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BONUS CASE:

6.67 or 7 mg IV Morphine IV TID / 20 mg IV OD Morphine

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1. Is she OPIOD naive or tolerant?
Patient is Opioid tolerant. Patient may require stronger and higher than conventional doses of opioid, may require longer acting agents.

2. Patient is a 54 F known NSC Lung cancer, already on Morphine 10 mg
with a 10/10 PS, on acute pain crisis. For this, we will SHIFT Morphine
IV to Fentanyl 200 mcg IV bolus then 100 mcg Q4H - monitor Q4H for pain reassessment, add adjuvant such as Dexamethasone IV 2 mg Q24 for
the bone pain and metastasis.

3. Monitor Pain scale thru Numeric Scale every 4 to 6 hrs.
Reassess the patient as needed, based on clinical reassessment.

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1. The patient is opioid tolerant, taking Morphine (prolonged release)

2. The pain of the patient will be managed with opioids with the addition of non-opioid and adjuvant pharmacologic regimen base on WHO 3-step Ladder Approach. The patient will be receiving a rescue dose of opioid Morphine 2mg every 5 to 10 minutes (max 15mg) since the current dosing is with prolonged release. Dexamethasone 32mg daily in 2 divided doses. The patient will be given an adjuvant Parcetamol 1g/ IV every 6 hours RTC.

3.   The pain will be monitored through the patient’s pain score using NRS every after intervention given while monitoring for side effects such as respiratory depression.

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Group 3 (Probadora, Cenil, Sarrosa, Mata, Zamora, Palao)

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Group 3 (Probadora, Cenil, Sarrosa, Mata, Zamora, Palao)

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1. This patient is considered as opioid-tolerant since she has been chronically taking morphine at least 60mg per day (10mg every 4 hours) for her back pain.

2. The morphine dose for this patient who complains of severe back pain (PS 10/10) may be doubled -- 20 mg every 4 hours (this can be re-dosed every 15 minutes). For the bone pain, we can also give dexamethasone 4mg-8mg/day (to address metastatic bone pain). As adjunct we can also give paracetamol 1g IV every 6 hours. Since this patient has a known metastasis, we also consider a possible hypercalcemia from malignancy which is contributing to the patient’s pain — for this we can hydrate the patient, with or without furosemide and/or zoledronic acid.

3. Monitoring response to Pain would still be primarily based on the patient’s subjective response. The patient may still present normal vital signs and is a weak correlation between nonverbal signs, such as tachycardia, tachypnea, and changes in patient expression and movements, and the patient’s report of pain, so we do not rely on these to determine the severity of a patient’s pain or their response to treatment. Because pain is dynamic and changes with time, periodic pain reassessment is needed.  In terms of response, the primary purpose of pain scales (Womg Baker, Visual analog etc.)  is to quantitate pain severity, guide the selection and administration of an analgesic agent, and reassess the pain response to determine the need for repeated doses or alternative analgesics .The patient’s subjective report of pain, not the healthcare provider’s impression, is still the basis for pain assessment and response, thus asking patient requires more analgesic may even be simpler and accomplish more than using any standardized pain evaluation tool

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1. DIFFERENTIAL DIAGNOSIS
PGO - abdominal XRAY
Spinal Cord Compression - MRI
Ileus from Medication Induced - History and PE
Electrolyte Imbalance - Serum Chemistry, History and PE
Malignant Bowel Syndrome - Abdominal CT Scan
Cranial Metastasis - Cranial CT with contrast

2. How will you manage nausea and vomitting?
Place patient on NPO status.
Insert NGT - open to drain and IFC
Judicous IV fluid hydration and IV electrolyte replacement
Shift Morphine to other Opioids such as Fentanyl IV
Give Antiemetics such as Ondansetron 4 mg IV- may increase
For consideration of Brain metastasis, possibly contributing to increase ICP thus the symptoms of nausea and vomitting, may give IV steroids.

3. For the abdominal pain, may give IV Pain Medications - trial of NSAIDS.

4. For referral, opinion of Surgery and Medicine - Gastroenterology and Nutrition, Orthopedics-Spine, SHPM  and Pain Specialist Services are beneficial.

5. No, we will not allow the patient. But instead, we can provide ice chips as alternative.

In general for patients with nausea and vomiting, general supportive measures should be instituted. Unnecessary medications should be discontinued that might be contributing to the symptoms.

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1. DIFFERENTIALS:

PGO vs ileus from 1. Opioid-induced 2. Electrolyte imbalances from poor oral intake & GI losses; Pneumoperitoneum; SCC

We rule this out by Abdominal X-rays supine & upright, Serum electrolytes (Na, K, Cl)

2. Metoclopramide 10mg IV since this patient has vomiting

3. Fentanyl patch; discontinue morphine; NGT insertion for gastric decompression

4. Referrals: Medicine as primary service for the management of the overall condition of the patient,Adult neurology for the evaluation of a possible SCC, Surgery for evaluation of possible obstruction; Pallative care - given the age and prognosis of the patient, it is prudent to have the service on board, if not already, to enhance end of life care and establish the patients goal for initiating treatment

5. Will maintain the patient on NPO however, we will allow wetting of lips with wet cotton. Once the patient’s nausea and vomiting resolve, we may allow small sips of water

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Group 3 (Probadora, Cenil, Sarrosa, Zamora, Mata)

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Group 3 (Probadora, Cenil, Sarrosa, Zamora, Mata)

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1. Differentials include acute abdomen from PGO from the mass, neurogenic bowel from spinal metastasis, metabolic ileus, drug-induced ileus (morphine), and functional constipation. We can do plain abdominal xray upright and supine, serum electrolytes (especially potassium).

2. Understanding the underlying cause for the patient's nausea and vomiting is important in the management of his symptoms. He has been on narcotic analgesic (Morphine) which can cause vomiting. Some helpful medications include Ondansetron 8 mg initial dose which may be given 2x a day per orem or via NGT. Steroids may be helpful as well in improving symptoms of bowel obstruction in patients with cancer.

3. The investigation into potential causes of decreased bowel movements or constipation involves several diagnostic steps. These include taking a thorough history and conducting a physical examination, which may include a digital rectal examination (DRE). Additionally, performing a plain film abdomen (PFA) can help identify the presence of any obstructions that might be contributing to the issue. These diagnostic measures are crucial in understanding the underlying factors behind the reduced bowel movement or constipation.

The management plan includes several key steps. Firstly, if there is evidence of fecal impaction, manual extraction should be performed. This is followed by considering a surgical referral or clearance if a surgical abdomen is suspected. Additionally, the administration of peripherally acting μ-receptor antagonists (PAMORAs), such as methylnaltrexone, naloxegol, and naldemedine, should be considered. To promote healthy bowel function, patients are encouraged to follow a high-fiber diet and stimulants like Bysacodyl may be administered. Electrolyte replacement and fluid administration are also important aspects of the overall management strategy.

4. We will refer to surgery for the assessment of an acute abdomen. But once a surgical abdomen has been ruled out, and electrolyte derangements have been addressed, we will refer this patient also to ortho-spine surgery (for assessment of spinal metastasis), medical oncology (for possibility of palliative chemotherapy), and to pain and palliative care service.

5. Yes but only with small sips of water and only to relieve the feeling of thirst. If the patient is confused, explaining the problems with oral intake while you have episodes of vomiting in bowel obstruction is difficult, and so small sips of water while informing the patient that we will be limiting fluid intake (and just supplement with IVF) so he does not continuouslt vomit would be a good middle ground in terms of comfort and still properly managing this patient

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GROUP 3 (Probadora, Cenil, Sarrosa, Digamo, Mata, Palao, Gonzales)

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GROUP 3 (Probadora, Cenil, Sarrosa, Digamo, Mata, Palao, Gonzales)

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1. We will give fluid resuscitation but not aggressive. The patient is hemodynamically stable, with signs of dehydration (elevated lactate, elevated Creatinine). The patient will benefit from fluid maintenance to improve her laboratory parameters and her overall clinical picture
2. Yes, as treatment for her pneumonia.
3. No. Given that the patient is on her end-stage of disease, we will opt to just give her comfort measures, and not necessarily intensive case. But this decision must be in agreement with her family
4. For this patient, knowing that her goals for home hospice care is for symptom control, intubating this patient is too aggressive of a management to help control the dyspnea. Giving IV medications for symptom control such as morphine to help control dyspnea can be a less invasive measure for symptom control, and further help pain control for patient
5. No, this is an invasive procedure
6. At the moment there is no indication for initiating inotropic support. Inotropic support in a terminally ill patient is more oriented towards treating the "vital signs" rather than treating the patient holistically. Decreasing BP may primarily lead to delirium as a symptom from poor perfusion to the the brain, which may be treated by IV anxiolytics and opioids rather than trying to treat the BP itself

GIVEN THAT THIS PATIENT IS ALREADY ON HOSPICE SUPPORT AT HOME ONLY SUPPORTIVE AND COMFORT MEASURES TO PROMOTE THE QUALITY OF LIFE OF THE PATIENT

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The patient had end-stage COPD presenting with significant symptoms at rest despite therapy. The patient will benefit from palliative care. We should assess and respect the patient’s goals, risks and benefits of interventions, and individualize the treatment.

1. Will you give aggressive fluid resuscitation? Why?

No, This patient is an elderly male, possibly at risk for congestion and will likely not benefit the patient given the aforementioned goals.

2. Will you give parenteral antibiotics? Why?

Yes, because the patient has pneumonia then shift to oral/NPO antibiotics once for home which can prevent the severe deterioration of the patient

3. Transfer to ICU? Include rationale.

No, Because the patient is terminally ill and is for supportive and end of life care. The patient no longer requires close monitoring.

4. Intubation? Include rationale.

No, the patient opted for beset supportive care; NIV instead

5. What would you do for symptom control? Be specific.

Morphine 0.05mg/kg IV

Monitor for sedation

Monitor for hypoventilation

Goal: 10-12 breaths per min

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CASE 2 Palliative GROUP 1 (Aliman, Tamayo, Lladoc, Pascual, Nicdao, Mamangon, Limbo)

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CASE 2 Palliative GROUP 1 (Aliman, Tamayo, Lladoc, Pascual, Nicdao, Mamangon, Limbo)

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1. Yes we will give hydration but as maintenance, not aggresive. Aggresive hydration may lead to further complication such as fluid overload. Our goal is to give the best supportive care for the patient and we can do this by hydrating him on maintenance, we may add D5 containing fluids.

2. Yes we will give parenteral antibiotics that is appropriate since Pneumonia is reversible.

3. No, not any more for ICU. To give the patient the chance to be able to spend his remaining time with his family in appropriate ward/room. Quality of life is very important.

4. We will offer the option of ET Intubation since there is indication but if they express advance directives of DNI, we will provide instead the best O2 support that is available which is low flow O2 support.

5. We will provide adequate pain control for the patient. We will give IV OPIODS (e.g. Fentanyl) and/or benzodiazepines as needed. We will also provide Paracetamol IV for fever. We will provide Nebulization as needed. The utmost goal is  aggressive symptom control, to relieve the patient's suffering.
We will provide relief from distressing symptoms and to achieve the best possible quality of life for this patient.

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Group 3 (Probadora, Cenil, Sarrosa, Digamo, Mata, Palao, Gonzales)

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Group 3 (Probadora, Cenil, Sarrosa, Digamo, Mata, Palao, Gonzales)

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1. No. There is no need for aggressive fluid resuscitation at this patient since the patient is hemodynamically stable, and currently the more pressing problem is respiratory/breathing. We can maintain patient only on maintenance fluid therapy especially that we expect this patient to be on NPO for a while as this patient is dyspneic and at risk for aspiration when fed per orem.

2. Yes we will continue with providing parenteral antibiotics for this patient. The current problem is infectious in nature (pneumonia) which exacerbated his COPD

3. No we will not transfer to ICU since there will be no further aggressive measures (no intubation), and family will be more free to visit the patient in the general wards.

4. Even with the requirement for high flow oxygenation, intubation is an uncomfortable procedure and is minimally beneficial for the patient. Instead, we can do high flow nasal cannula to address the hypoxia then give opioids to help decrease the feeling of breathlessness. Although BIPAP would be better for a COPD patient, it is also very uncomfortable and may worsen the feeling of breathlessness of the patient

5. high flow nasal cannula

continue opioid, (may start morphine at 0.05mg/kg IV)

give paracetamol 500mg IV q4 for fever

nebulization, salbutamol + ipratropium q30 minutes as long as dyspneic

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1. Fluid resuscitation as needed, not necessarily aggresive. with close monitoring

2. Yes, must treat antibiotics

3. No, patient has a terminal condition which cannot

4. Yes, unless this patient has explicitly stated that they do not want to undero intubation then I will provide the option for them.

Will provide information regarding other forms of oxygenation. Still advise them on what is medically indicated

5.  No

Central line access

First, we should ask, what is the wishes of the patient? Is there an indication to do central line?  Ask family of their wishes.

If the patient is for palliative care, CLI entails aggressive management which is not in line

6. Not indicated at this time

But above all, we offer all treatments, yet we do what's the px wishes. At the end of the day, utmost palliative care shall be rendered.

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1 & 2) . For this patient, we will provide aggressive hydration and parenteral antibiotics for treatment of Infection (Severe Pneumonia) For this, the main current problems must be the priority for a terminally ill patient.

3). No more ICU. Patient may be admitted in a regular room so she can spend the rest of her days with her family sparing the ICU resources at the same time

4). No more Intubation. If warranted O2 support, may provide low flow O2 support that is appropriate for a COPD patient, something that would benefit her instead of the high flow O2 support that was initially given. Patient may also be given adjunct medications such as Nebulization, Pain Medications for symptom control.

5). No more invasive critical care procedures such as central line because of the principle of doing no further harm to the patient. Quality of life must be preserved

6). For now, inotropes not warranted

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ogs

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Test

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YES YES YES! VERY HANDSOME

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Si Kenjie