case 1

Published on 24/06/2015 by admin

Filed under Internal Medicine

Last modified 24/06/2015

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INTRODUCTION

CASE IN DETAIL

RW’s problems started 11 years ago when he was incidentally diagnosed with Hodgkin’s disease when admitted to hospital with a traumatic injury related to a motor vehicle accident. His Hodgkin’s disease was treated with mantle radiotherapy alone on subsequent biopsy and staging. He denies any side effects associated with this treatment.
He was well until 7 months ago, when he presented to his general practitioner with retrosternal discomfort. He could recall experiencing drenching night sweats over the days preceding his presentation, but denied fevers or known weight loss. Chest X-ray performed subsequently showed mediastinal widening suggestive of mediastinal lymphadenopathy and he was referred to a haematologist, who diagnosed recurrent Hodgkin’s disease. He has had multiple investigations, including lymph node biopsy, CT of thorax and abdomen, a gallium scan and bone marrow biopsy. He was immediately commenced on the ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) combination chemotherapeutic regimen. He showed good disease response, with disappearance of symptoms as well as lymphadenopathy on follow-up imaging. His treatment was prematurely terminated after three cycles (5 months ago) due to his developing bleomycin-associated pneumonitis. At this stage he denied any respiratory symptoms. The lung toxicity was discovered on routine screening with the carbon monoxide diffusion capacity test.
Four and a half months ago he was commenced on the MOPP (mechlorethamine, vincristine, procarbazine, prednisone) combination chemotherapy regimen. He suffered side effects of nausea, vomiting and alopecia associated with this treatment. He also experienced easy bruising and oral candidiasis associated with the steroid use, but denied any mood swings or insomnia. He has not been investigated for diabetes or osteoporosis. After three cycles of therapy, 2 months ago he was admitted to hospital with high fevers and was diagnosed with febrile neutropenia. During this admission he was also treated in the intensive care unit for 5 days. He could not recollect in detail the events surrounding this episode and the treatment he received. After 2 weeks in hospital he was discharged on prophylactic trimethoprim and sulfamethoxazole one tablet daily. He has been compliant with this treatment and denies any associated side effects.
He had his fourth cycle of chemotherapy without any complications. He is currently waiting for his fifth and final cycle of MOPP, the administration of which has not been planned as yet. He has had a PET scan 1 week ago and has been told by the haematologist that he still has some residual disease activity. He currently suffers from extreme lethargy, weakness and exertional dyspnoea on walking 100 metres on flat ground. He has lost a total of 10 kg over the past 7 months.
His medication summary includes trimethoprim/sulfamethoxazole and occasional paracetamol. He denies any known allergy to medications.
His father is alive at the age of 71 and suffers from ischaemic heart disease. His mother is 69 and suffers from severe rheumatoid arthritis. He has only one sister, who is well at the age of 36. He has no family history of malignancy.
He worked as a private security guard until 6 months ago. He is currently unemployed and survives on a single-parent benefit from the government. He finds it difficult to meet his and his family’s needs with this income.
He has never smoked. He previously consumed 100 g of alcohol per day in the form of beer and did so for approximately 10 years. He has not consumed any alcohol during the past 7 months. Prior to his current diagnosis he denies experiencing any lymph node pain associated with alcohol consumption.
He separated from his wife 2 years ago. Before that he was married for 3 years. He has two children, a boy aged 5 and a girl aged 4, both of whom live with him. His mother looks after his children when he is in hospital. She finds it difficult to continue supporting him due to her debilitating arthritis.
He is independent with daily activities and drives too. He lives in a house for which he is paying off a mortgage.
He has never been depressed, even with the current diagnosis and the stormy course he has had. He is very positive about the future. His main problem, as he identifies it, is finding enough finances to support his family and to pay off the mortgage. His only social support is his ailing mother.
The dietary history suggests satisfactory nutrition. He has good insight into his disease and the chances of survival and cure as well as the toxicities associated with his treatment.

ON EXAMINATION

RW was alert and cooperative. He was alopecic and cushingoid. He had a portacath in the inner aspect of his left forearm and the site was not inflamed.
His pulse rate was 50 beats per minute and was regular in rhythm and normal in character. His blood pressure was 125/80 mmHg and there was no postural drop. His respiratory rate was 12 per minute at rest. He was afebrile. His estimated body mass index was 28 and his cognition was intact, with a Mini-Mental State score of 30/30.
He did not have any palpable lymphadenopathy. There was no mucositis or mucosal pallor. He had multiple ecchymoses, particularly in the dorsal aspects of his forearms and the thighs. He had a buffalo hump, but there was no bony tenderness or kyphoscoliosis.
His respiratory system examination showed reduced but symmetrical expansion of the upper and lower thorax. His lung fields were resonant throughout and the breath sounds were vesicular. There was fine early inspiratory crepitation in the lower zones bilaterally that did not clear with coughing.
In his cardiovascular system examination, the jugular venous pressure was not elevated. He had two heart sounds of normal intensity and no third heart sound or pericardial rub. There was no peripheral oedema.
His gastroenterological system examination was remarkable for oral thrush but his abdomen was soft, not distended and non-tender. There was no organomegaly or palpable mass.
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