Debra Mulkey Mott

A Case Study of Lung Cancer

Module I Learning Activity

Presented to
Dr. E. Stephens
THE UNIVERSITY OF TEXAS
MEDICAL BRANCH at GALVESTON

In Partial Fulfillment
Of the Requirements for the Course
GNRS 5310: Educator -Advanced Clinical

By
Debra Mulkey Mott
February 15, 2015

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GNRS 5310 - Educator: Advanced Clinical
Module I: Case Study

Introduction
Small cell lung cancer, also known as oat cell cancer, accounts for 10-15% of all
lung cancers, and tends to metastasize quickly (American Cancer Society webpage,
2015). Ms. B.T. is a 62 year old African American Female who has Stage 4 small cell
lung cancer, in addition to diabetes mellitus, anemia, hypertension, and atrial fibrillation.
She also had uterine cancer which resulted in massive hemorrhaging requiring a
hysterectomy in 2003. She is a former half-a-pack a day smoker of 34 years, who stopped
smoking 12 years ago. She is a single mother who raised three children by herself by
working three jobs to provide for her family. She has been admitted to the hospital
several times over the last six months for syncope and possible transient ischemic attack.
She has been readmitted to the hospital for the current complications of pneumonia,
hemoptysis and anemia. The sources of information for the purpose of this case study are
the patient, her primary care nurse and the electronic medical record.

Chief Complaint
Ms. B.T. states that Once I got the first cancer, everything went crazy. I thought
once she took my women parts out, it would be over. Now its in my lungs, maybe my
bones. And I keep getting sick. Now Im coughing up clots of blood. Stage 4 lung
cancer indicates one of several things: 1) the cancer, which started in one lung, has spread
to the other lung 2) cancer cells have spread and are found in the fluid around the lung
and/or the heart or 3) the cancer has spread to a distant site, such as the liver (American

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Cancer Society webpage, 2015).

Present Illness
a. Ms. B.T. has stage 4 lung cancer with current complications of recurring
pneumonia and current anemia secondary to hemoptysis. She is status post three rounds
of chemotherapy. Her current hemoglobin is 5, and she is to receive two units of blood to
increase her hemoglobin levels and to replace what she has been coughing up over the
last two days. CT scan and chest x rays are consistent with a new right lower lobe post
obstructive pneumonia and a mass in her right middle lobe.
b. Medications- during this hospital Ms. B.T. was given the following
medications:
1. Amiodarone (200mg) 1 tab PO q 12 hours. This is an anti-arrhythmic
medication used to control Atrial Fibrillation (Drugs A-Z, 2015).
2. Ferrous Sulfate 325 mg ECT 1 tab PO BID with meals. This is an iron
supplement used to treat iron deficiency anemia (Drugs A-Z, 2015).
3. Meropenum (500mg) IV piggy back q 6 hours. This is a carbapenum
antibiotic that kills bacteria by blocking the growth of the bacteria's
cell wall (Drugs A-Z, 2015).
4. Metoprolol Tartrate (50mg) 1 tab q 12 hours. This is a beta-blocker
used to control hypertension and can be used as an adjunctive
treatment for atrial fibrillation (Drugs A-Z, 2015).
5. Vancomycin (1.25gm) q 24 hours. This an extremely strong antibiotic
used to treat bacterial infections, including pneumonia (Drugs A-Z,
2015).

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6. Ambien (10mg) 1 tab bedtime. This is a sedative used to treat

insomnia, but can cause hallucinations and sleepwalking (Drugs A-Z,
2015).
c. Allergies - NKDA
d. Tobacco Ms. B.T. stopped smoking 12 years ago, but smoked half a pack of
cigarettes a day for 34 years.
e. Alcohol/drugs- Ms. B.T. states that she has never done any drugs and rarely
drinks alcohol, as she has never liked the taste of it.
Past History
a. Childhood Illnesses
Ms. B.T. reports no medical or surgical history as a child.
b. Adult Illnesses
1. Medical- Ms. B.T. has a past medical history of uterine cancer in 2003,
hypertension, diabetes mellitus type II, atrial fibrillation, syncope, recurring urinary tract
infections and possible transient ischemic attack.
2. Surgical- Ms. B.T. has a surgical history of a hysterectomy in 2003
secondary to Uterine Cancer. She had a stent placed in 2005 due to left carotid stenosis.
3. OB/GYN (Ms. B.T.) GTPAL = G5P3023, with 3 vaginal term
deliveries, 0 preterm deliveries, 2 miscarriages, and 3 living children.
4. Psychiatric- None
5. Accidents & Injuries-None
Current Health Status
a. Immunizations- Ms. B.T. is current on her flu vaccine, which she received in

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October 2014. According to the Centers for Disease Control (CDC), people with cancer
should receive the flu shot to prevent contraction of the flu, which can develop into life
threatening pneumonia (CDC, 2014).
b. Screening Tests-Ms. B.T. has had multiple chest X-rays and CTs in relation to
her current health issues of stage 4 lung cancer and pneumonia
c. Environmental Hazards- Ms. B.T. lives alone on the second floor of an
apartment complex that has poor lighting in the walkways. She lives in a high-traffic
area and reports lots of air pollutions from the cars that travel near her home.
d. Use of Safety Measures Safety measures in place for this patient include
checking of two patient identifiers before giving medications or performing procedures,
proper hand hygiene for all persons in contact with the patient, use of masks for anyone
who might be sick and comes in contact with this immunocompromised patient, and use
of one patient only specific hospital tools to prevent cross contamination between
patients. Safety measures also include leaving a light on in the patients room as it is an
unfamiliar environment, leaving the path from the bed to the bathroom clear, and making
sure the call bell is within the patients reach at all times.
e. Exercise and Leisure Activities- Ms. B.T. reports that she loves to walk. She
walks 3-4 times a week for 35 to 45 minutes on the treadmill in her apartment gym. She
also enjoys watching her 14 year old nephews little league football games. She used to
be an avid bowler until she started chemotherapy treatments. She also used to be an
active church member but since she started chemotherapy, she does not often leave her
house for social activities.
f. Sleep Patterns - Ms. B.T. reports sleep insomnia. She started taking Ambien

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approximately six months ago to assist her with her insomnia. Fully 50-80% of patients
with lung cancer experience sleep insomnia related to a variety of causes, including a
history of smoking, difficulty breathing, pain, and anxiety. Severe lack of sleep can lead
to a multitude of other health issues, which can cause further complications for an already
immunocompromised person (Saldi, S. 2013).
g. Diet- At the time of this assessment, the patient is NPO for studies including an
abdominal CT with contrast and a chest CT with contrast. Normal dietary habits for this
patient include eating only one meal per day (lunch) and snacking throughout the rest of
the day. Ms. B.T. regularly skips breakfast and rarely eats dinner. She reports having lost
52 pounds in the last six months since she has been diagnosed with lung cancer. Prior to
her diagnosis, she reports that she was a very healthy eater, never missing breakfast,
avoiding red meats and eating lots of fish, fruits and vegetables. However, since starting
chemotherapy, she reports nausea and severe weakness for days after each treatment.
Family History
Ms. B.T. reports a family history of diabetes with her mother, maternal
grandmother, and three of her six brothers all having diabetes. She also reports that her
father had hypertension and died of cardiac complications. To her knowledge, no one else
in her family has any form of cancer.
Psychosocial History
Ms. B.T. reports that she lives alone, but her daughter lives within 5 miles of her
apartment. She has two sons, both of whom live in approximately 20 miles from her
apartment. She raised all three children by herself when her husband left her after 5 years
of marriage. She worked three jobs to provide for her family and she made sure that all

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three of her children graduated high-school. Ms. B.T. started vocational college, but had
to drop out to provide for her family. She is currently on Medicare and has not worked in
nearly 10 years. She has 5 grandchildren and enjoys spending time with her family.
Review of Systems
The source of information for the review of systems is Ms. B.T.
General: Ms. B.T. is a 62 year old African American female who has
unintentionally lost over 50 pounds in the last six months. Due to her lung cancer,
chemotherapy and pneumonia, she has generalized weakness, difficulty breathing,
insomnia and is currently anemic due to hemoptysis.
Skin: Ms. B.T. has dry skin and reports bruising easily. She has no rashes, moles
or sores anywhere. She reports hair loss after starting chemotherapy and having to use
lotion several times daily to treat her dry skin.
Head, Eyes, Ears, Nose, Throat: Ms. B.T. reports several instances of dizziness
in the past few months, which have resulted in two hospital admissions. She reports no
headaches and wears glasses for reading. There are no physical abnormalities of ears,
nose, or throat.
Neck: Ms. B.T. reports no pain, stiffness or problems in the neck area.
Breast: Ms. B.T. reports her last mammogram was 2 years ago and was normal.
Ms. B.T. reports no breast or nipple pain, tenderness or discharge.
Respiratory: Ms. B.T. reports some shortness of breath, especially with walking.
She is normally able to walk for 15 20 minutes at a time at a slow pace without
stopping. Over the last two days, she has begun to cough up blood. When this first
started, she reports coughing up enough blood to fill a cup. Currently, she is coughing up

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small, nickel to quarter sized clots of dark red blood. She has never tested positive for
tuberculosis.
Cardiovascular: Ms. B.T. reports that she occasionally has palpitations and brief
bouts of chest pain. She reports that she prefers to sleep sitting up or in a reclining
position.
Gastrointestinal: Ms. B.T. reports normal bowel movements every two to three
days, but occasional heartburn if she drinks acidic drinks such as orange juice. She is
often nauseas, but feels this is a complication of her chemotherapy. She has a minimal
appetite. She has never had gallstones, hepatitis or a hernia.
Urinary: Ms. B.T. reports recurring urinary tract infections (UTI) since she has
begun treatment for her lung cancer. She reports pain and burning on urination when she
has a UTI, but currently no issues voiding. There is no blood in her urine.
Musculoskeletal: Ms. B.T. has no limb deformities or stiffness, but reports
generalized pain and severe weakness after chemotherapy.
Neurological/Psychological: Ms. B.T. reports no seizure activity, although she
admits she may have had a transient ischemic attack in the past 4 months. She reports
occasional extreme dizziness. She has not fallen, but does not always feel especially
steady on her feet. She reports no memory loss. Ms. B.T. reports feeling depressed at
times, but states that she is confident that she will beat this cancer.

Physical Examination
General: Ms. B.T. is a 62 year old female with a current weight of 59.3 kg
(approximately 131 pounds). She is frail in appearance and has the smell of sweat.

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Vital Signs: Heart rate is 66 (apical), respiratory rate is 20, oral temperature is
98.1, blood pressure is 117/68. Pain is a 4/10 currently, generalized to her body.
Skin: Skin color is dark brown, warm in temperature and dry in appearance. She
has a thin hysterectomy scar approximately 10cm in length along her lower abdomen.
She has lost much of her hair on top of her head and wears a hair covering to hide this.
She has a PICC line in her right upper arm that was inserted 2 months ago. The skin at
the insertion site has no redness or swelling and the site appears healthy. Nail bed color
is pink, capillary refill is less than 3 seconds.
Head, Eyes, Ears, Nose, Throat: Head is normocephalic. Oral mucosa is pink
and moist. Nares are patent. Normal conjunctiva, no discharge noted. PERRL 3 mm. Ear
canals patent.
Neck/Lymph Nodes: No masses noted to neck. The trachea is midline. No
thyroid palpable. No lymphadenopathy.
Lungs and Thorax: Respiratory rate and rhythm are normal for an adult. Lung
sounds are clear, but diminished, especially to the right side. Patient is on room air. Chest
rise is symmetrical. Occasional cough, bloody sputum.
Cardiovascular: Normal clear heart sounds noted, S1S2. Rhythm is normal
sinus, rate is normal, no JVD noted. No murmurs, rubs or gallops auscultated. Pulses are
2+ to all extremities. Normal femoral and popliteal pulses are palpable bilaterally.
Breast: Breasts are sagging in appearance. Nipples are normal in appearance and
there is no puckering of the skin around the breast. No discharge noted.
Abdomen: Abdomen is soft, non-tender and non-distended. Bowel sounds are
normo-active in all four quadrants.

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Genitourinary: The patient is voiding appropriately, no current urinary tract

infection. There is no costovertebral angle tenderness.
Genital: Labia are normal in appearance, minimal hair noted.
Extremities: Normal movement noted. Normal tone is present. No deformities
noted. No clubbing, cyanosis or edema noted.
Musculoskeletal: No limb deformities are noted. Normal range of motion noted.
Neurologic: Patient is awake, alert and oriented x4. She is cooperative and calm
with appropriate affect and clear speech. Cranial nerves II through XII are grossly intact.
Gait is unsteady.

Diagnostic studies
Diagnostic studies performed for this patient include:
a. CT scan (computerized tomography) scan was done to give detailed
images of the mass in Ms. B.T.s lung for size, shape, growth,
appearance and possible metastases. Also done to assess for any
obvious causes of her current hemoptysis.
b. Chest X-Ray was done to assess the mass in Ms. B.Ts lungs for
growth and possible metastases. Also done to assess Ms. B.T.s current
pneumonia status.
c. Blood tests: Chem 10 (chemistry panel plus magnesium and
phosphorus), Urinalysis, Parathyroid Panel, CBC with Differential and
Platelets, CDM DIC screen, D-Dimer level, Fibrinogen level, Glucose
levels, Type and Screen Urine Strep and Pneumonia Antigen. These

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labs were run to attempt to identify any causes of Ms. B.T.s current
issues. Results may dictate treatment modalities.
Impact of illness
The American Lung Association reports that lung cancer is the third leading cause
of death in the United States (2015). For Ms. B.T., this lung cancer has led to a loss of her
independence and her love of being active. She feels more socially isolated and it is
difficult for her to participate in regular social activities where there are many people in
close quarters, such as church. She is afraid to be around too many people for fear of
being exposed to more germs that will put her life at risk. She does not have the energy
to play with her grandchildren the way she used to and misses spending active time with
them. She used to very much enjoy food and the social aspect of eating, but now eats
only because she has to do so. The generalized pain and nausea from chemotherapy are
crippling to her. She feels that her children are quieter around her and sad, even though
she has told them Dont put dirt on my grave just yet. Im not going anywhere.
Common problems, Education
Below is a list of common problems for patients with small cell lung cancer along
with educational interventions needed:
1. Generalized Health Issues People with small cell lung cancer tend to have the
following issues: persistent cough, hoarseness, weight loss and loss of appetite, shortness
of breath, weakness, chest pain, hemoptysis (coughing up blood), and recurring
respiratory infections such as bronchitis and pneumonia. If the cancer spreads, the patient
may also have enlarged and painful lymph nodes and bone pain. It is important that lung
cancer patients take special care in hygienic practice and that those around them do, also.

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Getting an annual flu shot can help prevent contracting a flu infection that turns into
bronchitis or pneumonia. Staying as active and eating as healthful a diet as possible can
reduce some of the symptoms of weakness associated with being ill (American Cancer
Society, 2015)
2. Paraneoplastic Syndromes Small cell cancer can create hormone-like
substances that cause issues with other organs, such as SIADH (Syndrome of
Inappropriate Anti-Diuretic Hormone), Cushing Syndrome, or Neurologic Problems.
These issues are sometimes the first symptom of lung cancer, but can be misleading, as
they are also caused by other conditions. It is important that anyone who develops these
conditions be aware that they may be caused by lung cancer. These are issues that require
immediate treatment as they can each lead to extreme health issues such as seizures,
coma, diabetes, hypertension, changes in behavior, nervous system issues, and death
(American Cancer Society, 2015).
3. Superior Vena Cava Syndrome Tumors in the upper right lung lobe can
compress the superior vena cava causing blood to back up in the vasculature. Eventually,
this can cause edema in the upper part of the body, dizziness, and change or loss of
consciousness. This syndrome needs immediate treatment as it can be life threatening
(American Cancer Society, 2015).
4. Horner Syndrome Tumors in the upper lung lobes can damage shoulder
nerves, causing great pain and a group of symptoms that are known as Horner Syndrome:
drooping or weakness of one eye lid, a smaller pupil in that same eye, and loss of the
ability to sweat on that same side of the face (American Cancer Society, 2015).
Community Agencies/ Resources

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This patient and her family might benefit from assistance from the following
community agencies: support groups from the MD Anderson Cancer Center, Memorial
Hermann Hospital Cancer Center Support Groups and Look good, feel better classes,
MD Anderson and Memorial Hermann nutrition groups and classes, Cancer Counseling
Incorporated and the United Way of Greater Houston Multi-Cultural Community
Services. They may also benefit from support groups from various churches including
Windsor Village United Methodist Church (Ms. B.T.s former church), which has many
active support groups and prayer groups for people in ill health.

Ethics, Legal and Economic Factors

Ethically, Ms. B.T. is a relatively young older American who has worked hard to care
for her children and instead of abusing the welfare system as a single mother, worked
multiple jobs to ensure her familys survival and flourishing. Legally, there are no issues
with Ms. B.T.s illness. She has never been in trouble with the law, nor is she a danger to
anyone. She is not a primary care provider for her grandchildren, so her health status does
not directly affect their overall wellbeing and care. She does not require food stamps,
Medicaid, or social work assistance. She pays for her care via Medicare and her own
funding. Economically however, there are upcoming issues with doctors dealing with
Medicare patients. In 2013, the Wall Street Journal reported that many doctors are opting
out of accepting Medicare patients due to low reimbursement rates and increasingly strict
rules (Beck, M., 2013). As this continues, many patients have to find new doctors or pay
for their care completely out-of-pocket. This means that some patients will have to forgo
their needed care and that some doctors may not be able to stay afloat as they lose

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patients to other doctors (Beck, M. 2013). Additionally, with the advent of the Affordable
Care Act, there are some changes to Medicare that may affect how Ms. B.T. has to pay
for her care, depending on her income level and chosen doctors (Adelman, A.2014).
Economically, the Affordable Care Act will affect many changes in the near future as the
government determines health cares economic future.

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References

Adelman, A. (2014). Will Obamacare Affect Medicare? Myths and Facts. US News and
World Report. Retrieved February 15, 2015 from
http://health.usnews.com/health-news/healthinsurance/articles/2014/11/14/will-

obamacare-affect-medicare-myths-and-facts

American Cancer Society. (2015). How Are Long Carcinoid Tumors Staged? Retrieved
on February 14, 2015 from
http://www.cancer.org/cancer/lungcarcinoidtumor/detailedguide/lungcarcinoid-

tumor- staging

American Cancer Society. (2015). Signs and Symptoms of Lung Cancer. Retrieved on
February 15, 2015 from
http://www.cancer.org/cancer/lungcancer-nonsmallcell/moreinformation/lungcancerpreventionandearlydetection/lung-cancerprevention-and-early-detection-signs-and-symptoms
American Cancer Society. (2015). Small Cell Lung Cancer. Retrieved on February 14,
2015 from http://www.cancer.org/cancer/lungcancer/
American Lung Association. (2015). Our Impact. Retrieved on February 15, 2015 from
(http://www.lung.org/about-us/our-impact/).
Beck, M. (2013). More Doctors Opt Out of Medicare. The Wall Street Journal. Retrieved
on February 15, 2015 from
http://www.wsj.com/articles/SB10001424127887323971204578626151017241898
Centers for Disease Control and Prevention. (2014). Preventing Infections in Cancer
Patients.

Retrieved

on

February

11,

2015

from

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http://www.cdc.gov/cancer/flu/
Drugs A-Z. (2015). Retrieved on February 15, 2015 from www.drugs.com
Saldi, S. (2013). University of Buffalo, NewYork News Center: Helping Lung Cancer
Patients Beat Insomnia. Retrieved on February 11, 2015 from
http://www.buffalo.edu/news/releases/2013/12/008.html