18 august ( 109 - 120 )

A 60-year-old man with lung cancer and liver and bone metastases was admitted to a hospice for symptom management. He was taking gliclazide 40 mg twice daily for type 2 diabetes mellitus. He had been found by the nursing staff sweaty and drowsy, and was “drifting in and out of consciousness”. His capillary blood glucose was 1.4 mmol/L. Investigations: prothrombin time 25.3 s (11.5–15.5) serum albumin 17 g/L (37–49) serum total bilirubin 57 μmol/L (1–22) What is the most appropriate next step in management, as recommended by Diabetes UK guidance ‘End of life diabetes care: clinical care recommendations’ (2013)?

A 54-year-old man presented with a 3-day history of worsening haematuria. He had metastatic prostate cancer that had been responding to palliative chemotherapy. Investigations: haemoglobin white cell count platelet count prothrombin time 11.7 s (11.5–15.5) activated partial thromboplastin time 35 s (30–40) fibrinogen 0.5 g/L (1.8–5.4) D-dimer 2400 mg/L (<0.5) In addition to a platelet transfusion,

A 61-year-old woman with breast cancer presented with a 2-day history of nausea, shaking, tearfulness and general distress. She had been feeling relatively well until she had attended her oncology appointment 2 days previously, where she had been informed that the CT scan showed progression of her cancer and that there was no further treatment. Her medication included citalopram, dexamethasone and morphine. She had a past history of high alcohol intake. On examination, she was agitated and alert. Her temperature was 36.8°C, her pulse was 96 beats per minute and her BP was 140/60 mmHg. Investigations: serum sodium 138 mmol/L (137–144) serum potassium 4.4 mmol/L (3.5–4.9) serumurea 4.0mmol/L(2.5–7.0)

A 66-year-old man with COPD presented with his third infective exacerbation in 2 months. He was taking inhaled salmeterol and fluticasone. His chest infection responded to a course of intravenous antibiotics. However, his respiratory function remained poor. He reported severe dyspnoea at rest and on mild exertion. Investigations: arterial blood gases, breathing air: PO2 8.2 kPa (11.3–12.6)

46 year-old man was advised to start chemotherapy for treatment of non Hodgkin lymphoma. He was at risk of developing tumour lysis syndrome.

A 53-year-old man with locally advanced bladder cancer presented with a 24- hour history of suprapubic pain and visible haematuria. He had experienced pink urine since his diagnosis 6 weeks previously. He was due to start palliative chemotherapy in the next week. He had a history of angina, atrial fibrillation and hypertension. He was taking warfarin and had recently started taking ciprofloxacin for a urinary tract infection. On examination, his temperature was 36.7°C, his pulse was 140 beats per minute and irregular, his BP was 90/60 mmHg and his respiratory rate was 25 breaths per minute. Investigations: haemoglobin 80 g/L (130–180) MCV 76 fL (80–96)

A 70-year-old man with metastatic cancer of the prostate presented with pain in the pelvis. The pain was well controlled most of the time with a combination of modified-release morphine sulfate 60 mg twice daily and paracetamol 1 g four times daily. However, he was experiencing exacerbation of the same pain when he took the dog on a 30-minute walk.

A 46-year-old woman with locally metastatic cervical carcinoma had persistent pelvic pain. She had been increasing the dosage of morphine sulfate with little effect and was beginning to show signs of opioid toxicity. As she was already taking gabapentin and amitriptyline, the decision was made to start a ketamine infusion. What best describes the principal mechanism of action of ketamine?

A 44-year-old woman had chemotherapy-induced nausea and vomiting during cisplatin-based chemotherapy for ovarian carcinoma. Her symptoms were treated successfully with aprepitant. What is the mechanism of action of aprepitant?

A 54-year-old woman with metastatic breast cancer presented acutely with bilateral leg weakness resulting from malignant spinal cord compression. She was fully mobile before the episode and had always been very active. She underwent successful spinal surgery but was struggling to regain full mobility on the ward. According to the NICE guidance ‘Metastatic spinal cord compression’ (2014), what is the most appropriate next step in management?

A 60-year-old man with metastatic prostate cancer was admitted with  severe leg weakness because of spinal cord compression. He had no response to radiotherapy. His main aims were to improve pain and to be hoisted into a chair. What scale best describes the extent to which an outcome measure set by the patient has been achieved?