Pain Management and End-of-Life Symptom Control — WACS Viva & Clinical Scenarios (Geriatric Medicine and Palliative Care)

Exam-style pain management and end-of-life symptom control viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: A 68-year-old male with metastatic prostate cancer and skeletal metastases presents with severe, unremitting lumbar and pelvic pain. He is currently taking oral tramadol 100 mg four times daily and paracetamol 1 g four times daily, with inadequate pain relief (numeric pain score 8/10). His serum creatinine is 220 micromol/L (estimated glomerular filtration rate 24 mL/min/1.73 m²). Formulate an analgesic step-up plan, calculate starting doses including breakthrough analgesia, justify your choice of opioid with respect to renal clearance, and outline essential supportive co-prescriptions.
• SCENARIO 2: A 72-year-old female with terminal metastatic pancreatic adenocarcinoma is admitted to the palliative care unit in the active dying phase. She is no longer able to swallow oral medications and exhibits noisy respiratory secretions (death rattle), intermittent dyspnoea, and terminal restlessness. Design a 24-hour continuous subcutaneous infusion (syringe driver) regimen to address her symptoms, state the clinical pharmacology and rationale for each agent, specify diluent selection and subcutaneous site management, and outline key communication points for her relatives.
• SCENARIO 3: A 58-year-old woman with advanced breast cancer presents to the emergency medical unit with severe thoracic back pain, progressive weakness in both lower limbs, sensory blunting below the T6 dermatome, and acute urinary retention. Detail the immediate diagnostic and pharmacological emergency management, outline the corticosteroid dosing schedule, specify the definitive imaging protocol, and discuss the multidisciplinary referral pathways.
• SCENARIO 4: A 64-year-old man with squamous cell lung carcinoma presents with profound lethargy, confusion, nausea, constipation, and dehydration. Laboratory investigations reveal a corrected serum calcium of 3.45 mmol/L and normal renal function. Discuss the pathophysiological mechanisms of hypercalcaemia of malignancy, detail the immediate fluid resuscitation protocol, prescribe definitive antiresorptive pharmacotherapy, and explain the indications for second-line therapy in refractory cases.
• SCENARIO 5: A 70-year-old patient with end-stage renal disease and metastatic renal cell carcinoma receiving escalating doses of oral morphine for bone pain develops multifocal myoclonus, worsening diffuse hyperalgesia, visual hallucinations, and acute-on-chronic delirium. Differentiate opioid-induced neurotoxicity from progressive metabolic encephalopathy or disease progression, and formulate a step-by-step management protocol including opioid rotation and dose calculation.