Q : 121 - 132

A 48-year-old woman with advanced cervical cancer and bilateral nephrostomies presented with drowsiness, confusion and hallucinations. She was taking modified-release oral morphine 40 mg twice daily. Investigations: serum sodium serum potassium serum creatinine estimated glomerular filtration rate (MDRD) 15 mL/min/1.73 m2 (>60)

An 87-year-old man with oesophageal cancer had increasing difficulty swallowing. He was offered an endoscopy and oesophageal stent. He considered this option carefully, but decided that he did not wish to undergo any further procedures.

A 46-year-old woman with metastatic ovarian cancer was admitted to a hospice for symptom control. On discharge, she was unable to leave her two-bedroomed flat but could walk around and care for herself independently. What best describes her current score on the Australia-modified Karnofsky performance scale?

A 69-year-old man with COPD was admitted to a hospice with an infective exacerbation. Despite oral antibiotics, oxygen and physiotherapy, he was becoming increasingly breathless and confused. Two months previously, he had sent a letter of complaint to the hospital about his recent care, and following this had signed an advance decision to refuse treatment. This document explained that he did not want hospital treatment with intravenous antibiotics, even if his life was at risk, and did not want cardiopulmonary resuscitation. His preferred priorities of care document stated that he wanted to be cared for in the hospice. He had also appointed his son as his attorney for financial issues.

A 75-year-old woman with breast cancer and brain metastases was being cared for in a hospice during the last days of her life. She had dementia and an MRSA- positive infected pressure ulcer on her heel. Her medication included dexamethasone 8 mg twice daily. Chemotherapy had been stopped 3 months previously. She had previously stated that she wished to donate her corneas after her death. What is the most important factor to consider in determining her suitability to donate corneas?

Sandra, 69 years old, has lung cancer with metastasis to bone. She has been taking morphine 30 mg po q4h straight, with a breakthrough of 15 mg po q2h prn (she takes no more than 1 per day). She now presents with confusion and nightmares. After your assessment and delirium work-up, you decide to rotate to hydromorphone.

You wish to switch a patient from hydromorphone (short acting) to transdermal fentanyl patches. The patient’s pain is now well controlled after titrating the hydromorphone dose. Her hydromorphone dose is 4mg orally every 4 hours which is equivalent to 25 micrograms per hour of fentanyl transdermally changed every 3 days. How will you switch her to the fentanyl?

A 67-year-old man with metastatic prostate cancer developed hot flushes. His only medication was monthly luteinising hormone-releasing hormone antagonist. According to NICE guidance ‘Prostate cancer: diagnosis and management’ (2014),

A 25-year-old man with relapsed Hodgkin disease presented with an 8-week history of widespread itch, which was worse at night. On examination, there were excoriations on his legs and trunk. The consultant suggested treating him with cimetidine.

A 78 year old male with metastatic renal cell carcinoma who has trialled surafanib, evorolimus and nivolumab and is refractory to all medical therapy presents to the emergency department with intractable fevers and night sweats.