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CASE
HISTORY - MASTER
ACUTE PAIN IN PALLIATIVE CARE
Jean is a 72 year-old woman with recurrent bowel cancer following a hemi-colectomy two years ago. She is known to have both local recurrence and liver metastases and her pain has been under control on MST 90 mg bd. She has a small sacral pressure sore which is dressed regularly by her district nurse. She lives with her 78 year-old husband who has angina.
Question 1.
You are the district nurse visiting to change her sacral dressing one Sunday morning. Jean's husband is relieved to see you as she has had quite severe pain in the right upper abdomen for the past hour despite having taken her normal dose of MST. He is not sure what to do. What would you do in this situation?
- Give oramorph (1/6 total daily dose of morphine) i.e. 30 mg. Reassess in 30 minutes to see if effective.
30 minutes later there has been no significant improvement in Jean's pain. You telephone BORDOC to discuss the case with the duty doctor.
Question 2.
You are the duty doctor at BORDOC and receive the message to phone back the district nurse. Before speaking to her you consider the possible reasons for Jean's sudden onset abdominal pain. What might they be?
- Obstruction
- perforated bowel
- biliary colic
- myocardial infarction
- ischaemic bowel
- haemorrhage
As the pain has not settled with oramorph you decide that Jean needs a home visit.
Question 3.
You are the doctor doing home visits that morning. What features would you look for to try and establish the cause of her acute abdominal pain?
- Tenderness, rebound and guarding
- bowel sounds
- temperature
- pulse and BP
You find that she has an enlarged liver which is hard and irregular. There is marked localised tenderness over the right lobe of her liver. Her abdomen is otherwise soft and non-tender and the bowel sounds are normal. She is apyrexial. You conclude that the likely cause of her pain is a small haemorrhage from a metastatic deposit in her liver.
Question 4.
What action would you take?
- Intramuscular diamorphine at 1/3 of the correct oral dose for breakthrough pain (1/3 of 30mg) i.e. diamorphine 10 mg.
- Review after 30 minutes to assess effectiveness
Jean's pain settles with 10 mg diamorphine intramuscularly. The pain does not recur and she remains comfortable on the same dose of MST.
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