Question of the Week # 340

340)  A 52 year old woman with history of triple-negative, metastatic breast cancer presents to the Emergency Room with increasing shortness of breath. This is her third Emergency room visit in the past 2 months. Earlier, she was admitted to the hospital  twice for massive pleural effusion and underwent therapeutic thoracentesis.  She was told that the cancer had spread to her lungs and pleura. She received multiple courses of chemotherapy in the past and her cancer has progressed despite initial response to chemotherapy. Her oncologist recommended palliative care. On examination, she is afebrile,  respiratory rate is 24/min, Blood pressure 120/70 mm Hg and Heart Rate 106/min. Breath sounds are decreased on right side of the chest. D-dimer level is 60ng/ml ( normal < 500 ng/ml) . A chest X-ray is shown below:

Which of the following management options is most appropriate for this patient?

A) Obtain Pleural biopsy

B) Tube thoracostomy and Pleurodesis

C) Start Heparin and obtain CT Angiogram

D) Pleuro-perintoneal shunt

E) Repeat Therapeutic thoracentesis

Question of the Week # 263

263 )  A 69 year old man with history of metastatic prostate cancer is admitted with nausea, vomiting and constipation of three days duration. He denies any abdominal pain. He was seen in the oncology clinic for severe bone pain and was started on sustained release Oxycodone as well as short acting oxycodone one week ago. His pain is well-controlled but he is distressed by his  newly developed symptoms.  On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 120/80 mm Hg. Chest is clear to auscultation and abdominal examination is benign. Obstructive series is negative for bowel obstruction. A CT scan of the adbomen does not reveal any small bowel obstruction. The patient is given promethazine and metoclopromide for vomiting. Which of the following opiod-induced adverse effects are expected to be persistent despite continued use of opiod analgesics ?

A) Nausea

B) Drowsiness

C) Constipation

D) Respiratory depression

E) Itching

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