Managing Pain in Terminally Ill Patients

Managing pain in terminally ill patients can be challenging, but there are several strategies that can be employed to provide relief. When prescribing narcotics, it is important to start a laxative regimen to prevent constipation. Sedation may occur in the first few days, but this typically wears off. If pain relief is inadequate, the dose should be increased, although it is important to note that cocaine may produce hallucinations. It is also important to note that addiction is not a concern in terminally ill patients. Injections are typically three times more effective than oral medication. By employing these strategies, healthcare providers can help alleviate pain and improve the quality of life for terminally ill patients.

The Shoulder Joint: Flexible and Unstable

The shoulder joint is known for its remarkable flexibility, allowing for a wide range of motion. This is due to the small area of contact between the upper arm bone and the socket on the scapula, which is also shallow. However, this same feature also makes the shoulder joint unstable, making it the most susceptible to dislocation.

In summary, the shoulder joint flexibility is due to its small contact area and shallow socket, but this also makes it unstable and prone to dislocation.

Investigating Perforated Peptic Ulcers: Imaging Modalities

When investigating a possible perforated peptic ulcer, there are several imaging modalities available. However, not all of them are equally effective. The most appropriate first-line investigation is an erect chest X-ray, which can quickly and cost-effectively show air under the diaphragm if a perforation has occurred.

A supine chest X-ray is not effective for this purpose, as lying down changes the direction of gravitational effect and will not show the air under the diaphragm. Similarly, an ultrasound of the abdomen is not useful for identifying a perforated ulcer, as it is better suited for visualizing soft tissue structures and blood flow.

While a CT scan of the abdomen and pelvis can be useful for investigating perforation, an erect chest X-ray is still the preferred first-line investigation due to its simplicity and speed. An X-ray of the abdomen may be appropriate in some cases, but if the patient has vomited coffee-ground liquid, an erect chest X-ray is necessary to investigate possible upper gastrointestinal bleeding.

In summary, an erect chest X-ray is the most appropriate first-line investigation for a possible perforated peptic ulcer, as it is quick, cost-effective, and can show air under the diaphragm. Other imaging modalities may be useful in certain cases, but should not be relied upon as the primary investigation.

Investigating Perforated Peptic Ulcers: Imaging Modalities

During intercurrent illness such as diarrhoea and vomiting, it is important to suspend the use of metformin as it increases the risk of lactic acidosis. Increasing the dose of ramipril is not recommended as it may increase the risk of electrolyte disturbance while the patient is unwell. Similarly, there is no indication to double the dose of lansoprazole. Suspending ramipril is also not necessary as there is no evidence of acute electrolyte disturbance. However, reducing the dose of paracetamol to 500 mg may be considered if the patient has a low body weight.

The following table provides a summary of the typical side-effects associated with drugs used to treat diabetes mellitus. Metformin is known to cause gastrointestinal side-effects and lactic acidosis. Sulfonylureas can lead to hypoglycaemic episodes, increased appetite and weight gain, as well as the syndrome of inappropriate ADH secretion and liver dysfunction (cholestatic). Glitazones are associated with weight gain, fluid retention, liver dysfunction, and fractures. Finally, gliptins have been linked to pancreatitis.

Management of Hypercalcaemia in Palliative Care Patients

Hypercalcaemia is a common complication in patients with advanced cancer and can cause significant symptoms. The first step in managing hypercalcaemia is to confirm whether it is true hypercalcaemia by calculating the corrected calcium using the serum calcium and albumin values. Adequate hydration with intravenous normal saline is the first-line treatment, with a generous volume of 3000-4000 ml administered. If the calcium levels remain elevated, a single dose of intravenous bisphosphonate, such as pamidronate, may be prescribed. Local protocols for the management of hypercalcaemia should be followed. Other interventions, such as radiotherapy or oral prednisolone, are not first-line treatments for hypercalcaemia. In palliative care patients, simple interventions to relieve symptoms are warranted.

The Levonorgestrel intrauterine system is the appropriate choice for this patient as it is a long-acting contraceptive that can also help prevent heavy menstrual bleeding. It can be inserted immediately as the patient is within 48 hours of childbirth. The Copper intrauterine device should be avoided in those with a history of heavy menstrual bleeding. The lactational amenorrhoea method is only effective for up to 6 months post-partum, and progesterone injections must be repeated every 10-12 weeks, making them unsuitable for this patient’s desire for a long-term contraceptive.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

Treatment Options for Haemophilia B: Recombinant Factor IX and Cryoprecipitate

Haemophilia B, also known as Christmas disease, is a rare genetic disorder caused by a deficiency in factor IX. While it shares similar inheritance patterns and clinical features with haemophilia A, its incidence is much lower. Treatment for haemophilia B involves factor IX concentrates, with recombinant factor IX being the most commonly used. Prophylactic doses may be given twice a week for patients with severe disease or a history of significant bleeding, but there is a risk of developing inhibitors against the factor.

Cryoprecipitate, on the other hand, does not contain factor IX but rather fibrinogen, von Willebrand’s factor, and factors VIII and XIII. It may be used in certain situations, but it is not a primary treatment for haemophilia B.

It is important to note that recombinant factor VIII is not indicated for haemophilia B, as it is specific to haemophilia A. Similarly, factor XI is not a treatment option for haemophilia B.

While factor IX is a vitamin K-dependent clotting factor, the deficiency in haemophilia B is not caused by a lack of vitamin K. Understanding the appropriate treatment options for haemophilia B is crucial for managing this rare disorder.

Interpreting Glucose Levels in Insulin-Dependent Diabetes

Insulin-dependent diabetes is a condition that affects the body’s ability to regulate glucose levels. When interpreting glucose levels in insulin-dependent diabetes, there are several key factors to consider.

One important factor is the peak of plasma glucose that occurs between 1 and 2 hours after glucose ingestion. In normal individuals, this peak is typically sharper and occurs earlier than in insulin-dependent diabetics. In diabetics, the plasma glucose remains elevated throughout the 4-hour test period.

Another factor to consider is the presence or absence of an overshoot in the decline of plasma glucose at 3.5 hours. This overshoot, which is seen in normal individuals but not in diabetics, is a result of a pulse of insulin secretion.

A plasma glucose level of 4 mmol/l at zero time is unlikely in a diabetic patient, as they typically have high basal glucose levels. Similarly, a glucose concentration of 5.2 mmol/l at 4 hours is not expected in insulin-dependent diabetics, as their plasma glucose levels remain elevated throughout the test period.

Finally, it is important to consider the HbA1c level, which reflects average blood glucose levels over the past 2-3 months. In a diabetic patient who has been untreated for several weeks, the HbA1c would likely be elevated.

Overall, interpreting glucose levels in insulin-dependent diabetes requires careful consideration of multiple factors to accurately assess the patient’s condition.

Possible Embolic Cerebrovascular Accident in a Patient with History of DVT and Contraceptive Pill Use

This patient presents with symptoms suggestive of deep vein thrombosis (DVT), including calf pain and swelling, and has a history of using the combined oral contraceptive pill, which increases the risk of DVT. However, the sudden onset of right-sided hemiplegia indicates the possibility of an embolic cerebrovascular accident (CVA) caused by an embolus passing through the heart and crossing over to the systemic side of circulation via an atrial septal defect (ASD) or ventricular septal defect (VSD).

It is important to note that pulmonary embolism would not occur in this case without an ASD. While an aneurysm or hemorrhagic stroke are possible, they are less likely given the patient’s history of DVT. A tumor would also have a more chronic symptomatology, further supporting the possibility of an embolic CVA in this patient. Further diagnostic testing and treatment are necessary to confirm and address this potential complication.

The patient is exhibiting all four of Kanavel’s signs of flexor tendon sheath infection, namely fixed flexion, fusiform swelling, tenderness, and pain on passive extension. Gout and pseudogout are mono-arthropathies that only affect one joint, whereas inflammatory arthritis typically has a more gradual onset. Although cellulitis is a possibility, the examination findings suggest that a flexor tendon sheath infection is more probable.

Infective tenosynovitis is a medical emergency that necessitates prompt identification and treatment. If left untreated, the flexor tendons will suffer irreparable damage, resulting in loss of function in the digit. If detected early, medical management with antibiotics and elevation may be sufficient, but surgical debridement is likely necessary.

Hand Diseases

Dupuytren’s contracture is a hand disease that causes the fingers to bend towards the palm and become fixed in a flexed position. It is caused by thickening and shortening of the tissues under the skin on the palm of the hand, which leads to contractures of the palmar aponeurosis. This condition is most common in males over 40 years of age and is associated with liver cirrhosis and alcoholism. Treatment involves surgical fasciectomy, but the condition may recur and surgical therapies carry risks of neurovascular damage.

Carpal tunnel syndrome is another hand disease that affects the median nerve at the carpal tunnel. It is characterized by altered sensation in the lateral three fingers and is more common in females. It may be associated with other connective tissue disorders and can occur following trauma to the distal radius. Treatment involves surgical decompression of the carpal tunnel or non-surgical options such as splinting and bracing.

There are also several miscellaneous hand lumps that can occur. Osler’s nodes are painful, red, raised lesions found on the hands and feet, while Bouchard’s nodes are hard, bony outgrowths or gelatinous cysts on the middle joints of fingers or toes and are a sign of osteoarthritis. Heberden’s nodes typically develop in middle age and cause a permanent bony outgrowth that often skews the fingertip sideways. Ganglion cysts are fluid-filled swellings near a joint that are usually asymptomatic but can be excised if troublesome.