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CC: “I’m in a lot of pain, can you help me?” HPI: LC, a 77 yo male, is new to the outpatient palliative care service associated with his local cancer treatment center. LC was diagnosed 3 years ago after patient fell and experienced a pathologic fracture of his L hip and subsequent hip replacement. At that time he had been in good health and only had mild urinary symptoms of nocturia. Initially treated with leuprolide 22.5 mg IM Q 12 weeks x 24 months, but experienced disease progression despite this therapy. Switched to enzalutamide and has been taking this medication for the past year. Patient reports a deep, aching pain in his pelvis and muscles that he treats with morphine ER and morphine IR or breakthrough pain. Also reports knee pain and sharp bone pain in his hip area. Complains of daily fatigue which is not helped with sleep and is not much different if he takes less pain medications. Uses 5 doses of breakthrough morphine IR per day. Reports that he wants his wife to be his health care proxy and has determined himself to be DNR/DNI. PMH: Prostate cancer x 3 years; T2c, N4, M1b Chronic pain secondary to bone mets x 3 years OA x 10 years GERD x 20 years DM x 15 years Allergies: Sulfa- hives Adverse drug events: ASA (h/o GI bleed) Oxycodone (dizziness) Meds: Enzalutamide 160 mg PO daily Lupron Depot 22.5mg IM Q 12 weeks Morphine ER 60 mg PO Q8H Morphine 15 mg PO Q4H PRN pain Senna 8.6 mg 2 tablets PO BID PEG 3350 1 capful in 8 fl oz of fluid every other day Vitamin D 1,000 IU PO daily Pantoprazole 40mg PO daily Insulin glargine 58 units subcut daily at bedtime FH: F deceased age 92 from prostate cancer, M deceased age 90 from AD; sister age 73 alive with breast cancer, brother deceased SH: Retired pharmacist; married for 56 years with 2 daughters and 3 grandchildren; (-) tobacco (never smoked); Denies alcohol or illicit drug consumption; no longer drives due to pain medications ROS: Reports 1 BM every other day (dependent upon laxative use); (+) fatigue (limits what he can do each day); (+) 4-5 headaches per week; (+) loss of appetite; (+) ankle swelling (elevates his legs); (+) hot flashes, (+) knee pain; (+) achy muscle pain; (+) bone pain in hip. Denies fever, chills, nausea, urinary urgency or frequency, falls, or heartburn. PE: Gen: Cachectic male in mild distress from pain VS: BP 122/80 mmHg (sitting), 110/80 mmHg (standing), HR 78 bpm, RR 12 bpm, T 37 C, Ht 195cm, Wt 56kg, pain 7/10 in AM before meds, 4/10 after meds HEENT:PERRLA; EOMI Chest: (+) gynecomastia Lungs: CTA CV: RRR; (-) m/r/g Abd: NTND; soft, no masses Neuro: A&O x 3, short and long-term memory intact, CN II-XII intact, GU: Deferred Ext: (-) CCE; normal pulses, 1+ pitting edema Visual acuity: 20/80 MMSE: 30/30 DEXA: Left femoral neck T score: -2.7 Z-score: -2.0 A/P: Pain: Will consult pharm.d. for help with pain meds Labs (today): Na 135 mEq/L K 4.1 mEq/L Cl 101 mEq/L CO2 22mEql/L BUN 12 mg/dL SCr 1.4 mg/dL Glu 146 mg/dL Ca 9.1 mg/dL Alb: 4.0 g/dL Hgb: 11.1 g/dL Hct: 34.6% RBC: 4.0 × 103 /mm3 WBC: 8.5 × 103 /mm3 Plt: 257 × 103 /mm3 PSA 8.6 ng/mL HgbA1c: 8.5% Labs (6 months ago): Na 140 mEq/L K 3.7 mEq/L Cl 102 mEq/L CO2 22mEql/L BUN 10 mg/dL SCr 1.1 mg/dL Glu 110 mg/dL Ca 8.9 mg/dL Alb: 3.8 g/dL Hgb: 11.1 g/dL Hct: 34.6% RBC: 4.0 × 103 /mm3 WBC: 8.5 × 103 /mm3 Plt: 257 × 103 /mm3 PSA 8.6 ng/m 1.What is your assessment of this patient? 2. What type of pain does this patient have? 3. What is the severity of this patient’s pain? 4. What is your pharmacotherapy plan for this patient’s opioid regimen? What is your rationale?if you want to convert between opioids how? 5. What side effects may the patient see with his new opioid treatment? 6. What patient counseling should the patient receive? (In each pair, 1 student should counsel their partner on how to take their pain regimen) 7. What monitoring and questions should be assessed to see if the new pain regimen is working for the patient? 8. Since the patient has bone pain, what adjunctive treatment do you recommend
SCIENCE
HEALTH SCIENCE
NURSING
PHCL 434

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