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Cancer managment > Supportive treatment > Flashcards

Supportive treatment Flashcards

1
Q 
Learning
Outcomes
At the end of the sessions, you will
be able to

Describe common symptoms in
advanced cancer

Understand the causes of these
symptoms

Know how to assess and recommend
management of these symptoms
2
A

1

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2
Q 
Common Symptoms in cancer include: 
C\_\_
D\_\_
D\_\_
D\_\_
I\_\_
P\_\_
N\_\_
X\_\_
A 
Constipation
Diarrhea
Dyspnea
Depression
Delirium
Intestinal Obstruction
Pruritis
Nausea and Vomiting
Xerostomia
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3
Q

Constipation can have disease related causes such as i_______
t____ i__ leading to obstruction
Decreased f____ i___ and
L__ r____diet

A
  1. Immobility
  2. Tumor invasion
  3. food intake
  4. Low residue (low fibre)
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4
Q

Biochemical fluctuations such as __ and __ can lead to constipation. Fluid depletion via __ and __ may be a factor as well.

A
  1. Hypo-Kalaemia
  2. Hyper-Calcaemia
  3. Poor fluid intake
  4. Increased fluid loss
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5
Q

Medication such as __ (90%), __ and __ commonly cause constipation. The inability to __ (weakness) may be a reason as well.

anti cancer drug, ______, can also cause constipation

A
  1. opioids
  2. Iron and Calcium
  3. raise intra-abdominal pressure
  4. vinka alkaloids
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6
Q

Constipation cause the following complications :

  • *______ or constant ______ discomfort
  • __ diarrhea
  • *______ obstruction
  • __ incontinence
  • ____ ____/_____ (due to compressions on bladder)
  • *_____ or ______ if severe
A
  • *Colic or constant abdominal discomfort
  • Overflow diarrhoea
    • Intestinal obstruction
  • Faecal incontinence
  • Urinary retention/ frequency
  • *Confusion or restlessness if severe
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7
Q

Before prescribing laxatives for a constipated patient, we must __ and consider __.

A
  1. rule out bowel obstruction

2. underlying causes i.e. Hyper-Calcaemia or drugs

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8
Q

Patients on __ (i.e. Fybogel, Metamucil) should be counselled __. The usual dosing is __.

A
  1. bulk forming agents
  2. to drink extra fluids
  3. 1 sachet BD
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9
Q

Bulk forming agents can be Unpalatable, cause __ and __. Patients may feel bloated and abdominal discomfort. These agents are not commonly used in __ setting and is contraindicated in __.

A
  1. colic
  2. flatulence
  3. palliative care
  4. bowel obstruction
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10
Q

(KIV) Stimulant laxatives are commonly used at high doses in oncology. The usual dose for Senna is __ while the usual dose for bisacodyl is __, Max: __.

A
  1. 2-4 tabs daily

2. 5-10mg ON, Max: 20mg OD

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11
Q

Stimulant laxatives (i.e. Senna, Bisacodyl) are not suitable for patients with __. They may cause __, colic and __ due to the continued passing of fluid.

A
  1. complete bowel obstruction
  2. dehydration
  3. electrolyte imbalance
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12
Q

Patients on osmotic laxatives (i.e. Forlax, Phosphate enemas, PEG, Lactulose) must be counselled to __.

KIV: Lactulose is a commonly dispensed item that has a very sweet flavor and is usually dosed at __.

A
  1. drink extra fluids

2. 10-15ml BD

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13
Q

Osmotic laxatives have similar adverse effects as Bulk forming agents and may cause __, flatulence, __ and __ in debilitated patients

A
  1. Colic
  2. Dehydration
  3. electrolyte imbalance
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14
Q

__ is an osmotic laxative that also increases the stool volume and triggers colon motility via neuromuscular activity.

A

Macrogol (Forlax)

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15
Q

If the patient’s rectum is impacted with hard stools, we should l__ using ______ or soften with ______ enema, followed by ______ enema once softened. Once disimpacted, we should commence/increase ______ or ______.

A
  1. lubricate using glycerin suppositories
  2. olive oil
  3. phosphate
  4. oral stimulant or softener
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16
Q

If the patient’s rectum is impacted with soft stools, we should use a _______ i.e. bisacodyl suppositories or phosphate enema. Once disimpacted, we should commence/increase _______.

A
  1. a rectal stimulant

2. oral stimulants

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17
Q

If the patient’s rectum is empty but not dilated, we should exclude i_____ o_____. Ensure that the patient is on r_____ l______ and consider if additional l_____ are required. If exclusions are ruled out, __ are sufficient.

A
  1. intestinal obstruction
  2. regular laxatives
  3. additional laxatives i.e. osmotic laxatives (oral fleet) 15mls x 3 days
  4. regular laxatives
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18
Q

If the patient’s rectum is empty but dilated/’ballooned’, it often suggests that the constipation is higher up. We can give ______ over several days until it resolves. If colic is present, we should reduce any _______ and add ________ i.e. Forlax/lactulose. If colic is absent, add or increase _________ with softener being optional.

A
  1. high fleet (phosphate) enema
  2. stimulant laxatives
  3. softener/osmotic agent
  4. stimulant laxative
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19
Q

To prevent opioid induced constipation, we must ensure __. By optimizing the patient’s __, we can prevent constipation as well.

A
  1. compliance in bowel regime (regular laxatives)

2. existing laxative regimen

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20
Q

To prevent constipation, we should encourage __. Educating the patient and their family to __ is a good idea as well.

A
  1. fluid intake, particularly fruit juice and fruit

2. monitor bowel habits

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21
Q

Intestinal obstructions are often caused by cancers and classified by:

  1. __ vs __ (location)
  2. __ vs __ (i.e. motility issue)
  3. Complete vs incomplete
A
  1. Upper vs Lower GI tract

2. Mechanical vs Functional

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22
Q

Patient reported symptoms for intestinal obstruction is useful for differentiating __. __ is a common feature.

A
  1. location of obstruction

2. Abdominal pain (can be colickly/constant)

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23
Q

Upper GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.

A
  1. bilious, large volume
  2. anorexia
  3. constipation
  4. absent
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24
Q

Lower GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.

A
  1. faeculent, small volume
  2. constipation
  3. anorexia
  4. present
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25
Q

In intestinal obstruction, we want to __ and reverse obstruction if possible. We may do this via __, Nil-by-mouth or __.

A
  1. provide symptom relief
  2. Gut rest
  3. IV hydration
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26
Q

In complete intestinal obstruction, we may provide pain relief using __ and add on __ for colic. Trial of __ can be used for nausea/vomiting, __ can be used there is a high volume of vomiting.

A
  1. Opioids (i.e. morphine as it is most cost-effective)
  2. anti-cholinergic agents i.e. hyoscine butylbromide (buscopan)
  3. haloperidol
  4. NGT or octreotide
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27
Q

For in-complete intestinal obstruction, we may provide pain relief using __ (less constipating) and add on buscopan only if __. __ can be used for nausea/vomiting. We should continue to __ using __.

A
  1. fetanyl
  2. pain is not relieved
  3. Metoclopramide
  4. clear bowels
  5. high fleet/lactulose
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28
Q

If the patient’s intestinal obstruction (I/O) is not operable (i.e. not for stenting), we may consider __ as it can reduce peritumoral edema and improve intestinal transit.

A

trial of steroids (8-16mg)

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29
Q

Patients with __ are contraindicated for stenting. Patients with __ are also poor candidates due to risk of stent migration. Otherwise, stenting may be a strategy to relieve Intestinal obstruction.

A
  1. multiple levels of obstruction

2. rectal tumors

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30
Q

Prokinetics may be contraindicated in complete intestinal obstruction due to __.

A

risk of perforation

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31
Q

We should advise patients with Intestinal obstruction/Gastric outlet obstruction to:

  1. Avoid
    - ____, ____ or ____ fruits
    - ________
    - raw fruits/vegetables and remove skins before cooking
    - __ meats
  2. Limit __ (can increase stool bulk)
A
  1. seeds, nuts or raw/dried
  2. whole grain
  3. tough fibrous
  4. fat intake
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32
Q

Diarrhea can be a distressing and exhausting symptom for both the patient and their carers . It is important to remember that it can be __ and impacts __, mood and __.

A
  1. embarrassing
  2. dignity
  3. relationships
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33
Q

Diarrhea may be caused by diet when __, __ and __ is consumed.

A
  1. fruit
  2. hot spices
  3. alcohol
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34
Q

__ and __ (particular when involving abdomen or pelvis) can cause diarrhea.

A
  1. Chemotherapy

2. radiotherapy

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35
Q

Certain disease states can cause diarrhoea: __ insufficiency, __ (i.e. Crohn’s disease, ulcerative colitis), gastrointestinal infection and __ (overflow diarrhoea).

A
  1. Pancreatic
  2. inflammatory bowel disease
  3. faecal impaction
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36
Q

Diarrhoea can occur when the patient is on:

__ (overdose), antacids, antibiotics, __ and __ (sugar free) elixirs.

A
  1. Laxatives
  2. NSAIDs
  3. disaccharide containing
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37
Q

Before giving pharmacological treatment for diarrhea, we must rule out __, __ and __ related causes. We should consider the underlying cause as well.

A
  1. faecal impaction
  2. intestinal obstruction
  3. infection
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38
Q

(KIV) Codeine phosphate is dosed at __mg Q__hrs PRN for diarrhoea treatment. (lower than analgesic dose)

A
  1. 30-60

2. 4-6

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39
Q

For patients on codeine phosphate, they should avoid concurrent use of n__. Use with caution in patients with __ disease (elimination affected).

A
  1. narcotics

2. Hepatic/renal

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40
Q

Codeine phosphate may cause __ and __, which is why it should be used with caution in patients with __ (respiratory conditions). Understandably, concurrent use of __ and __ should be avoided as well.

A
  1. sedation
  2. respiratory depression
  3. COPD, Asthma
  4. sedatives
  5. alcohol
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41
Q

Codeine phosphate may cause c__, n__,

sedation, h__, d__ and respiratory depression in patients as side effects.

A
  1. constipation
  2. nausea
  3. hypotension
  4. dry mouth
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42
Q

(kiv) Diphenoxylate/atropine (Lomotil) is dosed at __ tabs __ times daily, Max: __ in oncology diarrhea management.

A
  1. 1-2
  2. 3-4
  3. 8/day
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43
Q

Diphenoxylate/atropine (Lomotil) should not be used for patients __, __ disease or __ diarrhea.

A
  1. <12 years old
  2. liver
  3. infectious
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44
Q

Diphenoxylate/atropine (Lomotil) may cause anti-cholinergic side effects, particularly in the elderly. They include: __ and __. Other side effects include: s__, d__ and r__.

A
  1. dry mouth
  2. urinary retention
  3. Sedation
  4. dizziness
  5. rash
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45
Q

(KIV) Loperamide HCl (Imodium) is dosed at __mg (2-4 capsules) daily. Max __/day in oncology diarrhea management.

A
  1. 4-16

2. 8 capsules

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46
Q

Loperamide HCl (Imodium) should not be used for patients __, or __ diarrhea.

A
  1. <12 years old

2. Infectious

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47
Q

Loperamide HCl (Imodium) can cause similar side effects as diphenoxylate: __, __, skin __, headache

A
  1. Constipation
  2. dry mouth
  3. rash
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48
Q

(KIV) Octreotide (Sandostatin) is dosed at SC __ mcg, __ times daily in oncology diarrhea management. It works by reducing secretions into the GI compartment and should used __.

note: used when there is a secretory effect from the tumor

A
  1. 50-200
  2. 2-3
  3. only as a last resort
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49
Q

Octreotide (Sandostatin) should not be used if patients have __.

A

Infectious diarrhea

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50
Q

Being an injectable, Octreotide (Sandostatin) may cause __. Other side effects include: Nausea, __, __ (rare) and __ imbalance.

A
  1. Pain at injection site
  2. abdominal cramps
  3. cholelithiasis
  4. glucose
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51
Q

We should advise diarrhea patients to avoid:

  1. __ (such as whole grain breads, cereals, raw vegetables, beans, nuts, seeds and dried fruits)
  2. __ (coffee, tea, milk and milk products, alcohol and sweets)
  3. __ (fried, greasy, or highly spiced food)
A
  1. high fiber food
  2. Gut stimulants
  3. Irritating foods
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52
Q

Good dietary recommendations for diarrhea patients would include eating __ meals, __ food, maintaining __ (avoid dehydration). They should gradually reintroduce proteins and then fats as diarrhea resolves.

A
  1. small frequent
  2. low-fibre
  3. good fluid intake of 2L/day
53
Q

__ diarrhea with __ which might indicate an infective cause.

A
  1. Persistent watery

2. systemic upset

54
Q

If the patient is suffering from Steatorrhea/fat malabsorption, __ enzymes (+- __to reduce gastric destruction of enzymes) may be useful.

A
  1. pancreatic

2. PPIs

55
Q

For patients who have undergone a surgical resection (stomach, ileal, colon) or suffer from bile salt diarrhea, __ would be useful.

A

Cholestyramine

56
Q

If the patient is suffering from diarrhea and carcinoid syndrome with typical anti-diarrheals are ineffective, we may give a trial of __.

A

Octreotide

57
Q 
Dyspnea can have many causes:
Physical (\_\_, effusions, \_\_)
Social (family stress, finances)
\_\_ (anxiety, disappointment)
\_\_ (suffering and meaning)

other causes: ______, _____

A
  1. anaemia
  2. drug toxicity
  3. Psychological
  4. Spiritual
  5. PE/COPD exacerbation
  6. abdominal: ascites, liver failure causing fluid overload
58
Q

Important to assess ___ of ___, (alleviating/precipitating factors), associated ___, severity and impact on ____ability/quality of life . Screen for associated __. Look for __ causes.

A
  1. pattern of SOB
  2. associated symptoms
  3. functional ability
  4. anxiety
  5. reversible
59
Q

In Dysnpea, __ are just as effective, if not more effective than pharmacologicals

A

non-pharmacologicals

60
Q

Oxygen therapy is useful only for __. (IMPT)

A

hypoxic patients (SpO2 < 90%)

61
Q

Opioids are useful for __, especially in terminal cancer/ non-cancer patients. We should start low and titrate carefully to avoid __.

A
  1. SOB at rest/minimal exertion

2. respiratory depression

62
Q

Usual starting dose of morphine for opioid naïve patients is __. Stepwise increase of __ in response to tolerance. If the patient is unable to tolerate orallyor shows terminal breathlessness, we can start __.

A
  1. 2.5-5mg q4h PRN
  2. 30-50%
  3. SC/IV morphine 0.2-0.4mg/ hr
63
Q

Fentanyl can also be used if patients have __________. Patches start at __ but for severe or terminal breathlessness, start __.

A
  1. renal impairment
  2. 6mcg/ hr
  3. SC or IV 5-10mcg/ hr
64
Q

Steroids are useful in __. Dexamethasone may be dosed at __ in lymphangitis and dosed __ in Superior vena cava obstruction (SVCO).

A
  1. reducing peri-tumoural edema
  2. 8-16mg/day
  3. 16mg/day
65
Q

Anxiolytics are useful for anxious patients not responding to __.

  • __ is useful if patient is unable to take orally/terminal.
  • __, Breakthrough dose: PRN 2.5mg up to 2-4 hourly
A
  1. opioid monotherapy
  2. Sublingual Lorazepam 0.5mg prn/bd
  3. IV/SC midazolam 5-10mg/24hr
66
Q

If patient has longer prognosis and has panic attacks, we should consider __
- __ (SSRI) 10mg daily and then increase to
__ after one week

A
  1. antidepressants with anxiolytic effect
  2. escitalopram
  3. 20mg/day
67
Q

__ (5ml prn) may loosen secretions but is useful only if __.

A
  1. Nebulized sodium chloride 0.9%

2. patient can expectorate

68
Q

_____ eg. buscopan __ or continuous infusion __ can decrease and loosen secretions.

A

Anticholinergics

  1. buscopan SC 20mg prn/q6h
  2. buscopan continuous infusion 60mg-240mg/24hr
69
Q

Suctioning of secretions can be __ and ineffective in __. It might not be able to lower secretions.

A
  1. distressing

2. providing symptom relief

70
Q

Non-hypoxic patients may __ to obtain relief from SOB while patients on opioids should consider __ prior to major movements/tasks. Patients with longer prognosis can consider __.

A
  1. open windows or use electric fans
  2. breakthrough opioids
  3. joining support groups or rehabilitation programs
71
Q

Patient advice of the following can help manage SOB:

  1. __. Plan and pace activities. Use aids (i.e. walking aids) as necessary
  2. Learn breathing techniques e.g. pursed lip breathing and __ techniques
  3. Learn how to __ e.g. stacking pillows underneath their head/shoulders while lying down
A
  1. Break tasks into smaller bits
  2. anxiety management
  3. find comfortable positions
72
Q

Nausea and vomiting is commonly caused by radiotherapy (esp radiation around __), chemotherapy and __(90% but patients develop tolerance in 1-2 wks)

A
  1. thoracic/abdominal cavity

2. opioids

73
Q

Chemical/toxic causes( e.g. __, uraemia) can lead to Nausea and vomiting, as well as __, gastric stasis and Raised intracranial pressure (ICP) from __.

A
  1. hypercalcemia
  2. Tumor/intestinal obstruction
  3. brain metastases
74
Q

There is a __ to nausea vomiting, with causes possibly being Multifactorial/unknown/refractory. Higher centres (pain/fear/anxiety) may be implicated.

A

psychological component

75
Q

When doing history taking, we should take __ for nausea and vomiting respectively. Check for other __ and exclude __ (managed differently).

A
  1. separate histories
  2. concurrent symptoms
  3. regurgitation
76
Q

When taking history for nausea and vomiting, note the following:

  • t__, v___, p___
  • exacerbating and relieving factors, including __
  • __ (to exclude constipation/ intestinal obstruction)
A
  1. triggers, volume, pattern
  2. medication history
  3. bowel habit
77
Q

(KIV dose) Domperidone is a _______ antagonist and a _________.
Starting dose: __
Max dose: __ (consider alternative in __)

A

Domperidone is a dopamine antagonist and a prokinetic.

  1. PO 10mg tds
  2. PO 20mg qds
  3. cardiac disease
78
Q

(KIV dose)

Metoclopramide is a ____ antagonist and ______ that acts _______.

Starting doses: PO __ or SC __
Max doses: PO __ or SC __ (higher doses have a risk of __)

A

Metoclopramide is a dopamine antagonist and prokinetic that acts centrally.

  1. PO 10mg tds or SC/IV 30-40mg/24h
  2. PO 20mg qds or up to SC/IV 240mg/24h
  3. EPS
79
Q

Haloperidol is an typical ______ (alpha-1 and D2 antagonist) that acts on the ____.

Starting doses: __
Max doses: __

A

Haloperidol is an typical antipsychotic (alpha-1 and D2 antagonist) that acts on the CTZ.

  1. PO 0.5-1.5 mg ON or SC/IV 0.5-1.5mg/24h
  2. PO 5mg BD or up to SC/IV 10mg/24h
80
Q

Ondansetron is a ____ antagonist that acts in CTZ and peripheral _____ receptors (gut), _____ the gut.

Starting doses: __
Max doses: __
Note that ondansetron may cause __.

A

Ondansetron is a 5HT3 antagonist that acts in CTZ and peripheral serotonin receptors (gut), slowing down the gut.

  1. PO 4mg BD or SC/IV 8mg/24h
  2. PO 8mg tds or SC/IV 16mg/24h
  3. Constipation
81
Q

Buclizine is an ____ that acts on the vestibular system.

Starting doses: __
Max doses: __
Buclizine is good for __.

A

Buclizine is an anti-histamine that acts on the vestibular system.

  1. PO 50mg tds
  2. PO 50mg tds
  3. nausea in absence of vomiting
82
Q

(KIV doses)

Mirtazapine is an noradrenergic/serotonin antagonist.

Starting doses: __
Max doses: __
Mirtazapine is rarely used due to __ but used in patients with __ depression.

A
  1. PO 7.5 - 15mg tds
  2. PO 45mg tds
  3. side effects
  4. concurrent
83
Q

KIV the doses

Olanzapine is a typical antipsychotic (M1, H1, a1, Dopamine, 5-HT antagonist)

Starting doses: __
Max doses: __
Olanzapine is used for __.

A
  1. PO 2.5mg ON
  2. PO 10mg ON
  3. refractory nausea and vomiting
84
Q

Nausea and Vomiting advice
Eating __ meals
Rinse mouth before eating with 1 teaspoon of baking soda/sodium bicarbonate powder to __
Avoid __ foods
Find a __ eating place
Candies like lemon drops, peppermints can relieve nausea
Encourage __ to prevent dehydration

A
  1. small frequent
  2. remove bad tastes
  3. irritating, strong flavoring, fragrant
  4. peaceful/relaxed
  5. fluid intake
85
Q

For a patient with nausea, vomiting from clinical toxicity (drug induced or metabolic/chemical upset), __ i.e. metoclopramide and QThaloperidol are indicated.

A

dopamine antagonists

86
Q

For a patient with nausea, vomiting from motility disorders (drug-induced or paraneoplastic gastroparesis), Prokinetics i.e. __ and __ are indicated.

A

metoclopramide and QTdomperidone

87
Q

For a patient with nausea, vomiting from Intracranial disorders i.e. vestibular dysfunction, motion disorders, __ or __ (cyclizine or hyoscine hydrobromide), corticosteroid, or __ are indicated.

A
  1. Anticholinergic
  2. antihistamine
  3. QTprochlorperazine
88
Q

If nausea and vomiting with oral/pharangeal/oesophageal irritation, use __ (cyclizine or hyoscine hydrobromide)

A

Anticholinergic or antihistamine

89
Q

If Multifactorial/unknown/refractory nausea and vomiting, use appropriate __ for known causes; or __.

A
  1. anti-emetics

2. broad spectrum anti-emetic

90
Q

If nausea and vomiting in Higher centres (pain/fear/anxiety), optimize __ and treat __.

A
  1. pain control

2. anxiety

91
Q

If Chemotherapy and/or radiotherapy-induced nausea and vomiting, __.

A

Refer to local guidelines

92
Q

Colicky abdominal pain after taking a prokinetic drug may suggest __.

A

bowel obstruction

93
Q

Despite logical and appropriate treatment, the patient may continue to vomit especially if there is __.

A

a duodenal/gastric outflow/bowel obstruction

94
Q

For persistent vomiting, management of __ and __ is essential.

A
  1. hydration status

2. nutritional status

95
Q

Symptoms of depression may manifest as __ change, insomnia, loss of energy, fatigue, __ slowing, loss of libido. __ should be assessed for depression.

A
  1. Weight/appetite
  2. psychomotor
  3. All patients
96
Q

__ are not preferred as the 1st line treatment in depression. Instead, referral to __ (palliative care specialist/ psychiatrist) and __ (Cognitive Behavioural Therapy (CBT), relaxation therapies, creative therapies, guided imagery etc.) may be more useful.

A
  1. Pharmacologicals
  2. support mechanisms
  3. therapies with psychological benefits
97
Q

When evaluating depression in patients, we must first rule out __ and __ induced causes. It is critical to educate patients that __ may occur immediately while __ can take 2-4wks or longer. __ is critical to ensuring treatment sucess.

A
  1. medical and drug
  2. adverse effects
  3. resolution of symptoms
  4. Adherence
98
Q

__ can be used as a screening tool for depression while the __ is an assessment tool suited for palliative care patients.

A
  1. PHQ-9

2. brief Edinburgh Depression Scale

99
Q

SSRIs are the 1st line treatment of depression. It can cause side effects of __. Due to risk of GI bleeds, avoid use in patients with __, __ or concurrent __.

A
  1. nausea, insomnia and sexual dysfunction
  2. history of GI bleed
  3. > 80 years old
  4. NSAIDs
100
Q

Mirtazapine is useful for patients who cant swallow as it has a __ ROA. It has __ and appetite stimulant effects particularly at lower doses. Mirtazapine is well tolerated in __ and patients with __.

A
  1. oro-dispensable tablet
  2. sedative
  3. elderly
  4. heart failure
101
Q

Xerostomia (Dryness of the mouth and altered salivation) affects eating, __, speaking and __. Patients may have to __ and __ frequently.

A
  1. sleeping
  2. physical exercise
  3. manually remove saliva
  4. expectorate
102
Q

Xerostomia may be caused by __ therapy (head/neck area), surgical removal of __, some chemotherapy agents and __.

A
  1. radiation
  2. salivary glands
  3. oral infection
103
Q

Useful daily management of xerostomia can include:

  • __ before and after meals and at bedtimes.
  • Lubricate the __.
  • Use __, or a teaspoon of olive oil, or a small pat of butter.
  • Apply __ to prevent drying and chapping of lips.
A
  1. Mouth care
  2. oral cavity
  3. saliva substitutes
  4. lip moisturiser
104
Q

Food choice advice for a patient with xerostomia:

  • Frequent __ and sips of water/juice.
  • __ can help to dissolve the thick saliva.
  • Increase intake of __ during meals.
  • Choose __ foods and use gravies and sauces on foods.
  • Suck on __ or chew on __.
A
  1. oral rinses
  2. Papayas or papaya juice
  3. fluids
  4. soft, moist
  5. hard sugarless candies
  6. sugarless gum
105
Q

Patients with xerostomia should avoid:

  • Avoid __ foods such as peanut butter or bread.
  • Avoid __ and __ drinks.
A
  1. dry, sticky
  2. alcoholic
  3. carbonated
106
Q

Pharmacological treatment for xerostomia can stimulate saliva production using __ dosed at 5-10ml tds. It is useful only if the patient has __.

A
  1. Pilocarpine

2. working salivary glands

107
Q

Delirium may come in either of 3 types:

  1. __: increased arousal and agitation
  2. __: quiet, withdrawn and inactive. More common but often missed or misdiagnosed as depression
  3. __ pattern
A
  1. hyperactive
  2. hypoactive
  3. mixed
108
Q

Drugs such as o__ (common, esp in elderly), a__, c__ (florid delirium), b__, a__, s__ are the key cause of delirium. Drug __ (including alcohol, sedatives, antidepressants, nicotine) may cause delirium as well.

A
  1. opioids
  2. anti-cholinergics
  3. corticosteroids
  4. benzodiazepines
  5. antidepressants
  6. sedatives
  7. withdrawal
109
Q

__, __ and dementia are risk factors for developing delirium, and __ and dementia should be excluded when evaluating delirium.

A
  1. Visual impairment
  2. deafness
  3. depression
110
Q

Delirium may occur secondary to Dehydration, __, urinary retention, __, Liver or renal impairment, electrolyte disturbance (sodium, glucose), hypercalcaemia, __, hypoxia, cerebral tumour or cerebrovascular disease

A
  1. constipation
  2. uncontrolled pain
  3. infection
111
Q

Delirium diagnosis mainly depends on __ and accurate history __ is important. Screening tools such as __ (MMSE) or __ (CAM) may be useful.

A
  1. careful clinical assessment
  2. from someone who knows the patient
  3. mental state examination
  4. confusion assessment method
112
Q

Check for __ in a delirious patient (drowsiness, agitation, myoclonus, hypersensitivity to touch) and __ if necessary. Consider __ if delirium persists.

A
  1. opioid toxicity
  2. reduce opioid dose by 1/3rd
  3. switching to another opioid
113
Q

The 1st line treatment for delirium is __ 500mcg-3g PO/SC OD (start low dose), repeat after 2h if necessary. Maintenance treatment may be required if __.

A
  1. Haloperidol

2. cause for delirium cannot be reversed

114
Q

2nd line delirium treatment __ may help with anxiety but __ and should be used with caution.

  • Lorazepam 500mcg - 1mg PO/SL
  • Midazolam SC 2mg to 5mg, 1 to 2 hourly or diazepam PO or rectally 5mg, 8 to 12 hourly.
A
  1. Benzodiazepines

2. do not improve cognition

115
Q

For a delirious patient, __ can help reassure them. We should pay attention to __ and encourage the patient to __ if possible.

A
  1. the presence of a close friend or relative
  2. the environment
  3. keep taking oral fluids
116
Q

Pruritis may be localized or systemic. __ pruritis is often worse at night and can be due to a large variety of causes. Patients with itchy usually have __.

A
  1. Systemic

2. dry skin

117
Q

Emollients improve dry skin which then improve itch. They may be used liberally and frequently as a __, or added to bath water as a __.

A
  1. moisturizer

2. soap substitute

118
Q

For inflamed but non-infected pruritic areas, __ may be applied sparingly OD for 2-3 days. Review after __.

A
  1. topical corticosteroids (mild to moderate potency)

2. 7 days

119
Q

The benefit of lidocaine patches in pruritis should be reviewed after __. 
__ 10% cream (i.e. Eurax) or __ 0.025% cream can be used for localised itch.

A
  1. 3 days
  2. Crotamiton
  3. capsaicin
120
Q

If pruritis is caused by cholestasis, all drugs are __. We have 3 choices based on individual circumstance and local guidelines:

  1. R__ 300mg to 600mg once daily
  2. S__ 50mg to 100mg once daily
  3. C__ 4g up to four times daily
A
  1. equally efficacious
  2. Rifampicin
  3. Sertraline
  4. Cholestyramine
121
Q

If pruritis is caused by uraemia,
1st choice: __ 100mg to 300mg daily (caution: accumulation in renal impairment may require Dose and/or frequency adjustment)
2nd choice: __ 50mg daily
3rd choice: __ 15mg to 45mg daily (caution: accumulation in renal impairment and doses as low as 7.5mg may be suitable)

A
  1. Gabapentin
  2. Naltrexone
  3. Mirtazapine
122
Q

If pruritis is caused by Lymphoma,
1st choice: __ 10mg to 20mg TDS
2nd choice: __ 400mg BD
3rd choice: __ 15mg to 30mg at bedtime

A
  1. Prednisolone
  2. Cimetidine
  3. Mirtazapine
123
Q

If pruritis is systemic opioid induced,
1st choice: __ 4-12mg (if benefit 4mg TDS)
2nd choice: If no benefit __
3rd choice: __ 8mg twice daily

A
  1. Chlorphenamine
  2. switch opioid
  3. Ondansetron
124
Q

If pruritis is paraneoplastic,
1st choice: __ 5mg to 20mg OD
2nd choice: __ 15mg to 30mg at bedtime

A
  1. Paroxetine

2. Mirtazapine

125
Q

If pruritis has unknown causes,
1st choice: __ 4-12mg (if benefit 4mg TDS)
2nd choice: __ 5mg to 20mg OD
3rd choice: __ 7.5mg to 15mg at bedtime

A
  1. Chlorphenamine
  2. Paroxetine
  3. Mirtazapine
126
Q

Systemic treatment of pruritis is often unnecessary if __. Reserve systemic medication for patients who have __.

A
  1. skin care improves symptoms

2. persistent symptoms despite topical therapy

127
Q

In pruritis, we should avoid:

  1. Avoid __ as they can cause allergic contact dermatitis.
  2. Avoid __ such as caffeine, alcohol, spices and hot water. (increases blood flow to the skin, including histamines, which are irritants)
A
  1. topical antihistamines

2. vasodilators

128
Q

Ointments are better at __ than creams or lotions (due to oil component), but take __ and may not be as well tolerated.

A
  1. relieving dry skin

2. longer to be absorbed into the skin

Cancer managment (4 decks)

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