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This document summarizes the medical history and physical assessment of a 20-year-old female patient diagnosed with non-Hodgkin's lymphoma. It details her chief complaint, history of present illness including multiple hospitalizations and chemotherapy treatments, past medical history, family history, social history, review of systems, and physical exam findings. The patient was admitted for her last scheduled dose of chemotherapy and was found to be in generally good condition despite weight loss and fatigue from her cancer treatment.
This document summarizes the medical history and physical assessment of a 20-year-old female patient diagnosed with non-Hodgkin's lymphoma. It details her chief complaint, history of present illness including multiple hospitalizations and chemotherapy treatments, past medical history, family history, social history, review of systems, and physical exam findings. The patient was admitted for her last scheduled dose of chemotherapy and was found to be in generally good condition despite weight loss and fatigue from her cancer treatment.
This document summarizes the medical history and physical assessment of a 20-year-old female patient diagnosed with non-Hodgkin's lymphoma. It details her chief complaint, history of present illness including multiple hospitalizations and chemotherapy treatments, past medical history, family history, social history, review of systems, and physical exam findings. The patient was admitted for her last scheduled dose of chemotherapy and was found to be in generally good condition despite weight loss and fatigue from her cancer treatment.
ADULT PATIENT HISTORY & PHYSICAL ASSESSEMENT by: Name: Lizlin Noemi C. Bajada DATE AND TIME OF ASSESSMENT Date of Interview: July 27, 2014 Time of Interview: 10:30 P.M I.General Data
Name : TME ( Teresa ) Sex : Female Age : 20 years old Birthdate : February 17, 1994 Civil Status : Single Educational Attainment : 3 rd year College Level (BS Accountancy) Nationality : Filipino Occupation : Student Height : 5 2 Weight : 45 kg. Religion : Roman Catholic Place of Residence : Barosong, Tigbauan, Iloilo Source of Data : Mother Reliability : 98% respectively Date of Admission : July 23, 2014 Room Number : F1
II. CHIEF COMPLAINT: Schedule for Chemotherapy last dose III. HISTORY OF PRESENT ILLNESS The patient was diagnosed with non-Hodgkins lymphoma on October 2012. She went to the hospital together with her mother for compliance of 6 cycle regimen of chemotherapy in relation to her condition apparently well and without any associated signs and symptoms. The patient was advised for admission, thus admitted. IV. PAST MEDICAL HISTORY Childhood Illnesses: Chickenpox. No Scarlet Fever or Mumps. Adult Illness: Surgical
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August to September 2012. The patient experienced fever, backaches, persistent barking cough, and a growing lump initially on her left neck. The patient sought consultation and undergone X-ray result presented mediastinal mass. Dr. Gargalicana and undergone Surgical Biopsy of her Neck Mass. Before the procedure. Myrin P Forte was prescribed and given with unrecalled dosage and timing as treatment to consider Tuberculosis (r/t Lymphadenopathy).
October 20, 2012. The patient had undergone Thoracocentesis. Her Lungs collapsed after the operation and was transferred to the ICU for further monitoring.
Previous Hospitalizations
October 13-30, 2012. The patient was admitted at Iloilo Mission Hospital due to Dyspnea and a choking sensation related to the enlarging neck mass. Admitted for 17 days. Biopsy results came in and resulted to the diagnosis of Non-Hodgkin Lymphoma Stage III. Lymphatic nodular enlargement was palpated in her axilla upon physical examination. The X-ray results revealed with Pneumonia with pleural effusion with approximated 1.6 liters. CT scan results revealed multiple lumps within the entire Lung and metastasis to the Stomach. The patient was discharge on Oct.30 with improved condition. The patient was advised for chemotherapy and home medications were given.
November 6, 2012. The patient was admitted at Iloilo Mission Hospital to begin her course of Chemotherapy. Her first cycle of chemotherapeutic drugs was given and she was discharged after 1 week (November 11, 2012).
November 16, 2012. She developed seizures, mouth ulcers, abdominal pain, and dysphagia after her first cycle, which made her being admitted in the ICU (1 week). Follow-up chemotherapeutic drug, Vincristine, which was supposedly given, was deferred due to the condition. On the third day of admission, the patient experienced Left Hemiparesis.The patient was admitted for 2 weeks and was discharged thereafter in an improved condition.
December 2012. The course of chemotherapy was continued for a total of 6 cycles every 21 days and experienced typical side effects of chemotherapy such as alopecia, nausea, and vomiting. No other untoward signs and symptoms were noted throughout the entire course. The patients chemotherapy courses were finished on April 2013.
April 2013. First courses of chemotherapy was finished.
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March 25, 2014. The patient was admitted at Iloilo Mission Hospital for a new session for chemotherapy after the discovery of a new lump on her left neck accompanied with difficulty of swallowing and dyspnea. Consultation was done prior to admission, where routine laboratories were once again done and X-Ray and CT Scan revealed another mediastinal mass, but was not as severe as the previous one.
May 6, 2014. The patient was admitted at Iloilo Mission Hospital for a cycle of her Chemotherapy and was closely monitored after the discovery of an increase in her left neck mass. The patient was also treated with Pneumonia and Pleural Effusion.The patient was maintained on her chemotherapy and the mass was found out to be decreasing in size, discharging her on May 22, 2014. She was discharge and continued her chemotherapy for 6 cycles every 21 days. Surgery: none Obstetric/Gynecological: Menach- 14 y.o Regular menstrual flow 2 packs of napkin/month
Psychiatric: None Allergies: none Immunizations: Complete DOH-recommended Screening Tests: V. FAMILY HISTORY Father is currently well, a retired army, and was diagnosed with Diabetes Mellitus and Hypertension. Mother is also well, Dept.Ed teacher, diagnosed with Diabetes Mellitus, Hypertension and positive of Tuberculosis otherwise well. Patient is the 2 nd child among three siblings. Her elder sister, 23 y.o, nurse well and healthy. Her younger brother, 18 y.o, well, studying marine engr. On the other hand, there were no familial lung disease, liver disease, kidney disease, seizure disorder, hematologic disorders, and mental disorder on both sides of the family. VI. PERSONAL AND SOCIAL HISTORY
Patient is a resident of Barosong, Tigbuan, Iloilo a B.S in accountancy student. Rarely goes out in their home because of her condition. Their house is along the road made of concrete with 5 rooms and 1 comfort room and utilizes a pour-flush type. Water source for cooking, bathing, washing, and cleaning is taken from a well. They bought sterilized water for drinking. Garbage is disposed by burning.
Patient diet are more on fish and vegetables and a cup of rice every meal. She drinks milo and 4 glasses of water/day. She often take MX3, Usana, Polynerve, Iberet, Amino vita as her food supplement.
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The patients stays at home most of the time due to her condition. She had limited activities.Her hobbies are surfing the internet, playing games in the computer and texting. The patient had a good academic performance. She is religious and usually goes to mass every Sunday but because of her condition, she rather stays at home. Her sleeping schedule usually 6-7 hours per day. No history of tobacco and alcohol.
VII. REVIEW OF SYSTEMS
General: (+) weight loss (+) weakness (+) fatigue (-) loss of appetite
Skin: (-) rashes (+) lumps (-) itching (-) dryness (-) change in skin color (-) change in nail color (+) change in hair /loss (-) change in size or shape of mole
HEENT
Head: (+) headache (+) dizziness (-) lightheadedness (-) head injury
The patient is sitting in bed awake, alert, and well groomed and respond cooperatively. Not in cardiopulmonary distress, slender, appears according to stated age. Ill looking and wearing facial mask. Makes eye contact and responsive to questions asked.Conscious, coherent, and not in cardiopulmonary distress. NSS 1 liter left cephalic
SKIN: The patient skin is light brown in color. No hypo or hyper pigmented areas. Without swelling, redness, bruise, cyanosis or pallor. No lesions noted. Normal skin turgor. Warm to touch. Hair is smooth and evenly distributed. Nails pinkish in color and slightly curved. Capillary refill < 2 seconds. No clubbing of nails.
HEENT:
A. HEAD: Hair is black unevenly distributed hair loss noted. Normocephalic and bilaterally symmetrical. Scalp is moist and without lesions. No nodules, masses, depressions, or tenderness noted upon palpation of the scalp and face. No edema or lesions.
B. EYES: Able to see surroundings and moving fingers. Intact Direct and Consensual Pupillary Reflex. Able to determine color. Eyebrows elevate and lower together at the same time. Eyelids are symmetrical, closing and meeting freely and together. No excessive blinking, lesions, and edema. No swelling or lumps on the Lacrimal Gland and Lacrimal Sac. Conjunctiva is pale and Sclera is Anicteric. No discharges. No opacities in the Cornea and Lens. Pupils Equally Round and Reactive to Light and Accommodation. Eye moves in conjugate fashion (CN III, CN IV, CN VI intact). Good blinking reflex (CN VII intact)
C. EARS: External Ears are symmetrical, normal in shape, and are of the same level. No cysts, lesions, deformities, nodules, and drainage. The tip of ears is in line with the outer canthus of the eyes. External canal is clear, with no redness, swelling, or lesions. Eardrum is pearly grey in color without lesions, perforations, and bleeding. No signs of hearing difficulties. Sound is equally heard in both ears.
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D. NOSE & SINUSES: The patients nose is normal in shape, position, and size. No bleeding, swelling, lesions, or masses noted. Nasal Septum is at midline and without perforations, lesions, swelling, or bleeding. No ulcers or polyps. No swelling around the nose and eyes. No tenderness upon palpation of the Frontal and Maxillary Sinuses.
E. MOUTH & OROPHARYNX: No Halitosis or Dental Caries. Lips are pinkish and are moist with no lesions, lumps, cracking, scaliness, or inflammations. Oral mucosa is pink, moist, smooth, and is free from lesions. Gums are pale red in color and there were no swelling or bleeding noted. No lose of teeth.
NECK: Jugular vein not visible/distended. No enlargements, masses, and tenderness noted. No inflammation or enlargement of the cervical lymph nodes. Thyroid Gland at midline. No tracheal deviations. No bruits upon auscultation.
LYMPH NODES: No lymphadenopathy. Lymph nodes are palpable but not enlarged.
THORAX AND LUNGS: Symmetric with good chest expansion. No intercostal space retraction of bulging. No contraction of accessory muscles during inspiration. No deformities or asymmetry. No masses or lesions. No superficial veins. No tenderness upon palpation. Fremitus symmetric and is felt on all lung fields. Good resonant lung fields upon percussion No adventitious sound like crackles, rales and wheezes noted. Spontaneous breathing, regular in rate and rhythm.
CARDIOVASCULAR SYSTEM: Adynamic precordium (beating and amplitude are normal). Jugular venous pressure is approximately 5 cm above the sternal angle with head of bed elevated to 30 degrees. No bounding pulses. No distended neck veins. Point of maximal impulse is diffuse, 8 cm lateral to the midsternal line in the 5 th intercostal space. Carotid pulse is palpable and brisk. No heaves or thrills. No bruits. Heart sound S2 louder tha S1 at apex.
BREAST: Symmetric and without masses or pain. Nipples without discharge.
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ABDOMEN: - Inspection: patients abdomen is flat, symmetric, and without masses and exaggerated pulsations. Umbilicus is depressed with ni signs of inflammation. No lesions and discolorations. - Auscultation: Normal bowel sounds. No bruits in all four quadrants. -Percussion: tympany at the upper left quadrant. Dullness noted over the right upper quadrant. - Palpation: Superficial - no tenderness and masses. Liver, Spleen, and Kidney not palpable. No rebound tenderness
FEMALE GENITALIA: Not assessed
ANUS AND RECTUM: Not assessed
PERIPHERAL VASCULAR SYSTEM: Extremities are warm and without edema. No varisocities or stasis changes. Calves are supple and nontender. No abdominal bruits. Brachial, radial, popliteal, dorsalis pedias and posterior tibial pulses are palpable 2+ and symmetric. Capillary refill <2seconds.
MUSCULOSKELETAL: Good range of motion in all joints. No presence of Heberdens nodes at the distal interphalangeal joints or Bouchards nodes at proximal interphalangeal joints. No evidence of swelling or deformity.
NEUROLOGIC: Mental Status: coherent and cooperative. She is oriented to time, place, person and other people. With good memory, remote memory and general knowledge. Level of consciousness: Alert with appropriate behavior and good hygiene. Has clear and spontaneous speech.
Cranial Nerves: I - XII = Intact Motor System: good muscle bulk and tone Muscle Strength: 4/5 upper extremities 5/5 lower extremities Cerebellar : finger-nose intact Gait with normal base Romberg test not elicited No pronator drift Sensory : Pinprick, light touch, able to distinguish light touch from pain. Babinski reflex absent [Type text]
Cranial Nerves CN 1 - Olfactory. - Sense of smell on each side intact. CN 2 - Optic. - Visual Activity - able to read newsprint at 12 inches with eyeglasses. CN 3 - Ocolomotor - Eyes move in conjugate fashion and converge when they CN 4 - Trochlear - Look at near object; Able to look up and down; CN 6 - Abducens - Able to look laterally; EOM - intact CN 5 - Trigemiral - Sensation - with good blinking reflex Mastication - No difficulty in mastication CN 7 - Facial Expression - patient is able to smile and frown symmetrically CN 8 - Vestibulocochlear - Hearing - Able to hear whispered words. CN 9 - Glossopharyngeal - Swallowing - Able to swallow CN 10 - Vagus - Gag Reflex - Intact Gag Reflex CN 11 - Spinal - Neck Motion - Able to rotate the neck, reflexion and Extension, Able to shrug shoulders. CN 12 - Hypoglossal - Tongue Protrusion - Able to stick tongue out
-bulky anterior mediastinal mass -massive mediatinal mass -breast swelling
5. Small lung Cancer -unexplained weight loss -unexplained fever -cough -dyspnea -back/bone pain -pleural effusion
-Hemoptysis -Stridor
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MANAGEMENT
Chemotheraphy -the most common; usually combination regimens
-Radiation theraphy -Ritusimab administration -Bone matrix transplantation: possible role relapsed high-risk disease -Radioimmunotheraphy -Transfusion of blood products -Antibiotics
Pharmacotheraphy Cytotoxic agents (Chlorambucil, Doxorubicin)- interfere the growth of neoplastic cells. Antineoplastic Agents, Histone Deacetylase Inhibitors (Vorinostat) Monoclonal antibodies-(Rituximab) against the cd20 antigen found in malignant b lymphocytes Colony-Stimulating factors- (epoetin alfa, epogen, Procit) Regulates the production of erythropoietin in the kidney to increase RBC. Immunomodulators(interferon alfa 2a)- responsible for immune reaction Cortecosteroids(Dexamehtason, Prednisone)- decrease the inflammatory response, antii-inflammatory response by inhibiting the recruitement of of leukocytes and monocytes.
-Ensure that the patient understand their diagnosis, treatment optioins and prognosis and complication therapy -Admit the patient if their complication of disease progression like dehydration secondary to diarrhea, vomiting requiring IV hydration, severe mucositis and fevere with neutropenia.