Symptom Management and Approach to Care 1

1. Patient is an 84-year-old male with multiple myeloma and is admitted to the hospital with cord compression and is made NPO awaiting corpectomy by a neurosurgeon. His pain is previously well controlled on a long-acting morphine dose of 30 mg P.O. Q8H. What is the equivalent IV dose?
2. 77-year-old white female with multiple myeloma s/p autologous hematopoietic stem cell transplant. Doing well overall except for recurrent post herpetic neuralgia. Multiple allergies/intolerance include tricyclic antidepressants, anticonvulsants, adhesives, and opioids. Which may provide best risk/benefit for patient?
3. 59-year-old male with initial presentation of follicular lymphoma s/p treatment with relapse and now diffuse large B-cell lymphoma. He has prior deep vein thrombosis. Patient has large 10 cm right flank mass currently receiving local radiation therapy only, and no chemotherapy treatment. He continues to receive weekly port flushes. Patient is on Pregabalin 25 mg P.O. QHS for bilateral lower extremity neuropathic pain with acute on chronic thrombocytopenia. Which is next step?
4. Despite appropriate step in question #3, patient remains thrombocytopenic and becomes more dyspneic. Which is the next step in treatment?
5. Despite appropriate treatment in question #4, patient remains thrombocytopenic. CT angiogram of the chest does not show pulmonary embolism. Which is the most likely case?
6. 58-year-old male with metastatic renal cell carcinoma diagnosed 5 years ago presents with progressive weakness in his bilateral lower extremities. He is very fatigued and his legs hurt at the end of the day. He denies bowel/bladder incontinence. Anal sphincter tone is adequate on exam. Recently his methadone was increased to 40 mg P.O. TID. He is also on atorvastatin, lisinopril, HCTZ, and oxycodone 15-20 mg every 4 hours as needed. What is the next best step in management?
7. Appropriate step chosen for patient in question #6. Which is next best step in treatment?
8. Which of the following has the fewest number needed to treat for neuropathic pain?
9. Which of the following has the greatest number needed to harm in treatment of neuropathic pain?
10. Methadone is superior to other opioids for neuropathic pain.
11. 69-year-old male with chronic back pain taking MSIR 15 mg P.O. Q4H as an outpatient admitted for right total hip arthroplasty develops acute on chronic renal failure postop and is placed on fentanyl 25 mcg patch with fentanyl 25 mcg IV every 2 hours PRN without relief. Which of the following would be the next best step?
12. After choosing the appropriate step in question #11, patient is more comfortable. On Post-Operative Day Three, no longer using breakthrough. Primary team would like to prepare pt for discharge within the next 48 hours, acute on chronic renal failure is improving but not resolved. Which is most appropriate?
13. Patient with recent discharge to home hospice after decompensation to NYHA Class IV from NYHA Class II. Patient is on appropriate CHF medications. Labs after discharge to home indicate a potassium of 5.9. Most likely cause is?
14. Patient with delirium for 12 hours with history of prostate cancer, CHF, and COPD with acute onset severe agitation and fever for the last 48 hours. Which is most likely cause?
15. Which of the following side effects of opioids do patient not become tolerant of?
16. A 74-year-old male with NYHA Class III CHF is referred for hospice care. The patient is ambulatory 75% of waking hours, eating 75% of meals, and able to complete ADLs independently. Patient with hypertension and LVH, also has been diagnosed with dementia (FAST 6e) 2 years ago, the patient has had one brief hospitalization in the last six months. The most appropriate action at this time:
17. Which is therapeutic range for phenytoin?
18. Patient is post-thoracotomy with recent visit to pain management for severe burning pain. Patient complains they are feeling funny. EKG shows torsade de pointes. Which is most likely cause?
19. 78-year-old African American male with history of prostate cancer with recent visit to pain management and change in regimen. Patient complains of urinary difficulty although pain now with improved control. Creatinine increased from 1 to 2.5. Which is most likely cause?

88-year-old African American female with metastatic breast cancer, minimal symptoms except for diminished P.O. intake with gradual decline. Patient with PPS of 20. Which would be the best intervention?