Symptomatic Management

Question 1

Indications of depression in a long term illness

Answer 1

Complete/absaloute anhedonia
Suicidal ideation
Inappropriate guilt

Question 2

Treatment of depression in palliative care and what type of treatments are these?

Answer 2

Methylphenedate/amphetamine
ECT
Immediate treatments for depression

Question 3

Types of pain

Answer 3

Nociceptive
Neuropathic
Visceral
Incident

Question 4

What is a hollow viscera?

Answer 4

Tubes surrounded by muscles (peristalsis)

Question 5

Pathology of neuropathic pain

Answer 5

Damaged nerves

Question 6

Features of visceral pain

Answer 6

Colic
Classic crescendo decrescendo pain
Midline
Poorly localised

Question 7

Examples of hollow viscera organs

Answer 7

Gut 
Biliary tree
Bladder
Uterus 
Fallopian tubes

Question 8

Features of incident pain

Answer 8

No pain to very sore to no pain
Associated with procedures, weight bearing
A trigger; when taken away the pain goes as well

Question 9

What types of pain can incident pain be?

Answer 9

Nociceptive
Neuropathic
Visceral

Question 10

What is the best symptom control?

Answer 10

Treating the underlying cause (if possible and appropriate)

Question 11

What to ask in a pain history?

Answer 11

SOCRATES
Type
Cause
Impact
- mood
- activities 
- sleep 
Meaning
- what are they scared of?
- what does the pain mean to them?
- what are they hoping for?

Question 12

A patient with metastatic cancer will have a median of how many pains?

Answer 12

3

Question 13

WHO pain ladder

Answer 13

Step 1 - mild pain
- NSAIDs
- Paracetamol 
- +/- adjuvants 
Step 2 - moderate pain 
- Mild opiates 
- + step 1 
Step 3 - severe pain 
- Strong opioid 
- + step 1

Question 14

Examples of mild opiates

Answer 14

Codeine
Dihydrocodeine
Tramadol

Question 15

How much of cancer pain can be controlled by the WHO pain ladder?

Answer 15

80% +

Question 16

What does adjuvant mean?

Answer 16

A treatment that helps pain that is not an analgesic

Question 17

What do steroids reduce?

Answer 17

Oedema

Question 18

What is codeine turned into in the body?

Answer 18

Morphine

Question 19

60mg of codeine 4x per day is the equivalent to how much oral morphine?

Answer 19

60mg x 4 / 10 => 24 mg of oral morphine per day

Question 20

What are the strong opioids?

Answer 20

Morphine
Fentanyl 
Penthidine 
Methadone
Diamorphine
Oxycodone 
Bupaenorphine
Hydromorphone

Question 21

S/Es of morphine

Answer 21

Resp depression in IV use when quick rate of change
Constipation
Drowsy
Nausea

Question 22

Regular prescription of morphine needs prescribed with what?

Answer 22

A laxative

Question 23

What can happen to nausea and vomiting side effects of morphine?

Answer 23

You can become tolerant and they can disappear

Question 24

What is morphine MST?

Answer 24

Modified release

Question 25

What is modified release morphine?

Answer 25

Morphine which releases over 12 hours so 2x a day

Question 26

What is oramorph (secudol)?

Answer 26

Oral morphine immediate release

Question 27

How do you work out the oramorph dose?

Answer 27

Total daily dose of morphine / 6 | Rounded to 5mg for a tablet as required for pain

Question 28

What is breakthrough pain?

Answer 28

Episodes of pain that break through despite background medication

Question 29

What must be done if oramorphine is required?

Answer 29

Change the MST dose as they need more | Then have to increase the breakthrough dose

Question 30

What must be investigated if the patient is confused?

Answer 30

Causes of their confusion e.g. hypercalcaemia, infection, urinary retention, medication

Question 31

Treatment of agitation/confusion

Answer 31

Haloperidol Also - chlorpromazine - levomepromazine

Question 32

What is haloperidol contraindicated in?

Answer 32

PD

Question 33

In the terminal phase of illness, agitation or restlessness is best treated with what?

Answer 33

Midazolam

Question 34

Treatment of hiccups

Answer 34

Chlorpromazine (intractable hiccups) Haloperidol Gabapentin Dexamethasone if hepatic lesions

Question 35

What symptom is common in the last days of life?

Answer 35

Secretions

Question 36

Treatment of secretions

Answer 36

Avoid fluid overload (stop IV or subcut fluids) 1st line - hyoscine butylbromide 2nd line - glycopyrronium bromide