Practice questions/AFL

Question 1

Patient with non-small cell lung cancer is dying in hospital. His pain is well controlled on a syringe pump infusing diamorphine 20mg/24hours.
The nursing staff are concerned that he is occasionally agitated with no obvious cause.Which is the most appropriate treatment?

Answer 1

Midazolam 2.5mg subcutaneous injection

(this is preferred for terminal agitation as diazepam is an irritant for SC)

Question 2

Patient with prostate cancer and bony mets is still having pain despite paracetamol 1g QDS. What is the most appropriate next analgesia to give?

Answer 2

Ibuprofen 400mg TDS (while waiting for X ray to confirm source of pain)

Question 3

78 y/o, non small cell lung cancer with a 3x5cm mass in lung as well as adrenal metastasis and mediastinal enlarged lymph nodes. Performance status of 3. What is the most appropriate treatment approach?

Answer 3

Palliative radiotherapy. This is likely to help with the lung cancer symptoms but the treatment cannot be radical, it has to be palliative due to the mets.

Question 4

What is the performance scale in Cancer?

Answer 4

Performance status:

0 = normal,
1 = symptomatic & ambulatory cares for self,
2 = ambulatory >50% time, 3 = ambulatory <50% time nursing care required
4 = bedridden

Question 5

A 64-year-old woman with hyperthyroidism and alcohol dependence complains of episodes of palpitations associated with breathlessness.

She is a non-smoker and is otherwise well. On examination her pulse is 88 bpm and regular, heart sounds normal, chest clear and no ankle oedema. What is the most suggestive diagnosis?

Answer 5

Paroxysmal Atrial Fibrillation

This is because alcohol and thyrotoxicosis are risk factors for AF. In this case, the episodic nature of symptoms suggest paroxysmal AF despite a normal heart rate on exam.

Question 6

If someone presents to GP with painless, intermittent haematuria, with a smoothly enlarged prostate, what is the most appropriate first line investigation and why?

Answer 6

Urine dipstick.

Exclusion of infection needs to be done before referral to urology for 2 week wait for suspicion of bladder cancer

Question 7

What are the main red flags of pancreatic cancer?

Answer 7

1. New onset of Diabetes
2. Reduced appetite
3. Weight loss

Question 8

A 28 year old man with a history of testicular cancer has been bitten by a dog on the lower leg. He is worried that his immunity may be low because of recent chemotherapy.Which is the most appropriate treatment?

Answer 8

Co-amoxiclav

This is used for all animal bites despite immune status.

Question 9

What antibiotic is used for skin infection in those who are penicillin allergic?

Answer 9

Erythromycin

Question 10

What is the management plan for a patient with subclinical hypothyroidism? e.g. TSH raised but T3 and T4 normal

Answer 10

Re-test TSH with thyroid autoantibodies in 3 months.
If TSH still raised after 3 months, consider levothyroxine.

Question 11

A 69-year-old man with myeloma is admitted to the oncology ward with constant nausea. He has vomited small amounts of bile stained fluid for the last 3 days and feels thirsty. What anti-emetic is indicated here?

Answer 11

Haloperidol - Because the cause is likely due to chemical/due to chemotherapy treatment/hypercalcaemia.

Question 12

A 63-year-old man undergoing treatment for prostate cancer complains his left leg ‘gave way’ yesterday and feels odd. He denies any back pain. Which is the most appropriate investigation and/or what diagnosis do you suspect?

Answer 12

• Suspected Metastatic spinal cord compression
• MRI spine indicated to conform diagnosis and determine whether surgery, radiotherapy or chemotherapy are best for management.

Question 13

What is the criteria for urgent direct access upper GI endoscopy?

Answer 13

Dysphagia
OR
55+ y/o, weight loss, upper abdominal pain, reflux or dyspepsia (indigestion symptoms)

Question 14

What percentage of patients with prostate cancer is due to obesity?

Answer 14

11-14% (one of the biggest risk factors)

Question 15

Patient with ECG confirmed diagnosis of Atrial Fibrillation with Chadvasc score of 2. PMHx: Asthma. Most appropriate management?

Answer 15

Rate limiting calcium channel blocker and an oral anticoagulant.

Beta blockers contraindicated due to asthma and aspirin is no longer given for stroke associated with AF.

Rhythm control not needed as no knowledge of AF underlying cause or duration of condition.

Question 16

A 73-year-old man with prostate cancer and multiple bone and lymph node metastasesis admitted to MAU with increasing fatigue and swollen ankles. He is currently taking paracetamol 1 mg QDS, oxycodone 20mg BD and dexamethasone 0.5 mg daily.

His blood tests on admission show: sodium 141 mmol/L (137–144), potassium 5.9 mmol/L(3.5–4.9) urea 25 mmol/L (2.5–7.0) and creatinine 487 μmol/L (60–110).

Which is the most likely cause of his renal failure?

Answer 16

Obstructive uropathy.

U+Es would be more skewed if he was dehydrated and hypercalcaemia is unlikely as well.

Obstructive uropathy is really common in prostate cancer as ureter can be obstructed quite easily.

Question 17

Which medications commonly cause hyponatraemia in the elderly?

Answer 17

Thiazide diuretics and SSRIs

Question 18

What medication can be given instead of amitriptyline for paraesthesia/neuropathy?

Answer 18

Duloxetine - specifically in diabetic neuropathy. Pregabalin and gabapentin are contraindicated in those with history of substance missuse e.g. someone on methadone

Question 19

Definition of restrictive lung disease by spirometry

Answer 19

FVC reduced, FEV1 reduced <80%, ratio normal

Question 20

Definition of Obstructive lung disease by spirometry

Answer 20

FVC normal, FEV1 reduced <80%, ratio reduced