Past MCQs

Question 1

Abigail, an 87 year old NZ European woman, is admitted to hospital with complete dysphagia due to an oesophageal carcinoma.
She is thirsty and clinically dehydrated.
Her prognosis is poor (probably a number of days to one week).

Which option is the most appropriate?

Select one:
Give regular mouth care only
Start a morphine syringe driver
Arrange urgent NG tube placement through which to give fluids
Refer urgently to gastroenterology for endoscopic oesophageal stent placement
Obtain a speech and language therapist (SLT) assessment
Organise urgent placement of a percutaneous endoscopic gastrostomy (PEG) tube through which to give fluids
Give mouth care and start an IV infusion of normal saline
Give steroids and refer for urgent radiation therapy

Answer 1

Give mouth care only

Question 2

Adam, a 65 year old NZ European man, is known to have advanced cardiac failure secondary to dilated cardiomyopathy due to excessive alcohol use.
He has taken maximal medical treatment for this but has become breathless at rest.
Pulse oximetry reveals oxygen saturations of 94% breathing air at rest. BP 100/60. Pulse 90 regular.
His renal function is normal.

What is the most appropriate next management to help control his breathlessness?

Select one:
Nebulised morphine as needed
Salbutamol nebulisers as needed
Midazolam in syringe driver
Morphine exilir as needed
Morphine in syringe driver
Clonazepam as needed
Modified release morphine regularly and NR (exilir) as needed
Fentynal in syringe driver
Fentynal in transdermal patch
Oxygen via nasal cannula
Regular diazepam

Answer 2

Morphine exilir as needed

Question 3

Adrienne, a 65 year old NZ European woman with progressive glioblastoma, has a likely prognosis of several months.
She has dysarthria, and a right hemiparesis.
She gives a history of trouble swallowing over the last few weeks, and increasing breathlessness and cough starting two days ago.
She is admitted to hospital and a diagnosis of an aspiration pneumonia is made.
Ben, Adrienne’s husband, was nominated as power of attorney (EPOA) when she was first diagnosed.

She is clinically stable. What is the best next step?

Select one:
Ask Ben whether Adrienne has an advanced care plan (ACP) to help guide decision making.
Assess Adrienne’s capacity to decide about treatment.
Start treating Adrienne with oxygen, fluids and intravenous antibiotics immediately.
Ask Ben whether Adrienne would want antibiotics to treat the infection.
Start Adrienne on a syringe driver containing morphine and midazolam.

Answer 3

Assess Adrienne’s capacity to decide about treatment.

Question 4

Wayne, a 45 year old NZ European man has recently been diagnosed with non small cell lung cancer and is on second cycle of first line chemotherapy.
He develops episodes of shortness of breath in which his respiratory rate increases, he feels dizzy faint, panicky and thinks he is going to die.
Anaemia, pulmonary emboli, progression of the malignancy and infection have been excluded.

What is the most appropriate initial management to help control his breathlessness?
Hand held fan
Regular diazepam
Paroxetine
Pulmonary rehabilitation
Salbutamol nebulisers as needed
Regular morphine modified release orally
Oxygen as needed
Breathing relaxation techniques
Regular opioids via a fentanyl patch
Haloperidol as needed
Levomepromazine regularly

Answer 4

Breathing relaxation techniques

Question 5

Ron, an 87 year old man NZ European with Parkinson’s disease, develops symptoms of gastric stasis - vomiting after meals and early satiety.

Which of the following would be the best drug help to control these symptoms?

Select one:
Domperidone
Cyclizine
Scopaderm transdermal patch
Haloperidol
Ondansetron
Metoclopramide
Levomepromazine

Answer 5

Domperidone

Would be met but he has Parkinson’s, domperidone doesn’t cross BBB

Question 6

Gwen, a 71 year old Maori woman with known end stage COPD and severe shortness of breath, has developed an overwhelming chest infection at home.
She is unable to swallow now, has a reduced conscious level with an occasional distressed look on her face and episodic agitation.
She has a written advance directive stating that she is not to be admitted to hospital, not to have antibiotics and expressing a wish to die at home at life’s end.
She is currently on regular oral morphine modified release, diazepam, frusemide, as well as salbutamol nebulisers and continuous oxygen.

What would the most appropriate medication approach be now?

Select one:
Convert morphine to a fentanyl patch
Convert the morphine to a fentanyl patch and start a syringe driver with haloperidol and midazolam
Start a syringe driver containing midazolam, haloperidol and buscopan (Hyoscine-n-butylbromide)
Start a syringe driver containing morphine and midazolam
Start a syringe driver containing morphine and haloperidol
Start as needed subcutaneous morphine, midazolam, buscopan and haloperidol without a syringe driver
Start a syringe driver containing morphine
Start a syringe driver containing morphine, midazolam and haloperidol

Answer 6

Start a syringe driver containing morphine, midazolam and haloperidol

Question 6

Kaia, an 88 year old New Zealand Māori, with multiple cerebral haemorrhages and dementia is admitted to hospital with increasing confusion due to pneumonia.
She is accompanied by her husband, and whānau who have a variety of views regarding the appropriateness of various management options that are possible.

From the options provided, who would be the most appropriate for the attending clinician to discuss the treatment options with?

Select one:
Kaia’s chaplain alone
Kaia and her whānau
Kaumatua (Elders)
Kaia and her husband
Kaia’s husband alone
The hospital’s whānau care service
Kaia alone
Kaia’s whānau without Kaia

Answer 6

Kaia and her whānau

Question 7

Eve is a 56 year old NZ European woman with ovarian cancer and known lung and peritoneal metastases with ascites.
She is on regular morphine, metoclopramide and laxsol.
Over the last two days she has started having bad dreams, falling asleep easily during the day, and has developed occasional bothersome jerking of upper and lower limbs. Her attention span is decreased and she has stopped doing her daily crossword.

What is the most likely cause of these new symptoms?

Select one:
Metoclopramide extrapyramidal side effects
Meningeal metastases
Brain metastases
Hyponatraemia
Hypercalcaemia
Hypoxia
Renal impairment

Answer 7

Renal impairment

Question 8

Kim, a 62-year-old Chinese New Zealand man with non-small cell lung cancer, complains of a dull persistent pain in his right humerus, which started spontaneously one week ago and is not relieved by paracetamol.

What is the most appropriate next step regarding management of his pain?

Select one:
Prescribe regular oral treatment with modified-release oxycodone
Prescribe fentanyl patches for use every 3 days
Prescribe regular oral modified-release morphine
Refer for a radiation oncology opinion for palliative radiotherapy
Prescribe regular topical NSAID gel
Prescribe regular oral gabapentin
Prescribe regular oral bisphosphonate
Prescribe regular oral treatment with codeine

Answer 8

Prescribe regular oral treatment with codeine

Question 9

Hilary, a 41 year old Māori man with advanced colon cancer, is to be started on modified release morphine for liver and bone pain.

Which is the most appropriate medication to be started given he is to be started on morphine?

Select one:
Pamidronate
Paracetamol
Laxsol
Haloperidol
Dexamethasone
Ondansetron
Diclofenac
Metoclopramide
Omeprazole

Answer 9

Laxsol

Question 10

A 63 year old NZ European woman presents with a new severe mid thoracic back pain radiating bilaterally to chest wall, and worse in lying flat.
She had right breast carcinoma diagnosed and treated 5 years ago with mastectomy, chemotherapy, and radiotherapy.
She takes no regular medication currently apart from laxative for recent constipation. OTC paracetamol, ibuprofen, and prescribed codeine regularly has made no difference.
She has no bladder problems, mobility is good though limited by pain, and no abnormal sensations in her lower limbs.
She has mild focal tenderness over her mid thoracic spine. Chest auscultation is normal. There is no upper or lower limb motor disturbance. There is perhaps some alteration to soft touch on the left at T7/8 dermatome

From the options provided, which radiological test would be most appropriate?

Select one:
a. MRI scan whole spine
b. CT scan thorax
c. Isotope bone scan
d. Plain x-ray spinal views
e. CXR including lateral

Answer 10

MRI scan whole spine

Question 11

With the patient’s permission, a medical registrar is asked to speak with the whānau of a patient identifying as NZ Māori, who developed pneumonia while receiving palliative treatment for end stage renal failure. His death is now imminent.

Which of the following statements regarding cultural beliefs is most relevant regarding the time following death?

Select one:
a. Cremation should not be discussed with whänau before death.
b. Hair should only be cut after death.
c. Whānau try not to be present immediately after death.
d. The patient should not be left alone.
e. The patient’s body cannot be donated to medical science.

Answer 11

d. The patient should not be left alone.

Question 12

An RMO is called to see Janine, a 68-year-old NZ European woman with progressively worsening breathlessness at rest on the hospital ward.
She has non-small cell lung cancer and chronic obstructive pulmonary disease.
The breathlessness interferes with her ‘getting on with life’ and stops her interacting with others. Anxiety, though present, is not overwhelming.
She is nearly bed/chair bound, and needs the support of one other for transfers. She can talk in short sentences.
She is taking maximal inhaled bronchodilator therapy, ad her breathlessness.
On examination, she is apyrexial, her respiratory rate is 18 breaths per minute and her oxygen saturation is 94% breathing air. She is cachectic and has some dullness to her right base on examination CXR shows changes consistent with COP. Antibiotics, and oral corticosteroids. Fans and other non pharmacological measures have not helped, a known right hilar mass rapidly enlarging over the past month, and some basal atelectasis.
Blood film shows:
haemoglobin 92 g/L (1 15-165)
white cell count 8.2 ‘ 109/L (4.0-11.0)
platelet count 194 ‘ 109/L (150-400)

From the options provided, which measure might best aid in the immediate relief of breathlessness?

Select one:
a. I.V Bronchodilators
b. benzodiazepines
c. oxygen
d. blood transfusions
e. Opioids

Answer 12

Opioids

Question 13

Ian is a 70-year-old NZ European man who is brought to his GP, by his family, with a short history of confusion and abnormal behaviour.
His family also reports he has become constipated despite being thirsty all the time and drinking lots. In addition, he has had increasing ‘belly’ pain associated with this constipation.
He has lung cancer with extensive bone metastases.

On examination, he is afebrile, blood pressure slightly lower than normal, mouth dry, JVP not observable, lungs clear, abdomen non tender, no bladder palpable, and no swelling of ankles.
From the options provided, what is the most likely cause of the confusion?

Select one:
a. Intracerebral metastases
b. Hypercalcaemia
c. Constipation
d. Depression
e. Progressive bone pain
f. Hypoglyceamia
g. Hyponatreamia => vomit + seizure
h. Urinary tract infection
i. Respiratory tract infection
j. Myocardial ischaemia
k. Early dementia
l. Hyperglyceamia
m. Drug toxicity
n. Alcohol withdrawal

Answer 13

b. Hypercalcaemia

Question 14

Jane is a 71-year-old NZ Māori patient who has central abdominal pain from pancreatic cancer.

In hospital, the team has been titrating her morphine elixir and found that this is helping to control her pain. She is currently on 10mg every 4 hours of the elixir (including overnight) and finds this method disrupts her sleep.

What is the most appropriate plan for her ongoing analgesia?

Stop oral morphine and start oxycontin b.d. (slow release oxycodone) and oxynorm liquid as needed
Add in a non-steroidal anti-inflammatory (NSAID) with omeprazole
Start 30mg M-Eslon b.d. (slow release morphine) and 2.5-5mg morphine elixir as needed
Stop oral morphine and start a syringe driver with morphine over 24 hours
Start 30mg M-Eslon bd (slow release morphine) and 10mg morphine elixir as needed
Stop oral morphine and start a fentanyl patch
Add in tramadol

Answer 14

Start 30mg M-Eslon bd (slow release morphine) and 10mg morphine elixir as needed

Question 15

Robert, a 68-year-old NZ European man is receiving clinically assisted nutrition through a percutaneous endoscopic gastrostomy (PEG) because of dysphagia due to advanced motor neurone disease.

He is able to communicate effectively, though slowly, and requests to have his feeding stopped, knowing it may hasten his death.

To begin the process of decision-making, what is the most important first step?

Assess whether his next of kin agrees with the decision to stop nutrition
Assess whether his whānau agrees with the decision to stop nutrition
Assess whether his reason for stopping feeding makes sense to the clinicians supervising his care
Assess whether this is consistent with his Advanced Care Plan
Assess whether his enduring power of attorney agrees with the decision to stop nutrition
Assess whether he has mental capacity to make this decision

Answer 15

Assess whether he has mental capacity to make this decision

Question 16

1. Janet is a 68 year old Dutch woman with stable severe COPD. She is on appropriate doses of inhaled medication. She has attended the pulmonary rehabilitation programme a year ago which helped. However her lung function has gradually deteriorated since then, and she is now housebound due to breathlessness and fatigue.
   Her O2 saturations are 94%, respiratory rate 24. She complains of episodic breathlessness and sometimes feels a little anxious.
   What is the next appropriate step in management for her breathing?
   1) Nasal oxygen
   2) Breathing + relaxation techniques
   3) Morphine long-acting, orally
   4) Benzodiazepines
   5) Chest wall vibration exercises
   6) Oral steroids

Answer 16

2) Breathing + relaxation techniques

Question 17

2. Tania is a 56-year-old lady Samoan woman with multiple myeloma and extensive bony metastases visits her GP for a planned appointment to review pain control.

Two weeks ago, her GP had seen her because of midline thoracic backache, and sharp shooting band-like pain around her chest wall.
Regular oral morphine was added to regular paracetamol at that time. Her pain has improved but not gone away.
She has no undue side effects from the morphine or the paracetamol. On examination she has some allodynia in a T10 dermatomal distribution on the left side of her chest.

As part of an established management plan her GP is referring her to radiation oncology.

What is the most appropriate next step to manage her pain currently?

a) Add amitriptyline
b) Add citalopram
c) Add sodium valproate
d) Stop morphine, start amitriptyline
e) Stop morphine, start citalopram
f) Stop morphine, start valproate
g) Switch morphine to fentanyl patches
h) Switch morphine to methadone
i) Switch morphine to oxycodone

Answer 17

Add amitriptyline

Question 18

3. Xui is an 80 year NZ Chinese lady who has severe congestive cardiac failure due to myocardial ischaemia, as well as mitral regurgitation. Her ejection fraction is markedly reduced on echocardiography.

She has been admitted to the medical ward with progressive breathlessness, getting worse over many months. She can only just get from bed to toilet without debilitating breathlessness and spends most of her time housebound.

Xui has been titrated up to maximal medication for her heart failure over the last three months: current medication includes frusemide, carvidelol, enalapril, aspirin, and a statin.

No other disease is considered to be contributing to her breathlessness. Her renal function is normal.

From the options provided which opioid medication would be most appropriate to help her breathlessness?

1) Fentanyl IV
2) Fentanyl oral
3) Fentanyl patch
4) Fentanyl SC
5) Methadone oral
6) Methadone SC
7) Morphine IV
8) Morphine oral
9) Morphine SC
10) Tramadol IV
11) Tramadol oral

Answer 18

Morphine oral

Question 19

4. Waiti is a 52yr old Māori man with cholangiocarcinoma undergoing palliative chemotherapy via a Hickman line. He last had chemotherapy 8 days ago, and started to feel more breathless over the last few days, and developed a fever of 38.3 degrees at home.
   He was advised to present to ED, where the findings are an ongoing fever, new dysuria, with suprapubic tenderness. Pulse is 100bpm, respiratory rate is 22, oxygen saturations are 96% and BP is 104/67.
   His bloods reveal Hb 90, WBC of 2.4 and neutrophils of 0.7, platelet 100. Blood cultures have been collected.

What is the most important step in immediate treatment?
a) Broad spectrum IV antibiotics and IV antifungals
b) Broad spectrum IV antibiotics
c) Broad spectrum IV antibiotics, IV antivirals and IV antifungals
d) IV fluids +1 lmao you gonna let them die
e) Granulocyte Colony Stimulating Factor
f) Oxygen

Answer 19

Broad spectrum IV antibiotics

Question 20

5. Michael, a 41-year-old Māori man with advanced colon cancer, is started on slow-release morphine for liver and bone pain.
   What additional drug treatment would be most appropriate to start at this point?
   1) Laxsol (docusate sodium and senna) as needed and metoclopramide as needed
   2) Laxsol as needed and metoclopramide regularly
   3) Laxsol as needed and ondansetron as needed
   4) Laxsol as needed and ondansetron regularly
   5) Laxsol regularly and metoclopramide as needed
   6) Laxsol regularly and metoclopramide regularly
   7) Laxsol regularly and ondansetron as needed
   8) Laxsol regularly and ondansetron regularly

Answer 20

Laxsol regularly and metoclopramide as needed

Question 21

6. Derek is a 90yr old frail European man with severe osteoporosis and has a new collapsed vertebrae at L2. He is taking long-acting morphine, 20mg twice a day regularly plus 2-3 doses of short-acting morphine for breakthrough pain.
   He has developed a severe pneumonia as a result of immobility, and has deteriorated significantly despite antibiotics, oxygen and fluids. He understands and accepts he is dying, likely within the next few days. He has started to take a long time to swallow his tablets. He is bedbound and incontinent of urine and faeces.
   Which is the most appropriate factor that should prompt consideration of a continuous subcutaneous syringe driver for him?
   1) He is incontinent of urine and faeces
   2) He is likely to die within three to five days
   3) He is requiring more than two extra oral short-acting morphine doses to be comfortable.
   4) He is requiring over 40mg morphine in 24 hours.
   5) He is unable to swallow his tablets
   6) He is starting to develop retained secretions
   7) He is bed bound and fully dependent on others
   8) He wishes to die

Answer 21

He is unable to swallow his tablets

Question 22

7. Roger is a 54-year-old Samoan man with severe COPD. He normally is independent with a walking frame at home, with a package of care twice a day. He was admitted 4 days ago with a severe exacerbation of his COPD, needing 24-hour non-invasive ventilation as well as his normal long-term oxygen therapy, steroids and regular inhalers.
   Even with this treatment he has been deteriorating despite this. He is now bedbound and too weak to get out of bed to the toilet, so was catheterised 2 days ago, which is working well. The NIV has been withdrawn and Goals of care are palliative.
   He becomes increasingly agitated overnight. He is restless in bed, grimacing and groaning at times, and can’t seem to get comfortable. He repeatedly pulls at his covers but is too unwell to articulate what’s wrong. Sometimes he says things that don’t make sense, and sometimes the nurses wonder if he is hallucinating.

What is the most likely unifying explanation of his current presentation?
1) CO2 retention
2) Hypercalcaemia of malignancy
3) Hypoxia
4) Sepsis
5) Terminal agitation
6) Urinary retention

Answer 22

5) Terminal agitation

Question 23

Eve is a 56-year-old NZ European woman with metastatic ovarian cancer. She has known lung and peritoneal metastases causing hydronephrosis on her CT scan 2 weeks ago.

She is on a regular long-acting morphine, metoclopramide and laxatives. Her O2 saturations are 93% and she has had no recent changes to her analgesia.

Over the last two days she has started falling asleep easily during the day, having vivid dreams and has developed occasional bothersome jerking of upper and lower limbs. Her attention span is decreased and she has stopped doing her daily crossword.

What is the most likely cause of these changes?

1) Development of brain metastases
2) Hypoxia due to lung metastases
3) Hyponatraemia secondary to syndrome of inappropriate ADH (SIADH)
4) Hypercalcaemia of malignancy
5) Metoclopramide extrapyramidal side effects
6) Renal impairment leading to morphine toxicity

Answer 23

Renal impairment leading to morphine toxicity

Question 24

Myrtle is a 61-year-old Māori woman who has had breast cancer and bone metastases for 4 years.
She presents with early morning headaches and nausea, and her GP commences dexamethasone and simple analgesia, and requests a CT head.

What is the most appropriate anti-emetic to prescribe?

1) Cyclizine
2) Domperidone
3) Haloperidol
4) Levomepromazine
5) Metoclopramide
6) Ondansetron

Answer 24

Cyclizine

Question 25

Ron, an 87-year-old NZ European man with Parkinson’s disease, develops symptoms of gastric stasis - early satiety and nauseated after meals.

Which of the following would be the best drug to use to manage these symptoms?

1) Cyclizine
2) Domperidone
3) Haloperidol
4) Levomepromazine
5) Metoclopramide
6) Ondansetron
7) Scopaderm (hyoscine hydrobromide) transdermal patch

Answer 25

2) Domperidone

Question 26

2) 60 year old Chinese NZ women with renal cell cancer complains of dull persistant pain R) humerus. Started 1 wk ago, not helped with paracetemol.
Hx w/ reflux , rejected NSAIDs

Next step for pain control?

Answer 26

Regular oral codeine

Question 27

3) Wiremu, 58y/o with known advanced pulmonary fibrosis. He was previously admitted 1/12 ago with SOB + cough + irreverisble functional decline. He has not responded to anti-fibrotic meds and does not want to consider a lung transplant. He does not have an advance care plan.

He now presents with SOB hospital. O2 sats 70% on room air, BP 70/40. The team think he is dying within hours. He wants to be fully informed regarding his current situation and what will happen. What is the most appropriate next step?

Ask if he wants to be resuscitated.
Explain that he is dying and he will be cared for.
Ask his EPOA if he should be resuscitated.
Perform airway, breathing, circulation assessment.

Answer 27

Explain that he is dying and he will be cared for.

Question 28

4) Rob is a 34M with advanced MS. They are estranged from family and socially isolated. Although they are being treated in hospital for lower limb cellulitis, they have been told they they have a prognosis of short months.
He has started waking early in the morning and is asking for something to help with their insomnia.

What is the clinical team’s first step?

Explore their concerns about poor sleep
Offer pastoral care
Offer to contact family
Refer to psych
Start syringe driver with midazolam
Start oral zopiclone
Start morphine
Start an antidepressant

Answer 28

Explore their concerns about poor sleep

Question 29

5) Following the death of a Maori patient, it is the attending clinicians responsibility to provide support for the patients whanau and to respect their cultural belieffs.
From options, what is the most likely request that Maori whanau will ask of the clinician?

To call patients GP
To have a lock of hair
To see the patient notes
To take the patients jewelry home
To wash the patient
To go to the mortuary with the body
To take the body to the marae

Answer 29

To go to the mortuary with the body

Question 30

6) Bill is a 74M Nz European with prostate cancer + bone mets, who lives with his wife. He is on M-Eslon and sevredol for his bone pain, with appropriate co-prescriptions. He is admitted w/ increased generalized pain, nausea, constipation and acute confusion and has become paranoid about taking his meds, fearing someone is trying to poison him. He is partially deaf + nurses have been uncertain if he is understanding their instructions.

eGFR 64, normal Na+, K+ and urea. He has calcium 3.8 which is treated with fluids and pamidronate.

What is the next appropriate step?
Catheterize to rule out UTI
Ensure hearing aids work and he is in a calm environment
Give IV haloperidol
Increase morphine
Start omeprazole
Switch morphine to fentanyl patch

Answer 30

Ensure hearing aids work and he is in a calm environment

Question 31

7) Penny, 54F Tongan with met breast cancer presents with acute confusion at 2am, and CT head reveals a new large brain met. She is distressed, calling out and disorientated to time and place.

Initial investigations have not shown other causes of delirium. ED RMO has given dexamethasone 16mg to treat oedema associated with brain mets. On blood tests full count, renal function, calcium all normal.

What is the next step?
Refer to radiation oncology for urgent whole brain radiotherapy
Start syringe driver with morphine + cyclizine
Encourage family to stay by her bedside
Refer to neurosurgery for metastatectomy
Give IV midazolam
Give 1000mls normal saline over one hour.

Answer 31

Encourage family to stay by her bedside

Question 32

8) Wayne, a 45 NZ European man recently diagnosed with non-small cell lung cancer and is on second cycle of first line chemo. He develops episodes of SOB in which RR increases, he feels faint, dizzy and panicky and thinks he is going to die. His family are present and trying to reassure him

Pulmonary embolic, infection, anaemia, effusion and cardiomyopathy all ruled out.

In addition to oral med PRN, which intervention is most appropriate to help control breathlessness?

Oxygen as needed
Salbutamol nebulisers as needed
Breathing relaxation techniques
Regular levomepromazine
Regular diazepam
Regular fentanyl patch
Regular slow release oral morphine

Answer 32

Breathing relaxation techniques

Question 33

9) Jimmy 69M with severe COPD. He has SOBOE when going to toilet + back. He takes optimal inhaler treatment w/ good technique, and has undertaken a pulmonary rehab course previously.

Pulse is 95bpm regular, RR 25/min, O2 sats 94% and afebrile.
No reversible causes found. Not a panic attack. He tried a fan which didn’t help. From the options below, which intervention is most appropriate to help control his symptoms?

Diazepam regularly
Fentanyl patch regularly
Levomepromazine regularly
Haloperidol as needed
Oral morphine elixir as needed
Oxygen as needed
Salbutamol nebulisers as needed

Answer 33

Oral morphine elixir as needed

Question 34

10) Grace 56F Fijian women with metastatic colon cancer (liver + peritoneal metastates) presents with constant nausea and large volume faeculent vomiting every couple days.

She has severe colicky abdo pain espeically before she vomits, which has gotten worse despite her usual slow release oral morphine w/ appropriate coprescriptions. She has BNO 7 days, not passing any flatus.

OE/ very distended, mildly tender abdo + quiet bowel sounds. Slightly dehydrated but no significant renal impairment. You decide she needs a syringe driver to ensure she is absorbing the meds to treat her symptoms.

Which of the following syringe driver combos is best first step?

Morphine + metoclopramine.
Morphine + buscopan.
Morphine + ondansetron.
Oxycodone and metoclopramine.
Oxycodone and buscopan.
Oxycodone and ondansetron.
Fentanyl and metoclopramine.
Fentanyl and buscopan.
Fentanyl ondansetron.

Answer 34

Morphine + buscopan.

Metoclopramine - not in full

Question 35

11) Dorothy 47F Maori with motor neurone disease and who has been treated for urinary sepsis for last 2 days. Meds: cefuroxime, PRN morphine, PRN metoclopramine, PRN midazolam, PRN buscopan.
It is now obvious she is dying. Her GP thinks she is in the last days of her life and wants to ensure she has good symptoms control avaliable if she needs it.

Which medication is most appropriate to stop?

Answer 35

Antibiotics

Question 36

12) Sara is 87F on ward who has had palliative radiotherapy for advanced squamous cell cancer of tonsil + has fungating wound in her neck. GOC palliative, for for CPR or MET calls.

A TI is taking a daily review of the patient when she starts bleeding heavily from the wound, losing large volumes of blood. Her husband is compressing her neck with a towel.
What is the best next step?

Leave room and call for help
Leave room and find the nurse.
Leave the room and ask the nurse to prepare sedating medication for EOL
Leave room and ask nurse for some dark towels while you call her family
Stay in room and press emergency buzzer
Stay in room and offer to take over compression from her husband

Answer 36

Stay in room and press emergency buzzer

re: call bell

Question 37

Tua 44F Samoan, advanced COPD with smoking hx. She has been in hospital for 1 week with non-infective exacerbation of SOB.
She has been gradually deteriorating over the week and now dying in her final days.

RMO is called to see her because of agitation + severe SOB. She is calling out in distress, cannot speak in sentences. RR 40, 84% sats, dsespite oxygen therapy and her pulse is 110 bpm and bp 98/65. She is grey + sweaty

Immediate drug best option?
Clonazepam oral
Dexamethasone IV
Fentanyl SC
Fentanyl sublingual
Haloperidol IV
Morphine IV
Morphine SC
Salbutamol nebulizer

Answer 37

Morphine IV

Question 38

Ian is a 70 year old NZ European man who is brought to his GP, by his family, with a short history of confusion, noted by the GP as having short attention span. His family also reports he has become constipated despite being thirsty all the time and drinking lots. In addition he has had increasing abdominal pain perhaps associated constipation.
His past history includes hypertension, and for the last 10 years this has been satisfactorily controlled with a thiazide diuretic.
One year ago he developed pain in his right flank and investigations confirmed renal cell carcinoma with bone metastases.
On examination, he is afebrile, blood pressure slightly lower than normal, mouth dry, JVP not observable, lungs clear, abdomen non tender, no bladder palpable, and no swelling of ankles.

What is the most likely cause of his confusion?

Alcohol withdrawal
Constipation
Depression
Drug toxicity
Early dementia
Hypercalcaemia
Hyperglyceamia
Hypoglyceamia
Hyponatreamia
Intracerebral metastases
Myocardial ischaemia
Progressive bone pain
Respiratory tract infection
Urinary tract infection

Answer 38

Hypercalcaemia

Bone mets + thiazide