Practice Exam Questions

Question 1

14 year old with pelvic sarcoma and bowel obstruction presents to ED. List 4 classes of drugs that would improve her symptoms.

Answer 1

1) opioid
2) corticosteroid (dexamethasone)
3) 1st generation antipsychotic (haldol)
4) synthetic analogue to somatostatin (octreotide)

Pediatric MBO treated the same as adult?

Question 2

List 6 strategies to use when working with an interpreter

Answer 2

1) speak directly to the patient
2) speak slowly
3) short segments
4) one question at a time
5) avoid medical jargon
6) pause often
7) Use teach back/talk back method

Question 3

List 5 side effects of cannabis you would counsel patients about when prescribing medical canabis.

Answer 3

1) short term memory impairment
2) motor impairment
3) impaired judgement
2) dizziness
3) dry mouth
4) paranoia
5) psychosis
6) cyclical vomiting (moreso in recreational drug users)

Question 4

A patient wants to die at home. List 4 factors that are more likely to make a home death successful for him.

Answer 4

1) access to Injectable medication
2) involvement of palliative team/nurse
3) 24 hour care giver present
4) Controlled symptoms
5) family member willing to give subcut medications

Question 5

List 5 components of the PPS

Answer 5

1) ambulation
2) level of activity
3) self care
4) intake
5) level of consciousness

Question 6

What is the MOA for the following medications for constipation? Senna, lactulose, bisacodyl, glycerine (?supp)

Answer 6

1) Senna and Bisacodyl are stimulant laxatives. Myenteric plexus stimulation is increased motility. decreased absorption of fluid and electrolytes. (onset of action 6-12 hours)
2) Lactulose and sorbitol (sugar alcohol) is an osmotic laxative- Non absorbable molecules draw fluid into intestinal lumen via osmotic forces.
3) Glycerine supp: softening of stool in rectum induces defectaion by distension of rectum

Question 7

Specialist palliative care has been proven to improve health outcomes for patients and the health care system. List 8 ways.

Answer 7

1)

Question 8

List 4 treatments for severe hypercalcemia

Answer 8

1) IV hydration
2) IV bisphosphonate (synthetic pyrophosphate analogues)
3) calcitonin
4) steroids (hematological malignancies)
5) Denosumab (human monoclonal antibody)

Question 9

**You receive a consult to see a patient requesting removal of high flow oxygen in order to have a natural death. List 5 elements of informed consent relating to this specific case.

Answer 9

I have not found ‘the answer’

1. Ensure the patient has understanding of their diagnosis and indication for O2 therapy and prognosis
2. Ensure the patient understands the role O2 is playing (life sustaining)
3. Ensure the patient has an undertstanding that without O2 in place this will lead to their natural death
4. Ensure the patient is aware of all possible treatment options, if continuing on O2 therapy.
5. Ensure the patient has an understanding of all options available to them at end of life- palliative sedation vs MAID.

Question 10

Receptors implicated in itch (opioid related itch)

Answer 10

According to Oxford Text book (page 404) The mechanism remains indeterminate.

‘Some opioids, particularly morphine can generate histamine release from mast cells, other evidence suggests that opioid induced itch is mediatiated through central MORs.’

Question 11

List 2 opioid induced side effects that people typically develop tolerance to within the first few days.

Answer 11

1. Nausea
2. Sedation

Question 12

List 4 mechanisms for opioid induced vomiting.

Answer 12

1. Stimulate the medullary chemoreceptor trigger zone
2. Increase vestibular sensitivity
3. Increased gastric antral tone
4. dimninished motility
5. delayed gastric emptying
6. Increased fluid absorption in the small and large intestine
7. Impairs reflex relaxation of the anal sphincter in response to rectal distension.

Question 13

You wish to convert a patient from long acting oxycodone 10mg po q8 hours to morphine sc/iv infusion. List 5 steps that are necessary in this conversion. What rate would you start the infusion?

Answer 13

1. Calculate how much oxycodone used in 24 hour period (10 x 3= 30mg oxycodone in 24 hrs)
2. Convert oxycodone to OME (ratio used 2:1) 30 x2= 60 OME
3. Convert oral morphine to parenteral 60/2= 30mg parenteral morphine
4. Dose reduce for incomplete cross tolerance 30-50% (30/2)
5. 15/24= 0.6mg/hr

Question 14

What is the main methadone cytochrome enzyme? List 2 inducers and 2 inhibitors

Answer 14

CYP3A4

Medications that inhibit the cytochrome: fluconazole, erythromycin, ciprofloxacin, grapefruit juice.

Inhibitors: will reduce methadone metabolism and increase risk of sedation/respiratory depression

Medications that induce the cytochrome 34A: phenobarbital, phenytoin, saint John’s wart, rifampin)

May accelerate methadone metabolism and cause increased pain or possibly even withdrawal symtoms.

Question 15

What two opioids are associated with hypoglycaemia?

Answer 15

Tramadol and methadone

Question 16

List 6 commonly prescribed classes of medications that can cause constipation.

Answer 16

1. Opioids
2. 5HT3 antagonist
3. NSAIDS
4. CCB
5. Tricyclic antidepressants
6. Anticholinergics
7. Antacids
8. Antipsychotics

Question 17

What five key elements are recommended in order to accomplish informed consent? (pg 1150 Oxford)

Answer 17

1. Setting
2. Perception
3. Invitation
4. Knowledge
5. Strategy

Recommend applying ‘SPIKES’ approach when acquiring informed consent

Question 18

Define competency/capacity

Answer 18

competence/capacity: the mental ability to understand problems & decide whether to accept or reject medical treatment offered (UP to date)

Question 19

What information must be included when acquiring informed consent

Answer 19

Material facts — Material facts are those that are relevant to decision-making and usually include [4]:

●Diagnosis. The methods and alternative means of diagnosis may be relevant, particularly when invasive diagnostic techniques are utilized

●Proposed treatment or procedure.

●Alternative treatment options (surgical or medical) along with their risks and benefits.

●Risks and benefits of treatment.

●The risks of refusing treatment.

CMPA:

For consent to treatment to be considered valid, it must be an “informed” consent. The patient must have been given an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available. The information must be such as will allow the patient to reach an informed decision. In situations where the patient is not mentally capable, the discussion must take place with the substitute decision maker.

Question 20

2020 exam #1

List the DSM criteria for delirium (5)

Answer 20

Question 21

Review with group! 2020 exam #2

** You are caring for a man in hospice whose GOC are comfort. He doesn’t wish for anymore investigations. He is on an opioid for pain. He develops confusion. List five points related to how you would assess confusion.

Answer 21

1. Confusion assessment method

Question 22

2020 exam #3

A patient with end stage lung disease comes to hospital with vivid dreams and myoclonus. All other investigations are negative. Drugs include: hydromorphone 5mg sc q4 hours, olanzapine 2.5mg SL q 12 horus PRN. What is the first think you will do to treat this patient.

Answer 22

1. Opioid rotation

Answers from test: opioid reduction, IV fluids, opioid rotation

Question 23

2020 exam #4

What is the dose in mg/kg dose of oral morphine you will use in an opioid naive child for pain?

Answer 23

?Pain: 0.2mg/kg
?Dyspnea: 0.1mg/kg

Couldn’t find in Oxford for specific dosing in pediatrics. 7.18.

Question 24

2020 #5

A patient with cancer presents to the hospital with a calcium of 2.83 and albumin of 26. What is the corrected calcium for this patient? What are the first two treatments you will initiate for this patient?

Answer 24

Corrected calcium mg/dL= measured total ca + 0.02 (40- albumin)

2.83+ 0.02 (40-26)= 3.11

1. IV fluids
2. Bisphosphonate

calcitonin

Question 25

What constructs help to define the goals of palliative care?

Answer 25

1. Suffering
2. Illness burden
3. Quality of life (pg 39 oxford)

Question 26

A good death

What are some of the themes that have been identified that make up a ‘good’ death?

Answer 26

Preferences for dying process- dying during sleep, death scene (how, who, where and when), death preparation

Pain Free

Emotional well being- chance to discuss the meaning of death, emotional support

Family- Family acceptance of death

Dignity- respect as an individual

Life Completion- Saying good bye, acceptance of death

Religiosity/spirtuality- meet with clergy

Treatment preferences- belief that all available txt were used, control over txt MAID

QOL- maintaining hope, pleasure, gratitude

Relationship with healthcare professionals- Trust/support/comfort, discuss fears with physician

Other- recognition of culture, being with pets, physical touch

Question 27

A ‘good’ death

What are the four universally important aspects of care critical to promoting a good death?

Answer 27

1) Relief of distressing symptoms
2) Psychosocial, spiritual and social
3) Personal and cultural sensitivity
4) Adequacy of supports

Question 29

Truth Telling

What stepwise protocol can be used to help determine how much truth a pateint would like to know?

Answer 29

S- setting
P- perception
I- invitation
K- knowledge
E- empathy
S- Strategy