22 Aug 2022 ( 157-168 )

157. A patient with colon cancer and intra-abdominal metastases (no bone or lung metastases) presents with delirium. You decide to investigate for underlying causes of the delirium. Which of the following will be the least likely cause for the delirium?

158. An 82-year-old woman with chronic kidney disease stage 5 had chosen to have her renal failure managed without dialysis (conservative kidney management) but was troubled by itch. She had hyperphosphataemia, which may have been causing the itch. According to the NICE pathway ‘Hyperphosphataemia in Chronic Kidney Disease’ (2013, updated 2017), what is the most appropriate first-line treatment for adults?

158. A 56-year-old woman with progressive supranuclear palsy was attending a day hospice. Her husband reported that she was having increasing difficulty with her eyes closing for prolonged periods. He asked whether there were any treatment options. What is the most appropriate initial option for blepharospasm?

159. An 80-year-old man with advanced prostate cancer and bone metastases was admitted for control of bone pain. He had paroxysmal atrial fibrillation and was taking warfarin. He had previously used anti-inflammatory analgesics, with good effect. When considering use of an NSAID, which gastroprotective agent is most effective at reducing perforation and haemorrhage?

160. A 76-year-old man with lung cancer and metastatic spinal cord compression was transferred to a hospice for rehabilitation following surgical decompression. He was taking dalteparin as thromboprophylaxis. On examination, he had grade 3/5 muscle strength in both legs and could sit with good truncal balance. His anterior abdominal wall was bruised from the dalteparin injections. With regard to the thromboprophylaxis, what is the most appropriate management?

161. A 52-year-old woman was a participant in a randomised controlled trial for a new medication to treat severe pain in malignancy. During her morning phone call, she was found to have been admitted to hospital after an episode of loss of speech that had lasted for 1 hour and had completely resolved. What best describes the episode in relation to the trial?

162. A 54-year-old man with multiple sclerosis presented with painful spasms in his legs. He was advised to take baclofen, which was titrated to 15 mg three times daily, but it caused excessive drowsiness with no improvement in his spasms. He was, therefore, advised to gradually reduce the dosage over the next 2 weeks and then to stop treatment. What is the most likely adverse effect of abrupt withdrawal?

163. A 72-year-old woman was admitted with recurrent ascites. She had bowel cancer, with extensive bone and omental metastases, and had undergone paracentesis twice in the previous 3 months. Investigations: haemoglobin platelet count 105 g/L (115–165) 55 × 109/L (150–400) serum total protein serum albumin 40 g/L (61–76) 21 g/L (37–49) What is the most appropriate intervention before ultrasound-guided paracentesis?

164. A 58-year-old man with metastatic right upper lobe lung cancer presented with a 2-month history of severe right upper chest and shoulder pain. He was taking duloxetine, transdermal fentanyl, ibuprofen, paracetamol, pregabalin and immediate-release oxycodone as required. He had completed radiotherapy and chemotherapy 3 months previously. On examination, he had tenderness with allodynia in his right shoulder and upper arm. He was referred to the pain clinic. What is the most appropriate interventional approach in managing his pain?

165. A 54-year-old woman with metastatic breast cancer was admitted to hospital with increasing shortness of breath. Investigations: ultrasound scan of chest large right pleural effusion She had pleural drainage with pleurodesis performed. According to the British Thoracic Society pleural disease guideline (2010), what are the most common adverse effects of sclerosant administration following pleurodesis?

166. A 41-year-old woman was referred to the outpatient clinic following a recent diagnosis of metastatic pancreatic cancer. She was receiving sick pay from her employer but was still struggling financially. She asked if there were any benefits that she would be entitled to claim. What is the most appropriate benefit for her to claim?

167. A 70-year-old man with advanced COPD presented with worsening breathlessness, reduced physical activity and weakness. On examination, he was cachectic with evidence of significant muscle wasting. What intervention is most likely to improve his exercise tolerance?

168. An 89-year-old man with advanced Parkinson’s disease was admitted to hospital with abdominal pain and nausea. His medical history included closed-angle glaucoma. Examination showed a distended abdomen with generalised tenderness and quiet bowel sounds. Investigations: CT scan of abdomen disease perforation of the sigmoid colon with extensive diverticular What is the most appropriate antiemetic?