Possible Exam Questions Flashcards
List medications to be prepared for EOL in the home
- Hydromorphone 2mg/ml
- Haldol 5 mg/ml
- Midazolam 5mg/ml
- Scopolamine 0.4 mg/ml or glycopyrrolate 0.4 mg
- Tylenol suppositories 650 mg
- Foley 16 french and bag
- Mouth swabs
List medications that could cause constipation
- Opioids
- Anticholingerics
- Antihistamines
- TCAs
- 5HT3 antagonists (ondansetron)
- NSAIDS
- Iron
- Blood pressure medications (diltiazem, verapimil)
List side effects of opiods that you expect to resolve quickly
- Sedation
- Respiratory depression
- Nausea
- Urinary retention
List antipsychotics in order of EPS risk
High potency typical antipsychotics
- Haldol
- high affinity for D2–> highest EPS risk
- fewer ACh side effects
- fewer metabolic side effects
Low potency typical antipsychotics
- Chlorpromazine
- low affinity for D2 —> lowest EPS risk of typicals
- more likely to cause ACH side effects
- Methotrimeprazine (somewhere in the middle)
Atypical antipyschotics
- Risperdone (higher risk of atypicals)
- olanzapine (low risk)
- Seroquel (low risk)
- Lowest EPS risk
- more metabolic side effects, like glucose interolance
Describe CANMEDS competencies relevant to Adult palliative Medicine
Medical Expert:
- PC subspecialists integrate all canmeds roles, applyi medical knowledge, clinical skills, professional attitudes in the provision of patient centred care
Communicator:
- effectively facilitate the doctor patient relationship adn dynamic exchanges that occur before, during and after medical encounter.
Manager
- Subspecialists are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system.
Health Advocate
- Subspecialists use their expertise and influence responsibly to advance the health and well being of individual patients, communities and populations
Scholar
- Subspecialists demonstrate a lifelong commitment to reflective learning, and creation, dissemination, application and translationg of medical knowledge.
Professional
- PC subspecialists are committed to the health and well being of individuals and society through ethical practice, profession-led regulation and high personal standards of behaviour.
Leader
- PC subspecialists engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.
Motor testing by level
- C1-C4 Spontaneous breathing
- C5 Shoulder abduction (deltoid)
- C6 Wrist extension (carpi radialis longus and brevis)
- C7 Elbow extension (triceps)
- C8 Finger flexion (flexor digitorum superficialis/profundis, lumbricals)
- T1 Finger adduction & abduction (dorsal/palmar interossei, abductor digiti quinti)
- T1-T12 Intercostal and abdominal muscles
- T12-L3 Hip flexion (iliopsoas)
- L2-L4 Hip flexion, knee extension (quadriceps), hip adduction
- L4 Ankle dorsiflexion and inversion (anterior tibialis)
- L5 Big toe extension (ext hallucis longus), heel walk (ext digitorum), hip abduction (gluteus medius)
- S1 Ankle plantarflexion and eversion (peroneus longus), toe walk (peroneus brevis), hip extension (gluteus maximus)
- S2-S4 Rectal sphincter tone
Urinary incontinence - list types and 3 treatments
1. Stress Incontinence - Antimuscarinics (tolteridine)
- urethral sphincter unable to prevent flow of urine in the setting of increased intra abdominal pressure
- pelvis surgery. radiation, pregnancy
2. Urge incontinence - TCAs (Ach to increase sphincter tone) or Smooth muscle relaxant (oxybutynin)
- inability to control urine when detrusor contracts
- no warning, large volume
- infection, tumour, drugs, radiation
3. Overflow incontinence - alpha adrenergic blockers (terazosin or doxazosin)
- bladder fills to capacity but cannot contract
- constipation, prostatic hypertrophy, stricture, tumour
- small frequent volumes of urine
4. Total incontinence - timed self catheterization or indwelling cath
- complete loss of sphincter function due to tumour invasion or spinal cord injury
List 5 drugs that increase methadone levels (CYP3A4 INHIBITORS)
- INHIBITORS of CYP3A4
- decrease methadone metabolism and increase levels
- CNS depressants :
- Alcohol
- Benzos
- Cannabis
- Antiarrthymics
- amiodarone
- diltiazem
- Anti-depressants
- Fluvoxamine
- Sertraline
- Fluoxetine
- metronidazole
- Antibiotics
- Cipro
- Erythromycin
- Antifungals
- Fluconazole
- Ketoconazole
- Other
- Cimetidine
- topiramate
- Quetiapine
- haldol
- grapefruit juice
List 5 drugs that decrease methadone levels (CYP3A4 INDUCERS)
- Inducers of CYP3A4 etc —-> increase methadone metabolism and decrease serum levels —> pain
-
Anti-epileptics
- carbamazepine
- phenobarb
- phenytoin
- CNS depressants
- chronic alcohol use
- Dexamethasone (> 16 mg/day)
- Rifampin
- Spironolactone
- Vit C, St John’s wort
What enzyme metabolizes methadone
CYP 3A4
CYP 2B6
Serotonin Discontinuation Syndrome
HANGMAN
Headache
Anxiety
Nausea
Gait instability
Malaise
Asthenia
Numbness
Who should be present for a family meeting?
- Patient
- Patient’s identified substitute decision maker
- Patient’s family
- All allied care providers involved.
- Physician
List the format of a family meeting
Prepare:
- Familiarize yourself with chart, goals of care and objectives of meeting
- Consider a pre meeting with health care providers to discuss lead, goals, potential sources of conflict
- Consider contacting other consultants in advance if their opinion is needed
- If in a shared hospital room, make arrangements for roommates or inform them.
Meeting:
- private setting in a circle
- if patient unconscious, decide with SDM whether to hold in front of patient or not.
- Introductions
- Summary of goals /agenda
- Ask for input
- Clarify family’s understanding of the patient’s condition and treatment plan
- Summarize current situation from the perpsective of the treating team. Clarify any misunderstandings.
- Direct the meeting towards treatment plan, goals of care, disposition
- Summarize plan and goals of care. Discuss follow up, next steps. Identify a family spokesperson.
Components of reflective writing
- Description of event
- Feelings : what were you thinking and feeling during the event?
- Evaluation : What was positive or negative about the event?
- Analysis : How can you make sense of the event?
- Conclusions : What alternatives to your action existed?
- Action plan: What would you do the next time a similar event occurs?
Stages of reflection (Gibbs 1998)
DFEACA
Five reasons not to use family as interpreters:
- filtered, abbreviated or omitted information
- lack of medical vocabulary
- lack of understanding of medical terms
- Unfair burden on family/friends
- Issues of confidentiality
- Conflict of interest (potential)
Development stages and understanding in children
-
Infancy (0-2)
- sensory input, attachment, regulation, trust in caregivers
- aware of tension, separation, unfamiliar and absence
- use familiarity, routine, structure for comfort
-
Early Childhood (3-6)
- death is reversible, not personalized
- MAGICAL THINKING
- provide concrete info about the state of being dead
- address feelings of guilt
- dispel misconceptions
-
Middle Childhood (7-12)
- aware of finality of death
- aware of causality
- struggles with unfairness, spiritual issues
- worry about their health and others
- may request graphic details about death and decomposition
- may benefit from learning about the illness
-
Adolescence (>12)
- More adult understanding of universality of death
- existential/spiritual issues
- anticipation/worry about future
- self absorbed
- may engage in risky behaviours
Why not to use codeine in kids
- genetic polymorphism is CYP 2D6
- variable metabolism - can lead to respiratory depression and death
- increased side effects - toxicity
- lack of evidence for safety/efficacy in children
Steps of metabolism of codeine
- CYP3A4 –> norcodeine
- UGT2B7 –> Codeine 6 glucoronide
- CYP2D6 –> Morphine –> M6g, M3G (toxicity)
List 4 types of populations looked after in pediatric palliative care
1. Progressive conditions that are palliative at diagnosis
2. Conditions for which curative treatment is possible, but may fail
3. Conditions involving severe non progressive disability causing vulnerability to health complications
4. Conditions requiring intensive long term treatment to maintain QOL
List DSM Criteria for Delirium
- Disturbance in attention
- Acute change from baseline. Fluctuating
-
Must have one disturbance of :
- memory
- disorientation
- language
- visuospatial ability
- perception
- Not better explained by a neurocognitive disorder
- Evidence it is caused by a medical condition
You are caring for a man in hospice whose goals are comfort. He doesn’t wish for any more investigations. He is an opioid for pain. He develops confusion. List 5 points related to how you would assess confusion?
- CAM for delirium
- Assess for dehydration
- Assess for OIN / hyperalgesia
- Neurologic exam
- Physical exam
- Review all medications
- Assess for bloodwork if indicated
What is the mg/kg dose of ORAL morphine in opioid-naive child for pain?
For dyspnea?
- PAIN : < 50 kg : 0.2 mg/kg po q4h
- DYSPNEA : < 50 kg : 0.1 mg/kg po q4h
What is the formula for corrected calcium?
Corrected calcium = measured calcium + 0.02 (40-albumin)
List cancers that cause cord compression in men and women
Men:
- Prostate
- Lung
- Renal
- Myeloma
Women
- Breast
- Lung
- MM
- Renal
List 4 pyschosocial issues you will discuss with 16 year old patient with Duchenne’s muscular dystrophy?
- Mental health - coping, depression, anxiety
- Educational goals and planning
- Transition to independent living planning
- Relationships / social support
- Sexuality
- Risk taking behaviour
- Prognosis and goals of care
An Afghani immigrant who does not speak English is worked up for cough and found to have metastatic cancer. Bilingual son is adamant that the patient is not told about the diagnosis. List 5 points to consider as you address this patient’s ethical dilemma
- Fiduciary duty is to patient
- Patient Autonomy and preferences regarding disclosure must be respected.
- Discuss with patient his preferences for knowledge and communication
- Gather all pertinent information / prognosis, capacity
- Analyze information and generate all realistic options
- For each option, consider underlying principles, consequences and beliefs
- Judge which option brings the best consensus outcome
An elderly female has bladder cancer with hematuria. Not a candidate for cystectomy, not responded to radiation therapy. List 3 treatments to target bleeding for painful hematuria
- Continuous bladder irrigation
- Alum bladder irrigation
- Silver nitrate
- Percutaneous arterial embolization
- TXA oral
- Radiation if not already done
- Cystoscopy and ablation
List 6 specific questions you will ask when adopting dignity conserving care
- How would I feel in this situation?
- Is my attitude towards this patient based on my own experiences, fears, anxieties or assumptions?
- What do I need to know about you as a person to better care for you?
- What is bringing you joy and hope in your life right now?
- What are you most proud of?
- Who are the people who are most important to you?
- Are there things about you that this disease does not affect?
What are the components of dignity conserving care?
- Attitude (my own)
-
Behaviour
- kindness and respect
- treat the patient. not just illness
-
Compassion
- convey with look, touch
-
Dialogue
- use language to acknowledge the whole person
- know about them as humans to make sense of their suffering
- art of listening
List 4 ways of increasing access to palliative care for homeless populations
- Provide pall care in shelters and on the street
- Harm reduction strategies in hospices or hospital
- Patient navigators
- Increased training in mental health and susbtance abuse amongst palliative care professionals
- Access to hospital and not for profit hospices
List 4 aspects of palliative care practice that are improved with practicing self reflection
- Insight into personal limitations and assumptions
- Improves resiliency, reduces burnout
- Improves team functioning, resolution of conflict
- Improves ability to provide dignity based care
- Self learning
- Improved patient care
List 5 causes of intractable, chronic hiccups in advanced cancer
Central
- stroke
- tumour
- encephalitis
- neurodegnerative
Peripheral
-
Irritation of diaphragm
- pleural effusion
- hepatic mets
- ascites
- pneumonia, hepatic abscess
- lymphadenopathy
- malignancy (esophageal, stomach)
- MI
- pericarditis
-
Gastric / bowel distention
- obstruction
- gastroparesis
- GERD
- distention
-
Irritation of vagus nerve
- mediastinal lymphadenopathy
- pharyngitis / tumour
- esophagitis
- GERD, gastritis
-
Toxic/metabolic causes
- uremia
- hypocalcemia
- hyperventilation
- infection
- hypokalemia
- hyponatremia
- hyperglycemia
-
Drugs
- antibiotics
- antidepressants
- antiparkinsonian drugs
- benzos
- STEROIDS (dex)
- magnesium
- morphine
- NSAIDS
List three opioid side effects that resolve with time
- Respiratory depression
- Sedation
- Nausea
- Urinary retention
List 6 components of reflective writing?
- Description of event
- Feelings during the event
- Evaluation of positives and negatives
- Analysis : how can you make sense of the event?
- Conclusions : What alternatives to your action existed?
- Actions for future : What will you do next time?
List steps for conversion of oxycodone to morphine
- Current opioid regime and total daily dose
- Oxycodone : morphine 1.5 : 1
- Dose reduction 25-50%
List 5 potential consequences of interventional pain management
- Epidurals/ Intrathecals:
- infection
- local anesthetic toxicity
- catheter displacement
- pump malfunction - medication withdrawal / pain crisis
- epidural catheter fibrosis
- intrathecal catheter granuloma
- bleeding / epidural hematoma
Likelihood of EPS with anitpsychotics
- Typical antipsychotics
- haldol
- chlorpromazine
- prochlorpromazine
- Methotrimeprazine (somewhere in the middle)
- Atypical Antipsychotics
- Risperdone (worst)
- Quetiapine (low risk)
- Olanzapine (low risk)
Other drugs that case EPS:
- metoclopramide
- SSRIs
- SNRIS
- NDRI
A patient with end stage lung disease comes to hospital with vivid dreams and myoclonus. All other investigations are negative.
Drugs:
Hydromorphone 5 mg sc q4h
Olanzapine 2.5 mg sl bid prn
What is the first thing you will do to treat this patient?
- Reduce the dose of hydromorphone and reassess.
- Consider opioid rotation
- Treat myoclonus
List 6 classes of drugs that can be used to treat tenesmus
- Opioids
- topical calcium channel blockeres (diltiazem, nifedipine)
- belladonna / opium supp
- steroids (radiation proctitis)
- Antispasmodics - buscopan
- topical analgesics - lidocaine
- nitroglycerin (if fissure)
What is the mg/kg dose of ORAL Hydromorphone for pain for kids?
- Pain : < 50 kg : 0.06 mg po q4h
What are the treatments for hypercalcemia?
- Mild (< 3.0)
- avoid thiazides
- po hydration if possible
- avoid calcium and vit D
- Moderate (3.0-3.5)
- Hydration IV or PO
- Bisphosphonate
- Severe (> 3.5)
- IVF to urine output 150 cc/hour
- Calcitonin 100 u sc tid x 1-2 days
- Bisphosphonate
- Denosumab if RF or contraindication to bisphosphonate
A patient with ovarian cancer presents with colicky abdominal pain and feculent emesis. She has had no BM x 5 days and no flatus for 36 hours.
List 4 classes of medications that will improve her symptoms
- Opioids
- Corticosteroids - dexamethasone
- Antiemetics - haldol
- Antisecretory agents - somatostatin analogue
- Anticholingerics - buscopan
A patient with bladder cancer is in the palliative care unit. He has a PPS of 40%. He is on SC hydromorphone regularly and prn. He has a foley catheter that requires frequent irrigation. He is going to be discharged home.
List 5 systemic barriers to a home discharge
- Accessibility to palliative home care nursing
- Access to respite care for family
- Access to palliative care MD support
- Availability of pharmacy 24 hours
- Availability of training for family or patient to administer sc meds in home
- Financial barriers for catheter and sc supplies
- Equipment for functional decline (hospital bed, commode, etc)
A patient with Parkinson’s disease is in hospice and suddenly loses the ability to take oral medications. They develop symptoms that seem like neuroleptic malignant syndrome.
List one drug and one route than can be used to treat this patient
- Midazolam sc (hospice patient, EOL)
- Other :
- oral dissolvable carbodopa/levodopa
- rectal carbodopa/levodopa
- NG tube and levodopa
- Transdermal rotigotine patch (dopamine agonist)
- NMS: dantrolene, amantadine
A patient has end stage renal disease (uremia). List each of the following medications with the symptoms they treat (use each drug only once)
- Baclofen
- Cannabis
- Methadone
- Pramipexole (dopamine agonist)
- Zinc
- Restless leg syndrome
- Insomnia
- Alerations in taste and smell
- Hiccups
- Pain
- Neuropathy
- Restless legs - Pramipexole
- Insomnia - cannabis
- Alterations in taste and smell - Zinc
- Hiccups - baclofen
- Pain -
- Neuropathy - methadone
What is the major risk of acutely stopping antiparkinsonian medications?
Withdrawal syndrome
Parkinsonism-hyperpyrexia syndrome
- suppression of dopaminergic system
- NMS
- Rigidity, pyrexia, altered LOC, autonomic instability
- treat with reinstatement of parkisonism meds or TD Rotigotine
A patient with early stage dementia has seen three of her family members develop complications of dementia and die. She wishes to die before she loses competency. For her own reasons, she does not want to access the MAID program. She asks what other ways she can hasten her death.
List 2 legal and ethical ways of responding
- Review suicide risk and refer to psychiatry prn
- Discuss advanced care directives re: po intake in advanced dementia
- Goals of care for comfort rather than life prolonging treatments
List 4 agents that can be used for the management of agitation in a home setting and list 1 reason why this agent is a good choice. Use each reason only once.
- Lorazepam - useful for alcohol or benzo withdrawal. long lasting, sublingual route
- Methotrimeprazine - long acting, sedating
- Haldol - multiple routes available (IM, PO, sc)
- Olanzapine - useful for nausea, low risk EPS, oral dissolvable tablet
- Seroquel - useful for anxiety, comes in liquid form
A patient with cancer presents with a complete bowel obstruction and has nausea and vomiting.
List 4 non pharmacological treatments for this patient’s symptoms
- NG to suction
- Venting gastrostomy tube
- Surgical resection
- Mouth care
- Stent for proximal obstruction (GOO or duodenal)
- Radiation
A patient has ALS and dyspnea. All reversible causes have been ruled out. List 5 management strategies for chronic dyspnea in this patient
- NIPPV (noctural or 24 hours)
- Midazolam for anxiety related to dypsnea
- Opioids
- Portable suction for secretions
- Chest physio
- Cough assist device
- Nebulized NAC as mucolytic
List 4 types of life limiting illness that are most likely to result in depression
- Malignancy (pancreatic, lung, lymphoma - inflammatory cytokines)
- ESRD
- Parkinson’s
- MS
- ALS
- HIV/AIDS
List 4 changes that occur in skin from chronic untreated lymphedema
- fibrosis
- papillomata
- cellulitis
- ulceration
- hyperkeratosis
- hyperpigmentation
- lymphorrhea
- lymphangectasia
- Maceration
Other than etiology, list 2 differences between moisture induced dermatitis and pressure wounds
-
Moisture dermatitis:
- diffuse distribution
- pink or red
- partial thickness
- no slough or eschar
- painful
- Irregular shapes
- No necrosis
-
Pressure ulcer
- over bony prominence
- red to bluish purple
- partial or full thickness
- may have slough, eschar
- painful or painless
- circular or regular shape
- may have necrosis
List 4 topical treatments for the management of bleeding associated with a malignant wound
- topical TXA
- chemical cautery with silver nitrate
- calcium alginate
- topical thromboplastin
- Electrocautery
- zinc chloride paste (Moh’s paste)
A patient is in hospice and has terminal secretions. She appears comfortable. The family is distressed by the sound, but they do not want her any more sedated.
List 5 non pharmacological interventions for managing this situation.
- Reassurance and education that this is normal
- Repositioning regularly
- Gently suctioning of oropharynx only
- Discontinuation of fluids
- Music or fan in the room
List 4 broad categories of treatment for malodorous wounds
- Topical or systemic antibiotics (topical metronidazole/ gel)
- Odour absorbent dressings (charcoal)
- Environmental control (essential oils, peppermint, cat litter under the bed)
- Wound cleansing/ debridement
A patient with a long standing history of type 2 diabetes has neuropathy, some other complication and gastroparesis. Nausea and appetite are bothersome to patients.
List 4 interventions for managing this patient’s gatroparesis.
- Improved Glycemic control
- Dietary changes (small amounts, more frequently)
- Prokinetic agent (metoclopramide or domperidone)
- Anti-emetic (gravol, ondansetron)
A patient with a history of cocaine and alcohol use is seen by you. The patient tells you at their appointment that they need to increase their dose, but you don’t think they need it.
Other than an opioid contract, list 6 strategies to manage this patient’s care.
- Regular screening for abherrent use
- Interdisciplinary team
- Prescription with short dispensation
- Random urine drug screen
- Addictions counselling / support
- Frequent follow up to prescribe refills
- Maximize non opioid medications for pain
- Involve family in treatment plan
- Access to naloxone take home kit
- Choose medications with long duration and slower onset
- Inquire about involuntary diversion (stealing)
List 4 symptoms that can be managed using cannabinoids
- Nausea - chemotherapy induced nausea and vomiting
- Appetite / Anorexia from HIV/AIDS
- Neuropathic pain - CIPN
- Peds epilepsy
What enzyme converts codeine into active form?
Why is codeine dangerous to use in children?
- CYP 2D6
- genetic polymorphism:
- variable metabolism from poor to ultrarapid metabolizers
- ultrarapid metabolizers can result in rapid accumulation of morphine metabolites
- leads to respiratory depression and death
- increased side effects, variable efficacy
- lack of evidence for safety
List 4 indications for the use of a lidocaine infusion. List 2 specific symptoms that would prompt you to NOT increase the rate of infusion.
- Refractory pain.
- Neuropathic pain
- Dose limiting side effects of opioids and adjuvants
- Pain crisis from neuropathic pain
Symptoms that would cause you to NOT increase infusion:
- circumoral paresthesias
- tinnitus
- lightheadness
- metallic taste in mouth
- drowsiness
- bradycardia
- hypertension
Severe toxicity:
- restlessness
- tremor
- facial twitching
- seizure
- perspiration
- dyspnea
- apnea
List exclusion criteria for lidocaine infusion
- Uncontrolled hypertension BP > 160
- Altered LOC
- Prior allergy
- Liver failure
- Cardiac failure
- Heart block
- Uncontrolled seizures
- Hypokalemia
List 5 elements that are part of the Serious Illness Conversation Guide
SET UP the conversation
ASSESS illness understanding and info preferences
SHARE prognosis
EXPLORE key topics (goals, fears, trade offs)
SUMMARIZE conversation
DOCUMENT conversation, record goals of care
COMMUNICATE decisions with key clinicians, family (tracking record)
List 7 symptoms of complicated grief (Abnormal)
- Prolonged grief > 12 months
- Non acceptance of the death
- Intense anger
- Intense longing/yearning more days than not
- Symptoms are interfering with function
- Out of proportion to cultural norms.
- Not explained by another mental disorder
List 6 complications of a non resectable tumour that is encasing the celiac axis (vessel and nerves)
- Persistent epigatsric pain
- Weight loss
- Nausea and vomiting
- Bowel obstruction
- Biliary obstruction
- Thrombosis
Complications of a celiac plexus block
- Diarrhea (transient)
- Orthostatic hypotension (ephedrine 30 mg po tid)
- Paraplegia (ischemic cord injury)
- Aortic dissection
- Seizures
- Circulatory arrest
List 2 physical exam findings that palliative care physicians can use to predict death is likely to occur soon (< 8 hours)
- Cheyne Stokes breathing
- Periods of Apnea
- Mottling of extremities
- Cool extremities
- Decreased consciousness
- Pulselessness of radial artery
- Inability to clear secretions
List 5 regular elements of pharmacokinetics that are different in an adult and a a child OVER 2 years of age.
List 1 element of pharmacokinetics that is increased in children
LADME
- Liberation
-
Absorption
- skin and BBB more effective as child ages, making them less vulnerable to toxicities
-
Distribution
- higher volume of distribution
-
Metabolism
- liver metabolism faster in children
- drugs metabolized more quickly
- half life reduced, need more frequent dosing
-
Excretion
- greater rate of elimination of many drugs
- List 1 element of pharmacokinetics that is increased in children:
- CYP 450 liver metabolism is increased until adolescence
- reduced body fat
- increased vol of distribution
- increased rate of renal elim
- mg/kg dosing
- increased surface area
List 5 regular elements of pharmacokinetics that are different between an adult and a child LESS THAN 2 years of age.
-
Liberation (dissolution)
- decreased protein binding
-
Absorption
- decreased gastric emptying time
- increased surface area
- decreased abosrption in GI tract
-
Distribution
- increased fat to muscle ratio
-
Metabolism
- drug half life increased (2-3 x longer)
-
Excretion
- decreased renal clearance
Differences between adult and child < 2 years
A 22 year old male getting treated for testicular cancer presents to the hospital with dehydration. He has been vomiting profusely. The vomiting only subsides when he is immersed in hot water or a hot shower. What is the most likely cause of the vomiting?
Cannabis hyperemesis syndrome
List 2 opioid induced side effects that people typically develop tolerance to within the first few days
- Nausea
- Sedation
- Respiratory depression
- Urinary retention
List 4 mechanisms for opioid induced nausea
- Decreased GI motility - Constipation
- Delayed gastric emptying
- Direct effect on CRTZ
- Increased vestibular sensitivity
List 2 mechanisms for opioid induced constipation
- decreased GI motility
- increased rectal sphincter tone
- decreased awareness of rectal fullness
- prolonged bowel transit time
- increased fluid resorption
*
List 4 classes of agents that are used to treat opioid induced constipation and name 1 agent from each class
- Stimulants
- senna
- bisacodyl
- Osmotic laxatives (non absorbable)
- PEG
- lactulose
- Saline laxatives (absorbable, electrolyte imbalance)
- mag citrate
- sodium phosphate
- Opioid antagonists
- Naloxegol
- Methylnaltrexone
- Enema
- saline
- fleet
- mineral oil
List 6 commonly prescribed classes of medications that can cause constipation
- Opioids
- Anticholinergics
- 5HT3 receptor antagonists
- Antipsychotics
- TCAs
- Antacids
- NSAIDS
- CCBS
- Iron
List 2 typical antipsychotics. List 2 atypical antipsychotics. Then list them in order from GREATEST to LEAST likelihood of developing EPS
- Haldol (typical)
- Methotrimeprazine (typical)
- Risperdone (atypical, EPS worst offender)
- Olanzoapine (atypical, low risk)
- Quetiapine (atypical, lowest risk)
List 6 distinct receptors that antipsychotics work on:
- Dopamine D1, D2
- Serotonergic 5HT2, 5HT3
- Acetylcholine M1, M2
- Histamine H1
- Alpha 1 adrenergic