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HPC study info
| Question | Answer |
|---|---|
| Morphine by-product that leads to myoclonus (agitated delirium, hyperalgesia, and even seizures. Morphine and hydromorphone are the most common culprits) | Morphine 3-glucoronide |
| vomiting center receptors in the brain | 5HT-III (serotonin), d2 (dopamine), M (acetylcholine), substance P which acts on neurokinin 1 receptors, and (H-1) histamine |
| Higher cortical centers affected in nausea/vomiting by which of the following conditions? | increased icp, psychogenic stimuli, sensory stimuli |
| chemoreceptor trigger zone (outside bbb, in the medulla) affect n/v in which of the following conditions? | chemo, opioids; uremia, hypercalcemia, toxins (neurokinin/substance p, d2, 5Ht3 receptors) |
| GI tract affected in nausea and vomiting affected by which of the following conditions? | obstruction, stasis, metastatic dz, bacterial toxins, drugs, chemo agents, xrt (all receptors, including mechanical) |
| Vestibular apparatus in nausea and vomiting affected by which of the following conditions? | motion, opioids (histamine and acetylcholine (M)) |
| Tolerance of nausea/vomiting in opioids improve after how many days | 3-4; constipation never abates |
| Best antiemetic for chemotherapy induced? | 5HT-3 (ondansetron) during treatment, for delayed n/v then ****** |
| Best antiemetic for opioid induced nausea? | Dopamine antagonist!! |
| which anti-emetics work main in the the chemo trigger zone (CTZ)? which is least sedating? | Haldol ( D2), prochlorperazine(D2>>>Ach, H1-->does not have prokinetic effects), chlorpromazine (D2=Ach=H1=) very drowsy due to high ach and h1 but equally all around for this one in these receptors, promethazine (H1 class-very high, then Ach>>>D2) |
| Which ammonium salts have the least CNS penetration (for secretions) as quaternary ammonium salts? | Glycopyrrolate, hyoscine salt (NOT hyoscine hydrobromide, hydrobromide is tertiary and crosses BBB) |
| Drugs that cause constipation? | anticholinergics, TCAs, scopolamine, oxybutynin, promethazine, diphenhydramine, verapamil, ondansetron,, Fe, CALCIUM!!! |
| Which antidepressant best for insomnia, anorexia, nausea? | mirtazapine |
| which antidepressant best for anxiety, insomnia, neuropathy? | TCAS (duloxetine and venlafaxine aren't effective for insomnia) |
| Which antidepressants are the most activating? | Fluoxetine (Prozac) and bupropion |
| Which antidepressant is sedating that's not mirtazapine? | Paroxetine (Paxil) can be sedating! Citalopram is neutral (best for older people without other issues, as well as Escitalopram and sertraline as these both have low drug-drug interaction ) |
| Which antidepressant good for anxiety, neuropathic pain, advanced age? | Duloxetine (better tolerated in elderly than TCAs) |
| What is the only available disease modifying drug for ALS | Riluzole (prolongs median survival only by 2-3 months compared to placebo) but does little to improve functional outcomes or bulbar Sx |
| What antipsychotic is preferred agent in Lewy-body dementia ? | Quetiapine is preferred agent on the test (fluctuating cognition, visual hallucinations, REM sleep disturbances plus parkinsonism-within one year of cognitive issues) otherwise antipsychotics are contraindicated |
| Gabapetin is indicated for which type of puritis? | uremic puritis but not cholestatic puritis! Alleviate obstruction first if possible THEN cholystyramine (topical emollients ay help with xeroderma) |
| What antiemetics are best for opioid-induced nausea? | D2 antagonists!! haldol, metacllopramide (central and pherphreal antidopaneric a tivit!); no prmethazine as this is mostly H1!! |
| NMDA is a receptor for which neurotransmiter? | glutamate (excitatory neurotransmitter!): ketamine and methadone are examples |
| What factors into the palliative PROGNOSTIC score? | This is not the PPS! KPS, WBC, lymphocytes, clinical, anorexia, dyspnea |
| What factors in the palliative prognostic INDEX? | Again, Not PPS! but takes into account PPS, edema, oral intake, delirium; scale used for patients with advanced cancer |
| Poor prog for malignant A) hypercalcemia B)malignant pericardial effusion C)carcinomatous meningitis D) mult brain mets with + XRT and -XRT | A)8 weeks (except new breast CA or MM) B)8-12 w C) 8-12 w D) 12-14 w and 4-8 weeks |
| Immunotherapy effects the prognostics for which cancers? | MELANOMA, bladder, head/neck, Hodgkin's lymphoma, renal cell, NSCLC |
| COPD prognosis? | BODE index: BMI <21, obstruction FEV1, dyspnea scale (MMRC), exercise capacity 6 min distant walk test; better than FEV1 alone but still not predictive of 6 month (for hospice also needs <88% RA, FEV1<30% of pred, progressive Sx-dyspnea at REST, PO2 <55 |
| Liver disease hospice criteria | PT >5 or INR >1.5 and serum albumin <2.5 and +1 of Cirrhosis: refrac tx sbp hepatorenal enalencephalopathy recurrent variceal bleed |
| chonic renal failure hospice criteria | end stage (stage V) cr clearance 15w/out db and 10 w/db, not pursuing HD, albumin <3, comorbidities (pvd, chf, dm), malnutrition and age >80 |
| Acute Ischemic stroke are what percent of all strokes and what are the strongest predictors of prognosis? | 85% and NIHSS and age are strongest predictors (1/5 will die within 3 months and mortality rate increases with each complications while hospitalized) |
| Hemorrhagic stroke are what percentages of all stroke and what is one month mortality? What if brainstem bleed? What is the most PREDICTIVE in prognosis? | 15% of all strokes. 50% 30 day mortality but 90% with brainstem bleed at 30 days. Volume!!! >60 cc volume 90% mortality rate |
| TBI uses what scale to predict LONG-term functional assssment? | Glasgow OUTCOME scale: 1) ability to communicate verbally 2) motor 3) eye control (15 point scale: good outcome >13, moderate disabled 9-12, severely disabled 3-12, persistent vegetative state <3!) |
| ICU Ventilation prognosis: what factors are taken into account and what is prognosis if there are 0, 1, 2, 3+ present? | Must be mechanical vent at 21 days and: 1. Age >50 2. Pressor use 3. plt <50K 4. HD use Mortality rate at 1 year: 0=15% 1=42% 2 88% mortality (if dependent at 100% all ADLs) 3-4 95% |
| ALS prognosis average survival time? What factors predict a worse outcome? | 24-36 months after diagnosis. Older age, bulbar features, frontotemporal dementia (15-40%). |
| Dementia hospice LCD criteria? | Fast 7C! |
| What is nursing home patient mortality risk calculator and factors? Better predictor in patients in NH than fast scoring | Mortality risk index: ADL dependence, male sex, CA CHF, oxygen in last 2 weeks, bedfast, 83 y/o older, sob, unstable med condition, <25% po intake, sleeping most of day, bowel incont. Estimated 6 mortality: 1-2 10%, 3-5 20%, 6-8 40%, 9-11 60%, 12+ 70% |
| What is the 6 month mortality rate for dementia patient hospitalized with a PNA? What about hip fracture? What if cog intact for either? | Around 50% for both and around 10% for either IF cognitively intact |
| Frailty! What model is used? | Fried Model (3/5 required): reduced physical activity, slowed walking/mobility, weight loss (4.5 kg/year), diminished hand-grip, exhaustion (demonstrates a loss of physiologic reserve): to meet criterial of frailty. |
| What are the conceptualization of death in children 0-2 y/o? 3-5 (toddlers)? | 0-2: None-crying/distressed at noticing caregiver not around-sooth! Don't get it is permanent or grasp that "everybody dies" and grief: . Temporary "forgets" and repeats questions. Play therapy and expression of energy. ok to talk about feelings |
| What are the conceptualization of death in children 6-9 (school age)? | 6-9: understand finality and reversibility and don't get causality (did I cause it or someone else?) and thinks can escape if they don't discuss it. Some magical thinking, worried it's their fault of death. Validate the child, be honest when they ask Qs |
| What are the conceptualization of death in pre-adolescence? | They understand all prior plus that they will die one day and can be pre-occupied with death as normal behavior. Lean more on guilt than fear (may present with symptoms of HA or other "illness" if sibling with real illness). Judging/blaming self/others |
| What are the conceptualization of death in adolescence? Like 12+ years old | Death seen as "not fair", higher risk of developing impaired/complicated grief in this stage if death in home. Might have rejection of norms and could have development halting or prefer to talk to peer groups rather than parents/doctors (this is normal). |
| 37 weeks -18 y/o brain death | Same as adults + toxic and metabolic disorders are ruled out AND for infants first exam must be 24 h after insult then examination 24 h apart. Once 31 days to 18 years of age then first exam 24 h after insult and second examination 12 h apart . |
| 37 weeks-18 y/o brain death, what do ancillary tests help with (imaging, cerebral blood flow tests, etc.) | Only if validity of neurological exam is questioned!!! |
| Pay attention around anticipatory grief | Ex: 17 y/o with musc dystrophy who's friends around him are getting their driver's license and he is not: may act out in normal grief behaviors (see previous flashcard: acting out, getting bad grades, blaming others, etc) as a rxn |
| Pediatric delirium, can it happen???! | YES!!! Same causes as adults: hyper/hypo/mixed and look at meds and other reversible causes! |
| Acute conus injury would lead to localizing symptoms associated with which segments and what is the physical symptom? | S4-5 spinal cord segments: loss of sensation around the anus & absent or decreased anal sphincter tone. SOMETIMES damage involves T12 nerve root damage, leading to pelvic girdle sensory changes/ weakness of deep pelvic and hip flexor muscles. |
| Post mastectomy syndrome? | 5% women s/p any surgical procedure on th breast (lumpectomy to mastectomy): pain in medial arm, axilla, anterior chest (from intercostal brachia nerve-T1-2 cutaneous sensory branch interruption) up to 6 m post-op. flexed position, risk: froz shoulder |
| metastatic plexopathy? | associated with severe pain + horner's syndrome (droopy eye lid, constricted pupil, loss of sweating) |
| radiation plexopathy of the chest | Radiation plexopathy most commonly involves the upper cords of the brachial plexus, in the distribution of the C5-C7 roots and is characterized more by paresthesias and weakness than pain |
| Continuous care time? | MIN 8 h in a 24 h period with >50% each period must be provided by RN/LVN, balance can be CNA/HHA (can be 4h blocks bid) |
| stellate ganglion block | menopausal hot flashes, UE pain, CRPS, TRIGEMINAL NEURALGIA, angina, raynaud's, phantom pain, trigeminal neuralgia!!!! REMEMBER, GASSARIAN BLOCK IS NOT A SYMPATHETIC BLOCK |
| ganglion impar block | PERONEAL PAIN (the block is anterior to the sacrococcygeal junction for ( for broader pain in the perineum, groin, and anal area as pudendal more for pelvic pain BUT IS NOT A SYMPATHETIC BLOCK!) |
| superior hypogastric plexus block | pelvic pain from rectal, bladder, or gyne malignancies --does not do the external gentialia |
| Types of physician reimbursement: what's the relationship? | 1. hospice medical director, hospice physician, volunteer hospice MD 2. Attending physician for hospice patient (or covering physician for attending) 3. Physician consulted for issues related to diagnosis |
| What billing used for "attending of record" who is NOT the medical director OR contracted hospice physician for ANY care on Medicare hospice benefit | GV (Medicare part B gets billed); they can see for hospice related or not hospice related problems!! |
| What billing is used for care NOT related to hospice diagnosis? | GW (bills Medicare part B); can be consult or attending of record/covering physician |
| What billing used if hospice physician sees hospice patient and it's 1) related to hospice diagnosis? 2) not related to hospice diagnosis? 3) can you use GV? what if you are AOR??? | 1) hospice bills CPT code to Medicare part A 2) GW (bills Medicare part B) 3) NOOOOO!!! That's for anyone who is not a hospice doctor; not even if the hospice physician is the AOR (hospice physician trumps position of AOR) |
| What billing used if another physician provides care NOT related to hospice dx? What if related to hospice diagnosis??? | GW, bill medicare part B. if related then bill the hospice directly! |
| Which physician can ONLY bill for care plan oversight? hospice medical director? contract hospice physician? attending of record? | Only the attending of record!! The other two is considered care plan oversight and paid already per diem. |
| Who is the only person in hospice who can bill both GV and GW | attending of record AOR (if NOT also the hospice physician) and GV for ANY CARE PROVIDED while patient on hospice benefit), care not related to hospice diagnosis is GW; ex AOR who sees a PT on hospice but for unrelated would bill B w/ GV and GW |
Created by:
MandMEatemup