MCQs Review 325-336

329. William is a 63-year-old veteran who was diagnosed 1 year ago with adenocarcinoma of the lung metastatic to the other lung. He has undergone radiation therapy and received a dose of chemotherapy, which caused such severe nausea and vomiting that he refused further treatment. He was referred for hospice care. During the hospice physician’s assessment at William and Evelyn’s modest home, William complained of severe pain that does not respond to the 4-mg hydromorphone tablets he takes orally every 4 hours as needed for pain prescribed by his attending physician. During the interview, William moans and reports all-over aching pain but is unable to rate it on a numerical scale. He is obviously miserable.

 

Question One: What is the most appropriate course of action?

330. History and Physical Examination The physician’s first questions relate to the location of William’s pain. When asked to point to all the places where he hurts, William eventually indicates his chest, stomach, and back. William clearly has tenderness on his chest wall and sacrum and is experiencing cramping in his lower abdomen. The history further reveals that William is bed bound most of the time and needs help turning. When discussing his medication, William says he was taking acetaminophen with codeine but that it did not control the pain, so his physician prescribed hydromorphone. He reports falling asleep after taking 4 mg of hydromorphone and then feeling somewhat drowsy and confused when he wakes. Although he is experiencing persistent pain, he takes only one hydromorphone tablet every other day because he wants to remain awake. The history also reveals that William has not had a bowel movement in 4 days. His wife is arthritic and having increasing difficulty caring for William. The physical examination reveals a cachectic male who appears older than his stated age. The examination is remarkable for decreased breath sounds on both sides of his chest, tenderness of the left side of the chest wall where the skin was affected by radiation therapy, and mild lower abdominal distention consistent with constipation. The rectal examination reveals a soft fecal impaction but no masses. He has a stage-II pressure ulcer on his sacrum and severe muscle wasting.

 

Question Two: The four most likely causes of William’s pain all except

333. During the first visit to William and Evelyn’s home, the physician further explores William’s reasons for not taking the hydromorphone as prescribed and discovers that William is concerned about drug addiction and says that drowsiness and confusion are unacceptable side effects for him. Evelyn is also afraid of drug addiction and has been hiding the hydromorphone. She wants William to stay awake so he will eat more and regain his strength. The physician determines the need for patient and family education and explains that taking medications for cancer pain does not lead to addiction; William can gradually stop taking his medication if his pain goes away completely. The physician also explains that drowsiness and confusion are occurring because William isn’t taking the appropriate strength of medication and that a different medication can be used that won’t be quite as strong as the hydromorphone and won’t cause as much drowsiness and confusion. William will also need to take the new medication on a regular schedule every 4 hours. The physician explains that mild drowsiness may occur for the first day or two, but it won’t be as bothersome as it has been with the hydromorphone. William will be more awake, will be able to eat, and won’t be in as much pain. The physician reminds Evelyn that she should call the hospice if William becomes so sleepy that he can’t be aroused to take his next dose of medicine; in such a case the dose will be reduced. Evelyn is also advised that William should take an additional dosage if breakthrough pain occurs but should call the hospice if he has to take additional dosages more than two or three times in a 24-hour period so that the baseline dose can be increased. The dose of the new medication will probably have to be adjusted upward or downward in the next few days, depending on how it works for William. The physician concludes the visit by asking Evelyn to call the hospice any time, day or night, if she has concerns about William’s condition and reassures her that everyone is working together to relieve William’s pain. William and Evelyn agree that mild drowsiness for a day or two is an acceptable side effect. To determine the right initial dosage of a new medication, the physician calculates that William’s 4-mg dose of hydromorphone is roughly equivalent to 15 mg of an oral morphine (oral hydromorphone is about 4 times as potent as oral morphine; see Table 3). The physician decides that 15mg of oral morphine equivalent is more than William needs to control his pain but that 1 mg or 2 mg is inadequate, because the acetaminophen with codeine that William had been taking before the hydromorphone did not provide relief. Therefore, the physician concludes that 7.5 mg of an oral morphine equivalent every 4 hours is a good place to start; William is a normal-sized adult weighing more than 60 pounds with severe pain, and it is important to avoid unacceptable side effects.

 

Question 5 At this point, which of the following medications is the best choice?

334. The physician explains that William must take one tablet every 4 hours around the clock and one-half tablet for breakthrough pain. At bedtime, William can take two tablets so he doesn’t have to wake up at 2 am to take his dose. The physician then writes out a chart so William and Evelyn can check that he has taken one tablet at 6 am, 10 am, 2 pm, 6 pm, and two tablets at 10pm. The physician then orders bisacodyl suppositories and suggests that William insert one suppository as soon as possible. The physician explains that the medication usually works within an hour and recommends using two suppositories if the first one is ineffective. She also encourages the use of a suppository if bowel movement does not occur at least every other day and asks Evelyn to call the hospice if William needs to use the suppositories regularly. One tablet of senna with docusate twice daily is also prescribed to prevent recurrent constipation. The physician concludes the visit by making arrangements for the hospice nurse and social worker to visit William and Evelyn the next day to ensure William is comfortable and awake, reinforce what the physician said about addiction, and explore the family’s financial needs and help them obtain available community assistance. Evelyn calls the hospice at midnight the next night and reports that William is experiencing a lot of chest pain. The hospice nurse confirms that William has been taking one tablet of oxycodone every 4 hours, that his bowel movements are occurring regularly, and that the pain has the same character and location as before. It is most likely that the chest-wall pain is from the lung cancer.

Q6 At this point, which of the following is an appropriate order?

The hospice physician increases the oxycodone to two tablets every 4 hours and a whole tablet for breakthrough pain. William is comfortable by morning. A few days later, William is at home in a hospital bed and has a special mattress for his pressure ulcer. Evelyn has been taught how to reposition him on a regular basis. The social worker has arranged for the utility company to waive William and Evelyn’s overdue payments and for the Veterans Administration hospital to provide medications, and she has initiated procedures for William to obtain disability payments. The hospice chaplain has arranged for regular visits from William and Evelyn’s pastor at their request. During the next visit 3 days later, the nurse discovers that William is getting good pain relief with two oxycodone tablets but is sometimes confused and occasionally sees people on the wall. Evelyn thinks William is overmedicated. Although William obtains good pain relief with two oxycodone tablets, these side effects are unacceptable.Q7 At this point, what is the most appropriate response?