1. Mrs. Sinclair is an 80 year old woman with breast cancer and bony metastases. She presents to your ED complaining of the same chronic pain in her scapula – the site of her metastases – that she has been experiencing for months. She feels has been poorly controlled and is currently an 8/10. She is currently on: MS Contin 40mg PO BID, Fentanyl patch 25mcg/day, and Percocet 2 tabs PO Q4H PRN (although she is taking them on a standing basis when awake, for a total of 8 tabs/day). What is her Morphine Equivalent Daily Dose (MEDD)?
2. You calculate Mrs. Sinclair’s MEDD, and decide to give her a breakthrough for her pain here in the ED. What percentage of her MEDD should be used as a breakthrough dose?
3. You decide that, to simplify matters and make titration of Mrs. Sinclair’s opioid dose easier in the near future, you will change all of her medication to a long acting Hydromorphone divided BID with appropriate breakthrough doses of short acting Hydromorphone. You do this by converting from her MEDD to an appropriate oral dose of Hydromorphone. How should you alter her MEDD prior to doing so?
4. Because you’ve taken a course on Geriatrics Emergency Medicine, you realize that constipation is one of the few side effects that persist with opioid therapy. You decide to prescribe Mrs. Sinclair something to help her with this troublesome side effect. Which of the following is not particularly effective alone to manage opioid-related constipation?
5. A few months later, Mrs. Sinclair is back in your ED. She is attempting hospice care at home for her palliative breast cancer, but has developed debilitating nausea in the last few days for which she has to come to you seeking relief. Along with initiating a work-up for reversible causes of her nausea, which of the following would be an appropriate first line anti-nausea medication in the ED? Select all that apply