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  • Question 1 - A 65-year-old woman with advanced breast cancer has noticed an increase in nausea...

    Incorrect

    • A 65-year-old woman with advanced breast cancer has noticed an increase in nausea and vomiting as her opioid dose has been raised. She is currently experiencing persistent and severe vomiting with minimal relief of her nausea.
      Which medication is most likely to provide relief for this patient?

      Your Answer: Cyclizine

      Correct Answer: Haloperidol

      Explanation:

      Managing Nausea and Vomiting in Palliative Care: Medications to Consider

      Nausea and vomiting are common symptoms in palliative care, and can be caused by a variety of factors such as drug toxicity or metabolic disturbances. To manage these symptoms, several medications can be considered.

      Haloperidol is often the first-line drug for opioid-induced nausea, renal failure, and hypercalcaemia. Metoclopramide and levomepromazine are alternative options. For nausea caused by cytotoxic therapy or radiotherapy, ondansetron can be used.

      Ranitidine may be beneficial if gastric or oesophageal stasis is an issue. Cyclizine is useful for managing vagally-mediated nausea and vomiting caused by mechanical bowel obstruction, vestibular disturbance, and Intracranial disease. Dexamethasone can be added to cyclizine in scenarios where Intracranial pressure is raised.

      Finally, hyoscine butylbromide can be used for managing bowel colic and excessive gastrointestinal secretions. When selecting medications, it is important to consider the underlying cause of the nausea and vomiting, as well as the patient’s individual needs and preferences.

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  • Question 2 - A 70-year-old woman has terminal breast cancer. Her General Practitioner visits her at...

    Correct

    • A 70-year-old woman has terminal breast cancer. Her General Practitioner visits her at home. Until her diagnosis five years ago, she had no significant medical history. She is known to have liver metastases and is quite breathless. Her oxygen saturations are 92% in air, and her respiratory rate is 28 breaths per minute. She is alert, but very frail.
      Which of the following treatments is most likely to be of benefit for this patient’s dyspnoea?

      Your Answer: Morphine

      Explanation:

      Managing Dyspnoea in Terminally Ill Patients: Treatment Options

      Dyspnoea is a common symptom in terminally ill patients and can significantly impact their quality of life. When managing dyspnoea, it is important to identify and treat any reversible causes, such as cardiac failure or pneumonia. However, in cases where the cause cannot be reversed, there are several treatment options available.

      One such option is the use of opioids, such as morphine, which can reduce breathlessness at rest and in the end-of-life phase. A therapeutic trial should be given, and the patient should be monitored for response and side-effects. If morphine is not tolerated, alternative opioids can be used.

      Dexamethasone is another option, particularly in cases of lymphangitis carcinomatosis and superior vena cava airway obstruction. It reduces inflammatory oedema and can also be used post-radiotherapy.

      Furosemide is not likely to be of benefit unless there is evidence of cardiac failure.

      Lorazepam, a benzodiazepine, may relieve anxiety and panic associated with severe breathlessness, but it is less effective than opioids and should be considered a second-line treatment.

      Finally, if oxygen saturations are below 92%, a trial of oxygen can be considered for symptom relief. However, it is important to note that there may be a poor relationship between hypoxaemia, dyspnoea, and response to oxygen.

      In conclusion, managing dyspnoea in terminally ill patients requires a multi-faceted approach, including identifying and treating reversible causes and utilizing appropriate medications for symptom relief.

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  • Question 3 - You are requested to evaluate an elderly patient with advanced esophageal cancer. The...

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    • You are requested to evaluate an elderly patient with advanced esophageal cancer. The patient has metastatic cancer and is receiving palliative care with home visits. The patient reports increasing trouble in swallowing over the past few weeks, which is now hindering their ability to consume food properly. The patient describes the feeling of food getting stuck while swallowing. There is no pain while swallowing. What is the most suitable treatment to alleviate these symptoms?

      Your Answer: Nifedipine

      Explanation:

      Managing Dysphagia in Palliative Care

      When managing dysphagia in a palliative care setting, it is crucial to identify the underlying cause of the condition. Depending on the cause, different treatments may be necessary. For instance, a physical obstruction caused by a tumour may require a corticosteroid such as dexamethasone, while oesophageal spasm may respond to a muscle relaxant like nifedipine or baclofen.

      In the case of a patient with oesophageal cancer who experiences progressive difficulty in swallowing and food getting stuck on the way down, the most likely cause is a gradually enlarging tumour mass causing obstruction and progressive dysphagia. In this scenario, dexamethasone is the most appropriate treatment to prescribe.

      It is worth noting that oesophageal spasm typically causes odynophagia in addition to dysphagia. Therefore, a careful assessment of the patient’s symptoms and medical history is necessary to determine the most effective treatment plan.

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  • Question 4 - You are seeing an elderly patient with advanced gastric cancer at home who...

    Incorrect

    • You are seeing an elderly patient with advanced gastric cancer at home who has called you due to persistent vomiting. The patient is receiving palliative care.

      The patient reports persistent large volume vomiting with little preceding nausea, frequent hiccups, early satiety, and acid reflux. The patient also reports that vomiting provides relief.

      Which antiemetic medication would be the most appropriate to prescribe?

      Your Answer: Ondansetron

      Correct Answer: Cyclizine

      Explanation:

      Treatment options for gastric stasis in palliative care

      Gastric stasis can cause distressing symptoms such as large volume vomiting, acid reflux, hiccoughs, and early satiety. In palliative care, the use of metoclopramide is advised despite restrictions issued by the European Medicines Agency. However, caution should be exercised when prescribing prokinetic drugs with antimuscarinic activity. Haloperidol is effective in treating nausea and vomiting caused by chemical imbalances, while cyclizine is indicated for patients with cerebral disease, motion sickness, and nausea due to mechanical bowel obstruction. Levopromazine is a broad-spectrum antiemetic that can be used when first-line treatments fail. Ondansetron, a 5-HT3 antagonist, is commonly used to treat emetogenic chemotherapy. By understanding the various treatment options available, healthcare professionals can provide effective symptom management for patients with gastric stasis in palliative care.

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  • Question 5 - You are asked to assess an elderly 83-year-old man who has advanced prostate...

    Correct

    • You are asked to assess an elderly 83-year-old man who has advanced prostate cancer and is experiencing poor appetite and anorexia. Upon further inquiry, he reports that his nausea is well-managed with cyclizine as needed, and he doesn't have any difficulty swallowing. His pain is adequately controlled, and he has regular bowel movements. What would be the most beneficial approach in this situation?

      Your Answer: Nutritional supplements alongside any tolerated diet

      Explanation:

      Addressing Lack of Appetite in Palliative Care Patients

      A thorough history and clinical examination are crucial in identifying the underlying cause of anorexia and lack of appetite in palliative care patients. Pain, constipation, nausea, vomiting, and dysphagia are some of the potential causes that need to be treated accordingly. However, if the primary cause is a lack of appetite, specific measures should be taken to address it.

      Home care input may not be effective in improving appetite, and changing antiemetics is unnecessary if the current medication is working well. Nutritional supplements may aid in caloric intake, but addressing the lack of appetite is still the priority. Referral for PEG feeding is not appropriate if there are no physical problems preventing oral intake.

      The best option to stimulate appetite and improve oral intake is a course of prednisolone or dexamethasone. These corticosteroids have been proven to increase appetite and enjoyment of food in many patients. Progestogens are also effective but are more expensive.

      In conclusion, addressing the lack of appetite in palliative care patients is crucial in improving their quality of life. A thorough assessment of the underlying cause is necessary, and appropriate measures should be taken to address it. Corticosteroids such as prednisolone and dexamethasone are effective in stimulating appetite and improving oral intake.

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  • Question 6 - You are seeing a 58-year-old woman who has been diagnosed with early invasive...

    Incorrect

    • You are seeing a 58-year-old woman who has been diagnosed with early invasive breast cancer which is oestrogen-receptor-positive. Her oncologist is treating her with anastrozole 1 mg daily. Which one of the following is the most common side effect of anastrozole?

      Your Answer: Angioedema

      Correct Answer: Bone fractures

      Explanation:

      Anastrozole Side Effects According to BNF

      The British National Formulary (BNF) is often used as a reference for setting questions in the AKT exam. One of the topics that may be tested is the side effects of medications. The BNF categorizes side effects based on their frequency, ranging from very common to very rare. Anastrozole is a medication used in the adjuvant treatment of oestrogen-receptor-positive early invasive breast cancer in postmenopausal women. However, it is contraindicated for premenopausal treatment. According to the BNF, bone fractures are common or very common side effects of Anastrozole. On the other hand, vasculitis and angioedema are very rare side effects. Notably, interstitial nephritis and interstitial pneumonitis are not listed as side effects.

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  • Question 7 - An elderly patient has a terminal illness and it is likely that the...

    Incorrect

    • An elderly patient has a terminal illness and it is likely that the end stage of this is approaching. The General Medical Council (GMC) has produced guidance concerning treatment and care of patients coming towards the end of life.
      Which of the following options conforms to the principles described by the GMC regarding end-of-life care?

      Your Answer: The right to patient confidentiality can be waived

      Correct Answer: Treatment decisions must start from a presumption in favour of prolonging life

      Explanation:

      Principles for End-of-Life Decision Making

      When making decisions regarding end-of-life care, it is important to adhere to certain principles. These principles include equality and human rights, which dictate that patients approaching the end of their life should receive the same quality of care as all other patients. Additionally, there should be a presumption in favor of prolonging life, meaning that decisions about potentially life-prolonging treatments should not be motivated by a desire to bring about the patient’s death. It is also important to presume capacity in terminally ill patients and to maximize their capacity to make decisions through shared decision making. Finally, when a patient lacks capacity, the overall benefit of a potentially life-prolonging treatment must be weighed against the burdens and risks for the patient, with consultation from those close to the patient. By following these principles, end-of-life decisions can be made with the patient’s best interests in mind.

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  • Question 8 - A 59-year-old man calls for advice regarding persistent hiccups. His medical history shows...

    Incorrect

    • A 59-year-old man calls for advice regarding persistent hiccups. His medical history shows that he was diagnosed with pancreatic cancer two months ago. He has tried simple remedies like drinking cold water, holding his breath, and the Valsalva manoeuvre, but they have not worked. He is asking if you could prescribe something to help. What is the most suitable initial treatment to suggest?

      Your Answer: Chlorpromazine

      Correct Answer: Antacid

      Explanation:

      Treatment Options for Persistent Hiccups

      Persistent hiccups can be troublesome for some patients and are often difficult to treat. However, there are several simple manoeuvres that can be tried, such as sipping cold water, breath-holding, and the Valsalva manoeuvre. If hiccups are due to gastric distention, an antacid may help. If these options fail, metoclopramide or domperidone are usually the next treatment options. Baclofen, nifedipine, and chlorpromazine are third-line options that can be tried if the hiccups persist. Haloperidol may also be effective and better tolerated than chlorpromazine. In this case, trying an antacid and antiflatulent preparation is a suitable first-line option as the symptoms are of recent onset and no pharmacotherapy has been tried so far.

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  • Question 9 - Sophie is a 84-year-old woman with a history of osteoporosis and arthritis who...

    Incorrect

    • Sophie is a 84-year-old woman with a history of osteoporosis and arthritis who was discharged from hospital 4 weeks ago following a hip replacement surgery. Her GP last saw her during a home visit 3 days after discharge. She had been regularly seen by the district nurse since then. Unfortunately, she had declined significantly since her hospital admission and was found dead by her daughter this morning.

      What is the appropriate course of action for the GP regarding Sophie's death certificate?

      Your Answer: Sign the death certificate, putting myocardial infarction in section 1a

      Correct Answer: Refer the death to the coroner

      Explanation:

      If a doctor has not examined the deceased within 28 days prior to their death, the case must be referred to the coroner. This time frame was extended from 14 days due to the COVID pandemic.

      While it may be appropriate to list myocardial infarction as the cause of death in section 1a, the GP is not authorized to issue the death certificate in such cases. It is generally not recommended to cite old age as the cause of death.

      Only a medical practitioner who is registered can complete a death certificate.

      Notifiable Deaths and Reporting to the Coroner

      When it comes to death certification, certain deaths are considered notifiable and should be reported to the coroner. These include unexpected or sudden deaths, as well as deaths where the attending doctor did not see the deceased within 28 days prior to their passing (this was increased from 14 days during the COVID pandemic). Additionally, deaths that occur within 24 hours of hospital admission, accidents and injuries, suicide, industrial injury or disease, deaths resulting from ill treatment, starvation, or neglect, deaths occurring during an operation or before recovery from the effect of an anaesthetic, poisoning (including from illicit drugs), stillbirths where there is doubt as to whether the child was born alive, and deaths of prisoners or people in police custody are also considered notifiable.

      It is important to note that these deaths should be reported to the coroner, who will then investigate the circumstances surrounding the death. This is to ensure that any potential criminal activity or negligence is properly addressed and that the cause of death is accurately determined. By reporting notifiable deaths to the coroner, we can help ensure that justice is served and that families receive the closure they need during a difficult time.

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  • Question 10 - An 80-year-old man complains to the palliative care team of increasing fatigue and...

    Incorrect

    • An 80-year-old man complains to the palliative care team of increasing fatigue and breathlessness over the past four weeks. He is under their care and has ceased any active treatment; his preferred care plan is for symptom-related treatment only. He is living independently at home and has been reasonably well over the last six months.
      On examination, he is pale, with a pulse of 96 bpm at rest. He becomes breathless after undressing for the examination. There is a palpable spleen.
      Investigations:
      Investigation Result Normal values
      Haemoglobin (Hb) 66 g/l 130–175 g/l
      White cell count (WCC) 1.2 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 34 × 109/l 150–400 × 109/l
      Neutrophils 0.5 × 109/l 2.0–7.5 × 109/l
      Lymphocytes 0.6 × 109/l 1.0–4.5 × 109/l
      What is the most likely underlying diagnosis?

      Your Answer: Chemotherapy-related bone marrow suppression

      Correct Answer: Primary myelofibrosis

      Explanation:

      Differential Diagnosis for a Patient with Pancytopenia and Splenomegaly

      A patient presents with pallor, tiredness, and breathlessness, along with pancytopenia and splenomegaly. The most likely cause is a myelodysplastic disorder, specifically primary myelofibrosis, which results in scarring of the bone marrow and loss of bone marrow function. This disorder has a median survival of around five and a half years and can cause progressive symptoms. The splenomegaly is due to extramedullary haemopoiesis.

      Other potential causes, such as bowel cancer, prostate cancer, and metastatic oesophageal carcinoma, are less likely due to the absence of relevant symptoms or metastasis to the bone. Chemotherapy-related bone marrow suppression is also unlikely as the patient is not receiving any active treatment.

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