Mr. Lam
You enter the room to start admission process and you see Mr. Lam vomiting all over his bed. He and his family are looking to you for help.
Practically, what would you do first?
Get Mr. Lam a kidney basin, then get him some PRN anti-emetic
She tells you her nausea is particularly bad after chemo.
What is the most likely cause?
Chemotherapy-induced emesis
Her family also tells you that along with her confusion, patient is having more generalized pain, nausea and constipation.
Given her bone mets, what electrolyte abnormality would you be concerned about?
Hypercalcemia
Name 2 common causes of nausea/vomiting.
Drugs, infections, metabolic abnormalities, structural etiologies, other (anticipatory nausea, vertigo)
Mrs. Lewis tells you she has terrible headaches along with nausea. She also has some vision changes and unstable gait for the last few weeks.
What is the most likely cause?
Increased intracranial pressure from brain metastasis
What do you ask him on history?
OPQRST
Potential causes (DIMS-O)
Medications tried (dose, duration, benefits, SEs)
She tells you her nausea is particularly bad right after chemo.
Name 1 medication that might be helpful for her.
Anti-serotonergic (Zofran)
Anti-neurokinin (Aprepitant/Fosaprepitant)
Anti-inflammatory (Dexamethasone)
If Mrs. El-Sharif did not have bone metastasis - could she still have hypercalcemia of malignancy?
Yes because cancer cells release hormones to increase bone turnover
On history, Mr. Garcia tells you he has no nausea. When he eats, he feels food gets stuck and he has to cough it back out.
Would his symptom respond to anti-nausea meds?
Less likely since this is more a dysphagia issue rather than nausea/vomiting (i.e. not involving the emetic pathway)
You decided to look her up on UCI to review her recent investigations. What investigation would help confirm the cause?
CT Head (with contrast) or MRI
He tells you he vomits everything right after intake and has not had a BM or passed gas for 5 days. On exam, his abdomen is ++ distended with high pitched bowel sounds.
What investigation would be most helpful and why?
Abdo Xray or CT abdo - to detect malignant bowel obstruction
You want to try Zofran. What important side effect would you want to discuss with the patient?
Constipation +++
Her bloodwork does confirm elevated calcium. What anti-nausea medication might be helpful?
Centrally acting anti-emetic (e.g. Haldol, Zofran)
You check his oral cavity and see white plaques extending to his throat. What might this be?
Fungal infection (i.e. thrush)
Mrs. Lewis had a CT Head 2 weeks prior to admission to hospice which confirmed numerous brain metastasis. What medication would be helpful to help her symptoms of nausea and headache?
Steroid (Dexamethasone)
CT Abdo - small and large bowel dilatation with tumor invasion suggesting complete obstructions at duodeno-jejunal flexure and distal transverse colon with peritoneal carcinomatosis
What medication do you want to avoid and why?
Metoclopramide (maxeran) - risk of perforation as it is a prokinetic drug
She feels better after trying Zofran for a few days and now is ready to go home.
What logistical yet important consideration should the team always factor when sending patients home on Zofran?
Cost as Zofran is very expensive and not covered by Plan P
Cost will be covered if ordered by Med Onc / Rad Onc; Special Authority can be submitted if patient failed 3 other drugs
How long should she try her new anti-nausea medication to know its full effects?
Minimum 48 hours
He really wants to try some scopolamine patch as he had it before when he was travelling overseas. What is the availability of scopolamine patches in Canada?
It is no longer available.
When is the best time to administer Dexamethasone and why?
AM because it is very activating and can cause insomnia
Mr. Lam got started on Haldol PRN.
He wants to know if the anti-emetic drug is going to stop the vomiting. How would you respond?
No anti-emetics will truly stop the vomiting as the issue is that there is a physical obstruction. What will stop the vomiting is either the obstruction resolves or gastric content is alleviated in other ways (NG suction or venting tube).
She mentions she gets also nauseated before treatment with triggers like the sights, smells, or sounds of the treatment room. What medication might be helpful for her anticipatory nausea?
Lorazepam (Ativan)
You find out that Mrs. El-Sharif has Parkinson's. Name 1 medication you should avoid.
Anti-dopamine medications (e.g. Maxeran, Haldol, Olanzapine, Nozinan)
What are some side effects of scopolamine?
Sedation, delirium
What medication should Mrs. Lewis also be taking if she is on Dexamethasone for prolonged periods of time?
PPI (e.g. pantaloc)