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Background: Physician home visits (HVs) are an important model of care for the terminally ill. Hospice and palliative medicine (HPM) fellows make a minimum of 25 HVs. Objective: To describe HPM fellow hospice HVs in an academic palliative medicine practice. Methods: Retrospective chart review of HVs conducted by 1 HPM fellow. Results: Twenty-five HVs were made to 21 hospice patients. Nineteen had advanced cancer. Indications for visits were symptom management (22) and education (21). On average 2.8 symptoms (± SD 1) were addressed on each visit, usually pain. Medications were reviewed at every visit. Conclusions: HVs are an important part for patient care and fellow education, which provided an opportunity for medication revision and symptom education.

Introduction Cervical lymphadenopathy is a sign that can be presented in many diseases condition. We are presenting a case of fever with cervical lymphadenopathy due to kikuchi Fujimoto diseases. Kikuchi lymphadenitis is a rare, benign condition of unknown cause usually characterised by cervical lymphadenopathy and fever. While, 40% of patient with kikuchi disease were initially misdiagnosed as having lymphoma and were consequently over treated with chemotherapy. This pitfall remains an active source of diagnostic error. Case Mr. Am is a 25 years old Malay man initially admitted under Internal Medicine department with history of fever and neck swelling for more than 2 weeks. During admission, his routine blood tests were normal. Chest X ray was also clear. Thereafter patient transferred under Palliative medicine unit for the further evaluation and management. His CT-TAP (thorax, abdomen and pelvis) reported as normal study. He underwent FNAC (fine needle aspiration and cytology) of the cervical lymph node which showed T cell lymphoma. Although, FNAC report did not clinically correlate. Therefore, for the further workup we performed bone marrow aspiration and trephine. His bone marrow showed leukopenia. We started to treat with steroid which showed some clinical improvement. Mr. Am was seen in the NUH (National University hospital) Singapore for second opinion. His working diagnosis is now Kikuchi lymphadenitis. Unfortunately, he was presented with fever and low WBC count again in September 2014 and went to NUH Singapore and his current working diagnosis is recurrent Kikuchi lymphadenitis with Mycoplasma and Infectious mononucleosis infection. His PET CT scan reported as increased mediastinal masses with low significance. Currently he is under care of Palliative medicine of RIPAS hospital. Discussion Our case illustrates a significant role of palliative medicine for the complicated clinical case. Which could be achieved by meticulous history taking and symptoms assessment and relevant investigations. Hence, integrated palliative care service could prevent the miss diagnosis, and ensures a better outcome.

Nausea and vomiting are relatively common in advanced cancer and is dreaded more than pain by patients. The history, pattern of nausea and vomiting, associated symptoms, and physical examination provides clues as to etiology and may guide therapy. Continuous severe nausea unrelieved by vomiting is usually caused by medications or metabolic abnormalities, while nausea relieved by vomiting or induced by eating is usually due to gastroparesis, gastric outlet obstruction, or small bowel obstruction. Drug choices are empiric or based on etiology. Metoclopramide has the greatest evidence for efficacy followed by phenothiazines and tropisetron. Corticosteroids have not been effective in randomized trials except in the case of bowel obstruction. Treatment of nausea unresponsive to first-line medications involves rotation to medications which bind to multiple receptors (broad-spectrum antiemetics), the addition of another antiemetic to a narrow-spectrum antiemetic (a serotonin receptor antagonist such as tropisetron to a phenothiazine), rotation to a different class of antiemetic (tropisetron for a phenothiazine), or in-class drug rotation. Venting gastrostomy, octreotide, and corticosteroids will reduce nausea and vomiting associated with malignant bowel obstruction.