Mrs. M. is an 85-year-old woman with breast cancer with metastasis to the lungs and bone.

Mrs. M. is an 85-year-old woman with breast cancer with metastasis to the lungs and bone. She is receiving palliative chemotherapy. Her husband died 5 years ago, and she is currently living with her daughter, who works outside the home. A private caregiver has been hired through a community agency. Mrs. M. enjoys visits from her family and fellow church members. Mrs. M. is seen by the nurse practitioner when she comes to her follow-up appointment in the oncology clinic. She is experiencing moderate-to-severe right chest wall pain. She also is C experiencing dyspnea on exertion, nausea, constipation, and fatigue. A recent CT scan revealed disease progression on third-line chemotherapy. Her past medical history includes metastatic breast cancer, hypertension, and hypothyroidism. Current medications: hydrochlorothiazide 12.5 mg PO daily and levothyroxine 50 mcg PO daily; and senna PO bid for constipation/APAP. She has no known allergies. Exploring her symptoms: She rates her right chest wall pain at 7/10. It is a dull, aching pain and worsens with activity. The pain has been present for 2 weeks. Hydrocodone/APAP had initially helped, but is no longer effective. Because of the pain and dyspnea, she spends most of her time sitting in a reclining chair or lying in bed. Her appetite has decreased. She has not moved her bowels in 2 days. She complains of anorexia, fatigue, and insomnia. Focused physical examination: temperature 98.2°F, heart rate (HR) 75 beats per minute, respiratory rate (RR) 22 breaths per minute, blood pressure (BP) 120/80 mm Hg, oxygen saturation 94%, weight 105 pounds, height 5 feet 4 inches, body mass index (BMI) 18 kg/m 2 . Mrs. M. is in moderate distress. She appears thin and frail. Her color is sallow, and her heart sounds reveal regular rate and rhythm, no murmur, rub, or gallop. Her lungs have bibasilar crackles, greater on the right, no wheezing. Her abdomen is soft with active bowel sounds, nontender to palpation. What would you recommend for her symptom management?

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