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Blogs to Boards: Question 1


This is the first in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed will alternate publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  

We welcome comments about any aspects of the questions or the answers/discussions.  The feedback that we hope to get in the comment sections of the post will help us all learn important aspects for the boards. We also welcome an interdisciplinary viewpoint when answering these questions, so even if you are not taking the medical boards, your input is still very much welcome.


Question 1

Ms. V is a 68 year old with metastatic non-small cell lung cancer, congestive heart failure, and mild renal insufficiency residing in an inpatient palliative care unit for management of bone pain. Her medications include morphine IR, fentanyl transdermal patch, furosemide, senna, and Fleet enema’s prn. Ms. V did not have a bowel movement in 4 days. Basic labs were ordered for the next morning as well as a two of her prn enemas, although they failed to result in a bowel movement. The labs the next day reveal a serum sodium of 124, potassium of 3.0, creatinine of 1.4 (baseline of 1), low calcium of 6.5, and a very elevated phosphate of 17 mg/dl.

What is the most likely cause of her electrolyte abnormalities?

a) A medication adverse event 
b) Tumor lysis syndrome 
c) Bowel Impaction 
d) Osteolytic metastases


Discussion:


(For email readers - click here for the answer and discussion)

Comments

Bruce Scott MD said…
Inpatient hospice unit...basic labs were ordered...

Really? I think in 2 of the 3 inpatient hospice units I've worked in that ordering labs on this patient would be unheard of.

Okay, it said palliative care unit, and that she was there for bone pain. Fair enough.

General practitioners seem to have absolutely no clue as to the potential dangers of Fleets. Many really seem to just think of it as benign. A senior IM resident today gave a talk on acute kidney injury and listed off drug causes. It was not on the list. Every other medication you could think of was (including some that I think he just made up).

I wonder what other people's experience is with their hospice nurses. I've had a fair percentage of hospice nurses who seem to quite like Fleets and offer it as a suggestion even with little old ladies as patients. Education in the nursing field may well have as big of an impact as anything else in terms of changing HOSPICE practice, since I think nursing suggestions are more often followed in hospice than other settings.

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