Part 4 The patient has been at the skilled nursing facility for 2 weeks and is making progress toward rehabilitation goals; however, during a follow-up appointment to her surgeon, she learned that she has metastatic ovarian cancer. She states that she has not been sleeping well and has lost 7 lb (3.2 kg) since admission. She also states that she hates waiting for her pain pills and requests something longer acting. Pain Assessment: 8 out of 10 Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; hydrocodone/acetaminophen 10/325 mg every 4 hours as needed for pain (uses 6 doses per day). • What additional recommendations would you have at this time regarding pain management? • Are there any other therapeutic issues that should be addressed? _____________

Part 4 Her pain is not being adequately controlled with the hydrocodone and now she has a new diagnosis of metastatic ovarian cancer and sleep disturbances. I would not recommend a sedative-hypnotic such as Ambien for this patient given her age. I would try a low dose of Trazadone 50mg or Remeron 15mg to see if that would help her sleeping issues. Morphine is considered to be the gold standard for pain management in cancer patients. She did have and adverse reaction to the morphine after her surgical procedure, but it was not a true allergy and it did control her pain the best. I would discontinue the hydrocodone and try Oxycodone IR 15mg PO Q6. Given her cancer diagnosis I would not write for the oxycodone to be PRN but rather

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