Question of the Week # 254

254 )  A 72 year old man with history of metastatic prostate cancer is admitted with severe weakness and lethargy. He has been having vomiting and abdominal pain for the past two weeks.  He also reports intermittent diarrhea alternating with constipation over the past 2 months. Three months ago, he was noted to have progressive prostate cancer despite therapy with bicalutamide and leuprolide. His PSA at that time was 300ng/ml. He was started on Ketoconozole at that time and he is compliant with it. His most recent visit to the outpatient clinic was 4 weeks ago at which time his PSA was 60ng/ml. On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 70/40 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A CT scan of the adbomen reveals enlarged prostate and osteoblastic bone metastases in pelvis but no evidence of bowel obstruction. Urinalysis and Chest x-ray are benign. The patient is started on intravenous isotonic saline. Which of the following is the most appropriate next step in managing this patient?

A) Start Chemotherapy

B) Refer to Hospice

C) Intravenous Hydrocortisone

D) Start Norepinephrine drip

E) Intravenous Biphosphonates

 

9 Responses

  1. i think…norepinephrine drip

  2. E

  3. Ans is C.
    The most common adverse effects of ketoconazole by far are gastrointestinal in nature (mainly nausea and anorexia).Ketoconazole can also affect circulatory (of the blood vessels) system and cause tachycardia (fast heartbeat), fainting spells or dizziness.

  4. C

  5. Ketoconazole is used for cushing syndrome also and hence this patient has adrenal insufficiency give steroids.

  6. C) Intravenous Hydrocortisone

    Ketoconazole inhibits hydroxylation of deoxycortisol, which results in diminished cortisol production, especially when given in divided doses. In some patients, symptomatic adrenal insufficiency may occur, presenting with hyponatremia, hyperkalemia, hypotension, lethargy, depression, and malaise.

  7. C

  8. ccc

  9. c

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