Supportive treatment Flashcards
(128 cards)
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
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
3
Q
Constipation can have disease related causes such as i_______
t____ i__ leading to obstruction
Decreased f____ i___ and
L__ r____diet
A
- Immobility
- Tumor invasion
- food intake
- Low residue (low fibre)
4
Q
Biochemical fluctuations such as __ and __ can lead to constipation. Fluid depletion via __ and __ may be a factor as well.
A
- Hypo-Kalaemia
- Hyper-Calcaemia
- Poor fluid intake
- Increased fluid loss
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
- opioids
- Iron and Calcium
- raise intra-abdominal pressure
- vinka alkaloids
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
7
Q
Before prescribing laxatives for a constipated patient, we must __ and consider __.
A
- rule out bowel obstruction
2. underlying causes i.e. Hyper-Calcaemia or drugs
8
Q
Patients on __ (i.e. Fybogel, Metamucil) should be counselled __. The usual dosing is __.
A
- bulk forming agents
- to drink extra fluids
- 1 sachet BD
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
- colic
- flatulence
- palliative care
- bowel obstruction
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
- 2-4 tabs daily
2. 5-10mg ON, Max: 20mg OD
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
- complete bowel obstruction
- dehydration
- electrolyte imbalance
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
- drink extra fluids
2. 10-15ml BD
13
Q
Osmotic laxatives have similar adverse effects as Bulk forming agents and may cause __, flatulence, __ and __ in debilitated patients
A
- Colic
- Dehydration
- electrolyte imbalance
14
Q
__ is an osmotic laxative that also increases the stool volume and triggers colon motility via neuromuscular activity.
A
Macrogol (Forlax)
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
- lubricate using glycerin suppositories
- olive oil
- phosphate
- oral stimulant or softener
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
- a rectal stimulant
2. oral stimulants
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
- intestinal obstruction
- regular laxatives
- additional laxatives i.e. osmotic laxatives (oral fleet) 15mls x 3 days
- regular laxatives
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
- high fleet (phosphate) enema
- stimulant laxatives
- softener/osmotic agent
- stimulant laxative
19
Q
To prevent opioid induced constipation, we must ensure __. By optimizing the patient’s __, we can prevent constipation as well.
A
- compliance in bowel regime (regular laxatives)
2. existing laxative regimen
20
Q
To prevent constipation, we should encourage __. Educating the patient and their family to __ is a good idea as well.
A
- fluid intake, particularly fruit juice and fruit
2. monitor bowel habits
21
Q
Intestinal obstructions are often caused by cancers and classified by:
- __ vs __ (location)
- __ vs __ (i.e. motility issue)
- Complete vs incomplete
A
- Upper vs Lower GI tract
2. Mechanical vs Functional
22
Q
Patient reported symptoms for intestinal obstruction is useful for differentiating __. __ is a common feature.
A
- location of obstruction
2. Abdominal pain (can be colickly/constant)
23
Q
Upper GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.
A
- bilious, large volume
- anorexia
- constipation
- absent
24
Q
Lower GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.
A
- faeculent, small volume
- constipation
- anorexia
- present
25
In intestinal obstruction, we want to __ and reverse obstruction if possible. We may do this via __, Nil-by-mouth or __.
1. provide symptom relief
2. Gut rest
3. IV hydration
26
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.
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
27
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 __.
1. fetanyl
2. pain is not relieved
3. Metoclopramide
4. clear bowels
5. high fleet/lactulose
28
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.
trial of steroids (8-16mg)
29
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.
1. multiple levels of obstruction
| 2. rectal tumors
30
Prokinetics may be contraindicated in complete intestinal obstruction due to __.
risk of perforation
31
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)
1. seeds, nuts or raw/dried
2. whole grain
3. tough fibrous
4. fat intake
32
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 __.
1. embarrassing
2. dignity
3. relationships
33
Diarrhea may be caused by diet when __, __ and __ is consumed.
1. fruit
2. hot spices
3. alcohol
34
__ and __ (particular when involving abdomen or pelvis) can cause diarrhea.
1. Chemotherapy
| 2. radiotherapy
35
Certain disease states can cause diarrhoea: __ insufficiency, __ (i.e. Crohn’s disease, ulcerative colitis), gastrointestinal infection and __ (overflow diarrhoea).
1. Pancreatic
2. inflammatory bowel disease
3. faecal impaction
36
Diarrhoea can occur when the patient is on:
| __ (overdose), antacids, antibiotics, __ and __ (sugar free) elixirs.
1. Laxatives
2. NSAIDs
3. disaccharide containing
37
Before giving pharmacological treatment for diarrhea, we must rule out __, __ and __ related causes. We should consider the underlying cause as well.
1. faecal impaction
2. intestinal obstruction
3. infection
38
(KIV) Codeine phosphate is dosed at __mg Q__hrs PRN for diarrhoea treatment. (lower than analgesic dose)
1. 30-60
| 2. 4-6
39
For patients on codeine phosphate, they should avoid concurrent use of n__. Use with caution in patients with __ disease (elimination affected).
1. narcotics
| 2. Hepatic/renal
40
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.
1. sedation
2. respiratory depression
3. COPD, Asthma
4. sedatives
5. alcohol
41
Codeine phosphate may cause c__, n__,
| sedation, h__, d__ and respiratory depression in patients as side effects.
1. constipation
2. nausea
3. hypotension
4. dry mouth
42
(kiv) Diphenoxylate/atropine (Lomotil) is dosed at __ tabs __ times daily, Max: __ in oncology diarrhea management.
1. 1-2
2. 3-4
3. 8/day
43
Diphenoxylate/atropine (Lomotil) should not be used for patients __, __ disease or __ diarrhea.
1. <12 years old
2. liver
3. infectious
44
Diphenoxylate/atropine (Lomotil) may cause anti-cholinergic side effects, particularly in the elderly. They include: __ and __. Other side effects include: s__, d__ and r__.
1. dry mouth
2. urinary retention
3. Sedation
4. dizziness
5. rash
45
(KIV) Loperamide HCl (Imodium) is dosed at __mg (2-4 capsules) daily. Max __/day in oncology diarrhea management.
1. 4-16
| 2. 8 capsules
46
Loperamide HCl (Imodium) should not be used for patients __, or __ diarrhea.
1. <12 years old
| 2. Infectious
47
Loperamide HCl (Imodium) can cause similar side effects as diphenoxylate: __, __, skin __, headache
1. Constipation
2. dry mouth
3. rash
48
(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
1. 50-200
2. 2-3
3. only as a last resort
49
Octreotide (Sandostatin) should not be used if patients have __.
Infectious diarrhea
50
Being an injectable, Octreotide (Sandostatin) may cause __. Other side effects include: Nausea, __, __ (rare) and __ imbalance.
1. Pain at injection site
2. abdominal cramps
3. cholelithiasis
4. glucose
51
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)
1. high fiber food
2. Gut stimulants
3. Irritating foods
52
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.
1. small frequent
2. low-fibre
3. good fluid intake of 2L/day
53
__ diarrhea with __ which might indicate an infective cause.
1. Persistent watery
| 2. systemic upset
54
If the patient is suffering from Steatorrhea/fat malabsorption, __ enzymes (+- __to reduce gastric destruction of enzymes) may be useful.
1. pancreatic
| 2. PPIs
55
For patients who have undergone a surgical resection (stomach, ileal, colon) or suffer from bile salt diarrhea, __ would be useful.
Cholestyramine
56
If the patient is suffering from diarrhea and carcinoid syndrome with typical anti-diarrheals are ineffective, we may give a trial of __.
Octreotide
57
```
Dyspnea can have many causes:
Physical (__, effusions, __)
Social (family stress, finances)
__ (anxiety, disappointment)
__ (suffering and meaning)
```
other causes: ______, _____
1. anaemia
2. drug toxicity
3. Psychological
4. Spiritual
5. PE/COPD exacerbation
6. abdominal: ascites, liver failure causing fluid overload
58
Important to assess ___ of ___, (alleviating/precipitating factors), associated ___, severity and impact on ____ability/quality of life . Screen for associated __. Look for __ causes.
1. pattern of SOB
2. associated symptoms
3. functional ability
4. anxiety
5. reversible
59
In Dysnpea, __ are just as effective, if not more effective than pharmacologicals
non-pharmacologicals
60
Oxygen therapy is useful only for __. (IMPT)
hypoxic patients (SpO2 < 90%)
61
Opioids are useful for __, especially in terminal cancer/ non-cancer patients. We should start low and titrate carefully to avoid __.
1. SOB at rest/minimal exertion
| 2. respiratory depression
62
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 __.
1. 2.5-5mg q4h PRN
2. 30-50%
3. SC/IV morphine 0.2-0.4mg/ hr
63
Fentanyl can also be used if patients have __________. Patches start at __ but for severe or terminal breathlessness, start __.
1. renal impairment
2. 6mcg/ hr
3. SC or IV 5-10mcg/ hr
64
Steroids are useful in __. Dexamethasone may be dosed at __ in lymphangitis and dosed __ in Superior vena cava obstruction (SVCO).
1. reducing peri-tumoural edema
2. 8-16mg/day
3. 16mg/day
65
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
1. opioid monotherapy
2. Sublingual Lorazepam 0.5mg prn/bd
3. IV/SC midazolam 5-10mg/24hr
66
If patient has longer prognosis and has panic attacks, we should consider __
- __ (SSRI) 10mg daily and then increase to
__ after one week
1. antidepressants with anxiolytic effect
2. escitalopram
3. 20mg/day
67
__ (5ml prn) may loosen secretions but is useful only if __.
1. Nebulized sodium chloride 0.9%
| 2. patient can expectorate
68
_____ eg. buscopan __ or continuous infusion __ can decrease and loosen secretions.
Anticholinergics
1. buscopan SC 20mg prn/q6h
2. buscopan continuous infusion 60mg-240mg/24hr
69
Suctioning of secretions can be __ and ineffective in __. It might not be able to lower secretions.
1. distressing
| 2. providing symptom relief
70
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 __.
1. open windows or use electric fans
2. breakthrough opioids
3. joining support groups or rehabilitation programs
71
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
1. Break tasks into smaller bits
2. anxiety management
3. find comfortable positions
72
Nausea and vomiting is commonly caused by radiotherapy (esp radiation around __), chemotherapy and __(90% but patients develop tolerance in 1-2 wks)
1. thoracic/abdominal cavity
| 2. opioids
73
Chemical/toxic causes( e.g. __, uraemia) can lead to Nausea and vomiting, as well as __, gastric stasis and Raised intracranial pressure (ICP) from __.
1. hypercalcemia
2. Tumor/intestinal obstruction
3. brain metastases
74
There is a __ to nausea vomiting, with causes possibly being Multifactorial/unknown/refractory. Higher centres (pain/fear/anxiety) may be implicated.
psychological component
75
When doing history taking, we should take __ for nausea and vomiting respectively. Check for other __ and exclude __ (managed differently).
1. separate histories
2. concurrent symptoms
3. regurgitation
76
When taking history for nausea and vomiting, note the following:
- t__, v___, p___
- exacerbating and relieving factors, including __
- __ (to exclude constipation/ intestinal obstruction)
1. triggers, volume, pattern
2. medication history
3. bowel habit
77
(KIV dose) Domperidone is a _______ antagonist and a _________.
Starting dose: __
Max dose: __ (consider alternative in __)
Domperidone is a dopamine antagonist and a prokinetic.
1. PO 10mg tds
2. PO 20mg qds
3. cardiac disease
78
(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 __)
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
Haloperidol is an typical ______ (alpha-1 and D2 antagonist) that acts on the ____.
Starting doses: __
Max doses: __
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
Ondansetron is a ____ antagonist that acts in CTZ and peripheral _____ receptors (gut), _____ the gut.
Starting doses: __
Max doses: __
Note that ondansetron may cause __.
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
Buclizine is an ____ that acts on the vestibular system.
Starting doses: __
Max doses: __
Buclizine is good for __.
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
(KIV doses)
Mirtazapine is an noradrenergic/serotonin antagonist.
Starting doses: __
Max doses: __
Mirtazapine is rarely used due to __ but used in patients with __ depression.
1. PO 7.5 - 15mg tds
2. PO 45mg tds
3. side effects
4. concurrent
83
KIV the doses
Olanzapine is a typical antipsychotic (M1, H1, a1, Dopamine, 5-HT antagonist)
Starting doses: __
Max doses: __
Olanzapine is used for __.
1. PO 2.5mg ON
2. PO 10mg ON
3. refractory nausea and vomiting
84
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
1. small frequent
2. remove bad tastes
3. irritating, strong flavoring, fragrant
4. peaceful/relaxed
5. fluid intake
85
For a patient with nausea, vomiting from clinical toxicity (drug induced or metabolic/chemical upset), __ i.e. metoclopramide and QThaloperidol are indicated.
dopamine antagonists
86
For a patient with nausea, vomiting from motility disorders (drug-induced or paraneoplastic gastroparesis), Prokinetics i.e. __ and __ are indicated.
metoclopramide and QTdomperidone
87
For a patient with nausea, vomiting from Intracranial disorders i.e. vestibular dysfunction, motion disorders, __ or __ (cyclizine or hyoscine hydrobromide), corticosteroid, or __ are indicated.
1. Anticholinergic
2. antihistamine
3. QTprochlorperazine
88
If nausea and vomiting with oral/pharangeal/oesophageal irritation, use __ (cyclizine or hyoscine hydrobromide)
Anticholinergic or antihistamine
89
If Multifactorial/unknown/refractory nausea and vomiting, use appropriate __ for known causes; or __.
1. anti-emetics
| 2. broad spectrum anti-emetic
90
If nausea and vomiting in Higher centres (pain/fear/anxiety), optimize __ and treat __.
1. pain control
| 2. anxiety
91
If Chemotherapy and/or radiotherapy-induced nausea and vomiting, __.
Refer to local guidelines
92
Colicky abdominal pain after taking a prokinetic drug may suggest __.
bowel obstruction
93
Despite logical and appropriate treatment, the patient may continue to vomit especially if there is __.
a duodenal/gastric outflow/bowel obstruction
94
For persistent vomiting, management of __ and __ is essential.
1. hydration status
| 2. nutritional status
95
Symptoms of depression may manifest as __ change, insomnia, loss of energy, fatigue, __ slowing, loss of libido. __ should be assessed for depression.
1. Weight/appetite
2. psychomotor
3. All patients
96
__ 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.
1. Pharmacologicals
2. support mechanisms
3. therapies with psychological benefits
97
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.
1. medical and drug
2. adverse effects
3. resolution of symptoms
4. Adherence
98
__ can be used as a screening tool for depression while the __ is an assessment tool suited for palliative care patients.
1. PHQ-9
| 2. brief Edinburgh Depression Scale
99
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 __.
1. nausea, insomnia and sexual dysfunction
2. history of GI bleed
3. >80 years old
4. NSAIDs
100
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 __.
1. oro-dispensable tablet
2. sedative
3. elderly
4. heart failure
101
Xerostomia (Dryness of the mouth and altered salivation) affects eating, __, speaking and __. Patients may have to __ and __ frequently.
1. sleeping
2. physical exercise
3. manually remove saliva
4. expectorate
102
Xerostomia may be caused by __ therapy (head/neck area), surgical removal of __, some chemotherapy agents and __.
1. radiation
2. salivary glands
3. oral infection
103
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.
1. Mouth care
2. oral cavity
3. saliva substitutes
4. lip moisturiser
104
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 __.
1. oral rinses
2. Papayas or papaya juice
3. fluids
4. soft, moist
5. hard sugarless candies
6. sugarless gum
105
Patients with xerostomia should avoid:
- Avoid __ foods such as peanut butter or bread.
- Avoid __ and __ drinks.
1. dry, sticky
2. alcoholic
3. carbonated
106
Pharmacological treatment for xerostomia can stimulate saliva production using __ dosed at 5-10ml tds. It is useful only if the patient has __.
1. Pilocarpine
| 2. working salivary glands
107
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
1. hyperactive
2. hypoactive
3. mixed
108
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.
1. opioids
2. anti-cholinergics
3. corticosteroids
4. benzodiazepines
5. antidepressants
6. sedatives
7. withdrawal
109
__, __ and dementia are risk factors for developing delirium, and __ and dementia should be excluded when evaluating delirium.
1. Visual impairment
2. deafness
3. depression
110
Delirium may occur secondary to Dehydration, __, urinary retention, __, Liver or renal impairment, electrolyte disturbance (sodium, glucose), hypercalcaemia, __, hypoxia, cerebral tumour or cerebrovascular disease
1. constipation
2. uncontrolled pain
3. infection
111
Delirium diagnosis mainly depends on __ and accurate history __ is important. Screening tools such as __ (MMSE) or __ (CAM) may be useful.
1. careful clinical assessment
2. from someone who knows the patient
3. mental state examination
4. confusion assessment method
112
Check for __ in a delirious patient (drowsiness, agitation, myoclonus, hypersensitivity to touch) and __ if necessary. Consider __ if delirium persists.
1. opioid toxicity
2. reduce opioid dose by 1/3rd
3. switching to another opioid
113
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 __.
1. Haloperidol
| 2. cause for delirium cannot be reversed
114
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.
1. Benzodiazepines
| 2. do not improve cognition
115
For a delirious patient, __ can help reassure them. We should pay attention to __ and encourage the patient to __ if possible.
1. the presence of a close friend or relative
2. the environment
3. keep taking oral fluids
116
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 __.
1. Systemic
| 2. dry skin
117
Emollients improve dry skin which then improve itch. They may be used liberally and frequently as a __, or added to bath water as a __.
1. moisturizer
| 2. soap substitute
118
For inflamed but non-infected pruritic areas, __ may be applied sparingly OD for 2-3 days. Review after __.
1. topical corticosteroids (mild to moderate potency)
| 2. 7 days
119
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.
1. 3 days
2. Crotamiton
3. capsaicin
120
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
1. equally efficacious
2. Rifampicin
3. Sertraline
4. Cholestyramine
121
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)
1. Gabapentin
2. Naltrexone
3. Mirtazapine
122
If pruritis is caused by Lymphoma,
1st choice: __ 10mg to 20mg TDS
2nd choice: __ 400mg BD
3rd choice: __ 15mg to 30mg at bedtime
1. Prednisolone
2. Cimetidine
3. Mirtazapine
123
If pruritis is systemic opioid induced,
1st choice: __ 4-12mg (if benefit 4mg TDS)
2nd choice: If no benefit __
3rd choice: __ 8mg twice daily
1. Chlorphenamine
2. switch opioid
3. Ondansetron
124
If pruritis is paraneoplastic,
1st choice: __ 5mg to 20mg OD
2nd choice: __ 15mg to 30mg at bedtime
1. Paroxetine
| 2. Mirtazapine
125
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
1. Chlorphenamine
2. Paroxetine
3. Mirtazapine
126
Systemic treatment of pruritis is often unnecessary if __. Reserve systemic medication for patients who have __.
1. skin care improves symptoms
| 2. persistent symptoms despite topical therapy
127
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)
1. topical antihistamines
| 2. vasodilators
128
Ointments are better at __ than creams or lotions (due to oil component), but take __ and may not be as well tolerated.
1. relieving dry skin
| 2. longer to be absorbed into the skin
