Question

Mrs. Sienna

Mrs. Sienna is a 76-year-old woman referred to an internist for evaluation and management of hypercalcemia in the setting of recent complaints of fatigue, malaise, loss of appetite, and possible dysphagia for solids. Her known medical problems include hypertension, hypercholesterolemia, osteoporosis, hypertensive heart disease, and sick sinus syndrome. Mrs. Sienna smoked a few cigarettes a day over a 10-year period but stopped 50 years ago. She has no known allergies and has had cataract surgery to her left eye. A screening mammography in 2009 showed no evidence of breast cancer. In 1999, she underwent a colonoscopy without findings of colon cancer.

            Her only daughter accompanies her on the visit. Mrs. Sienna lives alone since her husband died of heart failure about 5 years ago. She is very active in her community and church, tending her garden, babysitting for a friend’s granddaughter, and volunteering at the local hospital one day a week.

            Due to her deteriorating condition, she is admitted to the hospital for further work-up of her symptoms and treatment of the hypercalcemia with hydration and pamidronate. On admission, the physical exam was within normal limits except that it revealed a chronically ill appearing 76-year old. A portable chest x-ray at the time showed a bibasilar atelectasis but no obvious evidence for a malignancy. Further laboratory analysis showed persistent anemia and hypercalcemia, but other chemistries, coagulation studies, hepatic and renal panels were within normal limits. Because of the high suspicion for a malignancy, a computed tomography (CT) scan of the chest, abdomen, and pelvis was ordered along with a positron emission tomography (PET) scan to rule out malignancy. Findings from the CT/PET scan showed enlarged lymph nodes in the lower abdomen and groin. A needle biopsy of the left groin was performed and was diagnostic for non-Hodgkin’s lymphoma.

            A 6-month aggressive course therapy was suggested using R-CHOP (rituxan, cyclophosphamide, doxorubicin, vincristine and prednisone). Risk and benefits were discussed including potential side effects such as myelosuppression (neutropenia, anemia, and thrombocytopenia), nausea and vomiting, fatigue, and mouth sores. Hematopoietic growth factors would be given after each cycle so that the patient would receive her treatment on schedule. Mrs. Sienna’s agreed to the treatment.

Critical Thinking Questions

1.      What are Mrs. Sienna’s risk factors for the development of cancer?

2.      What type of older adult was Mrs. Sienna’s before her diagnosis: fit, vulnerable, or frail? Explain why this important in terms of treatment.

3.      Why it is important to have Mrs. Sienna’s receive her treatments on schedule and at the planned doses? Should Mrs. Sienna doses be reduced?

Answer 1

1.The risk factors for the development of cancer are

• Age:It is common above 60 years of age
• Ethnicity :It is found in native inhabitants of America
• Hyprrcholestrolemia
• Smoking could have been a contributing factor

2.She is a vulnerable individual to get this disease because of being in elderly population list .This important in the selection of type of treatment .Usually monoclonal antibodies CHOP are preffered line Nov treatment

3.The main reason is the absorption rate and the continuity of treatment. The dose is always calculated with the BMI of the patient so a reduced or increased dose are not done.Doing so can aggravate the disease condition and detoriate the patient.