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Blogs to Boards: Question 9


This is the ninth 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 alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  


Question 9

BJ, a 65 yo woman with known non-small cell lung cancer, metastatic to her mediastinum, contralateral lung, and supraclavicular lymph nodes, returns to your clinic for follow-up for her cancer-related pain. She is getting chemotherapy, and has always expressed a desire for ‘the most aggressive’ treatments available for her cancer.

She complains of 2 weeks of worsening, midline low back pain. She has noticed difficulty in rising from chairs/toilet, and needed a wheelchair to make it into the clinic area today from the parking garage due to weakness. Examination is notable for an unremarkable back/spine exam, and 4/5 strength bilaterally in her lower extremities both proximally and distally.

You obtain a stat MRI which shows a T12 vertebral metastasis and cord compression.

In addition to administering glucocorticoids, then next best step is to:

a) Arrange an urgent radiation oncology consultation for the next day
b) Admit her to the hospital, and arrange a stat radiation oncology consultation
c) Admit her to the hospital, and arrange a stat spine surgery consultation
d) Adjust her pain medications appropriately, and instruct her to contact you immediately if her pain or disability worsens


Discussion:

Comments

Bruce Scott MD said…
This is absolutely a medical emergency, and stat surgical evaluation is necessary.

I wonder about the rationale for including in the question the idea that patient "always expressed a desire for 'the most aggressive' treatments available for her cancer".

This would be a case where I think you should be arguing for emergent surgical consultation even with a patient with much more comfort-based goals. Even in a patient who had decided against further chemotherapy, you'd still be advocating the stat consult (unless goals of care were strongly against surgery--but you'd better make sure the decision-maker is well-informed).

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