Symptom Control in Advanced Illness — MCQs

10 questions

Which of the following will have an organic cause?

A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

A 68-year-old male presents with cough, sputum production, bronchial breath sounds, respiratory rate of 20/min, urea of 44 mg/dl, and BP of 110/70 mmHg. What is the next step in management?

A 78-year-old woman is brought to the clinic by her daughter due to concerns about her mother's mood. The patient's husband of 48 years passed away six months ago after a lengthy illness due to metastatic colon cancer. Since then, she reports having a poor appetite, decreased interest in activities, and frequent thoughts about dying. She is started on nortriptyline to help improve her mood and functional status. Which of the following is a common side effect of nortriptyline?

A hypertensive patient who is non-compliant with medication presents to you with sudden onset breathlessness. A chest x-ray was done, which is shown below. How will you manage this patient?

Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?

All are management of PDPH except-

In acute left ventricular failure with pulmonary edema, which drug can be administered for immediate management?

A 55-year-old woman is undergoing chemotherapy for breast cancer and experiences severe nausea and vomiting. Which antiemetic, recognized for its minimal extrapyramidal side effects, would be appropriate for her condition?

Q10

Which thalamic nuclei can produce basal ganglia symptoms?

Symptom Control in Advanced Illness Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following will have an organic cause?

A. Schizophrenia
B. Delirium (Correct Answer)
C. Anxiety
D. Obsessive compulsive disorder

Explanation: ***Delirium*** - Delirium is an **acute, fluctuating disturbance of consciousness** and cognition that is directly caused by a **medical condition**, substance intoxication/withdrawal, or medication side effect [1], [2], [3]. - It always has an **underlying organic etiology** such as infection, metabolic derangements, drug toxicity, or neurological disorders [1], [2]. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** characterized by psychosis (hallucinations, delusions), disorganized thinking, and negative symptoms. - While it has a neurobiological basis, it is considered a **primary mental illness** and not typically caused by an acute, identifiable organic illness in the way delirium is. *Anxiety* - Anxiety disorders are characterized by excessive worry, fear, and physical symptoms of arousal. They are considered **primary mental health conditions**. - Although stress can precipitate anxiety, it is not primarily due to a **specific acute organic cause** that resolves with treatment of that cause. *Obsessive compulsive disorder* - Obsessive-compulsive disorder (OCD) is an anxiety-related disorder characterized by **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors (compulsions) aimed at reducing distress. - Like other primary mental health conditions, it has a neurobiological basis but is not classified as having an **acute organic cause** in the medical sense.

Question 2: A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

A. Oral morphine
B. Diazepam rectal suppository
C. Intercostal cryoanalgesia (Correct Answer)
D. IV fentanyl

Explanation: ***Intercostal cryoanalgesia*** - **Intercostal cryoanalgesia** involves applying extreme cold to the intercostal nerves, leading to temporary nerve denervation and prolonged pain relief. This technique is particularly effective for **post-thoracotomy pain** due to its targeted action and reduced systemic side effects compared to opioids. - The goal is to provide **long-lasting pain control** specifically at the surgical site, allowing for better respiratory mechanics and early mobilization. *Oral morphine* - Oral morphine can provide systemic pain relief, but its onset of action is slower, and it carries the risk of significant **sedation** and **respiratory depression**, which are major concerns in a patient who has just undergone thoracotomy. - While effective, it may not provide optimal local pain control for incisional pain and often requires higher doses to achieve adequate relief, increasing the risk of adverse effects. *Diazepam rectal suppository* - Diazepam is a **benzodiazepine** primarily used for anxiety, muscle spasms, and seizures, not for severe acute surgical pain. It has **no significant analgesic properties**. - Its sedative effects would be contraindicated after thoracotomy due to the risk of respiratory depression and masking potential neurological changes. *IV fentanyl* - IV fentanyl is a potent opioid with a rapid onset and short duration of action, making it useful for breakthrough pain or during immediate post-operative periods. However, it requires **continuous monitoring** and frequent re-dosing. - Like other opioids, it carries risks of **respiratory depression**, nausea, and sedation, making it less ideal for sustained primary pain control immediately after thoracotomy where lung function is critical.

Question 3: A 68-year-old male presents with cough, sputum production, bronchial breath sounds, respiratory rate of 20/min, urea of 44 mg/dl, and BP of 110/70 mmHg. What is the next step in management?

A. Admit in ICU without mechanical ventilation (MV)
B. Home treatment (Rx)
C. Admit in ICU with mechanical ventilation (MV)
D. Room admission (Correct Answer)
E. Observation in emergency department

Explanation: ***Room admission*** - The patient's **CURB-65 score** is **2** (one point for urea >7 mmol/L [44 mg/dL = 15.7 mmol/L] and one point for age ≥65 years), indicating **moderate mortality risk** and clear need for **hospital admission**. - **CURB-65 score of 2** mandates inpatient admission for monitoring, IV antibiotics if needed, and supportive care in a general medical ward. - While showing signs of respiratory infection, the vital signs are stable and do not meet criteria for ICU admission. *Admit in ICU without mechanical ventilation (MV)* - **ICU criteria** for pneumonia typically include severe respiratory failure, hemodynamic instability (shock requiring vasopressors), or impending organ dysfunction, which are not met. - The patient's respiratory rate (20/min) and blood pressure (110/70 mmHg) are within acceptable limits for a non-ICU setting. - CURB-65 score of 3-5 or presence of major severity criteria would warrant ICU consideration. *Home treatment (Rx)* - **CURB-65 score of 2** precludes outpatient management and requires hospital admission. - Outpatient treatment is only appropriate for CURB-65 scores of 0-1 in patients without other comorbidities. - Given the patient's age (68 years), elevated urea, and presence of **bronchial breath sounds** consistent with consolidative pneumonia, **hospital admission** is mandatory. *Admit in ICU with mechanical ventilation (MV)* - There is no indication of **severe respiratory distress** (e.g., severe hypoxemia with SpO2 <90% on high-flow oxygen, hypercapnia, or respiratory acidosis) that would necessitate immediate mechanical ventilation. - The respiratory rate of 20/min is normal, and there is no mention of altered mental status, severe tachypnea, or increased work of breathing. *Observation in emergency department* - While brief observation may be appropriate for borderline cases, a **CURB-65 score of 2** indicates the patient requires formal hospital admission rather than just ED observation. - The presence of consolidation (bronchial breath sounds) and elevated urea support the need for inpatient ward admission with monitoring and treatment.

Question 4: A 78-year-old woman is brought to the clinic by her daughter due to concerns about her mother's mood. The patient's husband of 48 years passed away six months ago after a lengthy illness due to metastatic colon cancer. Since then, she reports having a poor appetite, decreased interest in activities, and frequent thoughts about dying. She is started on nortriptyline to help improve her mood and functional status. Which of the following is a common side effect of nortriptyline?

A. weight loss
B. impaired cardiac contractility
C. heart block
D. anticholinergic side effects (Correct Answer)

Explanation: ***Anticholinergic side effects*** - **Nortriptyline** is a **tricyclic antidepressant (TCA)** known for its significant **antimuscarinic** activity, leading to anticholinergic effects. - Common anticholinergic side effects include **dry mouth, blurred vision, constipation, urinary retention**, and **tachycardia**. *Impaired cardiac contractility* - While TCAs can have **cardiac effects** (e.g., QT prolongation, arrhythmias), **impaired cardiac contractility** is not a common or typical direct side effect at therapeutic doses. - Other drug classes, such as certain **beta-blockers** or **calcium channel blockers**, are more commonly associated with this effect. *Weight loss* - **Weight gain** is a more common side effect associated with many antidepressants, including some TCAs. - While some individuals may experience initial appetite changes, **sustained weight loss** is not a characteristic side effect of **nortriptyline**. *Heart block* - TCAs can cause **conduction abnormalities** like **prolonged QRS duration** and **QT interval prolongation**, especially in overdose or in patients with pre-existing cardiac conditions. - However, direct **heart block** (e.g., AV block) is a less common side effect, usually associated with higher doses or specific patient vulnerabilities.

Question 5: A hypertensive patient who is non-compliant with medication presents to you with sudden onset breathlessness. A chest x-ray was done, which is shown below. How will you manage this patient?

A. Intravenous salbutamol
B. Nebulization with salbutamol
C. Oxygen and antibiotics
D. Intravenous nitroglycerin (Correct Answer)

Explanation: ***Intravenous nitroglycerin*** - The chest X-ray shows diffuse bilateral infiltrates and **cardiomegaly**, consistent with **pulmonary edema** due to **acute decompensated heart failure** in a hypertensive patient. - **Intravenous nitroglycerin** is crucial for patients with acute cardiogenic pulmonary edema, as it **reduces preload and afterload**, thereby decreasing pulmonary congestion and improving breathlessness. *Intravenous salbutamol* - **Salbutamol** is a **bronchodilator** used for bronchospasm in conditions like asthma or COPD. - It would not address the underlying pathology of **pulmonary edema** and could potentially worsen the condition by causing **tachycardia** and increasing myocardial oxygen demand. *Nebulization with salbutamol* - Similar to intravenous salbutamol, nebulized salbutamol is used for **bronchospasm** and is ineffective in treating **cardiogenic pulmonary edema**. - There is no indication of airway constriction, and its systemic effects could paradoxically **exacerbate heart failure**. *Oxygen and antibiotics* - While **oxygen** is always indicated for hypoxemia, it alone is insufficient to manage severe **pulmonary edema**. - **Antibiotics** are used to treat bacterial infections, but there are no signs of infection (e.g., fever, purulent sputum) to suggest **pneumonia** as the primary cause of breathlessness; the X-ray findings are more typical of edema.

Question 6: Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?

A. Lorazepam
B. Metoclopramide
C. Promethazine
D. Ondansetron (Correct Answer)

Explanation: ***Ondansetron*** - **Ondansetron** is a **5-HT3 receptor antagonist** and is considered a first-line agent due to its high efficacy and favorable side effect profile in preventing PONV. - It works by blocking serotonin receptors in the **chemoreceptor trigger zone** and the **gastrointestinal tract**, reducing the sensation of nausea and vomiting. *Lorazepam* - **Lorazepam** is a **benzodiazepine** primarily used for its **anxiolytic** and **sedative effects**, and sometimes as an adjunct for refractory nausea, but not as a first-line antiemetic for PONV prophylaxis. - While it can help indirectly by reducing anxiety, it does not directly target the key pathways involved in PONV as effectively as 5-HT3 antagonists. *Phenytoin* - **Phenytoin** is an **anticonvulsant** medication used to prevent seizures and has no role in the direct treatment or prophylaxis of PONV. - It primarily acts on voltage-gated sodium channels in neurons and does not possess antiemetic properties. *Metoclopramide* - **Metoclopramide** is a **dopamine D2 receptor antagonist** and a **prokinetic agent** that can be used for PONV, particularly when gastric stasis is a concern. - However, it is generally considered a second-line agent due to the risk of **extrapyramidal side effects**, especially with higher doses or prolonged use. *Promethazine* - **Promethazine** is a **first-generation antihistamine** with **antidopaminergic** and **anticholinergic properties** that can be effective for nausea and vomiting. - It is often used as a rescue antiemetic or in combination therapy, but its sedative effects and potential for extrapyramidal symptoms make it less preferable as a first-line prophylactic agent compared to ondansetron.

Question 7: All are management of PDPH except-

A. Stool softeners (Correct Answer)
B. Analgesic + caffeine
C. Intravenous / oral fluids
D. Upright position

Explanation: ***Stool softeners*** - While **stool softeners** may be prescribed to prevent **straining** in patients experiencing PDPH, they do not directly treat the underlying cause or symptoms of PDPH. - The primary goal of PDPH management is to re-establish **CSF pressure** and relieve headache, which stool softeners do not achieve. *Analgesic + caffeine* - **Caffeine** is a common component of PDPH management as it causes **cerebral vasoconstriction**, which can help alleviate the headache. - **Analgesics** (e.g., NSAIDs, opioids) are used to manage the pain associated with PDPH. *Intravenous / oral fluids* - Increasing **fluid intake**, both oral and intravenous, helps to promote **CSF production** and potentially increase intracranial pressure, thereby alleviating PDPH symptoms. - This is a supportive measure for rehydration and to potentially restore **CSF volume**. *Upright position* - An **upright position** typically **worsens** PDPH symptoms because it increases the gravitational pull on the CSF, further lowering intracranial pressure. - Patients with PDPH are usually advised to maintain a **supine (flat)** position to minimize headache severity.

Question 8: In acute left ventricular failure with pulmonary edema, which drug can be administered for immediate management?

A. Morphine (Correct Answer)
B. Amlodipine
C. Epinephrine
D. Propranolol

Explanation: ***Morphine*** - **Morphine** is a key drug in the **acute management of left ventricular failure with pulmonary edema** - It provides **anxiolysis**, reduces **sympathetic drive**, and decreases **preload** through venodilation - Reduces **oxygen demand** and **work of breathing** in acute decompensation - Standard dose: **2-5 mg IV**, can be repeated as needed - Caution needed for **respiratory depression** and **hypotension**, but benefits outweigh risks in severe pulmonary edema *Propranolol* - **Propranolol** is a **non-selective beta-blocker** that is **contraindicated in acute/decompensated heart failure** - Beta-blockers **reduce contractility** and can worsen acute cardiac output - While certain beta-blockers (carvedilol, metoprolol, bisoprolol) are used in **chronic stable heart failure**, propranolol is NOT a guideline-recommended agent for heart failure management - In acute settings, beta-blockers would precipitate or worsen decompensation *Amlodipine* - **Amlodipine** is a **dihydropyridine calcium channel blocker** used for hypertension and angina - **Not recommended in heart failure** as it can cause **negative inotropic effects** and peripheral edema - Does not provide mortality benefit and may worsen outcomes in LV dysfunction - Other vasodilators (nitrates, ACE inhibitors) are preferred *Epinephrine* - **Epinephrine** is a potent **catecholamine** with alpha and beta effects - Increases **heart rate**, **contractility**, and **systemic vascular resistance** - Would dramatically increase **myocardial oxygen demand** and **afterload** in LV failure - Reserved for **cardiac arrest** or **cardiogenic shock requiring inotropic support**, not routine LV failure management - Risk of **arrhythmias** and **ischemia**

Question 9: A 55-year-old woman is undergoing chemotherapy for breast cancer and experiences severe nausea and vomiting. Which antiemetic, recognized for its minimal extrapyramidal side effects, would be appropriate for her condition?

A. Metoclopramide
B. Ondansetron (Correct Answer)
C. Promethazine
D. Prochlorperazine

Explanation: ***Ondansetron*** - **Ondansetron** is a 5-HT3 receptor antagonist, highly effective against chemotherapy-induced nausea and vomiting (CINV) due to its action on serotonin receptors in the **chemoreceptor trigger zone** and **gastrointestinal tract**. - It is known for its favorable side effect profile, with **minimal to no extrapyramidal symptoms**, making it a preferred choice in patients where such effects are a concern. *Metoclopramide* - While effective against nausea and vomiting, **metoclopramide** (a D2 receptor antagonist) can cause **extrapyramidal symptoms** such as **dystonia** and **tardive dyskinesia**, especially with prolonged use or higher doses. - Its mechanism of action includes both prokinetic effects and central antiemetic action, but its side effect profile makes it less ideal when avoiding extrapyramidal symptoms is a priority. *Promethazine* - **Promethazine** is a first-generation antihistamine with antiemetic properties, but it can cause significant **sedation** and has some **anticholinergic side effects**. - Although its extrapyramidal risk is lower than some other drugs, it's not the primary choice for chemotherapy-induced nausea due to its sedative effects and generally less potent antiemetic action for CINV compared to 5-HT3 antagonists. *Prochlorperazine* - **Prochlorperazine** is a phenothiazine antipsychotic with strong antiemetic effects, acting primarily as a **dopamine receptor antagonist**. - It carries a significant risk of **extrapyramidal side effects**, including **acute dystonia** and **parkinsonism**, making it less suitable when such side effects must be strictly avoided.

Question 10: Which thalamic nuclei can produce basal ganglia symptoms?

A. Lateral dorsal
B. Pulvinar
C. Ventral anterior (Correct Answer)
D. Intralaminar

Explanation: ***Ventral anterior*** - The **ventral anterior (VA)** and **ventral lateral (VL)** nuclei of the thalamus receive significant input from the **basal ganglia** and project to the motor cortex [1]. - Dysfunction in these nuclei can disrupt the basal ganglia's influence on motor control, leading to symptoms like **dyskinesia** or **rigidity** [1]. *Lateral dorsal* - The **lateral dorsal nucleus** is primarily involved in **limbic system** functions and episodic memory. - It does not have direct nor significant connections with the basal ganglia motor circuits that would produce typical basal ganglia symptoms. *Pulvinar* - The **pulvinar** is the largest thalamic nucleus, primarily involved in **visual processing**, attention, and eye movements. - While it has extensive cortical connections, it is not directly involved in the motor circuits of the basal ganglia. *Intralaminar* - The **intralaminar nuclei** (e.g., centromedian and parafascicular) receive input from the basal ganglia but primarily project diffusely to the cerebral cortex and are involved in **arousal** and consciousness [2]. - While they modulate cortical activity, their dysfunction typically wouldn't produce the classic motor symptoms associated with basal ganglia disorders.

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