Question

History of Present Illness

MDJ is a 50-year-old woman whose routine mammogram showed a 2.3 - 4.5 cm lobulated mass at the 3:00 position in her left breast. Sheunderwent a stereotactic needle biopsy and was diagnosed with infiltrating ductal carcinoma that was both estrogen and progesterone receptor positive. The staging workup was negative for distant metastasis. Her final staging was stage IIB. She had a modified radical mastectomy with lymph node dissection. The sentinel lymph node and 11 of 16 lymph nodes were positive for tumor cells.

Past Medical History

Her medical history is significant only for starting menstruation early, at age 10, and being chronically 20 to 30 pounds over- weight since high school.

Family History

She decided to have a mammogram after learning that her maternal aunt and grandmother were diagnosed with breast cancer in the past few months. Her mother was diagnosed with breast cancer ,8 years ago at age 50.

Personal and Social History

Her home exercise program includes walking and gardening, and she describes her diet as healthy. She works part-time from home as a research editor, which involves to a lot of time on the computer.

Admission Order

• She is prescribed a chemotherapy regimen of six cycles of CAF (cyclophosphamide [Cytoxan] 600mg p.o. daily, PNSS 1 L +Fluorouracil [5-FU] 225 mg x 8hrs , and doxorubicin [Adriamycin])136 mg IV q 14days. During the her chemotherapy patient experiences a severe nausea and vomiting,loss of appetite,stomach upset but her oncologist give ZOFRAN(Ondansetron)4mg TIV q 4hrs.

She has now completed three cycles of CAF. Her height is 5 feet, 7 inches, and her weight is 155 pounds.

She comes to the emergency department with a 2-day history of fever, chills, and shortness of breath. On arrival, she is disoriented and agitated. Vital signs are BP =86/43, PR =119, RR= 28, T=39.8° C, O2Sat 85% on room air. Chest x-ray demonstrates diffuse infiltrates in the left lower lung. Her chem 14 is within normal limits, with the exception of BUN 28 mg/dL, creatinine 1.6 mg/dL, and lactic acid 2.4 mg/dL. requires endotracheal intubation and spends 3 days in the ICU receiving antibiotics and respiratory support. She is able to be extubated and returns to the oncology unit, where she remains for a few more days before being discharged to home.

Complete Blood Count

WBC	1200/mm3
Neutrophils	34%
Segmented (Polys)	30%
Bands	4%
Lymphocytes	60%
Monocytes	3%
Eosinophils and basophils	2%
Hct	24.9%
Hgb	8.7 g/dL
Platelets	85,000/mm

make a discharge planning

Answer 1

discharge planning:

diagnosis:

Left lower lung infection(pneumonia) with respiratory failure and disorientation in a case of Infiltrating left breast ductal carcinoma stage 2B ,status post left modified radical mastectomy with lymph node dissection surgery ,status post chemotherapy [3 cycles of chemotherapy  received]

Summary of hospital course:

Patient had come with fever,chills,breathlessness,hypoxaemia,disorientation after breast surgery and receiving three cycles of chemotherapy for carcinoma breast. Patient was intubated and admitted to ICU for 3 days.Respiratory support was provided along with intravenous antibiotics and later patient was shifted to oncology ward.Now patient is better and discharge is planned.

Significant inpatient investigations

Pancytopenia

[hemoglobin 8.7 gram percent WBC 1200 per cubic millimeter and platelets 85000]

elevation of serum blood urea nitrogen BUN 28 mg/dl, creatinine 1.6 mg/dl,.

Xray chest:left lower lobe diffuse lung infiltrates.

discharge plan

Medications :

1.Antibiotics [as prescribed in view of lower respiratory tract infection].

2.Hormone therapy tamoxifen [as  prescribed as the tumor is both estrogen and progesterone receptor positive].

3.Granulocyte Colony stimulating factor[ as  prescribed in view of pancytopenia ,hemoglobin 8.7 gram percent, WBC 1200 per cubic millimeter and platelets 88000]

4.Multivitamins, multiminerals, antioxidant supplements,

5.Fluoridated toothpaste,medicated  mouthwashes,

Diet

1,Eat fully cooked  food and avoid outside food in order to prevent food contamination and infection.

2.Avoid consumption of raw meat, seafood,unwashed fruits and vegetables in order to prevent bacterial/parasitic infections and food related illnesses

3.Eat soft, bland foods in order to decrease gastritis, nausea and vomiting

4.Eat food at regular frequent intervals in order to provide adequate nutrition to the body.

5.Eat foods rich in vitamins and minerals, iron rich foods( as hemoglobin 8.7) to provide energy for healing.

6.Eat foods rich in fiber in order to prevent constipation,GI discomfort,nausea and vomiting.

7.Maintain adequate fluid intake and drinking water at regular intervals in order to maintain hydration and prevent chemotherapy related renal damage.

Lifestyle,exercise and activity:

1.Patient should take adequate rest and sleep.

2.Patient should maintain an active lifestyle and exercise regularly in order to improve the general health and wellbeing and immune status. Relaxation exercises including yoga and brisk walking should be done on a regular basis.

3.Respiratory exercises ,deep breathing exercises should be done in view of lung infection.

4.Patient should do low intensity exercises and avoid high impact exercises/exercise injuries due to risk of infection and bleeding

Health teaching :

The health teachings to be given to the patient at discharge are

1.Explanation of the immunocompromised state with reinforcement of general hygiene precautions with hand washing before eating,after using washroom.

2.Avoid sick people, use of mask if somebody at home has a flu/ viral infection

3.Take short baths or showers  and use sun protectant creams /moisturizers to protect the skin.

4.Patient should avoid using the sharp objects ,razors in order to prevent injury and cuts as there is risk of bleeding.

5.Patient should keep moving about while she is working at computer at regular intervals and avoid sitting in one position for long intervals to prevent blood clotting and deep venous thrombosis.

6.As patient's home exercise is gardening, in addition to walking ,she should take strict precautions to protect herself from infection through gardening by using mask ,gloves while handling the mud and soil and wash her  hands thoroughly afterwards.

7.Adequate mouth care. using fluoridated toothpaste/mouthwashes and using soft brushes/oral swabs to prevent oral mucosal trauma while brushing as there is risk of  bleeding.Avoid flossing.

8. Adequate rest with good diet and regular exercises to improve the general immunity along with standard hygiene precautions and annual flu vaccine.

Additionally, the family should be educated that if anybody around the patient is sick,they should keep away from the patient till the time their infection settles  in order to decrease  the risk of the patient getting sick

To call / plan visit to the health care provider:

1.if experiencing breathlessness, fever or chest pain,

2.white patches in the mouth or having sore throat

3.significant bleeding,sudden skin/muscle hematomas

4.burning during passing urine

5.feeling dizzy or lightheaded

follow up investigation

Hemoglobin with the complete blood count , blood urea nitrogen and serum creatinine

X-ray chest

OPD follow up

The patient will follow up to the OPD after one week with her complete blood count report, blood urea nitrogen and serum creatinine, X-ray chest in order to see for resolution of lung infection, the increase in the WBC level and plan the 4th cycle of chemotherapy .

follow up treatment plan:

Fourth cycle of chemotherapy