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AN EXAMINATION OF KNOWLEDGE IN:
PALLIATIVE CARE
PAIN MANAGEMENT AND NON-PAIN SYMPTOMS
(EPERC TEST #1)
40 QUESTIONS; MULTIPLE CHOICE; SINGLE-BEST ANSWER
Supplied by:
End of Life Physician Education Resource Center (EPERC)
www.eperc.mcw.edu
David E. Weissman, MD and Deborah Simpson, PhD Project Directors
Judi Rehm, Project Manager
Copyright 2001, Medical College of Wisconsin, Inc. Test #1 Content Domains

A. Pain
Pain Assessment
types
causes
Pain treatment
NSAIDS's/Tylenol
opioid pharmacology
opioid toxicity
transdermal opioids
dose conversions
use of oral opioids
parenteral opioids
adjuvant analgesics
Addiction/tolerance/physical dependence
B. Non-pain symptoms/syndromes
Nausea/vomiting
Dyspnea
Constipation/diarrhea
Delirium
Depression/suicide
Anorexia/cachexia
Hypercalcemia
Imminent death
Persistent Vegetative State
Copyright 2001, Medical College of Wisconsin, Inc. Instruction: Select the single best answer

1.
A patient is taking 2 oxycodone/acetaminophen tablets (5 mg/325 mg), 6 times a day. What is the
equivalent dose of a long-acting morphine preparation?
A. 15 mg q12
B. 15 mg q8h
C. 30 mg q12
D. 30 mg q8h
E. 45 mg q12
2.
Mrs. Jensen is a 72 year/old woman with multiple sclerosis. She is dying, is at home, and has severe
pain, currently receiving MS Contin 60 mg q12h and prn oral hydromorphone. The home hospice nurse
feels she needs parenteral opioids. She is unable to swallow medication and has no intravenous access.
Which of the following is the most appropriate route to recommend for opioid analgesic administration?
A. Intramuscular
B. Intravenous via Hickman catheter or Mediport C. Intravenous via PICC line catheter D. Intravenous via peripheral IV catheter E. Subcutaneous 3. A 67 y/o man with prostate cancer has increasingly severe pain over the Left hip. Over the past two weeks the pain has worsened requiring increasing doses of opioid analgesics. The pain is constant, aching and well localized; there is no referred pain. Increasing pain in this patient most likely represents: A. Drug seeking behavior B. New onset depression C. Opioid 4. Pain that is described as “dull, achy” and is well localized, is best described as: A. Autonomic 5. After ingesting a dose of acetaminophen/oxycodone (Percocet), when would you expect a patient to report the maximal analgesic effect; in: A. 10--15 minutes B. 30--45 minutes C. 60--90 minutes D. 120-150 minutes E. 180-210 minutes Copyright 2001, Medical College of Wisconsin, Inc. 6. A patient is taking 12 oxycodone/acetaminophen tablets (5/325) per day with only partial relief. The most appropriate next step in drug therapy for this patient would be to discontinue Percocet, and start: A. oral hydrocodone (e.g. Vicodin, Lortab) B. oral hydromorphone (Dilaudid) C. oral long-acting morphine (e.g. MS Contin, Oramorph SR) D. oral meperidine (Demerol) E. oral 7. The most appropriate adjuvant analgesic for use when treating somatic pain is: A. amitriptyline 8. The most appropriate adjuvant analgesic for use when treating neuropathic pain is: A. clonidine 9. The most appropriate first drug to prescribe to prevent opioid constipation is: A. docusate E. senna concentrate (Senokot) 10. A 27 y/o woman with AIDS notes burning pain along the bottom of both feet. There is often a numbing sensation; the pain limits her ability to walk. She recently began taking acetaminophen with codeine, 2 tabs q4H. She says the medicine provides no relief and it makes her feel sleepy. This woman’s pain is best described as: A. Autonomic Copyright 2001, Medical College of Wisconsin, Inc. 11. Oral hydromorphone (Dilaudid) can be safely administered for pain as often as every: A. 2 12. Which one of the following statements concerning nausea while taking opioids is true: A. Nausea to opioids is due to bowel distention and stimulation of the vagus nerve B. Nausea to opioids is due to decreased bowel motility C. Nausea to opioids is usually accompanied with itching D. Nausea to opioids represents a drug allergy E. Nausea to opioids resolves in most patients within 7 days 13. Because of delayed onset of activity after the first application of a Duragesic Patch (transdermal fentanyl), it is especially important to have breakthrough pain medicine available for the first: A. 2-6 hours B. 7-12 hours C. 13-24 hours D. 24-36 hours E. 48-72 hours 14. Compared to morphine, which one of the following opioids is more likely to result in respiratory depression during dose escalation: A. hydrocodone (e.g. Vicodin or Lortab) B. hydromorphone E. oxycodone (e.g. Percocet) 15. For patients on chronic opioids, the most appropriate equianalgesic conversion ratio between oral and intravenous morphine is: A. 3 mg oral = 18 mg intravenous B. 3 mg oral = 9 mg intravenous C. 3 mg oral = 3 mg intravenous D. 3 mg oral = 1 mg intravenous E. 3 mg oral = 0.3 mg intravenous Copyright 2001, Medical College of Wisconsin, Inc. 16. The most appropriate equianalgesic conversion ratio between IV morphine and IV hydromorphone (Dilaudid) is: A. 1 mg morphine = 8 mg hydromorphone B. 1 mg morphine = 4 mg hydromorphone C. 1 mg morphine = 1 mg hydromorphone D. 1 mg morphine = 0.50 mg hydromorphone E. 1 mg morphine = 0.20 mg hydromorphone 17. The most appropriate equianalgesic conversion ration between IV morphine and Subcutaneous morphine is: A. 1.0 mg IV = 0.25 mg SQ B. 1.0 mg IV = 0.5 mg SQ C. 1.0 mg IV = 1.0 mg SQ D. 1.0 mg IV = 2.0 mg SQ E. 1.0 mg IV = 4.0 mg SQ 18. The single best indicator of opioid drug addiction (psychological dependence) is: A. An increasing need for the drug over time B. Complaint of pain exceeding that expected for a given medical problem C. Development of a withdrawal syndrome when the drug is stopped D. Evidence of adverse life consequences from drug use E. Requesting a specific opioid by name 19. Which of the following drugs has been shown to improve appetite in advanced cancer patients: A. conjugated estrogen (e.g. Premarin) B. haloperidol D. megesterol acetate (Megace) E. procholrperazine 20. Which one of the following statements about treating terminal delirium is true: A. Family members should leave the room to help decrease the agitation B. Paradoxical worsening may occur after administration of a minor tranquilizer (e.g. Ativan or Valium) C. Placing the patient in a dark room will help decrease sensory input and reduce the agitation D. The drug treatment of choice is an anti-cholinergic medication E. The drug treatment of choice is an opioid analgesic Copyright 2001, Medical College of Wisconsin, Inc. 21. Which one of the following statements about depression at end-of-life is true: A. Clinical depression is a normal stage of the dying process B. Depression associated with HIV is more difficult to treat than in cancer patients C. Feelings of hopelessness/worthlessness are indicators of a clinical depression D. The degree of appetite and sleep disturbance is predictive of response to anti-depressant medication E. Tricyclic antidepressants are the first choice for drug therapy 22. The best drug choice to treat dyspnea in the dying patient is: A. anti-cholinergic/anti-muscarinic (e.g. scopolamine) B. anti-depressant (e.g. amitriptyline (Elavil)) C. anti-histamine (e.g. diphenhydramine (Benadryl)) D. local airway anesthetic (e.g. inhaled lidocaine) E. opioid analgesic (e.g. morphine) 23. A 60 y/o woman has metastatic breast cancer with bone and pleural metastases. Her husband brings her to clinic stating that over the past week she has noted fatigue, thirst and frequent need to urinate. On examination she is dehydrated and lethargic but arousable, there are no focal neurological findings. Her only medication is oral morphine. The most likely diagnosis of this new problem is: A. Brain B. Hypercalcemia C. Hyperglycemia D. Hypernatremia E. Sepsis 24. The best class of drugs to treat "death rattle" is a(n): A. anti-cholinergic/anti-muscarinic (e.g. scopolamine) B. benzodiazepine (e.g. lorazepam (Ativan)) C. butyrophenone (e.g. haloperidol (Haldol)) D. local airway anesthetic (e.g. inhaled lidocaine) E. opioid analgesic (e.g. morphine) 25. Comfort measures during the Syndrome of Imminent Death include all the following, except: A. Anti-pyretic PRN fever B. Changing body position frequently C. Intravenous Copyright 2001, Medical College of Wisconsin, Inc. 26. At a daily dose of 240 mg of long-acting morphine, the most appropriate order for rescue (breakthrough) short-acting morphine (MSIR) is: A. 15 mg q 2h B. 30 mg q 2h C. 15 mg q 4h D. 30 mg q 4h E. 45 mg q 4h 27. Oral morphine used for breakthrough pain can be safely administered every: A. 15-30 B. 1-2 hours C. 3-4 hours D. 5-6 hours E. 7-8 hours 28. A patient has been taking 300 mg of long-acting morphine every 12 hours and an additional 120 mg of prn doses of short acting morphine. You want to start him on an equivalent dose of an intravenous morphine infusion; what is the equivalent morphine hourly rate: A. 5 mg per hour B. 10 mg per hour C. 15 mg per hour D. 20 mg per hour E. 25 mg per hour 29. When using patient controlled analgesia, the lockout interval for a bolus (prn) dose should be set between: A. 5-30 minutes B. 30-60 minutes C. 60-90 minutes D. 90-120 minutes E. 120-180 30. The maximum recommended daily dose of acetaminophen is: A. 2 grams B. 4 grams C. 6 grams D. 8 grams E. 10 Copyright 2001, Medical College of Wisconsin, Inc. 31. A man is receiving oral hydromorphone (Dilaudid) 10 mg every 4 hours. He needs to be NPO. What would be the best equivalent Intravenous dose of Dilaudid, administered as a continuous infusion? A. 0.1 mg per hour B. 0.5 mg per hour C. 1.0 mg per hour D. 1.5 mg per hour E. 2.5 mg per hour 32. The most important supplemental therapy to consider when starting patients on opioids for pain is: A. Amphetamines to increase alertness B. Antidepressants to supplement pain relief C. Antiepileptic medications to treat neuropathic pain D. Laxatives to prevent constipation E. Non-steroidals (NSAID’s) to treat inflammation 33. A 87 year old woman with advanced osteoporosis has chronic back and hip pain, poorly controlled on 2 Percocet (5 mg oxycodone and 325 mg acetaminophen each) six times per day. The single best reason not to increase the number of Percocet tablets is: A. Non-steroidals (NSAID’s) are the best drug choice for bone pain B. Oxycodone is a weak opioid C. Oxycodone is contraindicated in the elderly D. The maximal dose of oral oxycodone is 40 mg per 24 hours E. The dose of acetaminophen would exceed the recommended level 34. Neuropathic pain is often characterized by episodes of: A. Achy B. Colicky pain C. Gnawing pain D. Shock-like pain E. Squeezing 35. Patients with substance abuse and HIV: A. Have pain that responds poorly to tricyclics or anticonvulsants B. Should never receive opioids because of the risk of addictive behavior C. Should not be treated with a fentanyl patch D. Should only receive opioids on a PRN basis, not continuously E. Will likely need higher doses of opioids to achieve similar pain relief Copyright 2001, Medical College of Wisconsin, Inc. 36. Three months after a patients death her husband comes to your office. He says that he sometimes thinks that his wife is in the house talking with him, that he imagines he hears her voice, he has gained 10 pounds since her death, but otherwise feels well. He is concerned that he is “going crazy”. These symptoms are most consistent with a: A. Complicated grief reaction B. Major C. Normal grief reaction D. Post-traumatic stress disorder E. Psychotic 37. Which of the following is a characteristic of a patient who is in a persistent vegetative state?: A. The patient has no corneal, gag, or cough reflexes. B. The patient has the ability to recognize family and friends C. The patient is clinically brain dead D. The patient is in a coma at first, but then recovers sleep-wake cycles E. There is a 5% chance that the patient will recover higher cognitive function 38. The Syndrome of Imminent Death, also known as “actively dying”, typically includes which one of the following constellation of findings: A. Depression, cool extremities and pooled oropharyngeal secretions B. Depression, warm extremities and polyuria C. Delirium, cool extremities, and pooled oropharyngeal secretions D. Delirium, warm extremities and polyuria E. Delirium, warm extremities and pooled oropharyngeal secretions 39. Death resulting from side effects of opioid analgesics, used with the intent to treat severe dyspnea in a dying patient, is an example of: A. Acceptable medical practice B. Assisted C. Euthanasia D. Murder E. Unprofessional practice 40. All of the following are common signs of approaching death except: A. Decreasing interest in eating B. Decreasing recognition of family members C. Decreasing urine output D. Increasing Copyright 2001, Medical College of Wisconsin, Inc.
ANSWER KEY

1. C 2. E 3. E 4. C 5. C 6. C 7. C 8. E 9. E 10. B 11. A 12. E 13. C 14. D 15. D 16. E 17. C 18. D 19. D 20. B 21. C 22. E 23. B 24. A 25. C 26. B 27. B 28. B 29. A 30. B 31. B 32. D 33. E 34. D 35. E 36. C 37. D 38. C 39. A 40. E Copyright 2001, Medical College of Wisconsin, Inc.

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