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UKMLA Prep > Pallative Care 🧖 > Flashcards

Pallative Care 🧖 Flashcards

1
Q

What is neuropathic pain?

A

Pain which arises following damage or disruption of the nervous system

It often responds poorly to standard analgesia.

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2
Q

List four examples of neuropathic pain.

A
  • Diabetic neuropathy
  • Post-herpetic neuralgia
  • Trigeminal neuralgia
  • Prolapsed intervertebral disc
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3
Q

What are the first-line treatments for neuropathic pain according to NICE?

A
  • Amitriptyline
  • Duloxetine
  • Gabapentin
  • Pregabalin
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4
Q

True or False: Drugs for neuropathic pain are typically used as combination therapy.

A

False

They are typically used as monotherapy.

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5
Q

What may be used as ‘rescue therapy’ for exacerbations of neuropathic pain?

A

Tramadol

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6
Q

What is the role of topical capsaicin in neuropathic pain management?

A

Used for localized neuropathic pain (e.g., post-herpetic neuralgia)

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7
Q

What are the key opioid receptors involved in pain transmission?

A
  • Mu (µ) Receptors
  • Kappa (κ) Receptors
  • Delta (Δ) Receptors
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8
Q

Where are mu (µ) receptors primarily located?

A

In the brain, brainstem, and spinal cord

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9
Q

What is the primary site of metabolism for opioids?

A

The liver

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10
Q

What is a key role of cytochrome P450 enzymes in opioid metabolism?

A

Modifying opioids to form more water-soluble metabolites

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11
Q

What is the significance of genetic polymorphisms in CYP450 enzymes?

A

They can significantly affect the metabolism of certain opioids, leading to variability in clinical response.

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12
Q

What should be prescribed for all patients initiating strong opioids?

A

Laxatives

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13
Q

What is the breakthrough dose of morphine for patients on opioids?

A

One-sixth the daily dose of morphine

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14
Q

Which opioid is preferred in palliative patients with mild-moderate renal impairment?

A

Oxycodone

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15
Q

What is the conversion factor from oral codeine to oral morphine?

A

Divide by 10

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16
Q

What is the recommended first-line treatment for intractable hiccups?

A

Chlorpromazine

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17
Q

What is the most common symptom of Superior Vena Cava (SVC) obstruction?

A

Dyspnoea

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18
Q

List three common malignancies associated with SVC obstruction.

A
  • Small cell lung cancer
  • Lymphoma
  • Breast cancer
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19
Q

What is the first-line treatment for nausea and vomiting due to reduced gastric motility?

A

Pro-kinetic agents

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20
Q

What are two first-line medications recommended for chemically mediated nausea?

A
  • Ondansetron
  • Haloperidol
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21
Q

What is the role of cyclizine in palliative care?

A

Recommended as a first-line treatment for vestibular-related nausea

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22
Q

Fill in the blank: Guillain-Barre syndrome describes an immune-mediated demyelination of the _______.

A

Peripheral nervous system

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23
Q

What are two initial symptoms experienced by patients with Guillain-Barre syndrome?

A
  • Back pain
  • Leg pain
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24
Q

What is the characteristic feature of Guillain-Barre syndrome?

A

Progressive, symmetrical weakness of all the limbs

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25
Q

What type of investigation shows albuminocytologic dissociation in Guillain-Barre syndrome?

A

Lumbar puncture

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26
Q

What is autonomic involvement?

A

A condition where the autonomic nervous system is affected, potentially leading to symptoms like urinary retention and diarrhea.

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27
Q

What is urinary retention?

A

The inability to empty the bladder completely, which can lead to discomfort and other complications.

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28
Q

What is diarrhoea?

A

A condition characterized by frequent loose or watery bowel movements.

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29
Q

What is papilloedema?

A

Swelling of the optic disc due to increased intracranial pressure, thought to be secondary to reduced CSF resorption.

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30
Q

What is albuminocytologic dissociation?

A

A rise in protein with a normal white blood cell count, found in 66% of certain conditions.

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31
Q

What are some features of pulmonary oedema on a chest x-ray? (6)

A
  • Interstitial oedema
  • Bat’s wing appearance
  • Upper lobe diversion
  • Kerley B lines
  • Pleural effusion
  • Cardiomegaly
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32
Q

What is the first-line investigation for all patients HF according to NICE guidelines issued in 2018?

A

An N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test.

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33
Q

What should be arranged if NT-proBNP levels are ‘high’?

A

Specialist assessment, including transthoracic echocardiography, within 2 weeks.

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34
Q

What is B-type natriuretic peptide (BNP)?

A

A hormone produced mainly by the left ventricular myocardium in response to strain.

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35
Q

What are the high levels of BNP and NT-proBNP?

A
  • BNP: > 400 pg/ml (116 pmol/litre)
  • NT-proBNP: > 2000 pg/ml (236 pmol/litre)
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36
Q

What factors can increase BNP levels? (11)

A
  • Left ventricular hypertrophy
  • Ischaemia
  • Tachycardia
  • Right ventricular overload
  • Hypoxaemia
  • GFR < 60 ml/min
  • Sepsis
  • COPD
  • Diabetes
  • Age > 70
  • Liver cirrhosis
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37
Q

What is the first-line treatment for heart failure?

A

Both an ACE-inhibitor and a beta-blocker.

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38
Q

Which beta-blockers are licensed to treat heart failure in the UK?

A
  • Bisoprolol
  • Carvedilol
  • Nebivolol
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39
Q

What is the standard second-line treatment for heart failure?

A

An aldosterone antagonist, also known as a mineralocorticoid receptor antagonist.

40
Q

What are examples of aldosterone antagonists?

A
  • Spironolactone
  • Eplerenone
41
Q

What role do SGLT-2 inhibitors have in heart failure management?

A

They reduce glucose reabsorption and increase urinary glucose excretion.

42
Q

What are examples of SGLT-2 inhibitors?

A
  • Canagliflozin
  • Dapagliflozin
  • Empagliflozin
43
Q

What is the third-line treatment for heart failure?

A

Options include ivabradine, sacubitril-valsartan, hydralazine with nitrate, digoxin, and cardiac resynchronisation therapy.

44
Q

What are the criteria for prescribing ivabradine?

A

Sinus rhythm > 75/min and a left ventricular fraction < 35%.

45
Q

What are the indications for cardiac resynchronisation therapy?

A

Widened QRS complex on ECG, typically left bundle branch block.

46
Q

What does the New York Heart Association (NYHA) Class I indicate?

A

No symptoms and no limitation in physical activity.

47
Q

What does the New York Heart Association (NYHA) Class IV indicate?

A

Severe symptoms, unable to carry out any physical activity without discomfort.

48
Q

What is acute heart failure (AHF)?

A

A life-threatening emergency characterized by sudden onset or worsening of heart failure symptoms.

49
Q

What is de-novo AHF?

A

Acute heart failure occurring without a prior history of heart failure.

50
Q

What are common precipitating causes of acute heart failure?

A
  • Acute coronary syndrome
  • Hypertensive crisis
  • Acute arrhythmia
  • Valvular disease
51
Q

What are the typical symptoms of acute heart failure?

A
  • Breathlessness
  • Oedema
  • Fatigue
  • Chest signs
52
Q

What is the recommended initial treatment for all patients with acute heart failure?

A

IV loop diuretics like furosemide or bumetanide.

53
Q

What is the role of oxygen in treating acute heart failure?

A

To keep oxygen saturations at 94-98% as per guidelines.

54
Q

What should be monitored in patients on both ACE inhibitors and aldosterone antagonists?

A

Potassium levels, due to the risk of hyperkalaemia.

55
Q

What is high-output heart failure?

A

A condition where a normal heart cannot meet the body’s metabolic demands.

56
Q

What are some causes of high-output heart failure? (6)

A
  • Anaemia
  • Arteriovenous malformation
  • Paget’s disease
  • Pregnancy
  • Thyrotoxicosis
  • Thiamine deficiency
57
Q

What is the most common site for bone metastases?

A

Spine.

58
Q

What investigations does NICE recommend for all patients with suspected cancer? (9)

A
  • FBC
  • U&E
  • LFT
  • Calcium
  • Urinalysis
  • LDH
  • Chest X-ray
  • CT of chest, abdomen, pelvis
  • AFP and hCG
59
Q

What are ‘cannonball metastases’?

A

Multiple, round well-defined lung secondaries, often seen with renal cell cancer.

60
Q

What investigations does NICE recommend for patients with suspected malignancies? (4)

A
  • Urinalysis, LDH
  • Chest X-ray
  • CT of chest, abdomen and pelvis
  • AFP and hCG

These investigations are tailored for specific patient presentations.

61
Q

What is the purpose of a myeloma screen?

A

To investigate if there are lytic bone lesions present

This is part of the investigations recommended by NICE.

62
Q

What is the role of endoscopy in cancer diagnosis?

A

Directed towards symptoms

Endoscopy can help visualize internal structures to identify malignancies.

63
Q

What is the significance of PSA testing?

A

Used for prostate cancer screening in men

PSA stands for Prostate-Specific Antigen.

64
Q

What does CA 125 indicate in women?

A

Potential peritoneal malignancy or ascites

CA 125 is a tumor marker often associated with ovarian cancer.

65
Q

What imaging technique is recommended for men with germ cell tumors?

A

Testicular ultrasound

This imaging helps assess testicular masses.

66
Q

What is mammography used for?

A

Screening for breast cancer in women with clinical or pathological features

Mammography is a specialized imaging technique for breast tissue.

67
Q

How are metastatic bone tumors categorized?

A

Blastic, lytic, or mixed

This classification helps in understanding the nature of the lesions.

68
Q

Which type of metastatic disease has the lowest risk of spontaneous fracture?

A

Osteoblastic metastatic disease

In contrast, osteolytic lesions carry a higher risk of fracture.

69
Q

Where are lesions most prone to spontaneous fracture?

A

Peritrochanteric region

This is due to loading forces at that site.

70
Q

What is the purpose of the Mirel Scoring system?

A

To stratify the risk of spontaneous fracture for bone metastasis

It helps guide treatment decisions based on fracture risk.

71
Q

What score indicates an impending fracture according to the Mirel Scoring system?

A

9 or greater

This score suggests a 33% risk of fracture.

72
Q

What treatment is recommended for a Mirel score of 8?

A

Consider fixation

This score is considered borderline for fracture risk.

73
Q

What is the recommended management for a Mirel score of 7 or less?

A

Non-operative management

This indicates a low risk of fracture (4%).

74
Q

What symptoms may indicate spinal metastases?

A
  • Unrelenting lumbar back pain
  • Thoracic or cervical back pain
  • Worse with sneezing, coughing or straining
  • Nocturnal pain
  • Associated tenderness

These symptoms can be indicative of underlying malignancy.

75
Q

What should be suspected if neurological features are present with back pain?

A

Spinal cord compression

Prompt action is necessary to address potential neurological compromise.

76
Q

What imaging should be performed if no neurological features are present?

A

Whole spine MRI within one week

This is crucial as patients often present with multi-level disease.

77
Q

What are the usually transient side effects of opioids?

A

Nausea, Drowsiness

These side effects typically resolve over time.

78
Q

What are the usually persistent side effects of opioids?

A

Constipation

This side effect often continues as long as opioid treatment is maintained.

79
Q

What is the conversion factor from oral codeine to oral morphine?

A

Divide by 10

This means that for every 10 mg of codeine, one should use 1 mg of morphine.

80
Q

What is the conversion factor from oral tramadol to oral morphine?

A

Divide by 10

This indicates that 10 mg of tramadol is equivalent to 1 mg of morphine.

81
Q

How does oxycodone compare to morphine in terms of sedation, vomiting, pruritis, and constipation?

A

Less sedation, vomiting, and pruritis; more constipation

Oxycodone is preferred for its reduced sedative effects.

82
Q

What is the conversion factor from oral morphine to oral oxycodone?

A

Divide by 1.5-2

This range indicates that for every 1.5 to 2 mg of morphine, one should use 1 mg of oxycodone.

83
Q

What does a transdermal fentanyl 12 microgram patch equate to in oral morphine daily?

A

Approximately 30 mg oral morphine daily

This conversion helps in managing pain through alternative delivery methods.

84
Q

What does a transdermal buprenorphine 10 microgram patch equate to in oral morphine daily?

A

Approximately 24 mg oral morphine daily

Understanding this conversion assists in opioid rotation and dosing.

85
Q

What is the conversion factor from oral morphine to subcutaneous morphine?

A

Divide by 2

This indicates that to convert from oral to subcutaneous, you halve the oral dose.

86
Q

What is the conversion factor from oral morphine to subcutaneous diamorphine?

A

Divide by 3

This means that the subcutaneous dose is one-third of the oral morphine dose.

87
Q

What is the conversion factor from oral oxycodone to subcutaneous diamorphine?

A

Divide by 1.5

This indicates that for every 1.5 mg of oxycodone, one should use 1 mg of diamorphine.

88
Q

What is the first-line treatment for acute constipation not associated with opioid use?

A

Bulk-forming laxatives such as ispaghula husk

Ispaghula husk is recommended alongside dietary changes, hydration, and physical activity.

89
Q

What type of laxative is docusate?

A

A stool softener and a mild stimulant laxative

Docusate can be used for opioid-induced constipation or as an enema in faecal impaction.

90
Q

What is lactulose classified as?

A

An osmotic laxative

Lactulose is used in the treatment of acute constipation if bulk-forming laxatives and macrogol are ineffective.

91
Q

What is macrogol 3350 used for in acute constipation?

A

It is added second-line if treatment with a bulk-forming laxative is not successful

Macrogol is classified as an osmotic laxative.

92
Q

What type of laxative is senna?

A

A stimulant laxative

Senna is the first-line treatment for opioid-induced constipation, used with an osmotic laxative.

93
Q

True or False: Ispaghula husk should be used for acute constipation associated with opioid use.

A

False

Ispaghula husk is not recommended for constipation related to opioid use.

94
Q

Fill in the blank: Docusate can be given for _______ constipation.

A

opioid-induced

Docusate is also used as an enema for faecal impaction.

95
Q

Fill in the blank: Lactulose is added in treatment if bulk-forming laxatives and _______ have not been successful.

A

macrogol

Lactulose is an osmotic laxative.

96
Q

Fill in the blank: Senna is not commonly used first-line in acute constipation that is not associated with _______.

A

opioid use

Senna is primarily for opioid-induced constipation.

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