Odds and Ends Flashcards
1
Q
Diltiazem + opioid interaction via CYP
A
Ca-channel blockers increase serum fentanyl by inhibiting 3A4
2
Q
“Only” drug approved for HIV cachexia
A
dronabinol
3
Q
“Mild” thrush and can swallow
A
Nystatin over azoles (though less effective)
4
Q
fleet enema precautions
A
renal failure, CHF, cirrhosis, elderly and frail: can deplete intravascular volume and cause hyperPHOS, hypoK and hypoCa
5
Q
NK-1 (arprepitant) and steroids may be best for
A
delayed chemo n/v
6
Q
antipsychotics in morphine toxicity
A
may worsen symptoms
7
Q
Malignant cord compression first things
A
Steroids and surgery consult! Pick surgery consult before RT
8
Q
Dementia: dependent in ADLs but not incontinent
A
FAST 6 even if nonverbal!
9
Q
6 month mortality for dementia plus hip fracture
A
55%
10
Q
Prevalence of major depression or anxiety at end of life (range)
A
10-40%
11
Q
depression, insomnia, anorexia, nausea
A
mirtazipine
12
Q
depression, anxiety, insomnia, neuropathy
A
nortriptyline
13
Q
activating antidepressants
A
fluoxetine and bupropion
14
Q
depression, anxiety, neuropathy, advanced age
A
duloxetine (don’t give elders TCAs on the boards)
15
Q
riluzole
A
in ALS, prolongs median survival 2-3 months, but does not improve symptoms or QoL
16
Q
Once admitted GIP, one goal must be
A
transition to a lower level of care. No time limit on GIP, but you don’t get to stay for “imminent dying”
17
Q
Does Medicare require 24h home caregiver for hospice?
A
No
18
Q
I say burnout, you say
A
mindfulness
19
Q
defibrilator question
A
tape a magnet to him!
19
Q
what to tell children
A
truthful disclosure to children of all ages
20
Q
tx painful bleeding malodourous tongue lesion
A
hypofractionated RT
21
Q
Even on hospice, nonwhite people
A
get less care, have less pain control, are less likely to receive emotional support
22
Q
Cultures that prefer death at home
A
Samoan, Vietnamese, Asian Indian
23
Q
Piperdine metabolism
A
3A4, EXCEPT remifentanil, which has an ester sidechain and is metabolized by erythrocytes
24
Alfentanil metabolism
3A5, polymorphic and highly variable
25
norfentanil
The inactive metabolite the fentanyl becomes after hepatic metabolism (3A4)
26
fentanyl's elimination halflife
very dependent on total infusion time (even greater than morphine)
27
complicated grief, fMRI and psychology
Increased activation of the nucleus accumbens (reward center); the attachement model
28
worse prognosis in colon cancer (5)
signet, KRAS wildtype, NOT having microsattelite instability, high CEA pre-op, right-sided (proximal(
29
NSAIDs by half-life, shortest to longest
celecoxib (6-12h)
naproxen (14h)
meloxicam (15-20h)
nabumetone (20-24h)
oxeprozen (40-60h)
30
megestrol AE's (3)
VENOUS thrombosis
Adrenal insufficiency
Androgen insufficiency (males)
31
"hard stool in the vault"
enema first
32
Common inhibitors of 3A4
will increase FENTANYL concentrations!
Valproate
Isoniazid
Disulfiram
Erythro, Clarithromycin (not Azithro)
Omeprazole
Cimetidine
Allopurinol
Sulfonamides
Ethanol (Acute)
33
pain assessment, patient with dementia
PAIDAD: breathing, facial expression, vocalizations, body language, consolability
34
lowest rate of hospice utilization
asian/pacific islander
35
bupe binding
high affinity, low activity (partial agonist); lipophilic,
25-50x more potent than morphine
36
constipation exam
digital rectal more valueable than abdominal exam or xray
37
metabolite unique to heroin
6-MAM
6-monoacetylmorphine
38
death notice in person
if the family is less than 1h away
39
patients with hallucinations and delirium while dying
often develop myoclonus and seizures
40
Antidepressants with tamoxifen
venlafaxine, desvanlafaxine
(NOT SSRIs or bupropion due to 2D6 inhibition)
41
phenelzine and other MAO cautions
need 5+ weeks between SSRI or serotonin syndrome develops; get hypertensive with wine or cheese
42
one year survival of Child-Pugh C
45%, better than MELD 35 (die within months)
43
pain scale for neonates, infants and kids under 7
CRIES for NEONATES
FLACC for children 2-7
6 Faces also works for kids over 3
44
pruritis of unknown cause tx
gabapentin or paroxetine
45
test before citalopram
EKG for QTc
46
communication dissatisfaction stats
white is most satisified, then black, then hispanic,
47
lung cancer causes after smoking
radon
48
certification must occur
within 2 calendar days of hospice admission
49
meperidine caution
normeperidine, toxic metabolite that causes seizures in renal impariment and elderly
50
herb that causes serotonin syndrome
St John's Wort (acts as an SSRI)
51
intercostal nerve blocks
enter below inferior rib border, hit at least 2 levels
52
wintergreen oil (bengay) cautions
no hot packs! no blood thinners
53
post-op ibuprofen and tylenol
reduce pain and better outcomes in children to give both
54
complicated grief prevalence spouse versus child
10-20% spouse, 60% child
55
specific phobia and agoraphobia in cancer patients
higher than general population
56
tx pneumothorax at home
heimlich valve
57
gender and depression in cancer patients
no difference
58
octreotide for diarrhea TYPES (3)
secretory not osmotic--HIV, chemo-induced and high stoma output
59
"itching all over" in patient on opioids without cancer
diphenhydramine for some reason
60
Childs-Pugh criteria
encephalopathy, ascites
albumin, bili, INR
61
first line for unspecificied nausea
metaclopramide, if not contraindicated
62
osteosarcoma to lungs only
best prognosis for metastatic osteosarcoma, 40% survival
63
religious beliefs are associated with
aggressive care at end of life
64
Contraindications for organ donations (7)
active extracranial cancer, severe untreated sepsis, active HBV, HCV, WNV, rabies, CJD
65
Most patients on hospice die
At home
66
Medicare recipients who receive hospice
51.6%
67
tx neuropathic stump pain
ultrasound guided radiofrequency ablation
68
STEMI 30d mortality
2.5-10%
69
EF with increased risk in sudden cardiac death
35%
70
duration for complicated grief
1 year
71
most common causes of death associated with bereavement
cancer and cardiac disease
72
lower side effect TCAs
Nortriptyline, desipramine (secondary amines)
73
centrally acting antitussives
opioids, gabapentin (less evidence for TCAs, benzos)
74
dextromethorphan cautions
serotonin syndrome
75
CA15-3
breast cancer, along with CA 27.29
76
CA19-9
pancreatic and GI cancers
77
CA 117
GI stroma tumors and seminoma
78
Wound care: powder and cream
powder first; no hot water
79
Stark Law
limitations on self-referrals and kickbacks
80
myocardial vs pericardial mets
melanoma to myocardium, lung cancer to pericardium (and lung cuases more effusions)
81
ramelteon caution
CYP450 interactions
82
don't give benzos in
COPD
83
psych disorders caused or worsened by bereavement
depression, bipolar, PTSD, SUD, anxiety disorders
84
how TCAs cause sedation, weight gain, tachycardia, blurred vision and dry mouth
H1 histamine blockade
85
cancers associated most with recurrence anxiety
lung and melanoma
86
causes tachycardia, only used for rigors
meperidine (demerol)
87
high risk features of hormone resistant prostate cancer
anemia, poor functional status, cord compression
(anemia is worse prognosis than hypoalbumin in prostate ca)
88
elevated beta-2-microglobulin
poor prognosis in MM, CLL, some lymphomas
89
elevated AFP
poor prognosis in liver cancer and germ cell tumors
90
neuropathic pain and fistulas
radiation injury
91
NSAIDs in pregnacy
safest before 20 weeks
92
opioids in first trimester
increase risk of birth defects
93
acupuncture most validated for this pain syndrome
migraine
94
Strontium-89 and Sumarium-153
bone-seeking radionucleotides that provide 3-6 months of pain relief from bone mets
95
life expectancy in vascular dementia
3-5 years (compared to 7 for LBD, 9 for AD)
96
morphine half-life in neonates and infants
increased due to decreased total body clearance
97
early morning awakening and increased total sleep
more consistent with depression than grief
98
Potency compared to morphine: hydrocodone
3/4 as potent
99
Potency compared to morphine: hydromorphone
5-10x
100
Potency compared to morphine: fenantyl and sufentanyl
fent is 100x, sufentanyl is 500-1000x
101
Potency compared to morphine: oxymorphone
3x
102
secondary amine TCA, unlikely to be antichoinergic
desimipramine (desi doesn't cause urnibary retention)
103
methadone metabolite
2-ethylidene-1,5-dimethyl-3,3 diphenylpyrrolidine (EDDP)
104
methadone false positives on a drug test
verapamil, quetiapine, diphenhydramine, doxylamine (unisom, an antihistamine sleep aid)
105
6-MAM
heroin urine metabolite, clears in 24h
106
hydrocodone is synthesized from
thebaine and codeine
107
oxycodone is synthesized from
thebaine
108
prevalence of elder abuse/neglect
10%
109
best predictor of mortality risk in NAFLD
degree of fibrosis
110
nausea, anorexia, dehydration and orthostasis
consider adrenal insufficiency
111
L tryptophan caution
serotonin syndrome, don't give with fluoxetine
112
complicated grief
doesn't exist. Prolonged grief disorder (since 2022) 6-12 months after loss
113
Hgb < 3 prognosis
4-5 days
114
Most fatal blood transfusion risk
TRALI
115
Predict mortality in CKD/ESRD
degree of GFR reduction and proteinuria
116
continous care definition
8 hours of hospice care per day, >50% done by a nurse
117
AD prevalence over age 85
30-50%
118
Sepsis + AKI mortality
up to 35%
119
most common delirium subtype
mixed
120
morphine, hydromorphone and oxymorphone do not
have phase one metabolism, are not metabolized by CYP system
121
central alpha-2 adrenergic agonist, increases presynaptic inhibition of motor neurons
tizidanidine
122
Gaba agonist, works in the spinal cord, reduces substance P
baclofen
123
hospice at SNF is called
"routine home care"
124
celiac nerve fibers are
antero-crural, going from pancreas to large intestine (up to transverse)
125
cancer patients who meet criteria for psychiatric disorder
50%
126
worse prognosis at stage 4
small cell lung cancer
127
5HT antagonist with halflife of 40 hours
Palonosetron (note: zofran's halflife is about 5 hours)
128
loss of motor, pain, light touch and temperature after celiac plexus block
anterior cord syndrome
129
NSAID with highest cardiac risk
diclofenac
130
first line for cancer cachexia
olanzapine, then dex
131
EKG before TCA at what age
40+
132
highly emetogenic chemos (3)
cisplatin, cyclophosphomide, dacarbazine
133
ramelteon or trazadone
trazodone, since ramelteon has not been studied in a palliative setting for insomnia
134
IV NSAIDs (4)
meloxicam, ketorolac, ibuprofen and diclofenac
135
best assessment of curative resection in colon cancer
histology
136
Calculates risk of death from alcoholic hepatitis
Maddrey discrimination function (Lille determines response to treatment)
137
best SC opioid
fentanyl
138
days to repeat skin site for butrans
21
139
preferred benzo for panic disorder
alprazolam
140
common medications causing esophagitis
doxycycline, bisphosphonates, iron, potassium, NSAIDs
141
3 day rule
Medicare will cover SNF if you have a necessary 3 day hospitalization (hospice would be revoked)`
142
first line for nausea from bowel obstruction
haloperidol (by the way is less sedating than thorazine)
143
Behavioral pain scale (BPS) is used for
adults on ventilators
144
FLACC score
Pain scale for nonverbal children: Face, leg movements, activity, crying, consolability
145
biological / elimination halflife
same thing: time it takes a drig to lose 50% of its activity
146
context-sensitve half life
decreasing drug concentrations after infusion at steady state
147
most common incontinence
urge
148
increased depression risk after surviving cancer
smoking, poor body impage (women only)
149
ALS, place feeding tube before
VC drops below 50%
150
bupropion is safe with what other antidepressant
SSRIs
151
chronic cough most common in
head and neck cancer
152
SSRI least likely to cause withdrawal
fluoxetine, long half life
153
most families agree to this when asked
autopsy (not required at any percent threshold by JCHO)
154
Latino disease where your soul gets scared out of your body
susto
155
most common side effect of modafinil
headache! can also agitate and disturb sleep but headache is most common
156
respiratory alkolosis and opioids
increased nonionized forms and increases CNS penetrance
157
phenytoin and opioids
inducer, increases metabolism and decreased effect
158
best steroid for energy in cancer
dex
159
does megace increase energy
yes
160
screener for complicated grrief
inventory of complicated grief (25 is suggestive, 30 is very suggestive)
161
does hospice cover PT/OT
yes
162
NMS rather than serotonin syndrome
faster onset, clonus
163
metabolized to meprobamate
carisoprodol (soma)
164
epidural morphine
bimodal, can caused delayed OD, not safe for outpatient
165
ABCD for cultural needs
attitudes, beliefs, context, decision-making style
166
morphine decreases minute ventilation by
decreasing RR, not tidal volume
167
on opioids, the carbon dioxide curve
has decreased slope and RIGHTward shift (central response to CO2 is decreased)
168
HER2 positive
unfavorable, as are circulating cancer cells, age <35 at dx
169
naproxen and ibuprofen class
propionic acide derivative NSAID (indomethacin is indole derivative and ketorolac is mixed)
170
REAL duration of prolonged grief disorder
6 months for children/adolescents
1 year for adults
of yearning OR preoccupation
171
