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Teachable Moment
Less Is More
November 2017

Nil per Os Orders for Imaging: A Teachable Moment

Author Affiliations
  • 1Tulane University School of Medicine, New Orleans, Louisiana
  • 2now with Temple University Hospital Internal Medicine Residency Program, Philadelphia, Pennsylvania
  • 3now with Albert Einstein-Montefiore Medical Center Internal Medicine Residency Program, New York, New York
JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943

An older woman with a history of insulin-dependent type 2 diabetes and metastatic breast carcinoma presented for positron emission tomographic (PET) surveillance of her cancer. There was no institutional policy on PET scan preparation for patients with diabetes, so her status was nil per os (NPO) for the scan, but she took her regular dose of insulin, a sulfonylurea, and metformin as scheduled. The PET scan was cancelled when she had a syncopal episode. When she was seen in the emergency department, she was noted to have a blood glucose level of 19 mg/dL (1.05 mmol/L) and an oxygen saturation level of less than 92%. Findings from her physical examination and initial workup caused concern for a pleural effusion, so her status was kept as NPO per hospital policy for a computed tomographic (CT) scan of her chest, which confirmed an effusion; pleural fluid analysis supported a malignant etiology. The patient elected to pursue curative treatment of her cancer, so her status was kept as NPO again for a restaging CT. Later that day, she fell in her hospital room, which necessitated NPO status for a CT scan of her head, revealing cerebral metastases of her cancer and ruling out intracranial hemorrhage. During her hospitalization, the patient’s blood glucose level remained labile, and despite ordering fall precautions, she had multiple falls; fortunately, none of these resulted in serious injury.

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