Symptom Management Flashcards
Where is the vomiting centre located?
1 - cerebellum
2 - medulla
3 - midbrain
4 - pons
2 - medulla
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
1 - cyclizine
Cyclizine = H1 receptor
Metoclopramide = D2 receptor antagonist
Haloperidol = D2 receptor antagonist
Ondansetron = 5-HT3 receptor antagonists
Can head trauma, space occupying lesions and increased ICP lead to activation of the vomiting centre?
- yes
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
1 - cyclizine
Cyclizine = H1 receptor
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
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
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
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
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
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
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
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
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
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
Of the following medications, which should NOT be used in patients with Parkinsons disease and diarrhoea?
1 - cyclizine
2 - ondersartan
3 - levodopa
4 - metoclopramide
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
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
5 - all of the above
Dirty drug with lots of side effects
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 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
4 - raised ICP
Glioblastoma Multiforme causes a space occupying lesion
Photophobia is also present
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
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)
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
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
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)
4 - haloperidol
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
2 - Senna
Stimulant
3 - Docusate sodium
Stool softener and stimulant
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
3 - Ondansetron
5-HT3 antagonist
Cyclizine may appear safe, but has been shown to be poorly tolerated in Parkinsons disease
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
4 - Ondansetron
Associated with the following side effects:
- constipation
Could be used:
Metoclopramide = diarrhoea
Cyclizine = anticholinergic
Levomepromazine = sleepy, falls and anti-cholinergic
Domperidone
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
1 - Metoclopramide
Acts as a prokinetic
DO NOT USE IN COMPLETE BOWEL OBSTRUCTION
Which 2 of the following anti-emetics can be used in complete bowel obstruction?
1 - Metoclopramide
2 - Cyclizine
3 - Levomepromazine
4 - Ondansetron
5 - Haloperidol
2 - Cyclizine
5 - Haloperidol
AVOID Metoclopramide
According to NICE, what is the duration of chronic constipation?
1 - >2 weeks
2 - >1 month
3 - >3 months
4 - >12 months
3 - >3 months
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
1 - retention of faeces to the extent that spontaneous evacuation is unlikely
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
1 - unknown cause of constipation
IBS
Secondary causes are organic, which includes constipation
Which of the following medications does NOT cause secondary constipation?
1 - opiates
2 - antimuscarinics
3 - diuretics
4 - metoclopramide
4 - metoclopramide
Acts as a pro-kinetic, so more likely to cause diarrhoea
Which of the following autoimmune conditions does NOT typically cause secondary constipation?
1 - hypercalcaemia
2 - type 2 diabetes
3 - hyperparathyroidism
4 - hypothyroidism
2 - type 2 diabetes
Hyperparathyroidism = causes hypercalcaemia
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
1 - Motor neuron disease
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
1 - Sodium Docusate
Softener
2 - Senna
Stimulant
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
2 - mu opioid receptor
Morphine and Oxycodone cause constipation
Which of the following analgesics is is best for its use in patients with constipation?
1 - Morphine
2 - Oxycodone
3 - Buprenorphine
4 - Fentanyl
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
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
2 - change in mood, with aggression prevalent
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
Both features of 1 and 2 and a feature of 3 or 4ses of delirium
