Step 3 Question

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Palliative patient with known mets with 2 day hs. of progressive headace, nausea and extremity/abdomen pain drowsy, moaning, MOE, A&OX2
on morphine 10/hr
dexa 4/hr
reglan 10/hr

what to do..increase pain vs. increase dexa,
anything else?

I thought I would chime in since many have viewed and none have responded. This is pretty vague information. The primary diagnosis isn't given. The medication doses are atypical. 4 mg of dexamethasone per hour?? My suggestion would be take a history, perform a physical exam, and then think about treatment options. Also, I hope this is not based on an actual Step 3 question since it would be against USMLE policy to reproduce test questions.

C) None of the above.

I do not think this patient is actively dying. I do not think there is an iatrogenic treatment dilemma here either. I think this patient has a straight-forward, reversible problem, that if treated, the treatment burden likely will be far outweighed by a rapidly and significantly improved overall QOL, for the time being.

For a moment, I will put on my Emergency Medicine hat. The diagnostic gestalt that I pick up is:

• Stones (renal or biliary)
• Bones (bone pain)
• Groans (abdominal pain, nausea and vomiting)
• Thrones (sit on throne - [polyuria])
• Psychiatric overtones (depression, anxiety, cognitive dysfunction, AMS, delirium, coma)

STAT labs including Ca2+/(some like Ionized Ca2+), peripheral IV access, aggressive NS rehydration followed by furosemide, diuresis, calcitonin, and bisphosphonates.

I also think that in fact patterns like these, with metoclopramide and morphine on the med list, one does have to consider cumulative anti-cholinergic burden/side-effects. Steroid psychosis is a possibility but, "Look at the [groans]..." I think this is a pretty straight-forward case of hypercalcemia of malignancy.

Cheers!