Causes of Pathological Fractures in the Elderly

Pathological fractures are fractures that occur due to weakened bones caused by underlying medical conditions. While any type of bone tumour can cause pathological fractures, the majority of cases in the elderly are due to metastatic carcinomas. This is because as people age, their risk of developing cancer increases. Multiple myeloma, a type of cancer that affects the bone marrow, is also common in the elderly and has a high incidence of pathological fractures. Lymphoma, although uncommon, can also cause pathological fractures.

It is important to keep this information in mind when evaluating elderly patients who present with musculoskeletal problems such as shoulder or back pain. A thorough medical history and physical examination can help identify the underlying cause of the fracture and guide appropriate treatment. By understanding the common causes of pathological fractures in the elderly, healthcare providers can provide better care and improve patient outcomes.

Treatment options for oesophageal spasm

This patient is suffering from oesophageal cancer and is experiencing odynophagia and dysphagia. A clinical diagnosis of oesophageal spasm has been made. There are several treatment options available depending on the underlying cause of the symptoms.

Dexamethasone is useful if the dysphagia is due to tumour enlargement and physical blockage is causing dysphagia. Fluconazole is used to treat oesophagitis caused by candidal infection. Omeprazole is a proton pump inhibitor that can be helpful if symptoms of gastro-oesophageal reflux disease are present. Pamidronate is a bisphosphonate that is administered intravenously to treat bone pain and hypercalcaemia.

Nifedipine can work well in cases like this due to its action of relaxing smooth muscle and can help treat the painful spasm that is underlying the symptoms. It is important to identify the underlying cause of the oesophageal spasm to determine the most effective treatment option. With proper treatment, the patient can experience relief from their symptoms and improve their quality of life.

Drug Dose Calculations

Calculating drug doses can be a challenging task, especially when it comes to converting between different medications and routes of administration. One common question in medical exams involves calculating the appropriate dose of a medication for a patient.

To answer this question correctly, there are several steps to follow. Firstly, the total oral dose of morphine must be converted to diamorphine. Then, the breakthrough dose of subcutaneous diamorphine must be calculated, not the oral morphine dose.

To calculate the 24-hour dose of diamorphine for a patient, the total daily dose of oral morphine should be divided by 3. For example, if a patient is taking 90 mg of oral morphine over 24 hours, this is equivalent to 30 mg of diamorphine over 24 hours by syringe driver.

According to the BNF, the subcutaneous dose for breakthrough pain should be between one sixth and one tenth of the 24-hour dose. Therefore, for this patient, the correct breakthrough dose of subcutaneous diamorphine would be between 3 mg and 5 mg.

It is important to note that drug dose calculations are a common area of weakness in medical exams. Examiners often include questions on this topic, and it is essential for healthcare professionals to have a good understanding of how to calculate drug doses accurately.

Assessing Nausea and Vomiting in Palliative Care: Possible Causes and Treatment Options

When assessing nausea and vomiting in palliative care, it is important to seek a reversible cause. If none is found, a specific diagnosis should be made. One possible cause is anxiety, which can present with nausea in waves and anticipatory vomiting that may be relieved by distraction. Benzodiazepines or levomepromazine can be used for medication. Other causes include gastric stasis, gastric outflow obstruction, small stomach syndrome, oesophageal blockage, bowel obstruction, raised intracranial pressure, movement-related nausea, vestibular issues, drugs, metabolic issues, and carcinomatosis. It is important to consider all possible causes and choose appropriate treatment options accordingly.

The woman in question is likely suffering from intestinal obstruction, a condition that affects 3% of all cancer patients and up to 25% of those with advanced ovarian cancer. This can be caused by peristaltic failure due to opioid drugs or nerve damage, or by mechanical factors such as bowel wall infiltration, compression, or constipation. The presence of painful colic and hyperactive bowel sounds suggests a mechanical obstruction. To address her nausea and vomiting, a sequence of subcutaneous infusions of cyclizine, haloperidol, and levomepromazine may be tried until the most effective agent is found. However, stimulant laxatives like senna should be avoided due to the patient’s colic, and all oral laxatives should be stopped if there is complete obstruction. Bisacodyl, another stimulant laxative, should also be avoided in patients with colic, with sodium docusate being the preferred laxative for constipation. Metoclopramide, a prokinetic agent, is the drug of choice for functional obstruction but is contraindicated in the presence of colic and mechanical obstruction. For pain relief, continuous subcutaneous morphine/diamorphine or a fentanyl patch may be used, but the patient would benefit more from an antiemetic and addressing the underlying cause if possible.

Spinal Cord Compression: An Oncological Emergency

Spinal cord compression is a medical emergency that requires immediate attention. The sudden onset of bilateral leg weakness and loss of sensation are common symptoms, along with back pain, urinary retention, and constipation. This condition is often caused by metastatic cancer, with breast, bronchus, prostate, multiple myeloma, and high-grade non-Hodgkin lymphoma being the most common culprits. While patients may already have a cancer diagnosis, spinal cord compression can sometimes be the first sign of cancer.

To diagnose spinal cord compression, a whole spinal MRI scan is necessary. Treatment should begin immediately with intravenous dexamethasone, followed by either neurosurgery or radiotherapy. Peripheral neuropathy and spinal tuberculosis can be ruled out based on the time course and lack of relevant history. Paraneoplastic myelopathy is rare and typically associated with small-cell lung cancer, while a secondary spinal tumor deposit would present similarly but is less common.

In summary, spinal cord compression is a serious condition that requires prompt diagnosis and treatment. Early intervention can improve outcomes and prevent further complications.

Understanding Multiple Myeloma

Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is characterized by the presence of abnormal plasma cells that produce an excess of monoclonal antibodies, also known as paraproteins. Here are some key diagnostic markers and symptoms of multiple myeloma:

– Bence Jones protein is a reliable diagnostic marker.
– Bone pain is common, usually in the back, but not in the skull.
– White blood cell count is usually normal or low, with a classic leucoerythroblastic anemia.
– Paraprotein may be absent in 20% of cases, but there are light chains in the urine.
– Serum calcium can be normal or raised, and both ESR (usually) and CRP (nearly always) are raised.
– IL6 is a key myeloma growth cytokine. Serum IL6 is raised in active myelomatosis and it primarily controls CRP production. A rise in IL6 is mirrored by a rise in CRP.
– Bone lesions are lytic.

It is important to note that multiple myeloma can present differently in each individual, and a proper diagnosis requires a thorough evaluation by a healthcare professional. If you are experiencing any symptoms or have concerns about multiple myeloma, please consult with your doctor.

Superior Vena Caval Obstruction (SVCO)

Superior Vena Caval Obstruction (SVCO) is a condition where there is a blockage of blood flow in the superior vena cava. This can be caused by external compression or thrombosis within the vein. The most common cause of SVCO is malignancy, with lung cancer and lymphoma being the most frequent culprits. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

Typical features of SVCO include facial and upper body oedema, facial plethora, venous distention, and increased shortness of breath. Impaired venous return can cause dizziness and even syncopal attacks. Headache due to pressure effect is also seen.

Prompt recognition of SVCO on clinical grounds is crucial, and immediate referral for specialist assessment is necessary. If there is any stridor or laryngeal oedema, SVCO becomes a medical emergency.

Treatment for SVCO typically involves steroids and radiotherapy, with chemotherapy and stent insertion being indicated in some cases. Although dexamethasone may be given as an acute treatment, it is not the best answer for this patient, who needs to be referred immediately for inpatient treatment and monitoring.

In summary, SVCO is a serious condition that requires prompt recognition and referral for specialist assessment. Treatment options include steroids, radiotherapy, chemotherapy, and stent insertion, depending on the underlying cause.

The Gold Standards Framework (GSF) Prognostic Indicator Guidance aims to identify patients who are nearing the end of their life. The first step is to ask the surprise question to determine if the doctor would be surprised if the patient were to die in the next few months, weeks, or days. If the answer is no, measures should be taken to improve the patient’s quality of life. If the answer is yes, two further steps outline general indicators of decline and specific indicators for different diseases. For COPD, at least two of the following indicators should be present: severe disease, recurrent hospital admissions, long-term oxygen therapy criteria, MRC grade 4/5, signs and symptoms of right heart failure, combination of other factors, or more than six weeks of systemic steroids for COPD in the preceding six months.

In recent years, the issue of assisted suicide has gained relevance as UK patients have been travelling to Switzerland ‘Dignitas’ clinic. However, aiding someone to commit suicide is currently illegal. As a healthcare professional, it is important to address the patient’s fears about the terminal phase and discuss the advancements in palliative care. It may also be helpful for the patient to speak with others who have gone through similar experiences for reassurance. If the patient still insists on travelling to Switzerland, it is necessary to inform them of the legal implications of aiding suicide by providing information about appropriate clinics. It is important to note that the ‘double-effect’ principle only applies to accepting the side-effects of pain relief and not to intentionally hastening death. Implying otherwise is inappropriate.