A 72-Year-Old Man Is Evaluated for Refractory Constipation

question 123

Multiple Choice

A 72-year-old man is evaluated for refractory constipation.  He recently had an episode of stool impaction requiring manual disimpaction and is now passing flatus and small amounts of hard stool.  He has no abdominal pain, vomiting, or hematochezia.  The patient is receiving palliative care for stage IV lung cancer with multiple skeletal metastases and has adequate pain control with a fentanyl patch and oral immediate-release morphine.  His other medications include a fiber supplement, senna-docusate combination, and oral lactulose.
Examination shows a frail-looking, cachectic man.  Bowel sounds are normal.  His abdomen is soft, nondistended, and nontender.
Which of the following is the most appropriate next step in managing this patient's constipation?

• A)Add methylnaltrexone therapy
• B)Administer mineral oil enema
• C)Change morphine to hydromorphone
• D)Discontinue fentanyl patch
• E)Start misoprostol therapy

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Definitions:

Subcultures

Groups within a larger culture that distinguish themselves through unique traditions, values, or behaviors.

Hot/Cold Theory

A traditional belief system in some cultures that classifies diseases and substances by hot or cold properties to restore balance in the body.

Humors

In historical medicine, refers to the four body fluids (blood, phlegm, black bile, and yellow bile) believed to determine health and temperament.

Definition of Health

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.