Potpourri
You are seeing a follow up consult for a patient with cancer related pain and anxiety. His primary team note they have had a challenging time with him, his mood sometimes quite angry without an appreciable reason. You enter his room and he greets you with, "There he (she) is! The only doctor that's been able to help me here." You think back to your training. This patient's behavior is most consistent with ________ behavior.
What is splitting?
I'll accept Borderline.
You are seeing a patient with colon cancer who is receiving chemotherapy. She has noticed tingling of her lower and upper extremities with it sometimes feeling like a shock. This has made her anxiety worse for which she thought was well managed with just psychotherapy. You think about adding a (non-opiate) medication which may help with both with probably effects within 1-2 weeks. She notes she had tried some other medications in the past for pain which caused leg swelling and does not wish to try them again. The new medication you want to try is _______.
What is Duloxetine (Cymbalta)?
Your patient is in severe abdominal pain secondary to pancreatic cancer and started on a morp6hine PCA. Over the course of one week she is titrated to settings of 6/3/10/6. On your last visit you notice that her foley catheter output is concentrated, and she has some twitching. You rush to your attending and discuss the case. You think she has ____.
What is myoclonus?
A Medicare benefit that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life.
What is Hospice?
In the hospital, you are seeing a patient with the palliative care team. He notes he has been feeling anxious; his application for disability benefits is pending and he does not have a strong support system, living alone. He was just started on immunotherapy for renal cell carcinoma which he has been tolerating well. You all recall that even though he did not tolerate chemotherapy well he maintained a strong outlook on the future. What may be a treatment related concern that is contributing to his anxiety and what might you ask him?
What are financial hardships?
Are you having any financial difficulties paying for cancer care?
You are seeing a 52 year old female in the hospital for pain management. Upon your initial visit whilst stepping in the room you notice a foul odor. Recalling that your patient has breast cancer with a fungating wound, you think to yourself, "I remember learning about an antibiotic people sometimes use." The antibiotic is _________.
What is metronidazole (Flagyl)?
You are referred a patient with metastatic melanoma for pain management. He states that it has spread to his arm, causing significant pain. PRN morphine is started. You also suggest that he may benefit from another treatment (not a medication) to help his pain, of which a main side effect is ______.
What is fatigue?
(Radiation Therapy)
Jim Sterling has been in your care for several days in the hospital. He has metastatic lung cancer and was admitted with pneumonia that has been difficult to treat. Dyspnea has been his primary issue though he has declined opioids to assist. A medication free method to alleviate dyspnea is...
What is a fan?
A type of short-term inpatient care to relieve the family/primary caregiver for patients who are enrolled in hospice limited to usually 5 days.
What is Respite care?
You are seeing a patient who reports increased mood and energy after starting a therapy which incorporates energy transfer to promote relaxation and healing.
What is Reiki?
Bonus points for what Reiki means?
A 40 yr old woman, recently diagnosed with metastatic ovarian cancer, complains of depressed mood. She tells the Interdisciplinary team that she has felt this way the past 2-3 yrs but has been feeling more stressed and depressed since the diagnosis. She has little energy for social or work activities, has difficulty making decisions and concentrating, and has poor appetite. There are no delusions or hallucinations.
What is Dysthymia?
+/- some reactive depression/adjustment disorder
You are seeing an 80 year old female with osteoporosis in clinic for which you have been following for support and anxiety. She notes that over the last few weeks she has had progressive back pain. On examination she has tenderness over her thoracic spine; you also think to yourself, "did she get shorter?" She has no other symptoms, and her vital signs are WNL. You think she has a ______ and might be a candidate for _______
What is a Compression Fracture?
What is Kyphoplasty?
The main mechanism opioids cause nausea is by stimulation of this CNS location
What is the chemoreceptor trigger Zone?
You are the hospice medical director for an UES home hospice agency. You do not have the ability to start a regular IV on this patient, but an alternative would be a modality called _______ which utilizes the subcutaneous space. You remember that a limiting element in contrast to IV infusions is _______.
What is Hypodermoclysis?
What is the infusion rate?
This low cost practice, often done by positioning the body in various poses has been shown to meaningfully improve cancer symptoms in the following categories: Fatigue, Pain, psychological distress, cognitive impairment.
What is Yoga?
This opioid, rarely (if ever used in our institution), is much like methadone, affecting the NMDA receptor, is an SSRI/SNRI, has a shorter half-life and has no risk of QTc prolongation.
What is Levorphanol?
Bonus points : Levorphanol may also exhibit a ceiling effect in __________ though this is only really been studied in animal models.
Bonus Points: Some other NMDA receptor antagonists used for pain are ______
A 55 year old female with with rectal cancer presents for an initial visit to palliative care. She is currently on Morphine ER45mg TID with Morphine IR 15mg Q4 PRN and reports severe pain. She is unable to sit down secondary to severe rectal pain. She completed radiation treatment several months prior. She does not wish to increase/change her opioids or add more medications. What might you suggest to help with pain management instead?
What is Ganglion Impar Block?
You are evaluating a patient in the emergency room who has come in for dizziness with multiple falls. Standard workup has been negative aside from a noticeable degree of hypoglycemia. He is not a diabetic. He notes that he was just diagnosed with liver cancer and his doctor gave him a "weak" opioid for abdominal pain given his concerns about starting more medications. The medication he was most likely started on is _____.
What is Tramadol?
*Bonus Points if you can name another known side effect of Tramadol. Must be Unique.
*Also bonus points for naming another opioid which can cause hypoglycemia
You are taking care of an end stage COPD patient who was recently admitted to the hospital with shortness of breath. His primary medical team ordered an ultrasound of the heart to evaluate his anatomy. Evidence on ultrasound of ________ could be used to qualify this patient for hospice services.
What is right heart failure (or Cor Pulmonale)?
As you near the end of a clinical work day, you notice a colleague on a computer purchasing international airline tickets in the office. You excitedly ask your colleague about their travel plans, but your colleague replies they purchasing the tickets for an ill patient, not for themselves. Your colleague notes they have regretful feelings for not traveling overseas to visit their own mother prior to her death. They feel compelled to purchase these airline tickets for the patient so she can visit her family members prior to her own death. This prompt sparks concern that your colleague may be experiencing __________.
What is burnout?
Boundary blurring; buying tickets for patient to address their own emotional needs.
You are consulted for a patient with painful lesions on his arm. He has ESRD and is on chronic hemodialysis. He notes they are painful to the touch. Your examination also reveals a purple discoloration in a net-like pattern around the painful areas on his arm. You have an idea of what this might be; to confirm the diagnosis you order _________.
What is 'Nothing'?
You don't need a skin biopsy (usually...) for Calciphylaxis (calcium in the vessels, tissues etc.).
You are seeing a patient for the first time in clinic with cancer pain. His primary care physician started him on Codeine. You discuss changing to a different opioid as 1. his pain is not well controlled and 2. Codeine is ultimately metabolized to _______ as its active metabolite.
What is Morphine?
A 68 year old diabetic male with CKD3, retinopathy presented to your clinic with constipation which has become progressively worse over the last several months. He has tried senna, miralax, lactulose, reglan etc. which have not helped him. On examination he is quite uncomfortable and distended. He mentions that a friend with MSA (multiple system atrophy) recently started a medication his doctor prescribed for helping with his dizziness when standing that seems to have also helped with constipation. What class of medication might this be?
What are cholinesterase inhibitors (Neostigmine, pyridostigmine etc.)?
You are the hospice consultant for a nursing home in the UES. You are seeing an 82 year old female with advanced dementia who was recently discharged from the hospital where she was admitted with aspiration pneumonia. You observe the staff leaving her food tray in front of her and walking away. Her only medication is aspirin. You suggest they perform _____________ to reduce the risk of pneumonia.
What is hand feeding and good oral care?
You are seeing a patient in clinic with Breast cancer, treated with paclitaxel as part of her regimen. She shared that her oncologist also recently started a medication too help "keep her counts up" so she won't get a fever. She's also not sure what's going on but she's started to feel pain in her hips and thighs. She describes it as a deep ache "that just won't go away". This pain is likely due to _________[mechanism] and can be treated potentially by ______ or _______.
*This is a hard question - I want specifics.
G-CSF stimulation of bone marrow, leading to bone marrow expansion, nociceptive activation, inflammatory mediator release and increases in histamine.
NSAIDS or Anti-histamines (Loratidine/ famotidine)