Question 1
A 60-year-old woman with locally advanced cancer of the left breast presented with recent-onset lymphoedema of her left arm. She is not a candidate for radical resection, and due to her pulmonary co-morbidities, she is unable to tolerate radiotherapy. Her examination shows a very swollen left arm, elbow and wrist associated with ischaemic changes in the fingers of her left hand. There is no radial pulse and doppler ultrasound scan shows no thrombus in any of the veins however reduced flow within her brachial arteries. What is the most appropriate initial management of her lymphedema?
(A) Multilayer lymphedema bandaging
(B) Manual lymphatic drainage
(C) Frusemide and spironolactone
(D) Compression sleeve
(E) surgical debulking
B: Lymphedema can be devastating, and it is important to initiate treatment before fibrotic changes occur to the interstitium. Rigorous hygiene is imperative in order to prevent recurrent cellulitis and lymphangitis. First line therapy is physical, including compressive bandages, multilayer bandaging and pneumatic pumps. Manual lymphatic drainage is a gentle compression technique thats designed to ensure natural lymphatic drainage. Medications may also be used such as the benzopyrones however manual lymphatic drainage in this circumstance is the best answer. BMJ Case Rep. 2014
Question 2
A 78 year old male with metastatic prostate cancer with multiple bony lesions complains of sudden onset right hip pain. A CT scan shows a large lytic lesion with cortical thinning within the upper third of the femur. What is the most appropriate management for this patient?
(A) Densoumab
(B) Radiotherapy
(C) Surgical Fixation
(D) Non-weight bearing status
(E) Bisphosphonates and analgesia
C: Whilst bisphosphonates and denosumab have been shown in trials to delay skeletal related events and the appearance of pain, this man has a very unstable lesion that will require surgical fixation for definitive management. All patients with metastatic bone lesions should be evaluated for external beam radiotherapy with a singly 8Gy dose. Can Urol Assoc J. 2012 Dec; 6(6): 465–470.
Question 3
A 33 year old female with metastatic melanoma presents with anhedonia, low mood and decreased appetite. Consult Liaison Psychiatry deem her to be depressed and start her on duloxetine. What best describes the mechanism of action of duloxetine?
(A) Serotonin re-uptake inhibitor
(B) serotonin and noradrenaline re-uptake inhibitor
(C) GABA agonist
(D) selective noradrenaline re-uptake inhibitor
(E) alpha1-receptor antagonist
B: Duloxetine, venlafaxine, des-venlafaxine are all SNRI's N Engl J Med 2005; 353:1819-1834
Question 4
Which of the following medications is NOT used in the management of pruritus in the palliative care setting?
(A) Paroxetine
(B) Fluoxetine
(C) Promethazine
(D) Rifampicin
(E) Doxepin
B: Paroxetine is an SSRI that can be used in the management of pruritus. Promethazine is a sedating antihistamine that comes in 10mg and 25mg tablets, which can be used up to a total of 100mg/24 hours. Rifampicin 150mg BD can be used for cholesastis and is better tolerated than cholestyramine. Ondansetron can also be used for this same indication. Doxepin is an old tricyclic antidepressant that also has been used in the palliative care setting for this indication. eTG 2015
Question 5
A 78 year old male with metastatic renal cell carcinoma who has trialled surafanib, evorolimus and nivolumab and is refractory to all medical therapy presents to the emergency department with intractable fevers and night sweats. What is an appropriate medication to give this man?
(A) promethazine
(B) paroxetine
(C) amitryptiline
(D) hyoscine bromide
(E) Naproxen or paracetamol
E: J Clin Oncol 1995; 3 (4): 552-557
Question 6
A 72 year old male presents to the emergency department with significant dyspnoea at rest. He has Idiopathic pulmonary fibrosis and concomitant chronic obstructive pulmonary disease. He is on maximal inhaled bronchodilator therapy and oral corticosteroids. A chest X-ray confirms a small left sided pleural effusion. He has a mild anaemia (102 g/dL) What is the best management of his breathlessness in this scenario?
(A) Aspiration of effusion
(B) Oxygen
(C) Adding theophylline
(D) Benzodiazepines
(E) opiates
E: Opioids Chest. 1986;86:234-236.
Question 7
An 83 year old type 2 insulin dependent diabetic patient with metastatic non small cell lung cancer is nearing the end stages of his life and is found to have significant hypercalcaemia. What is the best way to manage her blood sugar levels during the last days of his life?
(A) Convert his SC Insulin to oral hypoglycaemic agents
(B) Optimise his already existing basal-bolus regime
(C) Convert to sliding scale insulin
(D) Convert insulin to long acting dose, reduce slightly to minimise hypoglycaemia
(E) Cease all insulin
D: Ceasing all medications is tempting, however hyperglycaemia may precipitate unwanted symptoms such as cerebrovascular events, polyuria, polydipsia and can pre-dispose to infection. Diabetes Care 2005;28:71–7
Question 9
Which of the following medications is NOT a therapeutic agent for the management of hyperhidrosis?
(A) NSAIDS such as diclofenac
(B) Antihistamines
(C) Corticosteroids
(D) SSRIs
(E) 5-HT3 antagonists
E: 5-HT3 antagonists include guanisetron and ondansetron, and they act centrally in order to decrease emesis. Medicine 2015, 43: 12
Question 10
A 68 year old female has significant peripheral neuropathy which is severely limiting function. She has renal impairment and narrow angle glaucoma. Which of the following is the preferred neuropathic pain option
(A) duloxetine
(B) amitryptiline
(C) gabapentin
(D) pregabalin
(E) local capsaicin cream
D: Gabapentin may accumulate in renal impairment. A and B can worsen glaucoma.
A 60-year-old woman with locally advanced cancer of the left breast presented with recent-onset lymphoedema of her left arm. She is not a candidate for radical resection, and due to her pulmonary co-morbidities, she is unable to tolerate radiotherapy. Her examination shows a very swollen left arm, elbow and wrist associated with ischaemic changes in the fingers of her left hand. There is no radial pulse and doppler ultrasound scan shows no thrombus in any of the veins however reduced flow within her brachial arteries. What is the most appropriate initial management of her lymphedema?
(A) Multilayer lymphedema bandaging
(B) Manual lymphatic drainage
(C) Frusemide and spironolactone
(D) Compression sleeve
(E) surgical debulking
B: Lymphedema can be devastating, and it is important to initiate treatment before fibrotic changes occur to the interstitium. Rigorous hygiene is imperative in order to prevent recurrent cellulitis and lymphangitis. First line therapy is physical, including compressive bandages, multilayer bandaging and pneumatic pumps. Manual lymphatic drainage is a gentle compression technique thats designed to ensure natural lymphatic drainage. Medications may also be used such as the benzopyrones however manual lymphatic drainage in this circumstance is the best answer. BMJ Case Rep. 2014
Question 2
A 78 year old male with metastatic prostate cancer with multiple bony lesions complains of sudden onset right hip pain. A CT scan shows a large lytic lesion with cortical thinning within the upper third of the femur. What is the most appropriate management for this patient?
(A) Densoumab
(B) Radiotherapy
(C) Surgical Fixation
(D) Non-weight bearing status
(E) Bisphosphonates and analgesia
C: Whilst bisphosphonates and denosumab have been shown in trials to delay skeletal related events and the appearance of pain, this man has a very unstable lesion that will require surgical fixation for definitive management. All patients with metastatic bone lesions should be evaluated for external beam radiotherapy with a singly 8Gy dose. Can Urol Assoc J. 2012 Dec; 6(6): 465–470.
Question 3
A 33 year old female with metastatic melanoma presents with anhedonia, low mood and decreased appetite. Consult Liaison Psychiatry deem her to be depressed and start her on duloxetine. What best describes the mechanism of action of duloxetine?
(A) Serotonin re-uptake inhibitor
(B) serotonin and noradrenaline re-uptake inhibitor
(C) GABA agonist
(D) selective noradrenaline re-uptake inhibitor
(E) alpha1-receptor antagonist
B: Duloxetine, venlafaxine, des-venlafaxine are all SNRI's N Engl J Med 2005; 353:1819-1834
Question 4
Which of the following medications is NOT used in the management of pruritus in the palliative care setting?
(A) Paroxetine
(B) Fluoxetine
(C) Promethazine
(D) Rifampicin
(E) Doxepin
B: Paroxetine is an SSRI that can be used in the management of pruritus. Promethazine is a sedating antihistamine that comes in 10mg and 25mg tablets, which can be used up to a total of 100mg/24 hours. Rifampicin 150mg BD can be used for cholesastis and is better tolerated than cholestyramine. Ondansetron can also be used for this same indication. Doxepin is an old tricyclic antidepressant that also has been used in the palliative care setting for this indication. eTG 2015
Question 5
A 78 year old male with metastatic renal cell carcinoma who has trialled surafanib, evorolimus and nivolumab and is refractory to all medical therapy presents to the emergency department with intractable fevers and night sweats. What is an appropriate medication to give this man?
(A) promethazine
(B) paroxetine
(C) amitryptiline
(D) hyoscine bromide
(E) Naproxen or paracetamol
E: J Clin Oncol 1995; 3 (4): 552-557
Question 6
A 72 year old male presents to the emergency department with significant dyspnoea at rest. He has Idiopathic pulmonary fibrosis and concomitant chronic obstructive pulmonary disease. He is on maximal inhaled bronchodilator therapy and oral corticosteroids. A chest X-ray confirms a small left sided pleural effusion. He has a mild anaemia (102 g/dL) What is the best management of his breathlessness in this scenario?
(A) Aspiration of effusion
(B) Oxygen
(C) Adding theophylline
(D) Benzodiazepines
(E) opiates
E: Opioids Chest. 1986;86:234-236.
Question 7
An 83 year old type 2 insulin dependent diabetic patient with metastatic non small cell lung cancer is nearing the end stages of his life and is found to have significant hypercalcaemia. What is the best way to manage her blood sugar levels during the last days of his life?
(A) Convert his SC Insulin to oral hypoglycaemic agents
(B) Optimise his already existing basal-bolus regime
(C) Convert to sliding scale insulin
(D) Convert insulin to long acting dose, reduce slightly to minimise hypoglycaemia
(E) Cease all insulin
D: Ceasing all medications is tempting, however hyperglycaemia may precipitate unwanted symptoms such as cerebrovascular events, polyuria, polydipsia and can pre-dispose to infection. Diabetes Care 2005;28:71–7
Question 9
Which of the following medications is NOT a therapeutic agent for the management of hyperhidrosis?
(A) NSAIDS such as diclofenac
(B) Antihistamines
(C) Corticosteroids
(D) SSRIs
(E) 5-HT3 antagonists
E: 5-HT3 antagonists include guanisetron and ondansetron, and they act centrally in order to decrease emesis. Medicine 2015, 43: 12
Question 10
A 68 year old female has significant peripheral neuropathy which is severely limiting function. She has renal impairment and narrow angle glaucoma. Which of the following is the preferred neuropathic pain option
(A) duloxetine
(B) amitryptiline
(C) gabapentin
(D) pregabalin
(E) local capsaicin cream
D: Gabapentin may accumulate in renal impairment. A and B can worsen glaucoma.
