| | TERMIANL CANCER
Doorway information about patient
The patient is a 69-year-old man with terminal lung cancer who comes to the clinic requesting pain medications .
Vital signs
. Temperature : 37 ‘C
. Blood pressure : 130/80 mmHg
. Pulses : 80/min
. Respiration ; 12 / min
Approach to the patient
PALLIATIVE CARE ASSESSMENT
Source of distress
. Pain
. other somatic symptoms (eg. cause , dyspnea )
. Psychologial & spiritual distress
. Functional & cognitive decline
. Caregiver burden
Support & resources
. Family . close loved ones
. Living situation
. Financial & material resources
. Outside supports (eg, caregiver , clergy . PT/OT[physical therapy/ occupational therapy])
Setting goals
. Expectation of disease course
. Priorities & preferences
. Objective to determine success
Flow up
. Care coordination
. Medication titration schedule
. Decision making & advanced directives
Evaluation pf pain at the end of life should address the Characteristic of the pain itself (eg,location , serenity , modifying factors ) as well as other sources of distress and the patient’s overall well-being. High-quality pain management should take into account the patient’s understanding of their illness , including natural history and potential sources of pain .
Individual patients defer widely in priorities and goals; some desire complete pain relief , even at the cost of diminished alertness or other side effects , whereas others prefer only nominal pain relief with a minimum of cognitive impairment . Input form family members (if present ) should be encouraged .
Differential diagnosis
In palliative care , the primary diagnosis is not usually in doubt . However , be alert for decompensation in comorbid conditions (eg, worsening , heart failure due to cancer treatment) as well as any new cognitive or psychological disorders (especially depression )
History and physical examination
history
History of physical illness
. I understand that you have been diagnosis with cancer ,. How can I help you today ?
. please tell me more about your cancer .
. I am very sorry to hear that , and I am sure that it has been difficult for you . Tell me more about your pain.
. How severe is the pain ?
. What makes your pain worse ?
. What are you doing now for the pain , and what have you tried in the past ?
. Do you have any symptoms otters than pain ?
. How is your appetite ?
. Have you lost nay weight ?
.How well are you sleeping at night ?
. How is your mood ?
Past medical history
.Have you been diagnosed you with any other medical conditions ?
. Have you had any surgeries ?
Medications
. Do you take any medications (prescription and over- the -counter )?
Social history
. Who do you live with ?
. Do you have otters family members or friends who provide assistance or emotional support for you ?
. Do you smoke ? At what age did you start , and how much do you smoke ?
. Do you drink alcohol ? How much and how often ?
The physical examination amy be limited . The primary symptomatic body system and adjacent system should be examined briefly , alone with an assessment of nutrition and hydration . During the interview , observe the patient’s affect , speech , alertness and psychomotor activity.
Closing the encounter
To close the encounter , begin by summarizing the status of the patient’s disease , pain love; , and prior interventions . Collaborate with the patient to set treatment goals and discuss what the patient would consider an objective measure of success (eg, “The pain is under control well enough that I can walk my dog in the evening and sleep at least 6 hours a night”.) Be positive and empathetic , but avoid setting unrealistic goals or giving false hope.
Treatment is not tested in the USMLE step 2 CS exam . However , you should be ready to discuss patient’s current treatment an counsel them on the purpose and primary side effects of any medications they are taking.
Diagnostic studies
Most patients coming to discuss pain due to known malignancy will not require diagnostic testing. However , limited imaging or laboratory studies may be appropriate in individual cases , especially if there are new or unexpected symptoms.
| | |
|
|
|
頂端 
加到"我的最愛"
主題管理：
總固頂 
取消總固頂 
Message
查看
搜尋
通訊錄
複製
引用
回覆
2018/05/11 06:49pm 
IP: 已設定保密