Mr. Lam
Mr. Lam is a 79yo M patient who was just admitted to PCCU. He was recently diagnosed with metastatic colon cancer. He presents with severe N/V for 3 days.
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.
What do you do first?
Get Mr. Lam a kidney basin, then get him some PRN anti-emetic
Ms. Singh is a young 29 yo F patient who was diagnosed with stage III NSCLC. She had surgical resection a few months ago and since then, has been started on cisplatin-based chemotherapy. She is admitted to PCCU for severe nausea.
She tells you her nausea is particularly bad after chemo.
What is the most likely cause?
Chemotherapy-induced emesis (acute if <24h, delayed if >24h)
Mrs. El-Sharif is a 85yo F patient with a history of breast cancer. She is not on any active chemo or radiation. She was admitted to the hospital after her family noticed she was more confused in the last 2 weeks.
Her family also tells you that along with her confusion, patient is having more generalized pain, nausea and constipation.
What electrolyte abnormality would you be concerned about?
Hypercalcemia
Mr. Garcia is a 56yo M with esophageal cancer. He recently completed 7 weeks of radiation therapy. He is now admitted to hospice. His family tells you he is having issues with “vomiting” and asks you to give him anti-nausea medication.
Name 4 common causes of nausea/vomiting.
Drugs, infections, metabolic abnormalities, structural etiologies, other (anticipatory nausea, vertigo)
Mrs. Lewis is a 67 yo F patient with metastatic small cell lung cancer. She was admitted to hospice a few days ago. You are seeing her for the first time in her room.
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?
Mr. Lam is a 79yo M patient who came to PCCU. He was recently diagnosed with colon cancer. He presents with severe N/V for 3 days.
What do you ask him on history?
OPQRST
Potential causes (DIMS-O)
Medications tried (dose, duration, benefits, SEs)
Ms. Singh is a young 29 yo F patient who was diagnosed with stage III NSCLC. She had surgical resection a few months ago and since then, has been started on cisplatin-based chemotherapy. She is admitted to PCCU for severe nausea.
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)
Mrs. El-Sharif is a 85yo F patient with a history of breast cancer. She is not on any active chemo or radiation. She was admitted to the hospital after her family noticed she was more confused in the last 2 weeks.
Mrs. El-Sharif has no bone metastasis - can she still have hypercalcemia of malignancy?
Yes because cancer cells release hormones to increase bone turnover
Mr. Garcia is a 56yo M with esophageal cancer. He recently completed 7 weeks of radiation therapy. He is now admitted to hospice. His family tells you he is having issues with “vomiting” and asks you to give him anti-nausea medication.
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)
Mrs. Lewis is a 67 yo F patient with metastatic small cell lung cancer. She was admitted to hospice a few days ago. You are seeing her for the first time in her room.
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
Mr. Lam is a 79yo M patient who came to PCCU. He was recently diagnosed with colon cancer. He presents with severe N/V for 3 days.
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
Ms. Singh is a young 29 yo F patient who was diagnosed with stage III NSCLC. She had surgical resection a few months ago and since then, has been started on cisplatin-based chemotherapy. She is admitted to PCCU for severe nausea.
You want to try Zofran. What important side effect would you want to discuss with the patient?
Constipation +++
Mrs. El-Sharif is a 85yo F patient with a history of breast cancer. She is not on any active chemo or radiation. She was admitted to the hospital after her family noticed she was more confused in the last 2 weeks.
Her bloodwork does confirm elevated calcium. What anti-nausea medication might be helpful?
Centrally acting anti-emetic (e.g. Haldol, Zofran)
Mr. Garcia is a 56yo M with esophageal cancer. He recently completed 7 weeks of radiation therapy. He is now admitted to hospice. His family tells you he is having issues with “vomiting” and asks you to give him anti-nausea medication.
You check his oral cavity and see white plaques extending to his throat. What might this be?
Fungal infection (i.e. thrush)
Mrs. Lewis is a 67 yo F patient with metastatic small cell lung cancer. She was admitted to hospice a few days ago. You are seeing her for the first time in her room.
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)
Mr. Lam is a 79yo M patient who came to PCCU. He was recently diagnosed with colon cancer. He presents with severe N/V for 3 days.
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
Ms. Singh is a young 29 yo F patient who was diagnosed with stage III NSCLC. She had surgical resection a few months ago and since then, has been started on cisplatin-based chemotherapy. She is admitted to PCCU for severe nausea.
She feels better after trying Zofran for a few days and now is ready to go home.
What important consideration should the team factor with sending her home on Zofran?
Cost as Zofran is very expensive (can be up to $650/month) 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
Mrs. El-Sharif is a 85yo F patient with a history of breast cancer. She is not on any active chemo or radiation. She was admitted to the hospital after her family noticed she was more confused in the last 2 weeks.
How long should she try her new anti-nausea medication to know its full effects?
Mr. Garcia is a 56yo M with esophageal cancer. He recently completed 7 weeks of radiation therapy. He is now admitted to hospice. His family tells you he is having issues with “vomiting” and asks you to give him anti-nausea medication.
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?
It is no longer available.
Mrs. Lewis is a 67 yo F patient with metastatic small cell lung cancer. She was admitted to hospice a few days ago. You are seeing her for the first time in her room.
When is the best time to administer Dexamethasone and why?
QAM because it is very activating and can cause insomnia
Mr. Lam is a 79yo M patient who came to PCCU. He was recently diagnosed with colon cancer. He presents with severe N/V for 3 days.
He 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).
Ms. Singh is a young 29 yo F patient who was diagnosed with stage III NSCLC. She had surgical resection a few months ago and since then, has been started on cisplatin-based chemotherapy. She is admitted to PCCU for severe nausea.
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)
Mrs. El-Sharif is a 85yo F patient with a history of breast cancer. She is not on any active chemo or radiation. She was admitted to the hospital after her family noticed she was more confused in the last 2 weeks.
You find out that Mrs. El-Sharif has Parkinson's. Name 1 medication you should avoid.
All anti-dopamine medications (e.g. Maxeran, Haldol, Olanzapine, Nozinan)
Mr. Garcia is a 56yo M with esophageal cancer. He recently completed 7 weeks of radiation therapy. He is now admitted to hospice. His family tells you he is having issues with “vomiting” and asks you to give him anti-nausea medication.
What are some side effects of scopolamine?
Sedation, delirium, anti-cholinergic toxidrome
Mrs. Lewis is a 67 yo F patient with metastatic small cell lung cancer. She was admitted to hospice a few days ago. You are seeing her for the first time in her room.
What medication should Mrs. Lewis also be taking if she is on Dexamethasone for prolonged periods of time?
PPI (e.g. pantaloc)