Symptom control 1

Question 1

What should you look for if confusion [6]

Answer 1

Infection
Dehydration 
Retention
Medication
Hypercalcaemia
Electrolyte imbalance

Question 2

Where are sources of information for reasons for confusion

Answer 2

Nurse
Relative
NEWS
Drug cardex
Blood results 
4AT

Question 3

What examination can you do in a palliative patient presenting with confusion [4]

Answer 3

Chest
Abdo
Neuro
PEARL

Question 4

What can you use if specific Rx fails

Answer 4

Haloperidol = 1st line

Chloropromazine

Question 5

What is used in terminal phase of agitation / restless

Answer 5

Midazolam

Question 6

What is licensed for intractable hiccups

Answer 6

Chloropromazine

Question 7

What is also used for intractable hiccups [3]

Answer 7

Haloperidol
Gabapentin
Dexamthasone - hepatic

Question 8

What are common in final days of life

Answer 8

Secretions

More troubling for family

Question 9

What is conservative Rx for secretions

Answer 9

Avoid overload - stop IV or SC fluid

Educate family that patient is not troubled

Question 10

What is medical management of secretions?
MOA?
SE profile [2]

Answer 10

Hyoscine hydrobromide
Centrally acting anti-muscarinic also used in motion sickness

SE:

• central anticholinergic syndrome (excitement, ataxia, hallucinations, behavioural abnormalities, drowsiness)
• anti-muscarinic side effects

Question 11

When is hycosine butyl bromide indicated? [2]

What are contraindications of hycosine? [3]

Answer 11

Bowel colic
Excessive respiratory secretions

Contraindications:

• GI obstruction,
• myasthenia gravis
• BPH, urinary retention

Question 12

What can cause nausea in palliative care [7]

Answer 12

Metabolic
Drugs
Infection
Intra-cranial
Abdominal 
Psychological 
SE chemo therapy

Question 13

What are metabolic causes of nausea [3]

Answer 13

Uraemia
Hyperclacaemia
Circulating Ig

Question 14

What drugs cause nausea [7]

Answer 14

Opioids 
NSAID
Chemo
Abx
SSRI 
Iron 
Digoxin

Question 15

What abdominal causes of nausea [3]

Answer 15

Gastric outlet obstruction
Constipation
Mass

Question 16

What is useful if intra-cranial lesion causing N+V [2]

Answer 16

Dexamethasone

Haloperidol

Question 17

What are RF of chemo related N+V [4]

Answer 17

Anxiety
<50
Concurrent use of opioids

Question 18

What is used if low risk of N+V Sx in chemo

Answer 18

Metoclopramide

Question 19

What is added if doesn’t work or if high risk [2]

Answer 19

5HT3 receptor antagonist - ondansetron

Dexamethasone

Question 20

What are used as anti-emetics [5] (class of drugs)

Answer 20

Neurotransmitter blockers
Dopamine antagonist
Anti-histamine
Anti-cholinergic
5HT3 antagonist

Question 21

What are dopamine antagonist and what are they useful for [3]

Answer 21

Haloperidol - N+V in palliative care
Metoclopramide - gut peristalsis
Levomepromazine - sedative

Question 22

What anti-cholinergic

Answer 22

Hyoscine hydrobromide

Question 23

Eg of 5HT3 antagonist

What is it useful for [4]

Answer 23

Ondanstron 
Post op use
Chemo
Gastroenteritis
Vestibular causes of nausea

Question 24

What is downside of 5HT3 antagonist [2]

Answer 24

Very constipation inducing

Expensive

Question 25

What happens to calcium in a sick person [2]

Answer 25

Albumin is low | Ca levels may be normal but ionised Ca will be too high

Question 26

What are consequences of malnutrition [6]

Answer 26

``` Impaired immune Poor wound healing Muscle wasting and weakness Impaired organ function Altered drug Poor response to Rx ```

Question 27

What is cancer cachexia [2]

Answer 27

Unintential body and lean tissue wasting | Metabolic abnormality results in increased energy, fat and oxidation

Question 28

What does it lead too [3]

Answer 28

GI disturbance Anorexia Undernutriton

Question 29

How do you treat [2]

Answer 29

Adequate replacement and supplements Appetite stimulates MUST screening on admission and weekly

Question 30

What replacement feed options do you have [6]

Answer 30

``` Energy and protein dense diet Food fortification Oral supplement NGT PEG TPN ```

Question 31

What stimulates appetite? [3]

Answer 31

Megace Dexamethasone Alcohol

Question 32

Indications for metoclopromide or domperidone (pro-kinetics) [3] Contraindications [3] SE [3]

Answer 32

Ind: - N&V from clinical toxicity (metoclopramide only) - motility disorders - migraine CI: - post-GI haemorrhage - obstruction, perforation - pheochromocytoma SE: - extra-pyramidal symptoms - hyperprolactinaemia - GI upset

Question 33

``` Haloperidol Class of drug Indications [3] Contraindication [2] SE [3] Interactions [3] ```

Answer 33

D2 receptor antagonist (plus anticholinergic and alpha adrenergic effects) Ind: - N&V due to clinical toxicity in palliative care - anti-psychotic - hiccups in palliative care CI: coma, pheochromocytoma SE: - extrapyramidal symptoms, hyperprolactinaemia - anti-cholinergic effects (constipation, urinary retention, dry mouth) Interactions: - potentiate effects of alcohol and sedatives, beta blockers

Question 34

Ondansetron Contraindication [1] SE [3] Interactions [3]

Answer 34

CI: congenital long QT syndrome SE: - constipation, headache, abdo pain, drowsiness - QT prolongation, arrhythmia - injection site reaction Interactions: - anti-arrhythmic, beta blockers, avoid in any drugs that cause QT prolongation

Question 35

``` Cyclizine MOA Indications [2] SE [2] Interactions [2] ```

Answer 35

Anti-histamine (blocks histamine receptor blockers) in vestibular system and VC Ind: vestibular causes, ICP SE: drowsiness, anticholinergic effects Interactions: alcohol, BDZ

Question 36

Levomepromazine MOA Indications [2] Contraindications [3]

Answer 36

Phenothiazine (dopamine, 5HT2, alpha 1 adrenergic, histamine and ACh antagonist) so broad spectrum anti-emetic Ind: - N&V post-op - refractory or multifactorial N&V in palliative care CI: coma, pregnancy, breastfeeding

Question 37

Levomepromazine SE [6] Interactions [1] Education [1]

Answer 37

SE: - hypotension - neuroleptic malignant syndrome - GI SE, respiratory depression - extra-pyramidal SEs - anti-muscarinic effects - prolonged QT interval * Interactions: avoid in any drugs that cause QT prolongation or drugs which have similar effects * Education: alcohol may potentiate effects