CC: “I’m in a lot of pain, can you help
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
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