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4/20/2015
ETSU Internal Medicine
Medicine Board Review
Patrick J. Macmillan, MD, FACP
Diplomate of the American Board of Psychiatry and Neurology
Diplomate Hospice and Palliative Medicine
East Tennessee State University
Disclosures and Conflicts
I, Patrick J. Macmillan MD, DO NOT have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of the subject
of this presentation.
Introduction
Common psychiatric mood and anxiety disorders
Psychiatric Emergencies
STAR D Trial (evidence based treatment for depression)
Psychiatric medications: adverse reactions and drugdrug interactions
Dementia Processes
Somatization Disorders
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Introduction
Palliative Medicine
End of life care (Hospice)
Psychosocial issues
Medication issues
Common Psychiatric Disorders
You evaluate a 60 year old woman for increased
irritability and anxiety. She was in a MVA 4 months ago.
Since the accident she reports nightmares about the
incident and is afraid to drive. She reports poor poor
sleep and her husband says she has become more
socially isolated. She denies any thoughts of harming
herself. Physical exam is otherwise normal. What is the
most likely diagnosis?
Common Psychiatric Disorders
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A. Generalized Anxiety Disorder
B. Major Depressive Disorder
C. Obsessive‐
Compulsive Disorder
D. Posttraumatic Stress Disorder
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Common Psychiatric Disorders
Posttraumatic stress disorder
Diagnostic Features---Exposure to traumatic event, intrusive
thoughts (nightmares, flashbacks)
Persistent avoidance of stimuli associated with the event
Negative alterations in cognition/mood (diminished interest or
participation in significant activities)
Marked alterations in arousal and reactivity (e.g. irritable
behavior and exaggerated startle response)
Duration of disturbance greater than 1 month
Common Psychiatric Disorders
Generalized Anxiety Disorder
Diagnostic Features: excessive anxiety and worry about
a number of events or activities—greater than 6 months
“Worry wart”
Individuals find it difficult to control worry
Restlessness, easy fatigue, difficulty concentrating,
irritability, muscle tension, sleep disturbance
Common Psychiatric Disorders
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Common Psychiatric Disorders
Obsessive-Compulsive Disorder
Diagnostic Features: (Obsessions) recurrent or
persistent thoughts, urges or images that are intrusive
and unwanted causing marked anxiety and stress.
(Compulsions) repetitive behaviors such as washing
hands checking, or counting that individuals feels driven
to perform.
“As Good As it Gets”
Common Psychiatric Disorders
An 84 year old man who is living in a SNF is brought to
your office by his daughter who reports he has become
less active in the past few months. No change in mood
noted. He has multiple somatic symptoms such as
headache, scalp pain and constipation. These are longstanding. No weight loss noted. His wife recently died 4
months ago. He has osteoarthritis and takes
Acetaminophen. PE is unremarkable except for slow
response time. He answers questions appropriately.
Labs are all normal. Which diagnostic test is the most
appropriate to perform next?
Common Psychiatric Disorders
A. Dix‐Hallpike
maneuver
B. Mini‐mental Status Examination (MMSE)
C. PHQ‐9 depression assessment
D. Timed “Up & Go” test
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Common Psychiatric Disorders
A 28 year old man is evaluated for a 3 month history of
lack of energy, hypersomnolence, and depressed mood.
He is experiencing disinterest in hobbies and finding it
more difficult to perform his duties as a physician. In the
past he had periods where he experienced euphoric
moods and needing little sleep. In those periods he
found himself engaged in risky behaviors. There is a
family history of alcohol abuse. Which is the most
appropriate treatment?
Common Psychiatric Disorders
A. Duloxetine
B. Lamotrigene
C. Clonazepam
D. Fluoxetine
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Common Psychiatric Disorders
Mood Disorders
Major Depression
Depression, NOS
Bereavement
Bipolar Disorder
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Common Psychiatric Disorders
Major Depression
Diagnostic features: (1)depressed mood or (2) loss of
interest or pleasure----2 weeks
Weight loss, sleep disturbance, psychomotor agitation,
loss of energy, feelings of worthlessness/guilt, poor
concentration, recurrent thoughts of death
Common Psychiatric Disorders
Other Specified Depressive Disorder
Recurrent brief depression: depressed mood with only 4 other
symptoms lasting 2-13 days which occurs once a month
Short duration depressive episode (4-13 days)
Depression Scales: Beck Depression Checklist, Hamilton
Depression Inventory, Patient Health Questionnaire (PHQ-9),
Geriatric Depression Scale
PHQ-9 is a validated tool with sensitivity of 80-90%, specificity
of 90% (www.cqaimh.org/pdf/tool_phq9.pdf)
Common Psychiatric Disorders
Persistent Complex Bereavement Disorder
Diagnostic features: Experienced the death of someone
close; longing for the deceased, intense sorrow,
preoccupation with the deceased, preoccupation with
the circumstances of the death
Normal Grief: feeling of emptiness or loss, lasts days to
weeks and occurs in waves (“pangs of grief”); May be
accompanied by positive emotions and humor; self
esteem usually preserved.
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Common Psychiatric Disorders
Bipolar Disorder
Diagnostic features: abnormally, persistently elevated,
expansive or irritable mood and persistently increased
activity or energy that is present for most of the day,
nearly every day, for a period of at least a week
Major Depressive Episode
Social Rhythm Therapy
What is the most appropriate
next step?
A. Schedule the patient for a
dementia evaluation.
B. Reduce the patient’s
Divalproex dose.
C. Add Donepezil to the
patent’s medication
regimen.
D. Check the patient’s serum
ammonia level.
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Key point
Hyperammonemia is an adverse effect of Valproate.
Thus, a change in cognitive status should prompt a
careful evaluation of liver and pancreatic function, which
should include obtaining serum ammonia levels.
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Psychiatric Emergencies
A 45 year old Schizophrenic male presents to the ER by
EMS with rigidity, fever and confusion. On physical exam
he is febrile with a temperature of 103.5. You are unable
to illicit any history from the patient and EMS has left.
What do you suspect is happening?
Psychiatric Emergencies
A. Tardive Dyskinesia
B. Extra Pyramidal
Symptoms
C. Neuroleptic
Malignant
Syndrome
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D. Serotonin
Syndrome
Psychiatric Emergencies
A 54-year-old female presents to the emergency room
with confusion. She is noted to be on bupropion at the
maximum dose, and recently was prescribed
Escitalopram in a small dose.
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What is the likely cause of her
confusion?
A. Dissociative
Episode
B. Delirium
C. Seizure
D. Stroke
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E. Drug overdose
Psychiatric Emergencies
A patient is being treated for depression with Sertraline
50 mg. She mentions to you that she has been taking
some St. John's Wort as well, and would like to know if
she could take both of them together. What adverse
reaction can result with this combination?
Psychiatric Emergencies
A. Neuroleptic Malignant
Syndrome
B. Tardive Dyskinesia
C. Serotonin Syndrome
D. Hepatic Failure
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E. Renal Failure
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Key points
Neuroleptic Malignant Syndrome: muscle cramps or rigidity, fevers, autonomic
instability, confusion, elevated CPK—associated with D2 blockade
Serotonin Syndrome: myoclonus, sweating, shivering, hyperreflexia;
Hyperthermia, elevated BP, hyperactive bowel sounds---associated with SSRI’s
Tardive Dyskinesia: Grimacing, tongue movements, lip smacking, lip puckering,
Pursing of the lips, excessive eye blinking
EPS: akathisia or akinesia
All anti-depressants can lower the seizure threshold
Remember Linezolid (zyvox) and use of SSRI’s
Psychiatric Emergencies
The incidence of benign rash with lamotrigine is
approximately:
Psychiatric Emergencies
A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
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Key points
Key points
Key points
Stevens–Johnson syndrome (SJS) usually begins with
fever, sore throat, and fatigue, which is commonly
misdiagnosed and therefore treated with antibiotics.
Ulcers and other lesions begin to appear in the mucous
membranes, almost always in the mouth and lips but also
in the genital and anal regions. Those in the mouth are
usually extremely painful and reduce the patient's ability
to eat or drink.
Associated with Lamotrigine
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Evidence Based Medicine
A 38 year old female returns to your clinic for follow up.
She has major depression for the past 5 months. She
was started on Sertraline (Zoloft) 50 mg/day and after 6
weeks her symptoms marginally improved. The dose
was increased to 100 mg/day with slight improvement.
After an additional 6 weeks the dose was maximized to
200 mg/day with no additional improvement. What would
you recommend?
Evidence Based Medicine
A. Stop Sertraline and start
Fluoxetine (Prozac)
B. Add Buspirone (buspar)
C. Switch to Escitalopram
(lexepro)
D. Add Buproprione
(wellbutrin)
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E. Switch to Nortriptyline
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Evidence Based Medicine
STAR*D Trial (Sequenced Treatment Alternatives to
Relieve Depression)
The NIMH-funded Sequenced Treatment Alternatives to
Relieve Depression (STAR*D) Study was conducted to
determine the effectiveness of different treatments for people
with major depression who have not responded to initial
treatment with an antidepressant. This is the largest and
longest study ever conducted to evaluate depression
treatment.
http://www.nimh.nih.gov/health/trials/practical/stard/index.shtm
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Key points
Level 1: SSRI (Citalopram)
Level 2: SSRI + bupropion or CBT
Level 3: SSRI or Other + Lithium or triiodothyronine (T3)
Level 4: MAOI’s (tranylcypromine)
Psychiatric medications
You are evaluating a 55 year old male patient in the ER for
mental status changes. He is unable to provide a history but
you check the EHR and find he has multiple admissions to
Woodridge Hospital for bipolar disorder. You astutely note that
he was started on an ACE inhibitor on his last admission to
Woodridge several weeks ago. You note tremors bilaterally in
his hands along with hyperreflexia. The psychiatry tech with
him notes that his balance has gotten worse over the past day
or so. Otherwise PE is normal aside from obvious
disorientation. BUN and creatinine are 40 and 2.6,
respectively. Other labs and tests are normal. Which of the
following drugs is the most likely the cause of this man’s
symptoms?
Psychiatric medications
A. Amitriptyline (Elavil)
B. Paroxetine (Paxil)
C. Aripiprazole (Abilify)
D. Lithium
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Key points
Lithium:
Commonly used for Bipolar Disorder and occasionally
refractory depression
Renal Execretion (urine 95%); half life 24 hr
Watch for toxicity when used with NSAIDs, ACE or
dehydration
Diabetes insipidus
Ebstein’s Anomaly
Psychiatric medications
A 50 year old female comes to your office for severe hot
flushes limiting her quality of life and causing vaginal dryness.
Her history is significant for stage II, estrogen and
progesterone receptor positive, HER2-negative, invasive right
breast cancer for which she received chemotherapy and
radiation. She was diagnosed 1 year ago and has been taking
tamoxifen for 3 months. She has been amenorheic since her
4th cycle of chemotherapy. Attempts to control the hot flushes
by non-pharmacologic means has failed. Further exam and
history is otherwise unremarkable. Which of the following is
the most appropriate therapy?
Psychiatric medications
A. Fluoxetine
B. Low-dose
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Key points
SSRI’s (e.g. Fluoxetine, Paroxetine, Sertraline): Potent
CYP2D6 inhibitors
SNRI’s (e.g. Venlafaxine, Duloxetine)
Others (bupropion, mirtazipine)
Avoid in seizure disorders or eating disorders--bupropion
Metabolic syndrome—Mirtazipine
Psychiatric medications
A 26 year old male who you treat for seasonal allergies
and occasional GERD symptoms comes to your office.
He has a history of schizoaffective disorder and comes to
your office for his annual physical exam. You note he
has gained 30 lbs. in the past year (BMI of 28), and his
blood pressure is 148/95. Lipid panel reveals
triglycerides of 256. He tells you “Dr. Mac” has placed
him on a new medicine 6 months ago. Which new
medicine is the patient likely taking that has caused the
changes noted.
Psychiatric medications
A. Haloperidol
B. Lithium
C. Olanzapine
D. Bupropion
E. Aripiprazole
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Key points
Typical and Atypical Antipsychotics (e.g Haloperidol,
Olanzapine)
Atypicals: Metabolic Syndrome
Aripiprazole and ziprazidone are less likely to cause
Metabolic Syndrome
3 of 5 criteria: abdominal (central) obesity, elevated blood
pressure, elevated fasting plasma glucose, high serum
triglycerides, and low high-density cholesterol (HDL)
levels.
Psychiatric medications
An 80 year old female had a hip fracture repaired 3 days
ago and has developed a UTI and episodes of atrial
fibrillation with RVR. She is experiencing a delirium and
her medications include digoxin, diltiazem, bactrim,
haloperidol, and enoxaparin, which have been started
while in the hospital. Her past medical history includes
PAF. Vitals are stable. EKG is performed and shows a
QTc of 520 (baseline QTc of 420). Which of the following
medications is most likely the cause of the EKG
changes?
Psychiatric medications
A. Diltiazem
B. Enoxaparen
C. Haloperidol
D. Bactrim
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Key points
Haloperidol and other psychiatric medications can
prolong QT interval thereby lengthening cardiac
repolarization
If QTc is greater than 500 msec or has increased by 60
msec or more than the offending agent should be
stopped because of the risk of torsades de pointes
Dementia Processes
Why should TCA’s be avoided in elderly patients with
Alzheimer's Disease?
Dementia Processes
A. They worsen
cognition
B. They cause weight
gain
C. They cause sedation
D. They cause dry mouth
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E. They cause urinary
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Dementia Processes
Which SSRI is most likely to worsen cognition in a patient
with Alzheimer's Dementia?
Dementia Processes
A. Paroxetine
B. Sertraline.
C. Fluoxetine
D. Fluvoxamine
E. Citalopram
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Dementia Processes
The head CT scan of a 68-year-old female patient
experiencing memory difficulty is interpreted by the
radiologist as showing "mild age-appropriate generalized
atrophy with signs of periventricular white matter
disease." Also, neuropsychological testing reveals
borderline functioning in the area of orientation and
memory, without any other abnormalities. You set up a
meeting with the patient and her family to discuss the
meaning of these findings and the course of treatment.
What would be LEAST appropriate to tell them at this
meeting?
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Dementia Processes
The patient may be at an early stage of
a dementing process.
The patient should start thinking about
legal processes such as designating
powers of attorney, advance directives,
and establishing a will.
D.
The patient should have a neurological
consultation.
E.
At this stage, the patient can continue
independent functioning.
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Alzheimer’s Dementia: linier cognitive decline; early onset
Vascular dementia: step-wise decline; later onset
Lew body dementia: visual hallucinations (seroquel)
Parkinson’s dementia: prior history
Frontal lobe Dementia: inappropriate behavior; early onset
BLACK BOX Warning: Long term use (greater than 30 days)
Antipsychotic medications and Dementia---Cerebrovascular
and cardiovascular events
Somatoform Disorders
A patient presents with his family to the emergency room.
He complains of leg paralysis that begun a week after his
father died. The doctor tests the patient for the Hoover
sign by asking the patient to lift the normal leg while
placing his hand under the heel of the paretic leg. The
results of this test are a possible indication of which
disorder?
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Somatoform Disorders
A. Body Dysmorphic
Disorder
B. Conversion Disorder
C. Dissociative Disorder
NOS.
D. Hypochondriasis
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Key points
Body Dysmorphic Disorder: Michal Jackson
Conversion Disorder: Unexplained neurological issue
Hypochondriasis: Medical students. “I think I have a brain
tumor” for tension headache
Somatization Disorder: Female, under 30, GI, GU, pain,
neurological “symptoms”
Malingering: secondary gain
Factitious disorder: look for someone in the medical field
intentionally producing illnesses “munchausen by proxy”
Factitious disorder
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Palliative Medicine
A 78-year-old man with metastatic colon cancer is admitted
with dehydration and anorexia. Upon discussion with the
patient, he tearfully reveals that he feels fatigued, has a
poor appetite, has lost 5 lbs over the past month, and
remains in bed for a majority of the day. His wife reports
that on some days he is tearful and spends a great deal of
time talking about his death. Both are in agreement that he
still looks forward to spending time with his grandchildren.
Which one of the following options is the most appropriate
diagnosis of the patient’s mood disorder?
Palliative Medicine
A. Major depressive
disorder
B. Anticipatory grief
C. Cancer-induced
failure to thrive
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D. Sadness
Palliative Medicine
An 88-year-old man with advanced dementia is admitted to
the hospital for his third episode of pneumonia over the
past 5 months. He has lost 5 lbs over this time period. He is
unable to participate in discussions about his care,
although his adult daughter is his documented health care
proxy and has taken over making decisions for him. A
speech and swallowing evaluation clearly demonstrates
that he is aspirating thin and thick liquids. The patient’s
daughter asks about the possibility of a feeding tube.
Which one of the following responses to her questions is
the most appropriate?
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Palliative Medicine
Feeding tubes have been shown to
reduce aspiration pneumonia in patients
with dementia
C.
Video swallowing studies are very
sensitive and specific to predict who will
develop aspiration pneumonia
D.
There is no evidence that a feeding tube
will either prolong life or reduce
aspiration risk in patients with advanced
dementia
E.
Feeding tubes will not help him gain
weight or remain at a stable weight
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A.
Palliative Medicine
A 65-year-old man with NSCLC is admitted to the hospital after
his wife found him tachypneic and with impaired speech at
home. She reports that this is new, as of 12 hours ago. His
medications include fentanyl patch and hydromorphone for pain,
and metoclopramide for nausea; he was recently started on
haloperidol for increasing confusion on a previous hospital
admission. On exam, he is tachypneic and restless in bed with
continuous movements of his hands and feet. He is unable to
appropriately answer complex questions. Which one of the
following steps in management is the most appropriate to ensue
with this patient?
Palliative Medicine
D.
Add olanzapine 5 mg PO
every 12 hours
E.
Rotate his fentanyl as this is a
true allergic reaction to
additives in the patch
0%
0%
0%
0%
0%
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.
A STAT head CT to evaluate
for possible CNS metastasis
os
e o
C.
is d
Discontinue haloperidol and
metoclopramide
h
B.
ble
Double his dose of
haloperidol
Do
u
A.
22
4/20/2015
Key points
Anticipatory Grief
No evidence to support Feeding Tubes
Remember EPS: “continuous movements of hands and
feet”---Akathesia
Palliative Medicine
A 20-year-old female was in a motor vehicle accident and had
prolonged resuscitation in the field prior to regaining a pulse 72
hours ago. She remains intubated and nonresponsive with no
sedatives in the ICU. Her core body temperature is 36.5 °C (97.7
°F). Her pupils are 3 mm, equal, and nonreactive to light
bilaterally. She has no corneal, oculocephalic, or oculovestibular
reflexes and cannot be stimulated to gag. She has no motor
responses to painful stimuli. The neurointensivist performed a 10
minute apnea test in which her PC02 rose by >10 mmHg on
arterial blood gas; she had no spontaneous respirations. Which
one of the following steps in management should ensue with this
patient’s care?
Palliative Medicine
Perform an EEG
E.
Correct all electrolyte
abnormalities
0%
0%
0%
0%
0%
RI
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lo
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D.
Pe
Perform a second examination to
assess her brainstem reflexes,
body temperature, and presence
of apnea
rm
a
n M
C.
th
i
Nothing further is needed—she
qualifies for brain death
rfo
B.
No
Perform an MRI brain to look for
cerebral blood flow
Pe
A.
23
4/20/2015
Key point
a second exam is needed to declare brain death.
If a patient has a core temperature above 32 °C, she has no
brainstem reflexes as evidenced by gag, corneal,
oculocephalic, and oculovestibular, and a positive apnea test
(a 10 mmHg rise in CO2 within 10 minutes and no
spontaneous respirations), and this is verified by a repeated
exam, the patient meets brain death criteria.
Any doctor can perform a brain death test SOURCE:
Morenski JD. Determination of death by neurological criteria. J
Intensive Care Med. 2003; 18(4): 211-221.
Palliative Medicine
Which one of the following factors is the most important
predictive factor in cancer survival?
Palliative Medicine
A. Age
B. Sex
C. Symptom burden
D. Performance status
di
ic a
l c
o m
or
bi
ed
M
Pe
0%
tie
s
0%
rfo
rm
an
om
b
ur
Se
x
de
n
0%
ce
st
at
us
0%
Sy
m
pt
0%
Ag
e
E. Medical co
morbidities
24
4/20/2015
Key points
A patient’s functional ability is a measure of how much a
patient can do for themselves, their activity, and energy level.
Patients with solid tumors typically lose ~70% of their
functional ability in the last 3 months of life.
The most common scales used to measure functional ability
are the Karnofsky Index and the ECOG scale (Eastern
Cooperative Oncology Group).
Age, sex, symptom burden, and co morbidities have not been
shown to be a reliable predictor of survival. SOURCE:
Lamont EB, Christakis NA.. Complexities in prognostication in
advanced cancer. JAMA. 2003; 290:98-104.
Palliative Medicine
A 47-year-old male with severe COPD is admitted to the
ICU with hypercapnic respiratory failure requiring
intubation. After 48 hours on a ventilator, he is
successfully extubated and remains on high-flow oxygen
via nasal cannula. He is frustrated with his recurrent
hospitalizations and experiences dyspnea with minimal
exertion. Palliative care is consulted to discuss advance
care planning with him and his wife. Which one of the
following variables is most predictive of poor one year
survival?
Palliative Medicine
A. Age
B. Smoking status
C. Oxygen requirement
D. Percent predicted
FEV1
Ag
e
0%
0%
0%
0%
in
g Ox
st
at
yg
us
en
re
qu
Pe
ire
rc
m
en
en
t p
t
re
di
ct
To
ed
ta
FE
l l
un
V1
g c
ap
ac
it y
(T
LC
)
0%
Sm
ok
E. Total lung capacity
(TLC)
25
4/20/2015
Key points
An FEV1 <35% predicted is indicative of severe COPD and using the
BODE index to calculate 1 and 2 year survival is indicative of worse
survival.
Although COPD is difficult to prognosticate for shorter-term survival,
studies have shown that FEV1 percent predicted, BMI, 6 minute walk
distance, and a dyspnea scale (0 = no dyspnea, to 4 = dyspneic
when dressing) are helpful in predicting 1 year and 2 year mortality.
Elevated pCO2 >50 mmHg and mechanical ventilation >72 hours
have also purported poor survival. SOURCE: Celli BR, Cote CG,
Marin JM, et al. The body-mass index, airflow obstruction, dyspnea,
and exercise capacity index in chronic obstructive pulmonary
disease. N Eng J Med. 2004; 350(10):1005-12
Palliative Medicine
An 86-year-old man, with end stage renal disease on
hemodialysis, is admitted to the hospital for hypertensive
emergency. His blood pressure is controlled via IV
mediations and an emergent session of dialysis. Because
of concern for cardiac arrest necessitating CPR, a codestatus discussion is initiated with him and his adult children.
His son asks if his heart would stop and he needed
prolonged CPR, what his chance of survival is. Which one
of the following options is the most associated with poor
survival to discharge post-CPR?
Palliative Medicine
A. Asystole or pulseless
electrical activity (PEA)
as the etiology of the
arrest
B. Myocardial infarction
C. Hypertension
..
Ra
ce
0%
Ve
nt
ric
ul
ar
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r il
ar
di
ul
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ys
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l
0%
s t
he
.
0%
se
le
ss
e
le
ct
ric
..
al
in
fa
rc
tio
n
Hy
pe
rt
en
sio
n
0%
n a
0%
E. Ventricular fibrillation as
the etiology of the arrest
la
tio
D. Race
26
4/20/2015
Key points
In hospital cardiac arrests with prolonged resuscitation, there is a
poor survival to discharge for all patients, with only approximately
one-quarter of these patients surviving to discharge.
If asystole or pulseless electrical activity occurs, 10% or less of these
patients survive to discharge. Of patients surviving to discharge post
resuscitation, only one-half of these will be able to return home.
Factors shown to increase likelihood of survival to discharge are MI,
HTN, and ventricular fibrillation or pulseless ventricular tachycardia
on arrest. SOURCE: Peberdy MA, Kaye W, Ornato JP, et al.
Cardiopulmonary resuscitation of adults in the hospital: A report of
14,720 cardiac arrests from the National Registry of
Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308
Palliative Medicine
A 72-year-old Chinese-speaking woman with advanced
gastric cancer is admitted with nausea and vomiting. She
speaks minimal English; however, she has a son who
speaks fluent English with her in her hospital room who
has offered to translate for his mother. You are asked to
help with management of her nausea and vomiting, and
discuss goals of care. Which one of the following steps in
assessment is the most appropriate to ensue with this
patient?
Palliative Medicine
Allow the son to interpret as long as the
patient is in agreement with this
C.
Ask the patient’s nurse to translate, as
she is also Chinese-speaking
D.
Begin the conversation in English, as
she is able to answer many “yes/no”
questions; get an interpreter for more
detailed discussion after she is feeling
better
E.
Allow the son to interpret for his
mother—a family member is an
accepted form of translation
0%
0%
0%
0%
0%
r a
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in
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..
B.
Al
lo
Ask for a Chinese interpreter prior to
proceeding any further with the consult
As
k fo
A.
27
4/20/2015
Key point
you must use a certified medical interpreter for all
interactions to ensure that you are effectively
communicating with your patient.
It is not acceptable for a family or staff member to serve
as an interpreter. Professional interpreters ensure that
the patient is hearing exactly what you say and vice
versa.
Has been shown to improve communication between
language discordant patients and clinicians. Palliative Medicine
A 22-year-old male with testicular cancer is started on
immediate-release morphine for pain control. Which one
of the following options is the most appropriate indicator
of potential opioid abuse problems?
Palliative Medicine
0%
0%
0%
0%
d d
os
e es
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la
...
dr
a
st
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ee
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nt
.
ra
tin
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te
r ..
.
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w
ith
ue
Difficulty concentrating after
taking a dose
Re
q
E.
r r
ap
i
Around-the-clock need for the
immediate-release morphine
in
g
D.
fo
Requests to multiple physicians
for prescriptions and regular need
for early refills
ee
d
C.
er
ie
nc
Experiencing withdrawal
symptoms with cessation of the
drug
A n
A need for rapid dose escalation
B.
Ex
p
A.
28
4/20/2015
Key point
Requests for more than one physician to write prescriptions for pain medications and
regular need for early refills.
Signs of opioid abuse or misuse include use causing adverse life events, need for early
refills or “lost” prescriptions, asking for specific medications by name, or asking multiple
physicians for opioid prescriptions.
The definition of addiction is primary, chronic, neurobiological disease with genetic,
psychosocial, and environmental factors influencing its development and manifestations.
Although rare, some patients develop problems with opioid abuse and addiction; everyone
on chronic opioids should be monitored for these signs.
Rapid dose escalation and need for around-the-clock dosing are often related to pseudoaddiction, which occurs from under-treated pain.
Remember Pseudoaddiction
Palliative Medicine
A 62-year-old man with advanced head and neck cancer
is admitted to the hospital with local wound breakdown
and pain. He notes that over the past 24 hours he had a
small amount of hematemesis that spontaneously
resolved. On physical exam, the patient has a large
tumor on the left side on his neck with erosion through
the skin and areas of oozing that cause significant pain
with neck rotation. The patient wishes to focus on comfort
and is hopeful to go home although he lives alone. Which
one of the following steps in management is the most
appropriate to ensue with this patient?
Palliative Medicine
Assess his swallowing function
for safety to continue pills by
mouth
B.
Discuss the possibility of carotid
blowout syndrome
C.
Increase his long-acting pain
medication by 25%
D.
Ask for a wound care nurse
evaluation and plan for dressing
changes
E.
Explain to the patient that he is
not able to leave the hospital
0%
0%
0%
0%
0%
As
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is s
w
a ll
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ow
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in
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p
os
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o
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lo
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..
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ie
nt
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at
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..
A.
29
4/20/2015
Key point
Discuss possible carotid blowout as this patient is at very high risk for
a catastrophic bleed. Carotid blowout is the rupture of any portion or
branch of the extracranial artery.
Risk factors for this include prior radiation, extensive surgery, skin
breakdown, or infection. A sentinel bleed—orally or transcervical—
indicates a higher likelihood of impending rupture. Careful discussion
about goals of care and symptom management are necessary, including
use of dark colored towels, acute medication strategies, and what home
support is available.
Although an increase in his pain medication or change in wound care
may be warranted, this is not nearly as important as recognizing the
signs of impending carotid blowout
SOURCE: Harris DG, Noble SI.
Management of terminal hemorrhage in patients with advanced cancer:
a systematic literature review. J Pain Sympt Manage. 2009; 38:913-27.
Palliative Medicine
An 85-year-old man, with colon cancer and a large metastatic
burden in his liver, has continued to have a poor appetite and
early satiety. He remains at home with hospice, but is now
mostly bedbound and eats a few bites at a time from large
meals his wife continues to cook for him. He denies any
nausea or constipation as well as any sensation of hunger. His
family is concerned that he is not taking in enough calories to
maintain his strength. Which one of the following steps in
management is the most appropriate to ensue with this
patient?
Palliative Medicine
0%
St
ti.
ar
.
ily
t m
t h
et
at
hy
h
lp
e he
i..
.
ni
da
te
5
m
g.
..
0%
va
lu
a
ni
st
e
la
in
t o
h
ut
rit
io
Ex
p
0%
is fa
m
rie
o
ra
...
0%
n
e 1
ig
h‐
ca
lo
5 m
g.
..
0%
r a
Start methylphenidate 5 mg with meals
az
ap
in
E.
h
Explain to his family that he is not
experiencing any discomfort or hunger
and that anorexia is a common side
effect of advanced cancer
As
k fo
Ask for a nutritionist evaluation and
consultation
D.
e m
irt
C.
m
en
d
Recommend high-calorie oral
supplements
Re
co
m
Prescribe mirtazapine 15 mg daily
B.
Pr
es
cr
ib
A.
30
4/20/2015
Key points
discuss with the family the nature of cancer, cachexia, and the
frequency of anorexia with advanced disease.
Although patients are not troubled by their lack of PO intake, many
family experience distress around poor feeding and nutrition.
Given his short life expectancy and progression of disease, no
medications are effective in treating the expected cachexia and
anorexia seen at the end of life.
Oral supplements for forced oral intake can cause significant nausea
and vomiting and is not recommended. While helpful in early-stage
cancers, nutritionists do not have a role in the end stage cancer
cachexia. SOURCE: Strasser F, Bruera E, Update on anorexia and
cachexia. Hematol Oncol Clin North Am 2002; 16:589-617.
Palliative Medicine
A 52-year-old woman, with metastatic ovarian cancer, is
admitted with nausea, vomiting, and 48 hours of acute
abdominal pain. A CT scan of her abdomen and pelvis reveals
a single site of complete bowel obstruction in her descending
colon, likely from a new metastatic lesion. An NG tube is
placed with a large amount of bilious output, and her nausea
and vomiting subside. Prior to admission, she was working
part-time in the business she owns with her husband. On
physical exam, she appears comfortable with diffuse
abdominal tenderness and hypoactive, high-pitched bowel
sounds. Which one of the following steps in the management
of her bowel obstruction is the most appropriate to ensue with
this patient?
Palliative Medicine
Consult interventional radiology for
possible stent placement
D.
Keep the patient NPO and reassess her
physical exam in 48 hours
E.
Start metoclopramide 10 mg IV every 6
hours
0%
0%
0%
0%
0%
t o
th
e p
at
ie
t s
nt
ur
a
ge
nd
Co
ry
h
fo
ns
..
r p
ul
t i
os
nt
s
i
er
ble
ve
Ke
..
nt
.
ep
io
th
na
l r
e p
ad
at
io
ie
St
...
nt
ar
N
t m
PO
et
a
oc
nd
lo
r.
pr
..
am
id
e 1
0 m
g .
.
C.
la
in
Consult surgery for possible surgical
interventions
ns
ul
B.
Ex
p
Explain to the patient and her husband
that there is nothing more to offer her
and hospice would be helpful in keeping
her comfortable at home
Co
A.
31
4/20/2015
Key points
Consult surgery for possible surgical interventions. Malignant bowel
obstruction is a common complication of ovarian cancer.
Decision making in management of bowel obstruction relies on several factors:
site of obstruction; single vs. multiple sites of obstruction; clinical assessment;
patient’s age; functional status; and functional vs. mechanical obstruction.
Presence of carcinomatosis, failed chemo trials, ascites: Unlikely to benefit from
surgery (ascites= NO PEG)
A surgical intervention is preferred when a patient has a good performance
status, there is a single site of mechanical obstruction, and distal bowel affected
Metoclopramide must be avoided in complete obstructions, as it could cause an
exacerbation of her pain. SOURCE: Ripamontia C, Eassonc M, Gerdesd H.
Management of malignant bowel obstruction. European Journal of Cancer 2008;
44: 1105-1115.
Palliative Medicine
A 48-year-old female, with head and neck cancer undergoing
concurrent chemotherapy and radiation, is admitted to the
hospital with failure to thrive. She has lost a significant amount
of weight (>20 lbs) since beginning treatment. She denies
significant nausea, vomiting, or odynophagia limiting her
intake, but notes that she does not have any appetite. On
physical exam she is cachetic with dry mucus membranes and
no oral lesions or evidence of thrush. Abdominal exam is
unremarkable. Her oncologist talked with her about use of
megestrol acetate during an outpatient visit and she asks if
this would be helpful. Which one of the following options would
make use of megestrol acetate contraindicated?
Palliative Medicine
A. History of
gastrointestinal
bleeding
B. History of arrhythmia
C. Current use of
dexamethasone
D. Renal insufficiency
0%
0%
0%
Cu
as
tro
i
Hi
st
or
y o
f g
Hi
st
or
0%
nt
es
tin
al
b
...
y o
rr
en
f
a
t u
rrh
se
yt
o
hm
f d
ia
ex
am
et
ha
Re
so
Hi
na
st
ne
or
l in
y o
su
f t
f fi
hr
cie
om
nc
bo
y
em
bo
lic
..
.
0%
E. History of
thromboembolic events
32
4/20/2015
Key points
Megestrol acetate, a synthetic progestin, is useful in some
patients with cachexia and severe anorexia to aid in weight
gain. Although the results are modest (less than 30% of
patients will have a significant response), the medication is
extremely helpful for selected patients.
The side effects are generally mild and the only strong
contraindication is a history of thromboembolic events.
SOURCE: McQuellon RP. Supportive use of megestrol
acetate with head/neck and lung cancer patients receiving
radiation therapy. Int J Radiat Oncol Biol Phys. 2002; 52:11805.
Disease Prognosis: Impending
Death
Last hours
Prognostic signs: Death Rattle, jaw movement with
breathing, Acrocyanosis (mottling), radial pulselessness
Feeding Tubes: DO NOT prevent aspiration, NO
evidence of benefit
Respiratory Congestion (Death Rattle): reposition, stop
IVF, meds (robinol), DO NOT suction.
Remember: IVF DO NOT treat sensation of thirst
Psychosocial Aspects of
Palliative Medicine
Substituted Judgement: Family attempts to discern what patient would say if they
were able
Futility Principle: only approach this strategy after establishing rapport with family
Thoughts of hastening death: Common, may be call for “help” don’t call
Woodridge so fast...
Pseudoaddiction: occurs when patients pain is under treated
Family Meeting: satisfaction correlates with increased proportion of time that
family members speak
Breaking bad news: ALWAYS start by asking the patient of her understanding of
the current situation
33
4/20/2015
Psychosocial Aspects of
Palliative Medicine
You are asked to do a consult on a 29-year-old man in a persistent
vegetative state who was transferred from a nursing home with his
fourth episode of urosepsis. He has a stage 4 pressure ulcer on his
coccyx and severe contractures. During each hospitalization, he has
had to be admitted to the intensive care unit (ICU) and put on
vasopressors and a mechanical ventilator for 1 to 2 weeks. The ICU
team feels that they have tried everything to convince the family that this
care is futile. Still, the family persists in their hope for a miracle. When
you sit down with the patient’s mother, she tells you that she is frustrated
by the endless meetings and that she wants “everything done to help
him.” She says that she feels like the ICU doctors do not care about her
son, and she resents having to talk to you (“Do they make you talk to
everyone?”). She says, “I cannot give up. I have faith that God will give
me a miracle and bring my son back.”
Which of the following would be the most appropriate response?
Psychosocial Aspects of Palliative Medicine
“Given how long your son has
been asleep, it is very unlikely he
will ever awaken.”
B.
“Maybe God has a different plan
for your son.”
C.
“Have you thought about what we
should do if you do not get a
miracle?”
D.
“Why do you think your son will
be the one to get a miracle?”
E.
“I can see how important a
miracle is to you.”
0%
0%
0%
0%
0%
“G
iv
en
h
ow
lo
“M
ng
ay
yo
be
ur
G
so
od
h
n h
“H
as
..
av
a e y
di
ffe
ou
re
th
nt
“W
ou
.
..
gh
hy
d
t a
o y
bo
ou
ut
w
th
“I
...
in
ca
k y
n s
ou
ee
r s
h
on
ow
..
im
.
po
rt
an
t a
..
.
A.
Key points
Developing a relationship is a critical first step when
stepping into a previously conflicted relationship.
Simple reflections that allow the family to be heard are
better options than convincing statements or interrogative
questions.
34
4/20/2015
THE END
Good Luck
35