Questions I got wrong :( Flashcards
List 6 measurable markers of an effective interprofessional team
- Patient-centred care (ease of referral, EBM, outcomes)
- Interprofessional communication (how, how often)
- Participatory leaders/Collaborative leadersip
- Conflict resolution mechanisms (e.g. complaints, M&Ms, suggestions)
- Clearly defined roles/responsibilities
- Team function/teamwork (how is this measured?)
Can be thought of as
- structure
- process
- outcomes
I’m still not sure what the exact answer to this is.
8 nonpharma prevention/treatments for delirium
- Reorientation
- Visual/hearing aids
- Early/regular mobilisation
- Monitor bowel/bladder function
- Sleep hygiene/routines
- Monitor nutrition/hydration
- Deprescribe
- Familiar people/objects
2 rx + 4 non-rx treatments for neuropathic pain
- Anticonvulsants
- Antidepressants
- Massage
- Mindfulness based therapies
- Acupuncture
- CBT
- Neuroablation surgeries/interventions
Which CYP metabolises methadone?
Name 2 inhibitors
Name 2 inducers
CYP 3A4
- Grapefruit juice inhibits
- Erythromycin inhibits
- Haloperidol inhibits
- Carbamazepine induces
- Dexamethasone induces
- Phenytoin induces
When do fentanyl pharmacokinetics change?
- TD form + hyper or hypothermia
- TD form + severe cachexia (anything that lowers Vd)
6 symptoms to expect after d/c hemodialysis
- Confusion
- Nausea/vomiting
- Itch
- Myoclonus
- Fatigue
- Dyspnea
- Pain
- Anxiety
- Depression
What are the 3 core components of the burnout syndrome?
- Depersonalisation/loss of empathy
- Emotional exhaustion
- Loss of sense of personal accomplishment
You have a new consult and you’re not feeling up to it (i.e. burned out). List 3 things you would check with yourself before doing that consult.
- Am I emotionally exhausted?
- Am I capable of empathy?
- Have I lost my sense of personal accomplishment?
No idea if this is the right answer.
8 non-symptom topics to discuss with a family toward EOL
- DNR
- SDM
- Family can be present, talk, touch, etc.
- Cultural norms they would like respected
- Funeral home contact
- Crisis preparation (what might happen, what the plans are)
- Nutrition education
- Prognosis/what to expect
6 non-rx pain management techniques for infants
- Distraction with toys/bubbles, etc.
- Music
- Swaddling
- Cuddling parent
- Sugar
- Calm environment
4 aspects of decisionmaking capacity
Understanding of illness/situation
Appreciation of risks/benefits of options
Reasoning ability to make a decision
Communication ability to express decision
8 vulnerable populations
- Indigenous
- Immigrant
- Children/dependent adults
- Unhomed
- Minority sexuality
- Minority race
- Low SES
- Rural/remote community
- Cognitive or physical disabilities
- Mental health/addictions
4 strategies to have culturally sensitive GOC discussions
- Interpreters
- Ask patient/family how they want to receive information
- Solicit agenda/questions
- Establish decisionmakers based on pt/family presence
4 causes of respiratory congestion at EOL
- Terminal upper airway secretions
- Pulmonary edema/fluid overload
- Lymphangitis
- TE fistula
- Pulmonary hemorrhage
- Pneumonia
What behavioural changes may indicate a child is in pain? (6)
- Loss of interest in surroundings
- Inconsolability
- Appetite changes
- Sleeplessness
- Grimacing/vocalising
- Irritability
- Poor performance in school
- Resistance to being moved
6 risk factors for bleeding in the cancer setting.
- Thrombocytopenia, any cause
- Anticoagulant medications
- Large central lung tumour
- ENT malignancy
- High-dose radiation
- Severe liver disease
3 rx + 3 non-rx treatments for ALS sialorrhea
- TCAs
- Anticholinergics
- Botox
- Suction
- Salivary gland XRT
- Parasympathetic nn ablation
6 risk factors for depression, not disease related
- Female sex
- Younger age
- FHx of MDD
- Personal hx of MDD
- Poor social supports
- Poor physical symptom management
3 tx for nonmalignant pleural effusion at EOL
- Tunnelled pleural catheter (allows drainage as outpatient)
- Diuresis (e.g. if CHF)
- Symptom management (e.g. opioids, O2 for dyspnea)
List 4 categories of interventions for dysphagia
- Dietary/texture modifications
- Enteral feeding
- Structural interventions (stenting, dilation)
- Oral care
- Positioning when eating
- Parenteral feeding
6 reasons a patient with SUD might overuse opioids
- Pseudoaddiction
- Poor absorption/rapid metabolism
- Diversion
- Euphoria/side effects
- High opioid tolerance
- Misunderstanding of dosing (e.g. thinking q1h prn dose is to be taken regularly)
4 causes + 1 invx of acute dyspnea/hypoxemia
- PE
- Pneumonia
- Pneumothorax
- Pulmonary edema/AECHF
- SCVO
CT
4 steps of confusion assessment before invx
CAM
1. Acute change, fluctuating
2. Attention assessment
3. Cognitive assessment (esp. orientation, psychosis)
4. Altered LOC
5. Review potential organic causes (i.e. H&P, chart review, med review)
4 considerations when family want feeding in dementia
- Explore family fears/needs/understanding
- Limited benefits of enteral feeding
- Harms of enteral feeding (bleeding, pain, infection, medicalisation, aspiration risk)
- Explore feeding at risk
- Explore reasons they may not be eating
6 components of a new palliative care program
- Existing resources (i.e. who is currently caring for this population)
- Who will the population be?
- Who will staff the service (which allied teams)
- Funding
- Where will care be provided (inpatient, outpatient, community, LTC)
- Referral / triage criteria and processes
- EBM options
4 relative contraindications to THC
- Cardiac risk factors
- Severe hepatic or renal failure
- Preexissting mood disorder
- Preexisting SUD
4 indications for an intrathecal pump
- Pain refractory to systemic analgesia
- Patient intolerant of systemic analgesia
- Good response to trial epidural/spinal
- Intractable tenesmus
- Locoregional pain
6 symptoms of complicated grief
Symptoms >1 year:
1. Rumination
2. Persistent intense longing for decedent
3. Social function impaired
4. Work function impaired
5. Denial
6. Anger
7. Intrusive thoughts about decedent or death
8. Suicidal ideation
4 mx for decubitus ulcers
DIME
1. Downloading
2. Infection prevention/treatment
3. Moisture mangement (dressings, continence products)
4. Edge effects (debriding, surgery, hyperbaric O2)
DSM-V criteria for delirium
- Acute onset / Fluctuating course
- Inattention + altered awareness
- At least 1 other cognitive deficit (e.g. disorganisation, disorientation, language alterations)
- Not explained by a baseline cognitive issue
- Organic cause identified
4 psychosocial issues to consider in a child with Duchenne
- Body image issues
- Processing his shortened life
- Sexuality/puberty
- Maintaining normalcy (school, peer relations)
- Distress at functional changes
Son requests you don’t tell his mother about her cancer diagnosis. List 5 considerations as you approach this.
- Explore son’s fears/goals/needs
- Explain to him your legal responsibility
- Speak to her directly, but plan discussions with son to allow him to feel he has a say
- Professional interpreters if there is a language barrier
- Establish patient wishes and autonomy
6 specific questions in dignity-conserving care
- What are some of the most important moments in your life? When did you feel most alive?
- What were some of your biggest accomplishments?
- What roles are you most proud of filling? What do you think you achieved in those roles?
- Do you have any life advice for family or friends?
- Do you have any instructions going forward?
- Do you have anything left unsaid?
- What would you most want to be remembered for?
- What are your hopes and dreams for your lived ones?
4 ways to increase access to PC in unhomed
- Partner with existing healthcare outreach
- Partner with existing resource services (e.g. housing)
- Mobile- or shelter-based teams
- Educating staff about needs more common in this population, including a resource limited setting
5 systemic barriers to home discharges
- Lack of equipment
- Lack of formal caregivers
- Lack of medication access/ease of administration
- Need for adequate informal caregivers as ADLs decline
- Medical needs (subq sites, tubes, CSCIs, lifts) requiring skills
4 aspects of PC that improve with reflection
- Reduced burnout/unplanned time off
- Improved patient satisfaction
- Improved practitioner satisfaction
- Improved empathy
5 causes of hiccups in cancer
- Central structural causes
- Iatrogenic (esp. dex)
- Diaphragmatic/phrenic irritation
- Airway irritation
- Ascites
- Gastroparesis/gastric obstruction
- GERD
Why not to suddenly d/c Parkinson’s meds
Parkinsonian crisis/NMS mimic “DAWS”
- abrupt functional decline
- rigidity
- ANS dysfunction
- confusion
- anxiety/depression
- craving dopamine agonists
- death
4 non-pharm treatments for SBO nausea/vomiting
- Bowel rest
- Venting (NGT/PEG)
- Stenting if able
- Excellent oral care
- IVF (isn’t this pharmacological?)
5 dyspnea strategies in ALS (not treating the cause)
- Positioning (upright when able)
- Breathing techniques / exercises
- NIPPV if hypoxemic
- Opioids for dyspnea
- Calm environment
4 types of terminal diseases that lead to depression
- ENT cancers
- CHF
- Dementia
- Progressive neurodegenerative conditions
6 strategies to manage opioids in substance abuse setting
- Long-acting formulations preferrable
- Adjuvant therapy to spare doses
- Taper if able (e.g. after XRT)
- Do not ignore/undertreat pain just because of SUD
- Shorter prescriptions, single-prescriber, single pharmacy
- Engage support network in managing pain
- Monitor for interactions with recreational drugs
Codeine enzyme; codeine in kids?
CYP 2D6
No codeine in kids–metabolism unpredictable and hypermetabolisers can overdose, while immature CYP enzymes may mean limited benefit.
SICG Components
- Set up conversation
- Assess illness understanding
- Assess information preferences
- Share prognosis
- Explore goals, fears, strengths, trade-offs etc.
- Close conversation
- Document
6 complicated grief risk factors
- Age >60
- Female
- Poorer
- Marginalised population
- Any psychiatric history
- Loss of child
- Loss of spouse
- Young decedent
- Death by trauma
- Multiple losses
4 treatments for DM gastroparesis
- Glycemic control
- Dietary modifications
- D2 antagonists
- Erythromycin
4 complications of celiac axis entrapment
- Gastroparesis
- Gastric outlet obstruction
- Obstructive hepatic failure
- Mesenteric ischemia
- Bleeding/clotting in celiac vessels
- Abdominal pain
4 indications for methadone
- Neuropathic pain
- Chronic nonmalignant pain
- Pain in renal failure
- Poor oral absorption
- OUD
List the 5 phases of reflection on a difficult encounter, error, etc.
- Describe the facts
- Describe your feelings
- Describe where things went wrong
- Review what could have been done differently
- Review what will be done differently next time
3 things to ask yourself when you don’t feel like a consult
I still don’t have an answer.
4 reasons you need to adjust dosing in peds
- Wee organs
- Immature enzymes
- Reduced glycoproteins
- Altered surface-area-to-volume ratio
- Altered fat-to-lean ratio
SCC–how to decide on XRT alone vs surgery + XRT
- Multilevel vs. single-level disease
- Performance status
- Radioresistant/sensitive tumour
- Radiosaturation
- +/- Metastatic disease
- Unstable fracture
- Goals of care
3 solid tumours associated with hyperCa
- Lung ca
- Breast ca
- Prostate ca
- Renal ca
3 CNS causes of fatigue
- Structural disease
- Post-WBR
- Dementia
- Lack of sleep
3 paraneoplastic sydromes that cause fatigue
- Lambert-Eaton Syndrome
- Hypercalcemia
- SIADH
- Limbic encephalitis
4 red flags in dyspnea that indicate urgent assessment
- Hypoxemia
- Stridor
- Fatiguing
- Marked tachypnea
- Marked new tachycardia
- Altered LOC
4 treatments of urinary fistulae
- Symptom palliation
- Surgical diversion
- Surgical repair
- Obstructive stenting (e.g. in ureter)
4 mechanisms of opioid-induced vomiting
- CTZ
- Gastroparesis
- Constipation
- Vestibular activation
5 areas where pharmacokinetics are different in kids (which is increased?)
- Absorption
- Distribution
- Metabolism I
a. faster prepuberty - Metabolism II
- Elimination
Absorption of dermal medications increased 2* area/volume ratio
6 steps in planning a family meeting
- Patient (or SDM) permission to arrange a meeting
- Identify reasons/agenda per care team + patient
- Chart review
- Review of previously-stated wishes, ACP, etc.
- Review social context of patient (e.g. home setup)
- Identify who should be present (from care team and from patient team)
- Identify a quiet, private space for the meeting with adequate chairs + time that works
5 serious risks of IVR interventions
- Bleeding
- Perforation of hollow viscus
- Infection
- Iatrogenic / thrombotic embolus
- Nerve damage
4 drugs that interact with cannabis
- Additive sedation with sedatives
- Induces olanzapine clearance
- Induces theophylline clearance (only when smoked)
- Increases INR on warfarin
4 factors that increase the perception of pain
- Opioid neurotoxicity
- Fear of what the pain signifies
- Anxiety, depression, negative houghts
- Lack of control, or feeling thereof
- Hypervigilance around pain
6 functions of PC associations that lets them advocate for palliative pts
- Public awareness campaigns
- Professional education
- Advocacy for policy change/resources
- Advocacy for medication access
- Social supports for palliative patients/families
- Networking between professionals
2 nonopioid receptors methadone acts on
- NMDA antagonism (S-methadone)
- SNRI (S-methadone)
- ACh antagonism
Distinguish NMS from serotonin syndrome.
Both:
- hypertension
- tachypnea/cardia
- hyperthermia
- sweating
NMS:
- hyporeflexia
- severe rigidity–“lead pipe”
- no GI symptoms
- high WBCs
- low iron
SS:
- hyperrflexia + clonus
- pupils dilated
- GI symptoms
4 components of existential distress
- Fear of death
- Meaninglessness
- Regret about opportunities/unfinished business
- Isolation
- Loss of control
List 5 considerations/foci when assessing confusion in a patient on opioids who does not want investigations.
- Full medication review
- S/sx evidence of infection
- S/sx of neurotoxicity
- Is it delirium?
- Assess GOC for empiric treatment
- Chart review for pre-existing contributors (e.g. structural disease, known cognitive impairment, known organ failure)
Pediatric mg/kg/dose morphine for:
- pain
- dyspnea
Pain: 0.3mg/kg/dose, q4h
Dyspnea: 0.15mg/kg/dose, q4h
What is the calcium correction formula?
[40 - (patient albumin)]*0.02 + measured Ca
e.g. 2.83, albumin 26
= [40-26]*0.02 + 2.83
= 0.28 + 2.83
= 3.11
This formula is outdated.
3 treatments for bladder-ca-induced hematuria.
No XRT.
- Systemic or local TXA
- CBI
- Cystoscopic cautery
- Local styptic (e.g. silver nitrate, alum)
In a 17yo with Ewing sarcoma met. ++ to lung, list 5 non-pain emergencies at EOL
- 1 drug + route to treat any
- Delirium
- Hemoptysis/bleeding
- Dyspnea crisis
- SVCO
- Symptomatic hypercalcemia
- Spinal cord compression
Midazolam subq
Match the drug with the symptom:
Symptoms:
Restless leg syndrome
Sleep disturbance
Alterations in taste and smell
Hiccups
Neuropathy
Medications:
Baclofen
Cannabis
Methadone
Pramipexole
Zinc
- Restless leg syndrome + pramipexole
- Sleep disturbance + cannabis
- Dysgeusia/anosmia + zinc
- Hiccups + baclofen
- Neuropathic pain + methadone
6 drug classes for tenesmus
- Topical anesthetics
- CCBs (e.g. nifedipine)
- Anticholinergics
- Opioids
- Stool softeners/osmotic laxatives
- Steroids
4 skin changes in chronic/late lymphedema
- Thickening/pitting
- Exaggerrated skin folds
- Chronic inflammation/erythema
- Papillomata
- Hyperkeratosis
3 differences between moisture dermatitis and pressure ulcer
- Location (skin folds/gluteal cleft vs. bony prominences)
- Necrosis (not present in dermatitis)
- Shape (“kissing” spots, diffuse spots in moisture vs. round/well defined in pressure)
- Edges (less distinct in MD)
- Depth (rarely any depth to MD)
- Colour (more variegated, blanchable in MD)
4 topical treatments for bleeding in malignant wounds
- TXA
- Styptics (silver nitrate, alum)
- Pressure dressings
- Calcium alginate dressings
- Cautery
- Epinephrine
4 treatment for malodorous wounds
- Topical antibiotics
- Debridement of necrotic tissue
- Environmental techniques (essential oils, kitty litter, ventilation)
- Charcoal dressings
4 indications for paracentesis in PC
- Abdominal discomfort
- Squashed stomach syndrome (NV, early satiety, reflux)
- Dyspnea 2* elevated diaphragm
- Diagnosis (e.g. suspicion of infection)
- Unresponsive to diuresis
4 side effects of cannabis
- Drowsiness
- Dry mouth
- Anxiety
- Confusion
4 validated pain scales in a nonverbal child.
FLACC
- face, legs, activity, cry, consolability
CHEOPS
- Children’s Hospital of Eastern Ontario Scale
FACES
Visual analog scale
5 reasons non-medical interpreters are a bad idea in palliative care
- They have the role of delivering bad news
- Limited medical knowledge/vocabulary
- Cannot confirm information being conveyed is correct
- They may not want to know everything they are required to translate
- Emotional stress added to having an ill parent
- They are caught between the doctor and family
Describe the 4 stages of pressure wounds
- At risk, blanchable redness.
- Nonblanchable redness, no breakdown
- Epidermal breakdown, dermis visible
- Skin breakdown, subcut fat visible +/- slough
- Full-thickness breakdown to connective tissue +/- slough
X. Excessive slough or eschar make staging impossible
4 chemical ligands involved in pain transduction
- Histamine
- Bradykinin
- Serotonin
- Heat/cold
- Prostaglandins
- Substance P
- Nerve Growth Factor
4 pathophysiological characterstics of neuropathic pain
- Related to direct nerve damage
- Experienced in distribution of nn.
- Associated with peripheral and central sensitisation (e.g. allodynia)
- Associated with nonpainful neuropathy such as numbness, tingling, dysesthesias
- Typical pain features (e.g. burning, electric)
4 steps in neurophysiology of pain
- Transduction (peripheral nn)
- Transmission (peripheral nn, spinal cord)
- Modulation (spinal cord, brainstem, thalamus)
- Perception (cortex)
4 factors that affect opioid pharmacokinetics
- Hepatic function
- Renal function
- Fat:lean ratio (esp. fentanyls, methadone)
- Age
- Perfusion/hypotension
What is lidocaine traditionally used for? (2)
- Local anesthesia
- Antiarrhythmic
What is the half-life of lidocaine?
1.5-2h
Name 6 blood tests in a breast cancer patient with nausea
- Na+
- Ca++
- Cr/BUN
- Bilirubin + ammonia
- CBC (esp. WBCs)
- Cultures
- Glucose
- TSH
Name 4 contraindications to ketamine
- Pregnant/breastfeeding
- Psychotic disorder
- Elevated ICP
- CHF or recent ACS
- Hypertension
Onset of po ketamine
30 min.
4 medication classes that can cause constipation
- Opioids
- Anticholinergics
- TCAs
- 5-HT3 antagonists
- Iron
- CCBs
- L-dopa
- Antihistamines
- Antidiarrheals
4 classes of oral laxative
- Stimulant
- Stool softener (e.g. docusate)
- Osmotic
- Lubricant
- Oral opioid antagonists (e.g. naloxegol)
- Bulk-forming
4 classes of medication to manage complete SBO
- Somatostatin analogues
- Non-prokinetic antinauseants (e.g. ondansetron, Haldol)
- Steroids
- Antispasmotics
- Other antisecretory agents (PPI, H2RA)
4 complications of PEG insertion
- Bleeding
- Infection
- Gastric perforation
- Pain
4 poor surgical prognostic factors in SBO
- Poor functional status
- Ascites
- Peritoneal/omental disease
- Extensive extraabdominal disease
- Low albumin/cachexia
- Multifocal obstruction