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B. Block E Palliative Care > Symptom Management > Flashcards

Symptom Management Flashcards

1
Q

Where is the vomiting centre located?

1 - cerebellum
2 - medulla
3 - midbrain
4 - pons

A

2 - medulla

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2
Q

The chemoreceptor trigger zone (CTZ) is an area of the medulla oblongata that receives inputs from blood-borne drugs or hormones, and communicates with other structures in the vomiting center to initiate vomiting. Which of the following drugs does NOT act on the CTZ?

1 - cyclizine
2 - metoclopramide
3 - haloperidol
4 - ondansetron

A

1 - cyclizine

Cyclizine = H1 receptor

Metoclopramide = D2 receptor antagonist
Haloperidol = D2 receptor antagonist
Ondansetron = 5-HT3 receptor antagonists

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3
Q

Can head trauma, space occupying lesions and increased ICP lead to activation of the vomiting centre?

A
  • yes
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4
Q

Vestibular problems can also initiate the vomitting centre and can be treated. Which of the following drugs would be effective at inhibiting the stimulus from the vestibular system?

1 - cyclizine
2 - metoclopramide
3 - haloperidol
4 - ondansetron

A

1 - cyclizine

Cyclizine = H1 receptor

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5
Q

Which 2 of the following are true regarding the mechanism of action of Metoclopramide?

1 - D2 receptor antagonist
2 - H1 receptor antagonist
3 - 5HT3 receptor agonist
4 - 5-HT3 receptor antagonists

A

1 - D2 receptor antagonist
Inhibits chemoreceptor trigger zone (CTZ) which feeds into the vomiting centre

3 - 5HT3 receptor agonist
Increases serotonin release, acting as a pro-kinetic

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6
Q

Which 2 of the following are true regarding the mechanism of action of cyclizine?

1 - Acetylcholine (ACh) antagonism
2 - D2 receptor antagonist
3 - H1 receptor antagonist
4 - 5HT3 receptor agonist
5 - 5-HT3 receptor antagonists

A

1 - Acetylcholine (ACh) antagonism
3 - H1 receptor antagonist

Acts as an anti-cholinergic
Good for raised ICP, but as anti-histamine it can cause drowsiness

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7
Q

Which 2 of the following are true regarding the mechanism of action of Ondansetron?

1 - Acetylcholine (ACh) antagonism
2 - D2 receptor antagonist
3 - H1 receptor antagonist
4 - 5HT3 receptor agonist
5 - 5-HT3 receptor antagonists

A

5 - 5-HT3 receptor antagonists

Inhibits chemoreceptor trigger zone (CTZ) which feeds into the vomiting centre

Can cause constipation due to serotonin receptors in the GIT

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8
Q

Which 2 of the following are true regarding the mechanism of action of Prochlorperazine?

1 - Acetylcholine (ACh) antagonism
2 - D2 receptor antagonist
3 - H1 receptor antagonist
4 - 5HT3 receptor agonist
5 - 5-HT3 receptor antagonists

A

2 - D2 receptor antagonist
5 - 5-HT3 receptor antagonists

Both inhibit chemoreceptor trigger zone (CTZ) which feeds into the vomiting centre

Can also reduce peristalsis in GIT and lead to constipation

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9
Q

If a patient presents with increased ICP, which of the following medications may be effective in reducing the risk of seizures and act as an anti-emetic?

1 - cyclizine
2 - ondersartan
3 - haloperidol
4 - metoclopramide

A

3 - haloperidol

Used as an anti-psychotic typically, but used as a D2 receptor antagonist to help treat nausea and reduce the risk of seizures

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10
Q

Of the following medications, which should NOT be used in patients with Parkinsons disease and diarrhoea?

1 - cyclizine
2 - ondersartan
3 - levodopa
4 - metoclopramide

A

4 - metoclopramide

D2 antagonist, so could reduce dopamine and make Parkinsons symptoms worse

Acts as a prokinetic on 5-HT3 receptors in GIT, so could make diarrhoea worse

Cyclizine is drug of choice

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11
Q

Which of the following does the drug Levomepromazine perform?

1 - Acetylcholine (ACh) antagonism
2 - D2 receptor antagonist
3 - H1 receptor antagonist
4 - 5-HT3 receptor antagonist
5 - all of the above

A

5 - all of the above

Dirty drug with lots of side effects

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12
Q

A 68-year-old lady with metastatic carcinoma of the lung, complains of worsening headaches, but no nausea or vomiting. She is known to have brain metastases and a recent history of seizures, though not for the past 2 weeks. She also described left-sided “shooting pains” radiating from her left shoulder, down her left arm with paresthaesiae noted.

A
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13
Q

A 72-year-old gentleman, retired fireman, with progressive Glioblastoma Multiforme, develops severe headaches accompanied by vomiting
He had his curtains shut as he felt that the light was uncomfortable to tolerate.

What is the likely cause of vomiting?

1 - hypercalcaemia
2 - hepatic failure
3 - renal failure
4 - raised ICP
5 - drug induced

A

4 - raised ICP

Glioblastoma Multiforme causes a space occupying lesion

Photophobia is also present

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14
Q

A 72-year-old gentleman, retired fireman, with progressive Glioblastoma Multiforme, develops severe headaches accompanied by vomiting
He had his curtains shut as he felt that the light was uncomfortable to tolerate. The vomiting and photophobia are likely due to raised ICP.

Which 2 of the following could be used to treat the vomitting and photophobia?

1 - cyclizine
2 - ondersartan
3 - levodopa
4 - metoclopramide
5 - dexamethasone

A

1 - cyclizine
H1 receptor antagonist

5 - dexamethasone

There are lots of H1 receptors in the brain. Inhibit these and the signal does not reach the vomiting centre

Dexamethasone is good for reducing inflammation and swelling in the brain so can reduce ICP (always give PPI as well)

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15
Q

76-year-old retired schoolteacher with inoperable Squamous Cell Carcinoma (SCC) of the Lung and liver secondaries. The patient has an acute confusional state characterised by auditory hallucinations.She presented to A&E with vomiting, but has not opened her bowels for 6 days. An ECG reveal’s an enlarged PR interval, but shorted QT. Which of the following blood results is the main cause of the patients clinical presentation?

1 - Na 135
2 - K 4.7
3 - eGFR 75
4 - Albumin 20
4 - Calcium 2.6 (corrected Calcium 3.0)
5 - Bilirubin 5

A

4 - Calcium 2.6 (corrected Calcium 3.0)

SCC of lung can cause paraneoplastic syndrome
Increased release of PTH causing hypercalcaemia

Hypercalcaemia causes:
- constipation
- prolonger PR and shortened QT interval
- confusion, also caused by constipation
- auditory hallucinations/delusion

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16
Q

76-year-old retired schoolteacher with inoperable Squamous Cell Carcinoma (SCC) of the Lung and liver secondaries. The patient has an acute confusional state characterised by auditory hallucinations.She presented to A&E with vomiting, but has not opened her bowels for 6 days. An ECG reveal’s an enlarged PR interval, but shorted QT. SSC can cause hypercalcaemia due to raised PTH, causing the patients symptoms. Which of the following should be started 1st?

1 - dexamethasone
2 - zolendronic acid
3 - fluids
4 - haloperidol (as an anti-emetic)

A

4 - haloperidol

17
Q

76-year-old retired schoolteacher with inoperable Squamous Cell Carcinoma (SCC) of the Lung and liver secondaries. The patient has an acute confusional state characterised by auditory hallucinations.She presented to A&E with vomiting, but has not opened her bowels for 6 days. An ECG reveal’s an enlarged PR interval, but shorted QT. SSC can cause hypercalcaemia due to raised PTH, causing the patients symptoms. Which 2 of the following medications would be good to encourage bowel movements?

1 - Metoclopramide
2 - Senna
3 - Docusate sodium
4 - Loperamide

A

2 - Senna
Stimulant

3 - Docusate sodium
Stool softener and stimulant

18
Q

An 82 year-old gentleman with severe Parkinson’s Disease, develops recurrent vomiting. The cause is thought to be the Co-amoxiclav he has been taking for a chest infection. The antibiotics are switched to a Cefotaxime IV but the vomiting persists. If the patients vomiting can be controlled with anti-emetics, he can then complete his course of antibiotics. Which of the following anti-emetics can be used in this patient?

1 - Metoclopramide
2 - Haloperidol
3 - Ondansetron
4 - Cyclizine

A

3 - Ondansetron
5-HT3 antagonist

Cyclizine may appear safe, but has been shown to be poorly tolerated in Parkinsons disease

19
Q

A 45-year-old pub landlady is receiving chemotherapy for metastatic pancreatic cancer. The medical team would like your input on how best to manage the vomiting induced by the chemotherapy. Which of the following is likely to be most effective?

1 - Metoclopramide
2 - Cyclizine
3 - Levomepromazine
4 - Ondansetron
5 - Domperidone

A

4 - Ondansetron

Associated with the following side effects:
- constipation

Could be used:
Metoclopramide = diarrhoea
Cyclizine = anticholinergic
Levomepromazine = sleepy, falls and anti-cholinergic
Domperidone

20
Q

A 77-year-old lady with metastatic oesophageal cancer and liver metastases, develops large intermittent emptying vomits. The vomiting appears to provide relief and there is little nausea between vomits. Examination reveals marked hepatomegaly. Imaging reveals likely Gastric Outlet Obstruction due to the enlarged liver. Which of the following antiemetics might be most useful here?

1 - Metoclopramide
2 - Cyclizine
3 - Levomepromazine
4 - Ondansetron
5 - Domperidone

A

1 - Metoclopramide
Acts as a prokinetic

DO NOT USE IN COMPLETE BOWEL OBSTRUCTION

21
Q

Which 2 of the following anti-emetics can be used in complete bowel obstruction?

1 - Metoclopramide
2 - Cyclizine
3 - Levomepromazine
4 - Ondansetron
5 - Haloperidol

A

2 - Cyclizine
5 - Haloperidol

AVOID Metoclopramide

22
Q

According to NICE, what is the duration of chronic constipation?

1 - >2 weeks
2 - >1 month
3 - >3 months
4 - >12 months

A

3 - >3 months

23
Q

According to NICE, what is the definition of faecal loading/impaction?

1 - retention of faeces to the extent that spontaneous evacuation is unlikely
2 - inability to pass stool for >2 weeks
3 - feeling of inability to empty bowels
4 - all of the above

A

1 - retention of faeces to the extent that spontaneous evacuation is unlikely

24
Q

According to NICE, what is the definition of functional idiopathic constipation?

1 - unknown cause of constipation
2 - mechanical obstruction of bowels
3 - constipation
4 - lack of peristalsis

A

1 - unknown cause of constipation
IBS

Secondary causes are organic, which includes constipation

25
Q

Which of the following medications does NOT cause secondary constipation?

1 - opiates
2 - antimuscarinics
3 - diuretics
4 - metoclopramide

A

4 - metoclopramide

Acts as a pro-kinetic, so more likely to cause diarrhoea

26
Q

Which of the following autoimmune conditions does NOT typically cause secondary constipation?

1 - hypercalcaemia
2 - type 2 diabetes
3 - hyperparathyroidism
4 - hypothyroidism

A

2 - type 2 diabetes

Hyperparathyroidism = causes hypercalcaemia

27
Q

Which of the following autoimmune conditions does NOT typically cause secondary constipation?

1 - Motor neuron disease
2 - Cerebrovascular Disease (stroke)
3 - Multiple Sclerosis
4 - Spinal cord injury

A

1 - Motor neuron disease

28
Q

If a palliative patient has lots of constipation, which 2 of the following can be safely used in combination to treat the constipation?

1 - Sodium Docusate
2 - Lactulose
3 - Loperamide
4 - Senna

A

1 - Sodium Docusate
Softener

2 - Senna
Stimulant

29
Q

Opioids can cause constipation by antagonising which of the opioid receptors?

1 - u opioid receptor
2 - mu opioid receptor
3 - delta opioid receptor
4 - kappa opioid receptor

A

2 - mu opioid receptor

Morphine and Oxycodone cause constipation

30
Q

Which of the following analgesics is is best for its use in patients with constipation?

1 - Morphine
2 - Oxycodone
3 - Buprenorphine
4 - Fentanyl

A

4 - Fentanyl

Works mostly in the CNS rather than the PNS in the bowel

Given as a patch and can take up to 24h before being effective

31
Q

NICE recommends the use of Confusion Assessment Method (CAM) to assess if a patient has delirium. Which of the following is NOT a feature of delirium?

1 - acute onset change in mental status
2 - change in mood, with aggression prevalent
3 - inattention
4 - disorganised thinking
5 - altered level of consciousness

A

2 - change in mood, with aggression prevalent

32
Q

How many of the following features of delirium do patients need to be diagnosed with delirium according to Confusion Assessment Method (CAM) and NICE?

1 - acute onset change in mental status
2 - inattention
3 - disorganised thinking
4 - altered level of consciousness

A

Both features of 1 and 2 and a feature of 3 or 4ses of delirium

B. Block E Palliative Care (4 decks)

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