Name of Patient: LC

Ward/bed/room no: 307 Tamayo Towers

Informant: Daughter-in-Law
Reliability: 85%
Dept. of Medicine
Preceptor: Dr.Evaristo
Date of History: December 1, 2014
Year: 2nd year Medical Students
Group 1

Date of Interview: December 1, 2014

Informant: Daughter-in-Law
Reliability: 85%

GENERAL DATA
This is the case of LC, a 60 year-old Female, married, Catholic, Filipino, Presently
residing at Brgy.Balibago Santa Rosa City, Laguna and was admitted for the fourth time at
University of Perpetual Help Medical Center on November 28,2014.

CHIEF COMPLAINT:Low Hemoglobin Count.

HISTORY OF PRESENT ILLNESS

7 months prior to admission, the patient noticed a palpable mass on her left breast when
she was doing self-breast examination. The mass was located on the left upper quadrant and
was estimated to be the size of a five peso coin; this prompted the patient to seek consultation
on our institution and there she was advised to have a mammogram then underwent needle
aspiration biopsy and eventually excision biopsy.
6 months prior to admission, she underwent Modified Radical Mastectomy to have the
mass removed preceded by six sessions of chemotherapy with a 21-day interval between
sessions.
4th to 5th month prior to admission, the patient had her first and second chemotherapy
session with the drug of Doxorubicin and one unrecalled drug as OPD patient on our institution.
After every chemotherapy session she felt body weakness and anorexia accompanied by
nausea. Home medications of Omeprazole given once a day and Metoclopramide as PRN basis
for nausea and vomiting were taken as prescribed.
2nd to 3rd month prior to admission, the patient had her third and fourth chemotherapy session
and the routine CBC analysis revealed a low hemoglobin count with no other associated signs
and symptoms. She was advised for a blood transfusion, hence admitted and was discharged.
1 month prior to admission she had her fifth chemotherapy session still revealing a low
hemoglobin count on her CBC analysis and was re-admitted on our institution and underwent
Blood Transfusion for the third time and was discharged.
1 day prior to admission, the patient had her routine check-up on our institution and routine CBC
analysis was done which still revealed low hemoglobin count accompanied by body weakness,
anorexia, mouth sores and fever which prompted for admission.

PAST HEALTH HISTORY

Hypertension - Uncontrolled, (2004) non-compliant to medication for 9 years
Maintenance medications: Losartan 50 mg OD and Amlodipine 5 mg(December, 2013)
Cancer- Breast, MRM (July 18, 2014)
(+) Blood Transfusions (2014)
(-) allergies to food and drugs
(-) PTB, DM, Asthma, CVD

FAMILY HISTORY
(+) Hypertension- Paternal side
(+) Asthma Maternal side
(+) Diabetes Mellitus- Maternal side
(-) Pulmonary Tuberculosis
(-) CVD,
(-) Cancer
The patient has four children having three daughters and a son, all are apparently well.
MATERNAL AND OBSTETRIC HISTORY
Menopause at age 50
G4P4 (4004)
All pregnancy delivered full term via NSD by a traditional hilot. No complications noted
PERSONAL AND SOCIAL HISTORY
LC lives with herfamily in a well ventilated-concrete bungalow type of house in a
peaceful and non-polluted environment. Their drinking water is purified, bought from the water
station. The garbage is collected once a week. She normally eats vegetables, chicken and fish
and is maintained on a low salt, low fat diet.She does not drink any alcoholic beveragesand
smoking. She used to run a sari-sari store before and she enjoys watching television during her
free time.

REVIEW OF SYSTEMS
Constitutional symptoms: (-) significant weight change, (-) fever, (-) chills
Skin: (-) itchiness, (-) excessive dryness, (+) pallor
HEENT: (-) dizziness, (-) vertigo(-) pain, (-) blurring of vision, (-) lacrimation (-) deafness, (-)
tinnitus, (-) ear discharge(-) change in smell, (-) nose bleeding, (-) nasal obstruction, (-) nasal
discharge,(-) toothache, (-) gum bleeding,(+) sore on lower gums (-) disturbance in taste, (-)
sore throat, (-) hoarseness
Neck: (-) pain, (-) limitation of movement, (-) presence of mass
Cardiovascular: (-) substernal pain, (-) palpitations, (-) paroxysmal nocturnal dyspnea,
(-) orthopnea, (-) syncope, (-) murmur
Genitourinary: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy, (-) polyuria, (-)
hematuria, (-) incontinence, (-) genital pruritus, (-) urethral discharge
Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) tenderness (-)
limitation of movement

Neurologic: (-) headache, (-) syncope, (-) loss of consciousness, (-) focal weakness, (-)
paralysis, (-) numbness, (-) paresthesia, (-) slurring of speech, (-) loss of memory, (-) confusion
Hematologic: (-) bleeding tendency,(-) easy bruising
Endocrine: (-) intolerance to heat and cold, (-) excessive weight gain or weight loss, (-)
polydipsia
PHYSICAL EXAMINATION
General Survey
The patient is alert, awake, well-kempt and neat not in cardio-respiratory distress.
Oriented to time, place and person, cooperative and accommodating, no slurring of speech, no
gross deformity seen, has congruent mood and affect.
Vital Signs
BP: 140/90mmHg
Skin

CR: 74bpm

RR: 24cpm

Temp:36.6 C

Skin is brown, slightly moist, elastic and mobile.

Has visible dilated blood vessels on the dorsum of the palm and at the inner forearm
No lesions noted
The nails are cyanotic, smooth, with intact nail folds and no lesions with capillary refill
time of 3 seconds

C. Head and Neck

1. Cranium
Head is normocephalic, has alopecia with fewgraystrands of hair unevenly distributed,
clean scalp, no dandruff, no lice, no mass and no tenderness noted. Temporal
arteries are not visible but palpable with strong equal pulsations, wall not thickened
and smooth
2. Face
Face is oval, no lesions, no involuntary movements
3. Eyes
Alopecia noted on eyebrows with few gray strands of hair unevenly distributed
Eyelids: no edema, ptosis and tremors noted, (-) lidlag
Palpebral fissure is normal in width and symmetrical
Eyelashes are thin, outward growth, evenly distributed and no matting
Eyeball is not protruding or sunken
Palpebral conjunctiva is pale, no lesions noted
Sclera is white, no lesions noted
Cornea is transparent, no lesions
Iris is brown and round

Pupils are equally rounded, reacted to light and accommodated.

Lens transparent, no opacity noted

4. Ears
Auricles are symmetric, has no deformities and lesions noted. No tenderness
upon palpation
Mastoid: no tenderness upon palpation
Otoscopy: External canal is pinkish, patent and no discharge seen
Tympanic membrane is pearly white, intact, flat and translucent
(+) Visible cone of light
5. Nose and Paranasal Sinus
Has symmetrical nose and no flaring of alanasi
Nasal septum is pinkish, straight at the midline, no perforation and no lesions
noted
Nasal cavity is patent, pinkish, with no discharges and turbinates are flat and dry
Frontal and maxillary sinus no tenderness noted
Frontal and maxillary sinus (+) transillumination.
6. Oral Cavity
Lips are pale, and dry, no lesions and symmetric
Buccal mucosa and gums are pale, with lesions on lower inner portion of the lip
noted
Incomplete set of teeth on both upper and lower gums
Tongue is symmetric, pinkish with rough papillae, can move from side to side
Hard and soft palate are pinkish with no lesions
Uvula at midline
Tonsils are not enlarged, no exudates
Posterior pharynx is pinkish, no lesions and no exudates
7. Lymph Nodes
With non-palpable Lymph nodes

Left axillary lymph nodes not palpable/removed (MRM)

8. Neck:
Neck is normal in size, symmetrical, no visible mass, normal muscle tone, no
tenderness, full range of motion;
Trachea in midline, thyroid gland not visible or palpable
No carotid bruit noted
D. Chest / Lungs:
Skin is brown, with hyperpigmented surgical site on left chest extending to left axillary
area, no visible dilated blood vessels. Thorax is symmetrical, no deformity. Symmetrical
chest expansion. No tenderness, no palpable mass, normal and equal tactile fremitus,
vesicular breath sounds, no crackles, no wheezes,
(-) bronchophony, (-) egophony, (-) whispered pectoriloquy.

E. Cardio
Apex beat at 6th ICS midclavicular line
(-) palpitation, (-) lift, (-) heave, (-) murmurs, (-) thrills
Within normal rate and regular rhythm of heart beat
F. Extremities
Grossly normal extremities
Full and equal pulses
(-) cyanosis and discoloration
(+) hematoma on left antecubital area
Full range of motion

G. Abdomen

Soft and non-tender abdomen

With normo-active bowel sound
Globular in shape

H. Genito-urinary System and Nervous System (patient refused)

Pertinent Positives

Body Weakness/ Fatigue

Pale conjunctiva
Capillary refill time- 3 seconds with pale/ bluish/ cyanotic nail beds
(+) lesion/sore on the inner portion of the lower lip-Side Effect of Drug
(+) Anorexia/ Loss of Appetite
(+) Alopecia- Side effect of drug

Chemotherapy Schedule

Number of Session

Date

First

August 26, 2014

Second
Third
Fourth
Fifth

September 16,2014
October 7, 2014
October 28, 2014
November 18, 2014

Sixth

December 9, 2014

Chemotherapy Drug: Doxorubicin

Doxorubicin is part of a group of chemotherapy drugs known

as anthracycline antibiotics. It slows or stops the growth of cancer cells.
Cancers treated with Doxorubicin include: bladder, breast, head and neck,
leukemia (some types), liver, lung, lymphomas, mesothelioma, multiple myeloma,
neuroblastoma, ovary, pancreas, prostate, sarcomas, stomach, testis (germ cell),
thyroid, uterus.

Doxorubicin is given through a vein by intravenous injection (IV). The syringe

needle is placed directly into the vein or central line and the drug is given over
several minutes. Doxorubicin can also be given by continuous infusion. Rarely,
Doxorubicin is given by injection into an artery. There is no pill form of
Doxorubicin.

Side Effects of Doxorubicin:

The following side effects are common (occurring in greater than 30%) for patients taking
Doxorubicin:
Early Side Effects: (within one week after treatment begins)

Pain along the site where the medication was given

Nausea or vomiting
Later Side Effects: (within two weeks after treatment begins)

Low blood counts. Your white and red blood cells and platelets may temporarily decrease. This
can put you at increased risk for infection, anemia and/or bleeding.
Nadir: Meaning low point, nadir is the point in time between chemotherapy cycles in which you
experience low blood counts.
Onset: 7 days
Nadir: 10-14 days
Recovery: 21-28 days

Mouth sores
Hair loss on the scalp or elsewhere on the body (called alopecia).
Most patients do lose some or all of their hair during their treatment.
But your hair will grow back after treatment is completed.
The following side effects are less common (occurring in 10-29%) for patients taking
Doxorubicin:
Early: (within one week after treatment begins)

Eyes watering

Urine may appear red, red-brown, orange or pink from the color of the medication for one to two
days after you receive a dose.

Later: (within two weeks after treatment begins)

Darkening of the nail beds.

Darkening of the skin where previous radiation treatment has been given.

Problems with fertility ability to bear children. (occurs in about 10% of both men and women
this should be discussed with your doctor prior to therapy).
A serious but uncommon side effect of Doxorubicin can be interference with the pumping action
of the heart. You can receive only up to a certain amount of Doxorubicin during your lifetime.
This lifetime maximum dose may be lower if you have heart disease risk factors such as
radiation to the chest, advancing age, and use of other heart-toxic drugs. Your doctor will check
your heart function before you may take any Doxorubicin and will monitor your heart closely
during your treatment. Dose-related heart problems can occur as late as 7 or 8 years after
treatments have ended.
Delayed Effects of Doxorubicin:
There is a slight risk of developing a blood cancer such as leukemia years after taking
Doxorubicin. Talk to your doctor about this risk.
This list includes common and less common and important side effects for those taking
Doxorubicin. Side effects that are very rare occurring in less than 10 percent of patients are
not listed here. But you should always inform your health care provider if you experience any
unusual symptoms.

UPH DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

Sto. Nino, Binan City, Laguna
COLLEGE OF MEDICINE

MEDICINE I Decury

Submitted by:
Leader:
Alzona, John Dale C.
Members:
Adove, NouellaVeannaMarie O.
Ambatali, Waldemar C.
Amita, Roselily Ann B.
Antonio, Jose Vien S.
Araa, Angela Loui V.
Bacud, Eliza Paula P.

Submitted to:
Dr. Allen S. Evaristo