You are FY2 in the Acute Medicine Unit.
Mrs Jasmine Jackson, aged 60, has been referred from the Oncology Department to Acute Medicine Unit for pain management. She was diagnosed with Breast Cancer 5 years ago and now she has presented with back pain.
Please talk to the patient, outline a treatment plan and address her concerns.
D: What brought you to the hospital? P: Doctor, I’m having this pain.
D: Can you tell me more about it? P: What do you want to know?
D: Where is the pain? P: It’s in my lower back.
D: When did it start? P: It started 3 months ago.
D: How did the pain start? P: It started gradually.
D: Is it continuous or does it come and go? P: It is continuous.
D: Has it changed since it started? P: It is increasing.
D: Could you describe the pain for me? P: It is a dull pain.
D: Does it go anywhere? P: No
D: Does anything make it better? P: I took Paracetamol, but it didn’t help.
D: May I know how much you took? P: I take 2 tablets 3 times a day.
D: How long have you been taking it? P: Been taking it for three months now.
D: Does anything make the pain worse? P: It’s getting worse on its own.
D: Could you please score the pain on a scale of 1 to 10, where 1 being the least and 10 being the most severe pain you have ever experienced? P: 8-9.
D: How about when the pain started? P: Doctor, it wasn’t that bad.
D: Is there anything else? P: No doctor
D: Has anything like this happened before? P: No
D: Have you been diagnosed with any medical condition?
P: I was diagnosed with breast cancer 5 years ago.
D: I’m so sorry to hear that. What was done for you after that?
P: I had a lumpectomy. I received Radiotherapy, Chemotherapy and Hormone Replacement Therapy for a while for that.
D: Has your disease been well controlled?
P: Doctor 2 years ago I was having back pain so I went to them. They did a bone scan and told me that now I have cancer in my bones.
D: What has been done for that?
P: They’ve already tried Radiotherapy on my back 3 months ago. It didn’t work. Oncologist decided not to do any active treatment.
Ask PMH, Lifestyle, and Psychosocial history.
D: What do you do for a living? P: I have an office job.
D: With whom do you live with? P: I live alone.
D: How has this condition affected your life? P: Doctor, it’s getting a bit harder. It’s affecting my day-to-day life. I have trouble walking.
I would like to do some Examination. I would like to examine your Vitals and your back.
Findings:
Doctor everything is normal. (+/-She has a mastectomy scar as described by the patient)
P: Doctor what can you do for my pain?
D: From what you told me, in order to control your pain, we need to consider moving to a weak opioid called Codeine. We will continue giving simple painkillers like Paracetamol or Ibuprofen along with it. It comes as co-codamol so we can give you that. Hopefully your pain will be under control, if not, then we have got many options. P: Like what?
D: If your pain doesn’t subside with Co-codamol, then we can give you a strong opioid like morphine. Again, we will continue giving you paracetamol with it.
P: I don’t want to take it.
D: Why don’t you want to take it?
P: I haven’t heard good things about it. I heard it makes you drowsy.
D: I do understand your concern. However, morphine is the best medication to treat your pain. One of the side effects of Morphine is drowsiness, but don’t worry, it will subside after a couple of days.
D: Morphine also has some other side effects that may include constipation, feeling sick, feeling sleepy. Which one would you like me to discuss?
Side effects of Morphine:
- Constipation: Try to eat food rich in fibres, such as fresh fruit and vegetables and cereals. Try to drink several glasses of water or other non-alcoholic liquid each day. If you can, it may also help to do some gentle exercise. Speak to your doctor about medicine to help prevent or treat constipation caused by morphine if your symptoms do not go away.
- Feeling sick or vomiting: You should take morphine with or just after a meal or snack to ease feelings of sickness. This side effect should normally wear off after a few days. Talk to your doctor about taking anti-sickness medicine if it carries on for longer.
- Feeling sleepy, tired or dizzy: These side effects should wear off within a week or two as your body gets used to morphine. Talk to your doctor if they carry on for longer.
- There are some serious side effects of morphine like seizure, breathing difficulty or short shallow breathing and muscle stiffness. If this happens, please contact your GP or go to the A&E.
P: Is morphine addictive?
D: This is unlikely to happen. People who usually become addicted to drugs, initially choose to take them and keep taking them because they have a psychological need to take these medications. This is very different from someone who is in physical pain and needs the drug to control the pain.
P: There is a wedding going on in the family in a couple of months and I want to attend it.
D: May I know what your concern is?
P: Doctor will I still be in pain by then? Will I be able to attend the wedding?
D: Don’t worry, hopefully we will be able to control your pain with Morphine. It is very important to take your medication as prescribed. Taking regular medication prevents pain and prevention is always easier than cure.
D: If you feel pain, we can increase the dose of your medication. If Morphine doesn’t work, we
have some other options to treat your pain.
We may prescribe you some other medications, which are not painkillers but help painkillers to minimize the pain. One of these medications is Bisphosphonate, which strengthens the bones.
P: Is there anything else besides tablets that you can give me? / What if I don’t want to take tablets?
D: There is another type of painkiller, which comes in the form of patch. It is not the first choice. We usually start with morphine since it’s the best choice for you. If there is any problem taking Morphine (Morphine tolerance/renal impairment/ poor compliance to oral morphine), we can prescribe this.
P: Is there any other route for the medication? Can any device be used?
D: We always have another option to consider which is a device called Syringe Driver. Would you like me to talk about it?
P: Yes
D: This is a small pump that gives you continuous doses of medication under the skin as an injection. We usually offer this to those who have been on oral morphine for long-term and have developed some side effects, especially nausea, vomiting and difficulty in swallowing.
As you have pain in your back, it might affect your nerves and you can experience difficulty in walking, sensation of numbness or pins and needles in your legs or difficulty controlling urine or bowel movements. If you experienced any of these symptoms, please come back to us urgently.
If you have shallow breathing, please contact your GP or come to the hospital.