Treatment options for oesophageal spasm

This patient is suffering from oesophageal cancer and is experiencing odynophagia and dysphagia. A clinical diagnosis of oesophageal spasm has been made. There are several treatment options available depending on the underlying cause of the symptoms.

Dexamethasone is useful if the dysphagia is due to tumour enlargement and physical blockage is causing dysphagia. Fluconazole is used to treat oesophagitis caused by candidal infection. Omeprazole is a proton pump inhibitor that can be helpful if symptoms of gastro-oesophageal reflux disease are present. Pamidronate is a bisphosphonate that is administered intravenously to treat bone pain and hypercalcaemia.

Nifedipine can work well in cases like this due to its action of relaxing smooth muscle and can help treat the painful spasm that is underlying the symptoms. It is important to identify the underlying cause of the oesophageal spasm to determine the most effective treatment option. With proper treatment, the patient can experience relief from their symptoms and improve their quality of life.

Managing Dyspnoea in Terminally Ill Patients: Treatment Options

Dyspnoea is a common symptom in terminally ill patients and can significantly impact their quality of life. When managing dyspnoea, it is important to identify and treat any reversible causes, such as cardiac failure or pneumonia. However, in cases where the cause cannot be reversed, there are several treatment options available.

One such option is the use of opioids, such as morphine, which can reduce breathlessness at rest and in the end-of-life phase. A therapeutic trial should be given, and the patient should be monitored for response and side-effects. If morphine is not tolerated, alternative opioids can be used.

Dexamethasone is another option, particularly in cases of lymphangitis carcinomatosis and superior vena cava airway obstruction. It reduces inflammatory oedema and can also be used post-radiotherapy.

Furosemide is not likely to be of benefit unless there is evidence of cardiac failure.

Lorazepam, a benzodiazepine, may relieve anxiety and panic associated with severe breathlessness, but it is less effective than opioids and should be considered a second-line treatment.

Finally, if oxygen saturations are below 92%, a trial of oxygen can be considered for symptom relief. However, it is important to note that there may be a poor relationship between hypoxaemia, dyspnoea, and response to oxygen.

In conclusion, managing dyspnoea in terminally ill patients requires a multi-faceted approach, including identifying and treating reversible causes and utilizing appropriate medications for symptom relief.

Spinal Cord Compression: An Oncological Emergency

Spinal cord compression is a medical emergency that requires immediate attention. The sudden onset of bilateral leg weakness and loss of sensation are common symptoms, along with back pain, urinary retention, and constipation. This condition is often caused by metastatic cancer, with breast, bronchus, prostate, multiple myeloma, and high-grade non-Hodgkin lymphoma being the most common culprits. While patients may already have a cancer diagnosis, spinal cord compression can sometimes be the first sign of cancer.

To diagnose spinal cord compression, a whole spinal MRI scan is necessary. Treatment should begin immediately with intravenous dexamethasone, followed by either neurosurgery or radiotherapy. Peripheral neuropathy and spinal tuberculosis can be ruled out based on the time course and lack of relevant history. Paraneoplastic myelopathy is rare and typically associated with small-cell lung cancer, while a secondary spinal tumor deposit would present similarly but is less common.

In summary, spinal cord compression is a serious condition that requires prompt diagnosis and treatment. Early intervention can improve outcomes and prevent further complications.

Managing Hypercalcemia in Palliative Care: Admission, Treatment, and Diet Recommendations

Hypercalcemia, a rise in serum calcium levels, can cause a range of symptoms including weakness, anorexia, nausea, and constipation. Severe cases can lead to delirium, seizures, and coma. While some patients may not experience symptoms, hypercalcemia can be an emergency in palliative care. In cases where treatment is not appropriate, fluid replacement and bisphosphonates can alleviate distressing symptoms. However, symptomatic or moderate to severe hypercalcemia requires immediate admission to a hospital or hospice for management with intravenous fluids and bisphosphonates. A low calcium diet is unnecessary, and good hydration is the first-line treatment for mild asymptomatic hypercalcemia. Thiazide diuretics should be avoided as they can exacerbate hypercalcemia, as can lack of mobility.

Understanding the Risk Factors for Developing Breast Cancer

Breast cancer is a prevalent disease that affects 1.4% of the overall population. However, the risk of developing breast cancer increases with a family history of the disease. The number of affected first-degree relatives and their age at diagnosis can significantly impact the risk. For instance, having one affected first-degree relative increases the risk to 4-5%, while having two close relatives affected raises the risk to 7%.

Women with BRCA1 mutation have a 40% carrier risk of developing carcinoma, while those with BRCA2 have a 25% risk. Additionally, women who have had many ovulations, early menarche, and nullipara are more likely to develop breast cancer. However, the use of the combined oral contraceptive pill is associated with a reduced risk of developing the disease.

In summary, understanding the risk factors for developing breast cancer is crucial in taking preventive measures and seeking early diagnosis and treatment.

Management of Mild Hypercalcaemia in Palliative Care

Mild hypercalcaemia, with an adjusted serum calcium concentration of 3.0 mmol/L or less, is a common complication in palliative care, particularly in patients with cancer. While asymptomatic cases may not require hospital admission, specialist advice should be sought to determine the necessity of treatment. In the meantime, patients should be advised to increase their fluid intake to 3-4 L per day to maintain good hydration. Non-steroidal anti-inflammatory drugs may be useful as adjuvant analgesics, but caution should be exercised to avoid renal toxicity from future bisphosphonate treatment. Calcitonin and intravenous bisphosphonates are effective in reducing serum calcium levels, but hospital admission may be necessary for their administration. A low calcium diet is not necessary as intestinal absorption of calcium is usually impaired. Overall, management of mild hypercalcaemia in palliative care requires a tailored approach based on the patient’s individual circumstances and preferences.

Drug Dose Calculations

Calculating drug doses can be a challenging task, especially when it comes to converting between different medications and routes of administration. One common question in medical exams involves calculating the appropriate dose of a medication for a patient.

To answer this question correctly, there are several steps to follow. Firstly, the total oral dose of morphine must be converted to diamorphine. Then, the breakthrough dose of subcutaneous diamorphine must be calculated, not the oral morphine dose.

To calculate the 24-hour dose of diamorphine for a patient, the total daily dose of oral morphine should be divided by 3. For example, if a patient is taking 90 mg of oral morphine over 24 hours, this is equivalent to 30 mg of diamorphine over 24 hours by syringe driver.

According to the BNF, the subcutaneous dose for breakthrough pain should be between one sixth and one tenth of the 24-hour dose. Therefore, for this patient, the correct breakthrough dose of subcutaneous diamorphine would be between 3 mg and 5 mg.

It is important to note that drug dose calculations are a common area of weakness in medical exams. Examiners often include questions on this topic, and it is essential for healthcare professionals to have a good understanding of how to calculate drug doses accurately.

The breakthrough dose is calculated as 1/6th of the daily morphine dose, which is equivalent to 5mg (30 mg total daily dose divided by 6).

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Treatment Options for Persistent Hiccups

Persistent hiccups can be troublesome for some patients and are often difficult to treat. However, there are several simple manoeuvres that can be tried, such as sipping cold water, breath-holding, and the Valsalva manoeuvre. If hiccups are due to gastric distention, an antacid may help. If these options fail, metoclopramide or domperidone are usually the next treatment options. Baclofen, nifedipine, and chlorpromazine are third-line options that can be tried if the hiccups persist. Haloperidol may also be effective and better tolerated than chlorpromazine. In this case, trying an antacid and antiflatulent preparation is a suitable first-line option as the symptoms are of recent onset and no pharmacotherapy has been tried so far.

Beta-blockers and Anxiety Symptoms

Beta-blockers are effective in managing the autonomic symptoms of anxiety, such as tremors and palpitations. However, they are not likely to alleviate the psychological symptoms of anxiety. While beta-blockers may help with physical symptoms, other approaches may be necessary to address the emotional and cognitive aspects of anxiety. Therefore, it is important to consider a comprehensive treatment plan that includes therapy, medication, and lifestyle changes to manage anxiety effectively.

If a patient or their representative believes that the patient may have a terminal illness, they can request a form DS1500 to be issued. According to Social Security legislation, a terminal illness is a disease that is advancing and is expected to result in death within six months.

Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.

Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.

Common Oral Conditions in Myelosuppressed Patients

Myelosuppressed patients, particularly those undergoing cancer treatment, are at a high risk of developing oral complications. One of the most common conditions is oral mucositis, which can occur in up to 70% of patients undergoing stem cell transplantation. This painful condition is caused by a combination of factors, including chemotherapy or radiotherapy damage, the oral environment, myelosuppression, and genetic predisposition. Symptoms include burning, erythema, and ulcerations in the mouth, which can impact the patient’s nutritional status and require supportive treatment with oral hygiene, mucosal-coating agents, and analgesia.

Other oral conditions that may affect myelosuppressed patients include herpes zoster infection, candidiasis, herpes simplex infection, and Stevens-Johnson syndrome. Candidiasis is the most frequent oral infection in myelosuppressed patients, presenting as white patches on the gums, tongue, and inside the mouth. Herpes simplex virus 1 (HSV-1) is another common viral infection that causes ulcers on the lips. Herpes zoster infection can involve the mouth and skin, while Stevens-Johnson syndrome is a potentially fatal skin reaction caused by drugs, presenting with macules, target lesions, and bullae affecting the skin and mucosal surfaces.

In conclusion, myelosuppressed patients are at a high risk of developing various oral complications, which can impact their quality of life and require supportive treatment. It is important for healthcare providers to be aware of these conditions and provide appropriate management to improve patient outcomes.

Hypercalcaemia: Symptoms, Complications, and Treatment Options

Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. This condition can cause a range of symptoms, including constipation, nausea, polyuria, confusion, depression, lethargy, weakness, and bone pain. In chronic cases, hypercalcaemia can lead to the formation of renal stones. If left untreated, calcium levels greater than 3.5 mmol/l can cause renal failure and arrhythmias.

The treatment of hypercalcaemia involves identifying and removing the underlying causes, rehydration, and, if necessary, the use of bisphosphonates. In cases where primary hyperparathyroidism is the cause, surgical treatment may be necessary.

In summary, hypercalcaemia is a serious medical condition that can cause a range of symptoms and complications. Early diagnosis and treatment are essential to prevent further health problems.

Common Medications Used in Palliative Care

When introducing an opioid in palliative cancer care, it is recommended to prescribe a stimulant laxative such as senna or a dantron-containing laxative to prevent constipation. Amitriptyline is commonly prescribed as an adjuvant analgesic for neuropathic pain, while ibuprofen is used for bone pain or pain due to soft tissue infiltration. Metoclopramide is a pro-kinetic drug used for vomiting due to gastric stasis, while prochlorperazine is not typically used in palliative care. It is important to consider the specific needs of each patient when selecting medications for palliative care.

Hypercalcaemia in a Patient with Squamous Cell Lung Carcinoma

This patient is presenting with signs and symptoms of hypercalcaemia, including confusion, lethargy, musculoskeletal aches and pains, thirst, abdominal pain, and constipation. The underlying cause of her hypercalcaemia is likely ectopic parathyroid hormone production associated with her squamous cell lung carcinoma.

It is important to consider other potential causes of her symptoms, such as anaemia or an infective cause like atypical pneumonia. However, her medication and superior vena caval obstruction are less likely to be the primary cause of her clinical picture.

Managing hypercalcaemia in patients with advanced cancer is crucial for symptom control and improving quality of life. The Scottish Palliative Care Guidelines provide recommendations for the management of hypercalcaemia, including hydration, bisphosphonates, and corticosteroids. Close monitoring and communication with the patient’s healthcare team are also essential.

Appropriate Management for a Patient Dealing with a Major Life Event

When a patient approaches their GP seeking advice and support for a major life event, it is important to provide appropriate management. Starting the patient on night sedatives or an SSRI antidepressant without an assessment for insomnia or depression would not be appropriate at this stage. Referring the patient to a Macmillan Cancer Care Nurse or community mental health services may be required in addition to providing ongoing GP support, but it would not be the initial next step. The initial management should focus on exploring the patient’s needs and offering ongoing GP support and follow-up, upon which later care strategies can be constructed. The GP is uniquely placed to provide medical and supportive care to the patient and possibly their wider family.

Advance Decisions to Refuse Treatment (ADRTs)

An Advance Decision to Refuse Treatment (ADRT) is a legally binding document that comes into force once a person loses capacity. It is applicable and valid, and family members cannot override it. It is important to note that there is no legal definition of next of kin.

For an ADRT that refuses potentially life-sustaining treatment to be valid, it must be written, signed, and witnessed. It should also include a statement indicating that the person completing the ADRT accepts the consequences, even if it means their life is at risk.

A Lasting Power of Attorney for Health and Welfare can only override the ADRT if it was made after the ADRT and the attorney has the authority to give or refuse consent for treatment related to the ADRT.

It is essential to complete an ADRT when one is 18 years or older and has the capacity to do so. The document comes into force when the person loses capacity.

Choosing the Right Pain Medication: A Guide to Opioids and Adjuvants

When it comes to managing pain, healthcare professionals often follow the World Health Organization’s analgesic ladder. This involves starting with non-opioid medications, such as paracetamol, and weak opioids, such as codeine, before moving on to stronger opioids like morphine if necessary.

In cases where bone pain or soft tissue infiltration is present, non-steroidal anti-inflammatory drugs like ibuprofen can be added as an adjuvant at any step in pain management. However, it is important to note that these adjuvants are unlikely to be a substitute for stronger opioids like morphine.

Dihydrocodeine and tramadol are both weak opioids and are therefore unlikely to provide significant pain relief in cases where stronger medication is needed. Amitriptyline, on the other hand, is an adjuvant typically used for neuropathic pain and is unlikely to be effective in this scenario.

For patients who require a strong opioid but are unable to take oral medication, fentanyl may be prescribed as a transdermal patch. Ultimately, the choice of pain medication and adjuvants will depend on the individual patient’s needs and the severity of their pain.

Understanding Equivalent Morphine Dose for Codeine Patients

When prescribing pain medication, it is important to consider the equivalent morphine dose for patients taking codeine. This can be calculated by dividing the dose of codeine by 10. For example, a patient taking 60 mg of codeine four times a day would have a total daily dose of 240 mg, which is equivalent to 24 mg of morphine.

Failing to consider the equivalent morphine dose can result in inadequate pain relief for the patient. It is important to note that some patients may metabolize codeine at different rates, but this should not be a major concern in most cases. The majority of patients are normal metabolizers, converting 10% of codeine to morphine.

Overall, understanding the equivalent morphine dose for codeine patients is a crucial aspect of pain management and should be taken into consideration when prescribing medication.

Understanding Lasting Power of Attorney for Health and Welfare

Lasting Power of Attorney (LPA) for Health and Welfare is a legal document that allows a person to appoint one or more attorneys to make decisions on their behalf when they are unable to do so themselves. This LPA can only be invoked when the donor loses mental capacity, which may occur if they have a living will or have been sectioned.

It is important to note that the LPA for Health and Welfare doesn’t give the attorney the right to make decisions about pensions and benefits. For such decisions, a separate LPA for Property and Financial Affairs must be considered.

Once registered, the appointed attorney can make decisions about the donor’s health and care. It is not necessary for the appointed attorney to be a family member; they can be a friend, relative, or even a professional such as a solicitor.

It is also important to renew the LPA every 12 months. The LPA will endure unless revoked by the donor while they still have mental capacity, revoked by the attorney, the donor loses mental capacity, they divorce or end a civil partnership, or they pass away.

In summary, understanding the LPA for Health and Welfare is crucial for ensuring that a person’s wishes are respected and their best interests are protected when they are unable to make decisions for themselves.

Recognizing Spinal Metastases: Symptoms and Risks

Spinal metastases pose a significant risk of spinal cord compression, affecting 5-10% of all cancer patients. While all options may indicate spinal metastases, it is crucial to identify specific symptoms. Lumbar pain that worsens with movement and improves with rest is a common symptom of mechanical back pain, but other concerning features include progressive and nocturnal spinal pain. If a patient presents with symptoms suggestive of spinal metastases, doctors should consult with the local metastatic spinal cord coordinator within 24 hours to ensure prompt and appropriate management.

Treatment for Symptoms of Raised Intracranial Pressure in Brain Metastases Patients

This patient is experiencing symptoms of raised intracranial pressure due to brain metastases. Depending on the treatment aims and ceiling of treatment, radiotherapy may be indicated. However, pharmacotherapy can also aid in palliating symptoms. High dose corticosteroids, such as dexamethasone at 16 mg daily for four to five days, followed by a reduced dose of 4-6 mg daily, can help alleviate headaches caused by raised intracranial pressure. Other options may be considered as adjuncts to treatment for pain, nausea, and agitation. Nevertheless, dexamethasone is the best option as it directly targets the underlying problem causing the symptoms in this case.

When an individual’s life expectancy is less than 6 months, a DS1500 form is filled out to expedite the process of receiving benefit payments.

Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.

Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.

Treatment Options for Seizures in Palliative Care

In palliative care, patients may experience seizures which can be distressing for both the patient and their family. To prevent further fits and provide symptom palliation, treatment is necessary. However, the method of administration must be considered as the patient may already be receiving medication via a syringe driver. Oral preparations may not be absorbed adequately, and phenytoin is not the medication of choice in this setting. Benzodiazepines can provide palliation of anxiety, restlessness, and breathlessness, as well as treat seizures. However, intramuscular and rectal administration of medication can be uncomfortable for the patient.

Midazolam is the benzodiazepine antiepileptic of choice for use as a continuous subcutaneous infusion. It is typically administered at initial doses of 20-40 mg over 24 hours. Lorazepam and diazepam also have their roles in palliative care, but they may be preferable in different situations, especially if delivery is by an alternative route to subcutaneous infusion and as required use is indicated for more infrequent symptoms. Overall, the choice of treatment for seizures in palliative care should be carefully considered to ensure the patient’s comfort and well-being.

Drug Calculation Learning Point

When it comes to drug calculations, it’s important to be careful and avoid getting caught out. One common scenario is converting a patient from oral medication to a subcutaneous infusion as their disease progresses. However, it’s also important to be able to take patients off a syringe driver and back on to oral medication. In this case, the total daily dose of diamorphine via syringe driver is one-third of the total oral dose of morphine. It’s easy to get the calculation the wrong way around, so it’s crucial to be familiar with this learning point.

For example, if a patient is having 30 mg of diamorphine over 24 hours, the total 24-hour oral dose of morphine would be 30 mg x 3 = 90 mg oral morphine. This is a common area of weakness in the AKT exam, and examiners have highlighted it as an area of poor performance. Therefore, it’s essential to practice this calculation repeatedly during revision time to ensure a thorough understanding of the concept.

It is probable that the patient passed away due to the initial fall, which necessitates referral to the coroner as per the guidance that mandates all deaths related to injury or poisoning.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

Acute Personality Change in Lung Cancer Patients: A Possible Sign of Cerebral Metastases

When a patient with known lung cancer experiences an acute personality change, it is important to consider the possibility of cerebral metastases. While depression associated with the condition may be a factor, an abrupt shift in behavior without an obvious trigger warrants immediate specialist assessment. This was the case for a real patient with lung cancer who presented with withdrawal and quietness, and was found to have brain metastases on CT imaging.

According to a review of psychiatric aspects of brain tumors, changes in behavior and personality are common in patients with cerebral metastases. These changes can include depression, anxiety, irritability, and apathy. It is important for healthcare providers to be aware of these potential symptoms and to promptly refer patients for further evaluation and treatment. By doing so, patients can receive appropriate care and support to manage their condition and improve their quality of life.

Converting Oral Morphine to Subcutaneous Infusion

In order to convert oral morphine to a 24 hour subcutaneous infusion of morphine, the total 24 hour oral dose must be calculated. For example, if the patient is taking a 12 hour release preparation of 60mg, the total daily dose of oral morphine is 120mg. To convert this to a 24 hour subcutaneous infusion of morphine, the figure must be divided by two. For diamorphine, the figure would be divided by three. Therefore, the patient needs 60mg morphine over 24 hours.

It is important to note that the question asks for the volume of morphine over 24 hours, not the dose. If the ampoules are 10 mg/ml, then to deliver 60mg in 24 hours, 6 x 10 mg/ml = 6 ml is needed. It is crucial to read the question carefully to ensure the correct answer is given.

A death should be referred to the coroner if the person who died was not visited by a medical practitioner during their final illness, if the cause of death is unknown, if the death was violent or unnatural, if the death was sudden and unexplained, if a medical certificate is not available, if the person who died wasn’t seen by the doctor who signed the medical certificate within 28 days before death or after they died, if the death occurred during an operation or before the person came out of anaesthetic, or if the medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning.

Notifiable Deaths and Reporting to the Coroner

When it comes to death certification, certain deaths are considered notifiable and should be reported to the coroner. These include unexpected or sudden deaths, as well as deaths where the attending doctor did not see the deceased within 28 days prior to their passing (this was increased from 14 days during the COVID pandemic). Additionally, deaths that occur within 24 hours of hospital admission, accidents and injuries, suicide, industrial injury or disease, deaths resulting from ill treatment, starvation, or neglect, deaths occurring during an operation or before recovery from the effect of an anaesthetic, poisoning (including from illicit drugs), stillbirths where there is doubt as to whether the child was born alive, and deaths of prisoners or people in police custody are also considered notifiable.

It is important to note that these deaths should be reported to the coroner, who will then investigate the circumstances surrounding the death. This is to ensure that any potential criminal activity or negligence is properly addressed and that the cause of death is accurately determined. By reporting notifiable deaths to the coroner, we can help ensure that justice is served and that families receive the closure they need during a difficult time.

Superior Vena Caval Obstruction (SVCO)

Superior Vena Caval Obstruction (SVCO) is a condition where there is a blockage of blood flow in the superior vena cava. This can be caused by external compression or thrombosis within the vein. The most common cause of SVCO is malignancy, with lung cancer and lymphoma being the most frequent culprits. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

Typical features of SVCO include facial and upper body oedema, facial plethora, venous distention, and increased shortness of breath. Impaired venous return can cause dizziness and even syncopal attacks. Headache due to pressure effect is also seen.

Prompt recognition of SVCO on clinical grounds is crucial, and immediate referral for specialist assessment is necessary. If there is any stridor or laryngeal oedema, SVCO becomes a medical emergency.

Treatment for SVCO typically involves steroids and radiotherapy, with chemotherapy and stent insertion being indicated in some cases. Although dexamethasone may be given as an acute treatment, it is not the best answer for this patient, who needs to be referred immediately for inpatient treatment and monitoring.

In summary, SVCO is a serious condition that requires prompt recognition and referral for specialist assessment. Treatment options include steroids, radiotherapy, chemotherapy, and stent insertion, depending on the underlying cause.