level 4?

A

Symptomatic cardiac disease at rest (hospice appropriate)

282
Q

What are the hospice criteria for COPD?

A 
--- BODE criteria ---
BMI < 21
Obstruction (FEV1 < 30% -- Gold 4)
Dyspnea
Exercise capacity
283
Q

What are the hospice criteria for liver disease?

A

PT > 5 or INR > 1.5

Serum Albumin < 2.5

284
Q

What does the MELD score calculate?

A 
Liver disease 3 month prognosis using INR, Bilirubin, and Creatinine
< 9 -- 4% death
10-19 -- 27% death
20-29 -- 76% death (Hospice)
30-39 -- 83% death
> 40 -- 100% death
285
Q

What does the MELD-NA look at?

A

Likelihood of death for hepatocellular carcinoma

286
Q

What is the hospice criteria for renal failure?

A

GFR < 15 in diabetics or < 10 in non-diabetics

Not pursuing dialysis

287
Q

What is the median length of hospice stay after discontinuing dialysis?

A

9.6 days

288
Q

What factors are associated with a worse outcome for patients with ALS?

A

Older age at diagnosis
Bulbar features
Frontotemporal dementia

289
Q

What is the average survival after diagnosis of ALS?

A

24 to 36 months

290
Q

What is the hospice criteria for admitting patients with dementia?

A

FAST 7c or worse

291
Q

What two events are associated with a greater than 50% risk of mortality in 6 months in patients with dementia?

A

Hospitalized with either pneumonia or hip fracture

292
Q

What does a midarm circumference of 22.5 equivalent to in BMI?

A

18.5

293
Q

What are the four disciplines required in a hospice?

A

Physician
RN
SW
Chaplain (or other counselor)

294
Q

What is compassion fatigue?

A

Secondary trauma from caring for those who are suffering

Characterized by fatigue, emotional exhaustion, and apathy

295
Q

What is the definition of Palliative Sedation?

A

The monitored use of medications intended to induce a state of decreased or absent awareness in order to relieve the burden of otherwise intractable suffering

296
Q

When a person shows neck hyperextension, nonreactive pupils, decreased responsiveness to verbal stimuli, and an inability to close the eyelids, how soon is death most likely?

A

Within 3 days (typically hours)

297
Q

What tool is useful in identifying changes in particular sources of suffering over time?

A

The Herth Hope Index

298
Q

What is a brief, empirically supported, individualized psychotherapy designed for adults at the end of life?

A

Dignity Therapy

299
Q

What are the effects of Dignity Therapy?

A

Improved dignity and quality of life

Decreased depression and anxiety

300
Q

What is a psychotherapy designed for the individual or groups that is applicable for patients with cancer?

A

Meaning-Centered Psychotherapy

301
Q

What are the effects of Meaning-Centered Psychotherapy?

A

Improved meaning, spiritual well-being, and quality of life

302
Q

What is a widely used self-reporting scale for depression in patients with advanced illness?

A

Hospital Anxiety and Depression Scale

303
Q

What is a widely used scale that tracks mood and detects depression in patients and caregivers?

A

Center for Epidemiologic Studies Depression Scale

304
Q

What is the first-line antidepressant of choice for a patient with major depressive disorder if a their life expectancy is 6 months or less?

A

Psychostimulants (i.e., Methylphenidate)

305
Q

What SSRI is the most associated with QTc prolongation?

A

Citalopram (greater than 40mg daily)

306
Q

What SSRI does not need to be tapered due to its long half life?

A

Fluoxetine

307
Q

What SSRI can have a very significant sudden discontinuation syndrome secondary to its very short half life?

A

Paroxetine

308
Q

What is a pain scale that is not copyrighted, valiated, reliable, and measures symptoms over time?

A

Edmonton Symptom Assessment Scale (ESAS)

309
Q

What is cachexia’s effect on oxycodone?

A

Cachexia lowers oxycodone clearance

Use lower doses

310
Q

What is cahexia’s effect on transdermyl fentanyl?

A

Cachexia lowers fentanyl absorption

Use higher doses

311
Q

What is the methadone dose of choice for daily morphine doses of 60mg or less?

A

No more than 2.5mg Q8hours

312
Q

What is the methadone dose of choice for daily morphine doses between 60 and 199mg?

A

10:1 conversion

313
Q

What is the methadone dose of choice for daily morphine doses greater than 200mg?

A

20:1, and no more than 30mg daily

314
Q

What QTc is a relative contraindication for methadone?

A

450msec

315
Q

What QTc is an absolute contraindication for methadone?

A

> 500msec

316
Q

What supplement can decrease serum methadone levels?

A

St. John’s Wort

317
Q

What spinal analgesic is associated with dizziness, nausea, and psychiatric symptoms?

A

Ziconotide (calcium channel blogger)

318
Q

What are the cardiovascular risks of long-term opiates?

A

Myocardial infarction

Heart failure

319
Q

Low doses of what opiate is found to be protective against depression?

A

Buprenorphine

320
Q

Which NSAID is linked to higher cardiovascular adverse events?

A

Celecoxib

321
Q

What pain types can Dexamethasone treat?

A

Neuropathic, bone, bowel obstruction, and headache

322
Q

What disease process is treated by topical capsaicin patches?

A

Post-herpetic neuralgia

323
Q

What is Denosumab?

A

Osteoclast inhibitor that has less skeletal events than Zoledronic acid
Used as an adjuvant agent in early breast cancer

324
Q

What is an effective modality for multifocal bone pain?

A

Bone-seeking radionucleotides

325
Q

What is the duration of effect of bone-seeking radionucleotides on pain?

A

Analgesia generally achieved at 4 days and lasting up to 7 weeks

326
Q

What are the four principles of ethics?

A

Autonomy
Beneficence
Non-maleficence
Justice

327
Q

What are the components that make up patient capacity?

A

Does the patient understand their medical condition, the recommended treatment, risks of treatment, treatment alternatives, and the implications of accepting/denying the treatment

328
Q

What are the clinical findings of a minimally conscious state?

A

Fixes gaze

Follows simple commands

329
Q

What are the clinical findings of a persistent vegetative state?

A

Non-intentional actions
Remains in such a state for more than 4 weeks
Must have intact complex reflexes

330
Q

For bony cancer lesions, what intervention results in durable symptom relief in nearly two-thirds of patients?

A

Radiation therapy to the lesion

331
Q

How long does it take for radiation therapy to result in pain relief?

A

Generally 3 to 4 weeks, but often sooner

332
Q

What is the current recommended regimen for palliative radiation therapy?

A

8 Gy in a single fraction that may be repeated in the future

333
Q

When is radiation isotope therapy indicated?

A

Widespread osteoblastic disease (i.e., prostate cancer)

334
Q

When are Strontium and Samarium radiation therapy indicated?

A

For pain control in patients with a good performance scale and prognosis

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