Maria, an 81 year old is a new resident at the nursing home in the rural town you visit 500km away from a tertiary hospital. On your first review she states her pain in her upper abdomen is quite severe, and has been getting worse for 9 months. She also has widespread muscle aches and pains and feels tired constantly.
Her previous GP put it down to her past peptic ulcer disease and osteoarthritis and doubled her nexium and added endep 10mg and regular mobic. She has a past history of peptic ulcer disease, cholecystectomy for gallstones, hypertension, osteoarthritis of her back, right THR 15 years ago and hypercholesterolaemia.
Her medications include perindopril 5mg/indapamide 1.25mg combination, atenolol 50mg, atorvastatin 80mg, nexium 40mg bd, endep 10mg nocte, temazepam 10-20mg nocte, panadeine forte 1g/60mg qid, meloxicam 15mg daily. She has no allergies. Her BP is 105/70 and HR 52.
Abdominal exam reveals a tender RUQ with hepatomegaly, but the epigastrium is soft and non tender.
What recommendations would you make to her medication regime? List 8
- Replace panadeine forte with slow release oxycontin 10mg bd
- Reduce SR oxycontin to analgesic effect
- Commence simple panadol
- Cease meloxicam 15mg due to side effects
- Cease endep 10mg
- Cease atenolol 50mg
- Increase perindopril if needed based on blood pressure
- Reduce atorvastatin to lowest tolerable dose
- Reduction of nexium to 40mg daily based on symptoms
- Reduce temazepam to lowest possible dose or cease
RACGP – Good answers in this case demonstrated applied knowledge to the case and co-morbidities and not a list of all possible analgesia options independent of the patients presentation and the appropriate steps in reducing her polypharmacy in line with evidence-base and appropriate guidelines. Those not scoring well were generally in the final section by not reading the question and focussing on the palliative stage of treatment and the cessation of oral medication and change to a syringe driver.
What initial investigations are indicated? List 5
- FBE for anaemia
- EUC for renal function
- LFT
- Creatine Kinase
- Abdomen ultrasound
- Urine MCS (1)
- Iron studies for fatigue (1)
- Vitamin b12 for fatigue (1)
Case continued…You simplify her medications and your investigations reveal normocytic anaemia Hgb 97, ALT/AST ~800 and abdominal USS shows multiple liver metastasis. You request a CT chest abdomen pelvis which shows widespread metastatic pancreatic cancer.
You review her in the nursing and inform her of the diagnosis. She is already feeling better since the change of medications, and takes the news relatively well. Her RUQ pain is still significant accompanied by nausea.
You discuss the case with oncology and palliative care who recommended palliative care. Over the coming 2 weeks she becomes mildly jaundiced and tired. Palliative care suspect she has 3-4 weeks to live. But she is still talking, able to take oral intake, mentally sound, and able to move around.
What further changes to her medication regime do you want to make?
- Add on Oral oxycodone 5mg q4h prn
- Titrate SR oral opioids to affect
- Ondansetron 4-8mg tds prn for nausea
- Cease atorvastatin
- Cease perindopril/indapamide combination
- Continue temazepam 10mg nocte prn
RACGP Feedback
This case requires the management and identification of appropriate medications for poor pain control in an 81 year old female new resident of a nursing home along with the management of her polypharmacy. The case then progresses to the need to identify the appropriate drugs and symptom control for her palliative care.
Good answers in this case demonstrated applied knowledge to the case and co-morbidities and not a list of all possible analgesia options independent of the patients presentation and the appropriate steps in reducing her polypharmacy in line with evidence-base and appropriate guidelines. Those not scoring well were generally in the final section by not reading the question and focussing on the palliative stage of treatment and the cessation of oral medication and change to a syringe driver.
In all RACGP assessments it is important to ensure you have read the question thoroughly, at least twice, to understand what is being asked. Furthermore it is important to identify the context in which the question is being asked before providing answers. Try to imagine the patient in front of you in general practice, rather than thinking about a textbook answer for a condition.
Further Reading
https://www.racgp.org.au/your-practice/guidelines/silverbook/general-approach-to-medical-care-of-residents/palliative-and-end-of-life-care/
