A 35-year-old woman with metastatic breast cancer is scheduled for her third cycle of palliative chemotherapy. However, she has experienced vomiting at home on the morning of her previous two treatments. What is the best medication to manage her vomiting?
A 68-year-old man with advanced small cell lung cancer that has spread to other parts of his body arrives at the Emergency Department showing signs of restlessness. He seems disoriented and is making unintelligible noises. He is uncooperative with the nursing staff’s attempts to measure his vital signs and becomes agitated when touched. He is breathing rapidly and using additional respiratory muscles.
What is the most suitable initial treatment for this patient?
A 32-year-old man with a history of Crohn’s disease presents to the Emergency Department (ED) with complaints of abdominal pain. He was diagnosed with Crohn’s disease at the age of 26 after presenting to his General Practitioner (GP) with persistent symptoms of diarrhea, weight loss, and abdominal pain. At the time of diagnosis, he was noted to have an elevated C-reactive protein (CRP) and fecal calprotectin. He has been managed by a dedicated gastroenterology service and has been on a maintenance dose of Infliximab for the past year. He has started a new job as a air flight controller and has been experiencing increased stress due to the COVID-19 pandemic. His current medications include paracetamol as required and Infliximab every 8 weeks. He denies any rectal bleeding or changes in bowel habits. This is his third presentation to the hospital within the past year.
On examination, his abdomen is tender in the right lower quadrant with no rebound tenderness. Bowel sounds are present. A pregnancy test, urine dip, and routine blood tests are unremarkable. A recent CT scan of his abdomen showed mild inflammation in the terminal ileum, consistent with his known Crohn’s disease. A recent colonoscopy showed mild inflammation in the cecum and ascending colon.
What is the most appropriate management choice for this patient?
A 67-year-old man with metastatic squamous cell lung cancer is admitted to the Acute Medical Unit for the management of hypercalcaemia. He is currently taking slow-release morphine sulphate (MST) 90 mg bd to control his pain along with regular naproxen and paracetamol. While in the hospital, he reports experiencing pain in his right arm, which is the location of a known skeletal metastasis. What medication would be the best choice to alleviate his acute pain?
A 65-year-old man has been admitted to the urology department due to difficulty passing urine and back pain. A bladder scan revealed 980 mls of urine in his bladder, and he was catheterized by the admitting doctor, which resulted in haematuria. The patient has a medical history of metastatic prostate cancer, hypertension, hypercholesterolemia, hypothyroidism, atrial fibrillation, and a previous NSTEMI. He is currently taking warfarin and modified-release morphine 30 mg every 12 hours.
The urology consultant has recommended inserting a 3-way catheter if the haematuria persists and referring the patient to the palliative care team for pain management. The palliative care specialist has suggested increasing the modified-release morphine to 45 mg every 12 hours.
What is the appropriate dosage of immediate-release morphine for the patient’s breakthrough pain?
You are caring for an 85-year-old man with a history of metastatic colorectal carcinoma and end-stage renal failure. He is experiencing significant pain and is currently receiving 6mg of alfentanil via a syringe driver. What additional analgesic medication will you prescribe for breakthrough pain?
An 80-year-old man with metastatic prostate cancer is admitted to the palliative care unit for end of life care. He is currently receiving morphine, levomepromazine, and midazolam via a syringe driver. The nursing staff has reported that he experiences severe pain when being turned onto his side during personal care, despite his pain being well controlled throughout the day.
How should his pain be managed in this situation?
A 68-year-old man with metastatic lung cancer is in the final stages of life and requires end of life care. The medical team plans to use a syringe driver to manage his symptoms as he cannot take medications orally. However, some medications may not be compatible when mixed together in a solution, leading to precipitation issues. Which of the following drug combinations can be safely mixed with water for injection in a syringe driver?
You are requested to provide guidance on a patient who is in their late 60s and has metastatic renal cell carcinoma with pulmonary and bone metastases. They are receiving community palliative care at home, but their swallowing ability has started to decline. It is now believed that they are nearing the end stage of their illness, and a decision has been made to initiate a syringe driver. They have reported satisfactory pain management with their current analgesic regimen.
The patient’s current analgesic regimen consists of 60mg oxycodone modified-release capsules taken twice daily, along with oxycodone instant-release as needed. The oxycodone modified-release dose is converted to the equivalent subcutaneous dose for an oxycodone syringe driver.
What would be the appropriate dose of breakthrough analgesia to prescribe based on the current syringe driver dose?
An 87-year-old man was admitted to the acute medical admissions unit due to acute confusion referred by his GP. The patient was prescribed trimethoprim 200mg BD for a presumed urinary tract infection three days ago, after his nursing home reported new urinary incontinence and offensive smelling urine. Unfortunately, his condition worsened, and he became confused and unable to mobilize, leading to the admission. The patient’s medical history included Alzheimer’s disease, hypertension, hypercholesterolemia, and osteoarthritis. He was taking donepezil 10 mg OD, amlodipine 5mg OD, atorvastatin 20mg ON, and paracetamol 1g QDS. The patient was usually able to mobilize independently and had intermittent confusion, but he could hold lucid conversations with his care workers. He had no lasting power of attorney or advanced directive in place, and his daughter, who resided abroad, had not contacted him in several years.
During the examination, the patient’s temperature was 39.6ºC, heart rate 122 bpm, respiratory rate 26/min, and blood pressure 97/58 mmHg. The cardiovascular system examination revealed a bounding peripheral pulse and a capillary refill time of three seconds. The respiratory system examination revealed tachypnea, and the abdominal examination revealed no abnormalities. The patient was not compliant with formal neurological examination, and his GCS was 14 (E4 S4 M6). He was very confused and unable to maintain a formal conversation, and his speech did not resemble any form.
When the doctor attempted to perform venous cannulation, the patient became very aggressive and hostile. He refused all forms of treatment, stating that he did not require medical treatment and requested to leave the ward immediately. The patient did not appear to comprehend the risks of refusing medical admission and was unable to recall the information disseminated.
What is the best course of action for managing this patient?