Chapter 40: Nausea And Vomiting: In for a Tune-Up Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Develop a prophylactic antiemetic regimen based on the chemotherapeutic agents’ emetic risk that optimizes the management of nausea and vomiting.

• Design an appropriate treatment regimen for anticipatory and breakthrough nausea and vomiting.

• Design a monitoring plan to assess the effectiveness of an antiemetic regimen.

• Discuss with patients and caregivers the reason for antiemetics, their appropriate use, and the management of side effects.

• Recommend appropriate alternative antiemetic strategies based on patient-specific conditions, such as previous response to chemotherapy and side effects.

PATIENT PRESENTATION

Chief Complaint

“I have difficulty swallowing.”

HPI

Mr Wilson is a 57-year-old man who presents to his primary care provider with complaints of pain in the back of his throat and difficulty swallowing. He has had a 14-lb weight loss over the previous 2 months because it has been difficult to eat. Upon physical exam, a mass is felt in his neck. His primary care provider orders a biopsy, and the histopathology reveals squamous cell carcinoma. A PET-CT scan reveals a 3-cm mass in the oropharynx with disease found in multiple cervical lymph nodes. A diagnosis of advanced stage oropharyngeal cancer is made with the plan to begin systemic chemotherapy and radiation in the outpatient setting.

PMH

BPH

Cancer of the oropharynx (p16 negative)

GERD

FH

Father died at age 82 of heart and renal failure; mother died at age 68 with emphysema, obesity, MI, hypertension; two sisters, one with diabetes; three adult children, alive and healthy.

SH

Single and works as a salesman at a car dealership. He has smoked 1–1.5 packs of cigarettes a day starting at the age of 14. He still smokes but has cut back because his employer has a campus-wide no smoking policy. He routinely consumes alcohol, averaging four to five alcoholic drinks per week.

ROS

Complaints include difficulty swallowing, pain in throat, and weight loss over the past 2 months.

Home Meds

Tamsulosin 0.4 mg PO daily

Esomeprazole 40 mg PO daily

Oxycodone ER 10 mg PO Q 12 H

Oxycodone 5 mg PO Q 3 H PRN

All

NKDA

Physical Examination

Gen

This is a pleasant thin Caucasian man who appears to be in acute distress ...