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CASE
HISTORY - MASTER
NAUSEA
Miss R. is a 63 year-old retired schoolteacher with metastatic breast cancer. She has been on MST 30 mg bd for the past six months with good pain control. Over the past week she has experienced increasing nausea and loss of appetite. She was given oral prochlorperazine but, despite this, her nausea has worsened and she is vomiting once a day. She has a tendency to constipation and is well known to the district nurse who has had to administer suppositories frequently in the past. She has requested the nurse to visit because she has been constipated for four days.
Question 1.
You are the district nurse visiting Miss R. How would you handle this situation?
- Discuss history of nausea and vomiting
- Effect of drug
- Assess oral intake/output
- Check obs
- P.R. – Loaded rectum
- Administer 2 suppositories/Micralax
The nurse notices that the nausea pre-dates the constipation and informs Miss R's GP of her current condition.
Question 2.
What action should the general practitioner take?
- Visit
- History and examination
- U&E’s, LFT, Ca, Alb, FBC
Question 3.
What are the possible causes?
- Subacute obstruction
- Hypercalcaemia
- Hyponatraemia
- Liver dysfunction
- Constipation
- Drugs
You suspect that the cause is liver metastases but send off a blood sample to exclude a metabolic cause.
Question 4.
What measures would you take in the meantime?
- Commence syringe driver – metoclopramide, methotrimeprazine and diamorphine. Doses?
The following day the nausea has settled. Her blood tests reveal no underlying metabolic cause.
Question 5.
What would you do next?
- Run syringe driver for 2-3 days then convert to oral medication- dose?
- Review laxatives
- Commence steroids – dose?
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