GEMP 4 2020: Case Study 1

Objectives

1. To be able to describe the disease trajectory of cancer.

2. To understand the importance of ensuring adequate pain relief in palliative care.
3. To understand that the concept of total pain requires a multimodal approach.
4. To have a practical approach and understanding towards adequate pain assessment and
management incorporating the WHO pain step ladder and adjuvants, together with non-
pharmacological measures.
5. To understand the relevance of ordering laboratory and radiological investigations in
metastatic cancer.

Mrs Beauty Khumalo is 55 years old. She presented with a history of breast cancer diagnosed 18
months ago when she found a lump in her right breast. She had a right mastectomy and 3 out of 10
axillary nodes were found to be positive. The tumours were positive for oestrogen and progesterone
receptors and she has been taking tamoxifen since the surgery. She has been well, except for
occasional headaches and lower back pain which she ascribes to “all the heavy work” she must do.
She works as a domestic worker and has been with her current employer for 14 years.

She lives with her husband who is retired, and their two children aged 22 and 15. Her mother died
three months ago after a long struggle with COPD. Her father is now living with her, having moved in
after her mother died. She has two sisters who live in the Eastern Cape with their families.

She has come to see the doctor because she has been having more episodes of back pain which are
now associated with pains in her right leg. She had been taking some tablets called ‘stilpane’, which
a friend gave her for her pain. These do not always alleviate the pain fully. She is having difficulty
walking due to the pain which is impacting on her ability to attend church, where she is an active
member of the community. This is especially upsetting to her although she is also having trouble
coping with her work and says she is worried that her employer will think that she is lazy.
Sometimes, she can’t sleep at night, and is feeling more fatigued every day.

1. List all the possible causes of back pain that may apply to her.

2. What further information regarding her pain would you like from Mrs Nyathi?

3. What would you be looking for on examination?

4. What important diagnosis (palliative emergency) would you like to exclude? Explain why.

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On further questioning, she says that the pain in her back is constant and aching and is worse on
bending over and when she walks. She grades the pain as 5/5. The pain in her R leg is intermittent
and sharp. She says that she has been aware of the back pain for about 3-4 months but that it has
been getting worse in the last 2 weeks, when the leg pain also started. She adds that she has a patch
of tingling “pins and needles” sensation on her right thigh.

Her headaches are occasional and are usually worse in the evening, feeling like a tight band around
her head. Sometimes Panado tablets seem to help for her headaches. She grades them as 3/5, but
occasionally 5/5. She has no episodes of dizziness or of falling. She has not noticed any specific
weakness of her legs. She has been experiencing constipation.

She is also worried about her work. She cannot do all the work expected of her because of the pain
and she gets tired. She needs the salary to support her children and she sends money home to her
family.

On examination, her general condition is good, although she says she has lost a little weight. She has
slightly pale conjunctival mucosa. Other than the scar on her right chest, there are no significant
findings on examination of her chest and abdomen. She has tenderness over her lower lumbar spine.
Neurologically, she has normal sensation to pin prick and light touch and the power and reflexes are
normal in all limbs.

5. Why would you request the following laboratory and radiological investigations?
FBC:
X-ray spine:
CXR:

6. Discuss all the factors that could be contributing to her total pain.

7. What are the ingredients of stilpane tablets?

8. The X-rays do not show any abnormalities and further investigations are not required. What
type of pain is Mrs Khumalo most likely suffering from? (i.e. nociceptive, neuropathic or
both?) Explain your answer.

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 9. Using the Total Pain (biopsychosocial) approach to pain, how would you initially manage Mrs
Khumalo’s pain?

Six months later, Mrs Khumalo returns to the clinic complaining of worsening pain in her back and in
both legs. It is 5/5 constant, aching, burning and is worsened with movement. She has not been able
to work for the past week. Yesterday, she fell while stepping onto the pavement and since then she
feels that her legs are getting weaker. She needed assistance getting out of bed this morning.

She is currently taking:

 Morphine syrup (10mg/5ml) 10ml 4 hourly,

 Ibuprofen 400mg tds,
 Amitriptyline 75mg nocte,
 Sennakot - 2 tablets, and liquid paraffin 10mls nocte.

On examination, she moves with great difficulty. She looks distressed and has noticeably lost weight
as evidenced by temporal wasting and loose-fitting clothing. She has severe tenderness over her
lumbar spine. She has decreased sensation in both legs and lower trunk and power in both legs is
2/5 with reflexes (ankle jerk and knee jerk) ¾ bilaterally.

10. What important palliative emergency that needs to be considered in this patient? What is
the treatment of choice for this possible emergency?

11. Name two medications that need to be initiated immediately and explain your reasoning.

12. What investigations need to be done urgently? Discuss the findings thereof.

13. Discuss in detail how you would you manage her pain?

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 14. What is the important conversation that will need to be initiated?

15. Draw a graph describing the general disease trajectory of cancer

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