Name: Ang yi moi

R/N:
Date of Birth:
Age: 74 years old
Gender: female
Ethnic Group: chinese
Ward: palliative care unit
Date of Admission: 1/4/19
Date of Discharge: --

1. Presenting complaint(s)

My Patient 74 years old lady with underlying stage 4 bladder carcinoma presented to the emergency
department (yellow zone ) with pain over the right leg, nausea and vomitting.

2. History of presenting complaint(s)

Regarding the pain over the right leg , was gradual onset and continous,throbbing pain,it was
radiating to the right iliac fossa and backbone, associated with nausea ,exerbated my
movement, relieved by taking medication such as fentanyl patch,score pain was 7.Patient also
complain of more episode of nausea than vomitting.,there was generalized body pain , and
malaise.Patient family complained that patient was always drowsy and tired,She did not
defecate for 3 days but had flatus ,and had difficulty in passing urine for 2 days even with help
of urinary cathether.Patient complained of having colicky abdominal pain over umbilicus region
on and off when trying to defecate. Patient had reduced oral intake and poor appetite.Patient
could not quantify her weight loss but family member say her clothes gone loose.

3. Review of Systems

Positive findings was loss of appetite for the past 4 days,there was nausea but no complaints of
vomiting,there was drowsiness but no dizziness and headache, body ache,dehydrated,warm
peripheries. There was no complaints of chest pain, shortness of breath,, no cough ,flu and sore
throat.
Review of all the other systems are unremarkable

4. Past Medical History

Patient has comorbid such as dyslipidemia and hypertension and is on medication.

On february 2017-presented with painless hematuria, loose about 4-5 kg in 2 months.

On 19 june 2017--done cystocopy at hospital fatimah, attempted stent but
failed,Histopathological (HPE: astypical cells)
On july2017- diagnosed to have Right uretric tumour , nephroureterectomy and trnasurectal
resection of bladder tumour (TURBT) done.(HP: high infiltration carcionoma)
ON 12 january 2018- done TURBT, and (HPE:pappilary transitional cell carcinoma with no muscle
invasion)
.

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 On 9 APRIL 2018,CT TAP, done, noticed irregular bladder wall thickening with enhancing lesion
suggestive of tumour metastasis. Case discussed with oncologist in HKL planned for CECT biposy,results
was postive. On 21 june 2018.

29 june 2018-TURBT done for recurrent bladder carcinoma extended to bladder neck.
18 september 2018- radical cystectomy done.
Chemotheraphy was not done due to age factor and other risk factor.only radiation was done at hospital
selayang.
2019-refered to palliative care unit IPOH hospital.

5. Past Surgical History

Apart from metioned above, no other surgery was done.

6. Drug History
Felodipine 5 mg
Simvastain 20 mg
Fentanyl patch 12 mg
Ensure 38000p + 100 cc water 3 times hourly

7. Allergies
There is no known food or drug allergies.

8. Family History

Patient has 5 children, 3 daughters and 2 sons.Patient father had hypertension.There was no
significant family history of any type of cancer is patient family.

husband wife

*caretaker

Daughter
Son Son Daughter Daughter
Stays in ipoh
Stays in kl Stays in singapore Stays in ipoh Stays in ipoh

9. Social History
Patient is a housewife married with 3 children.Patient had her menopause at the age of 50.
Patient is non-smoker and do not consume alcohol. Patient husband had passed away in year
2017 due to road traffic accident.Patient stays with her younger daughter in first garden ,
ipoh.Patient has her own room and attached toilet . Her eldest daughter and youngest daughter
and son is in ipoh,they normally take turn to take care of her.
Patient has all her children support, she loves her children alot and claims they take care her
alot.

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 Patient is very depressed that she has cancer and wont be able to live longer.Patient is still not
aware that she has what type of cancer and still has hope to live painless.Patient daughters
( decision maker)-understands progression of her disease and accepts the truth that her mother
does not have much time to live. They want to give the best to their mother and let her have a
peacefull and painless death.
They have not prepared about their mother after death such as funeral, they are still discusing.

Summary:

Patient 74 years old lady with underlying stage 4 bladder carcinoma admitted to palliative care unit
with somatic and neuropathy pain for optimization of pain control.

10. Physical Examination

General Examination
Patient is alert, conscious, cooperative, not in tachypnea state and respiratory distress. She is
lying down supported by 1 pillow.with branula inserted on the dorsum of her right hand.

Vital Signs
Temperature 37.3⁰C
Pulse Rate 80 bp/m
Respiratory Rate 20 b/m
Blood Pressure 120/90
SPO2 at room atmosphere 97%

Examination of hands:
Patient’s hands are of normal temperature. There is pallor of the palmar creases and nail beds.Patient
had warm peripheries. Patient has blusih discolouration patchs over her left dorsum of hand due to iv
line. Otherwise there is no other abnormalities such as finger clubbing, koilonychias, palmar erythema,
muscle wasting, asterixis or Dupuytren’s contracture noted. Capillary refill test is normal (< 2 secs).
The pulse is of good volume and rhythm.
Examination of the arms reveals no spider naevi and no engorged vein.

Examination of face:
Examination of the eyes shows conjunctival pallor; otherwise no jaundice noted.
Examination of the mouth reveals poor hydration status with no glossitis and no angular stomatitis.
There was poor oral hygiene and dental carries.

Examination of neck:
There are no neck swelling or palpable cervical, supraclavicular or infraclavicular lymph nodes noted.

Examination of legs:

There is no pedal oedema and no bruises noted.

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There was swelling at her right knee develop within 3 days , there was no redness noted,
Impresion: bursitis or septic arthirits

Examination of back:
There is no bony tenderness or deformity noted.

Systemic Examination
Respiratory system:

On inspection there was no scar marks , no abnormal deformity or no engorged vein seen.
Upon percusion, it was resonance.
Lungs field was clear..Air entry equal for both lungs

Gastrointestinal Tract:
On inspection, the abdomen is moving with respiration and appears symmetrical with no abdominal
distension. Thee was a well healed vertical scare seen over the lower quadrant measuring about 9 cm ,
there was a weel healed horizontal scar seen over suprapubic region moz probably a surgical
intervention was done, and a weel healed 6 cm horizontal scar at the right iliac fossa with no
prominent veins, no visible mass, no visible pulsation and no peristalsis noted. The umbilicus is centrally
located and not everted. Hernial orifices are intact.
On palpation, the abdomen is soft and tender with no guarding or rigidity. There is no palpable mass, no
hepatomegaly, no splenomegaly and the kidneys are not ballotable.
On percussion, the abdomen is resonant with no ascites noted.
On auscultation, normal bowel sounds heard. There is no hepatic or renal bruit noted.

.
Cardiovascular System:
The jugular venous pressure (JVP) is not raised.
On auscultation, S1 and S2 are heard with no added sound such as murmur or third heart sound.

Central nervous system examination:

Cranial nerves were intact.
Speech for coherent , mental status : patient is well orientated ti time and place
The power of muscle was 3 ,the tone was normal, superfical and deep reflexes was intact, there was
muscle atrophy seen on the right and left leg, muscle bulk of the right thigh is lesser then left thigh,
plantar reflex was negative.Kernigs sign and brudzinki’s sign was negative.
Cerebellum examination such as Romberg’s sign was not be done due to patient unable to stand .

Examination of all other systems reveals no abnormalities.

11.Summary
Miss Maradiah ,47 yeard old lady c complained of fever for 4 days ,headache and generalized body
pain,upon examination there was petechial rashes found on her face,hand ,trunk.legs and poor
hydration status .

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12. Diagnosis

Secondary anemia due to 4 th stage bladder carcinoma metastasizeto liver , lung. Right femur, and
proximal tibia,which is causing neuropathy painto patient.
14. Investigations
I. Full Blood Count (FBC):
This is to look for leucocytosis which may suggest an infection as well as to confirm anaemia.

Type Value Normal value

WBC 13.3 x 10³ /uL 4.0 -11.0
RBC 8 x 10⁶ /dL 12.0 - 14.0
Haemoglobin 8.5.6 g/dL 12.3 – 15.3
Haematocrit 41.1% 37 -47
MCV 89.7fL 77 - 96
MCH 29.5pg 27 - 32
MCHC 32.9g/dL 31 -35
PLatelets 22x 10³/uL 150 - 400
Neutrophils 2.96 x 10⁹/L 2.00 – 7.00
62.1% (40 – 75)
Lymphocytes 2.59 x 10⁹/L 1.00 – 3.00
30% (20 – 45)

Based on the results, there is presence of leucocytosis which indicates infection.

And hemoglobin with suggest patient is having anemia .

2. Coagulation Profile:
This is to look for derangement which may suggest bleeding tendency in the patient.

Type Value Normal Value

PT 14.0s 11.5 – 14.3
PT ratio 1.12
INR 1.15
APTT 36.1s 27.4 – 44.5
APTT ratio 0.95

3. Renal Profile

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This is done as a baseline investigation as well as to look for kidney injury or electrolyte imbalance due to
excessive blood loss and to check for hypokalemia in case of dehydration.
Urine output 1. 5 L in 24 hour.
Type Value Normal Value
BUN 5.5 mmol/L 2.5 – 6.4
Sodium 158 mmol/L 136 - 145
Potassium 5.3mmol/L 3.5 – 5.1
Chloride 121 mmol/L 98 - 107

Creatinine 110mmol/L 53 - 88

The results are are suggestive of acute renal injury and need to be treated.

4.Corrected calcium level-2.23 mmol/l (2.19-2.54)

5. Ufeme should be done to check any signs of urinary tract infection

-nitrate (negatif)

6. ABG- done to check for metabolic acidosis

-in this patient it was normal value.

7. liver function test

albumin 69 mmol/L
GLOBULIN 34.0 mmol/L
A:g ratio 1.0 mmol/L
ALP 72 mmol/L
ALT 95 mmol/L
AST 60 mol/L
BILIRUBIN 6.9 mmol/L

7. Bone scan should be done to see the metastasize of cancer.

.
.

16. Principles of Management

Management of patient in the ward- supportive treatment

-Monitor vital signs
-Trace investigation results
a. Allow oral intake for now

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 .check on hydration status on patient and ask her to have 2 to 3 litres per day to prevent further
complications. Put the patient on normal saline iv drips since she has loss of appetite.
d. treat symptomatically
e. analgesic given –paracetamol and fentanyl pathy 6 mg/hr given foroptimization of pain

ANTICIPATING CONDITION:
1. Check on patient hydration status 4 times daily to prevent patient going in hypovolemic shock.
2. chest x ray done to appreciate any pleural effusion if the patient develops shortness of breath.
3.check patient hematocrit level to prevent compensated shock.
4. if there is upper gastrointestinal bleeding tendency in patient ,do not give NSAIDS.

Progression in ward from 1/4/2019 - 12/4/2019

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1/4/19- admitted in casualty due to complain to pain over right pelvis radiating to right thigh,family
claimed patient had reduced oral intake, difficulty is defecating and urination.

1/4/19 - 4/4/19 : Patient was then admitted to ward 2b for further managment.

4/4/19

@7.30 P.M : Patient was transferred to palliative care under family agreement, patient was weak but
was conscious

Vital sign bp-132/85, rr-18 b/min ,pulse rate-99/min, spo2 93%, pain upon movement

Management: on fentanyl infusion 12mg hr(running at 12/s/hr)

Cbd change on 16/4/19

Iv maxalon 10 mg PRN

5/4/19-6/4/19: patient was weak, ECOG 4, patient had colicky abdominal pain, patient unable to sleep.
Abdomen was soft , not tender and not distended.Patient was able to defecate and urinate. Patient had
fever 37.8 0 c.

Management:fentanyl infusion continue 12mg/hr(72 hr)

-off fentanyl after 12 hr overlap.

-continue aq. Morphine 5 mg PRN

-iv antibiotic ceftriaxone continued until 9/4/18 (last dose)

7/4/18/-9/4/19 : patient has feeling better, no breakthrough pain, no vomitting, no fever but still has
nausea,patient was drowsy and sedation score was 1,poor oral hygiene.

Management done:-oral care NA HCO3 mouthwash

-plan to off fentanyl 12 mg , encourage PRN morphine

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 -T. Maxalon 10 10 mg PRN

10/4/19-12/4/19/:patient was less drowsy,still poor oral intake, no fever

Patient develop swelling over right knee and right calf, there was tenderness upon palpation but no
redness noted.

Impression is right proximal tibia metastasis, septic arthritis

Management: TD fentanyl 6 mg/hr change to subcutanous/iv Fentanyl 6 mg/hr

Reffered to ortho department

Keep patient over the weekend

Continue current medication

Haloperidol 1mg PRN (antiemetic)

Continue paracetamol( adjuvant for pain not for fever and act as antiinflammatory)

Discusion- Pain control among cancer patient

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 cancer pain is is mainly caused by the tumour pressing on bones, nerves or other organs in the
body.Sometimes pain is due to cancer treatment. For example, some chemotherapy drugs can
cause numbness and tingling in your hands and feet. Or they might cause a burning sensation at
the spot where you have the drug injection.Radiotherapy alsocan cause skin redness and
irritation.

Nerve pain (neuropathy) . It's caused by pressure on nerves or the spinal cord, or by damage to the
nerves.People often describe nerve pain as burning, shooting, tingling or a feeling of crawling under their
skin. It can be difficult to describe exactly how it feels. Nerve pain can sometimes be more difficult to
treat than other types of pain.Management of neuropathy pain is Carbamazepine (brand name Tegretol),
Gabapentin (brand name Neurontin), Oxcarbazepine (brand name Oxtellar XR, and Trileptal), Pregabalin
(brand name Lyrica),Topiramate.

Cancer can spread into the bone and cause pain by damaging the bone tissue. The cancer can
affect one specific area of bone or several areas.You might also hear bone pain called somatic
pain. People often describe this type of pain as aching, dull or throbbing. Management is opiods
( morphine and fentanyl )and NSAID,adjuvants can be given.

Soft tissue pain means pain from a body organ or muscle. For example, you might have pain in
your back caused by tissue damage to the kidney.You can't always pinpoint this pain, but it is
usually described as sharp, cramping, aching, or throbbing. Soft tissue pain is also called visceral
pain.

Phantom pain means pain in a part of the body that has been removed. An example is pain in the
breast area after removal of the breast (mastectomy).Phantom pain is very real and people
sometimes describe it as unbearable.Doctors are still trying to understand why phantom pain
happens. One theory is that your brain's thinking section knows that part of your body has
gone but your brain's feeling section can't understand this. Other possible causes are poor pain
control at the time of surgery.

Sometimes people can feel pain from an organ in the body in a different part of their body. This
is called referred pain.People with chronic cancer pain might have times when their medicines do
not control the pain. This is called breakthrough pain.For this pain, they are given overlap doses
of opiods.

Incident pain means pain upon movement. Management is give analgesic before movement. For
example morphine take 1 hour to work.

References:

1. https://www.spine-health.com/treatment/pain-management/medications-neuropathic-pain
2. Lecture notes on pain management
3. https://academic.oup.com/annonc/article/22/suppl_6/vi69/272115

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