Dr. Lim (Consultant)
Good morning, team. Let's review Mr. Tan in Bed 8. He was admitted two days ago with poorly controlled cancer pain secondary to metastatic pancreatic carcinoma.
Dr. Ng (Registrar)
Yes, Dr. Lim. He's currently on oral morphine 20 milligrams every four hours, with 10 milligrams breakthrough doses. Overnight he required three breakthrough doses.
Dr. Lim (Consultant)
Three breakthrough doses suggests his baseline analgesia is inadequate. What was his pain score this morning?
Dr. Ng (Registrar)
He rated it 7 out of 10 at rest, and 9 out of 10 on movement. The pain is predominantly in the epigastric region, radiating through to the back.
Dr. Lim (Consultant)
That's a classic pattern for pancreatic pain. The back radiation suggests possible celiac plexus involvement. Have we considered adjuvant analgesics? What about neuropathic pain component?
Dr. Ng (Registrar)
He does describe some tingling and burning quality, which suggests a neuropathic component. I was thinking of adding pregabalin 75 milligrams twice daily as a starting dose.
Dr. Lim (Consultant)
Good thinking. Let's also titrate up the regular morphine. Calculate his total 24-hour opioid requirement including the breakthroughs, then increase the regular dose by approximately 30 to 50 percent.
Dr. Ng (Registrar)
So his total 24-hour morphine is 120 milligrams regular plus 30 milligrams breakthrough, that's 150 milligrams total. A 30 percent increase would bring the regular dose to about 30 milligrams every four hours.
Dr. Lim (Consultant)
That's correct. And adjust the breakthrough dose to one-sixth of the new 24-hour total. Also, let's add dexamethasone 4 milligrams in the morning as an anti-inflammatory adjuvant. Monitor for side effects — especially drowsiness and constipation.
Dr. Ng (Registrar)
Understood. I'll also ensure the laxative regimen is optimized — he's currently on senna and lactulose. Shall I discuss with the pain team about a possible celiac plexus block if we can't achieve adequate control with medications alone?