Name: RB ID: M728571 Admission Date: 9/2/2010 (Infusion Suite) Consulting Physicians: Dr.

Abesada
Identifying Data Age/DOB Height Weight (kg) Gender HPI: RB was admitted to MMMC on July 20, 2010 due to shortness of breath for three days, epigastric pain for 1 week, and pts abdominal bloating. Pt underwent a CT scan of the chest which revealed widespread lymphadenopathy and a CT scan of the pelvis revealed bulky adenopathy and an enlargement of the spleen. A lymph node biopsy of the left neck revealed Large BCell Type Non-Hodgkins Lymphoma. During hospital stay, pt received R-CHOP chemotherapy regimen. Pt was discharged on 8/23 and will receive chemotherapy at MMMCs Cancer Center Infusion Suite.

Rm #: OUTPATIENT CrCl =156 mL/min

62 4/11/1948 68 (in) 173 (cm) 57.6 IBW 68.4 M Race C

Calculations IBW = 50 + 2.3 (8) = 68.4 kg SCr=0.4 mg/dL CrCl = (140 62) x 57.6 kg = 156 mL/min 0.4 mg/dL x 72 BSA = 1.65 m2 PmHx: Charocot-Marie-Tooth Disease COPD SurHx: Inguinal Hernia Repair Appendectomy Left neck exploration scalene node excision EGD with biopsies

Soc Hx/Lifestyle Alcohol: Moderate Tobacco: + 1PPD Caffeine: Not reported Dx/Clinical Impression: NHL, Large B-Cell Type FamHx Noncontributory Illicit Drugs: Not reported

Allergies Penicillin

Reaction Not reported

Vitals/Lab Data BP Temp Pulse RR Wt Na K Cl CO2 BUN SCr Glucose A1C Ca Phosphorous Total Protein Albumin Hgb Hct WBC RBC MCV MCH MCHC RDW MPV Poly Lymph Mono Baso Eos PLT AST ALT Alk Phos LDH Bili INR

7/19/10 7/21/10 7/29/10 8/18/10 8/21/10 8/23/10 9/1/10 140/70 98.1 86 20 64.636 138 6.0 110 17 60 1.2 88 9.0 6.0 3.5 11.6 34.5 12.3 3.65 94.5 31.8 33.6 15.1 12.4 79 10 7 142 3.2 105 33 15 0.3 81 7.3 6.0 3.6 11.0 31.9 19.6 3.63 87.9 30.3 34.5 16.7 10.6 67 7 24 2 319 28 26 103 139 3.5 100 33 7 0.3 95

9/2/10 126/85 98.5 104 16 57.606

11.4 34.6 0.6 3.94 87.8 28.9 32.9 15.1 11.5 17 81 1 1 16 14 19 61 599 745

95 52 22 68

1.1

Yellow shading in table indicates higher than reference value. Gray shading in table indicates lower than reference value.

*All the following Imaging, Lab, & Cultures are from previous hospital stay* Imaging Results:
Date (2010) 7/20 Image CT Abdomen Impression Bulky abdominal adenopathy; massive enlargement of spleen with central probably necrosis/infarcts, both superiorly and posteriorly, and inferiorly. Both findings most compatible with lymphoma. 1. EF 55%, 2. mild mitral regurgitation, 3. mild tricuspid insufficiency, 4. mild pulmonary HTN, 5. Decreased LV compliance by doppler Trace pleural fluid on left 1. Cervical adenopathy with scattered numerous anterior and posterior cervical chain lymph nodes, some of which are enlarged anteriorly. The adenopathy is most pronounced in supraclavicular regions, left greater than right. Adenopathy was also noted in abdomen and mediastinum on additional CT scan. 2. Few scattered nodes seen within parotid gland parenchyma. Left lower extremity venous US negative for DVT 1. Superficial venous thrombosis involving left basilic vein 2. No evidence of DVP in left upper extremity Successful bone marrow aspiration Stable appearance of patchy air space opacities, right greater than left 1. Normal LVF. EF = 60%. Focal area of inferior basal hypokinesis noted 2. Mild-to-moderate mitral regurgitation 3. Moderate tricuspid insufficiency with pulmonary artery; systolic pressure estimated at 39 mmHg 4. Abnormal diastolic function Nonspecific bowel gas pattern, no evidence of obstruction Significant reduction in diffuse inflammatory change in lungs with patchy areas of consolidation. Most notable at the right lung base, somewhat more rounded and nodular. Bilateral pleural effusions; no evidence of pulmonary embolus. PICC line catheter on left. 1. decreased size of spleen and slight decrease in central adenopathy; multiple probably infarcts vs abscesses within spleen 2. left inguinal hernia despite prior hernia repair; contains non-obstructed loop of descending sigmoid colon 3. gas & foley catheter within urinary bladder 4. generalized anasarca

7/21

Cardio/Echo w/ Doppler + Flow MAP Right Iliac Wing

7/21 7/22

US Chest/Mediastinum CT Neck soft tissue

8/4 8/9

Cardio/DVP venous study unilateral-left Cardio/DVP venous study unilateral-left

8/9 8/10 8/10

CT Guidance Biopsy Rad/Chest- PA or AP view Cardio/Echo w/ Doppler + Flow MAP

8/18 8/18

Rad/Abdomen Obstruction Series CT/CTA Chest

8/18

CT Abdomen

Lab Results: Date 7/31 7/31 7/31 7/31 8/9

Lab Test Hep B Surf AG Hep B Core IgM Hep A IgM AB Hepatitis C AB Chromosome Bone Marrow

Impression Negative Negative Negative Positive Very small population of monotypic B-cells (approx 0.4% of leukocytes) lack CD5 and CD10 expression. Results suggestive of B-cell lymphoproliferative disorder. The B-cells are monotypic and express kappa light chains, CD19, CD20, and CD22 but not CD5, CD10 or CD103. T-cells appear phenotypicall normal. Culture Staphylococcus epidermis Resistance Penicillin, Tri/Sul, Levofloxacin, Erythromycin, Clindamycin

Date 7/20

Location Blood

Gram Stain Gram + cocci clusters

7/25 8/5 8/8 8/19 8/20

Blood Tissue Resp lower Urine: catheter Resp lower

No growth WBCs occasional; No organisms seen 1+ gram positive cocci gram + rods

Normal respiratory flora Yeast ~20,000 CFU/cc

9/1

Urine

1+ gram positive rods, 2+ Normal respiratory flora gram positive cocci gram negative rods= few No growth

*Outpatient Regimen administered at Infusion Suite*

Medication
acetaminophen diphenhydramine meperidine HCl

Dose/Frequency
650 mg 50 mg 25 mg

Used For
Prevention of infusion reaction Prevention of infusion reaction Moderate-to-severe pain

Start/Stop Dates Monitoring

9/2-09/23 9/2-9/23 9/2-9/23 N/A Mental alertness Pain relief, respiratory and mental status, blood pressure; observe patient for excessive sedation, CNS depression, seizures, respiratory depression N/A N/A CBC w/ diff & Platelet count prior to chemo; platelets & HCT regularly; evaluate fever, pulmonary infiltrates, and respiratory distress; evaluate for left upper abdomonial pain,

ondansetron HCl ondansetron HCl in sodium chloride pegfilgrastim

24 mg 16 mg in 50 mL of sodium chloride 6 mg

antiemetic antiemetic Decrease incidence of infection, stimulate granulocyte production

9/2-9/23 9/2-9/23 9/3-9/24

rituximab Sodium Chloride 0.9

500 mg 130 mg

NHL

9/2-9/23

sodium chloride 0.9

567 mL

Fluid therapy

cyclophosphamide in sodium chloride

vincristine sulfate in Sodium Chloride

1000 mg 260 mg in 250 mL of sodium chloride 2 mg in 50 mL of sodium chloride

NHL

9/2-9/23

NHL

9/2-9/23

doxorubicin HCl

85 mg

NHL

9/2-9/23

shoulder tip pain, or splenomegaly; monitor for sickle cell crisis in patients with sickle cell anemia CBC with diff & platelets weekly to monthly intervals, peripheral CD20* cells; HAMA/HACA titers, renal function, fluid balance; vital signs; monitor for infusion reactions Na+, K+, Cl-, Bicarb concentrations, I&O, weight CBC with differential and platelet count, BUN, UA, serum electrolytes, serum creatinine Serum electrolytes (sodium), hepatic function tests, neurologic examination, CBC, serum uric acid; monitor infusion site CBC with differential and platelet count; liver function tests (bilirubin, ALT/AST, alkaline phosphatase); serum uric acid, calcium, potassium, phosphate and creatinine; cardiac function (baseline, periodic, and followup): ECG, left ventricular ejection fraction (echocardiography [ECHO] or multigated radionuclide angiography [MUGA]) Hemoglobin, occult blood loss, serum potassium, and glucose; intraocular pressure (with use >10 days)

dexamethasone in sodium chloride

20 mg in 50 mL of sodium chloride

antiemetic

9/2-9/23

Assessment: 1. Non Hodgkins Lymphoma: Patient will receive second cycle of R-CHOP in Cancer Infusion Suite at Martin Memorial. 1 Lifetime cumulative dose prior to second cycle for Adriamycin is 85 mg. Risk for developing congestive heart failure increases rapidly with increasing total cumulative doses of doxorubicin >400 mg/m2.2 Lifetime Dose is maxed at 550 mg/m2 for normal cardiac functioning patients.3 2. Chemotherapy-Induced Nausea and Vomiting: Patient will take Ondansetron prior to chemotherapy o Cyclophosphamide <1500 /m2 & Adriamycin have a moderate emesis risk (30-90% without emetics).4 o Vincristine has a minimal emesis risk (<10% without emetics).4 Acute N/V: RB will be administered Ondansetron IV. Delayed N/V: RB will take Ondansetron orally. 3. Anemia &Lymphocytopenia: Low RBC (3.63 m/mm3), low HgB (11.0 g/dL), low HCT (31.9%), and high RDW (16.7%). Lymph 7%. Possibly secondary to cancer. Monitor patient for s/sx of anemia and infection. 4. Prevention of chemotherapy-induced neutropenia: Patient will receive Neulasta (pegfilgrastim) 24 hours after completion of chemotherapy. Monitor for s/sx of febrile neutropenia. Evaluation of a patients risk of febrile neutropenia includes patients disease, chemotherapy regimen, patient risk factors, and if the treatment is intended to cure or if the treatment is intended for palliative care. In RB, our patients disease, NHL, has a risk of febrile neutropenia with the R-CHOP regimen and RB is an older patient (62 years old) who has had previous chemotherapy with no reports of febrile neutropenia. Therefore, RB is at an intermediate risk of febrile neutropenia following his chemotherapy and the guidelines suggest considering the use of CSF in these patients.11 5. Prevention of Rituxan Infusion Reaction: Prior to chemotherapy infusion, premedicate RB with acetaminophen and diphenhydramine. Severe infusion-related reactions have been reported with Rituxan and fatalities have been reported up to 24 hours after.9 Monitor patient closely for s/sx of reaction to medication. 6. Pain Control: Monitor for s/sx of pain and adjust medication accordingly. 7. Charcot-Marie-Tooth Disease & COPD: Refer to PCP.

Plan: 1. Non Hodgkins Lymphoma: Patient will receive 2nd cycle of R-CHOP:1, 10 Rituximab 730 mg IV Cyclophosphamide 1260 mg IV Doxorubucin 85 mg IV Vincristine Sulfate 2 mg IV Dexamethasone Sodium 20 mg IV 2. Chemotherapy-Induced Nausea and Vomiting: RB will be administered ondansetron 16 mg IV thirty minutes before chemotherapy.5 RB should take ondansetron 24 mg po daily for 2-3 days after chemotherapy to prevent delayed N/V.5

Counsel RB that these medications will most likely prevent N/V, however it is important for him to take Ondansetron prior to feeling nauseated. Counsel patient on possible side effects of ondansetron (headaches, mild constipation or diarrhea).9 3. Anemia &Lymphocytopenia: Monitor RBs HgB ten days after chemotherapy. HgB 11 g/dL or 2 g/dL below baseline, contact physician. Patient may need blood transfusion. ESAs not recommended in this type of cancer.6 Also, counsel patient on s/sx of anemia: shortness of breath, dizziness, headache, coldness in hands and feet, pale skin, and chest pain.7 Counsel RB on ways to avoid infection: wash hands frequently, eat healthy, balanced diet, avoid undercooked/raw foods, maintain good mouth care & avoid people who are sick. Contact physician if pt shows any s/sx of infection. RB is to call physician right away if fever >100o F, chills, sweating, loose bowel movements, frequent urgency to urinate or burning feeling when urinating, severe cough or sore throat; redness, swelling, or tenderness around a sore or catheter site; sinus pain or pressure; earaches, headaches, stiff neck; blisters on lips or skin; mouth sores.8 4. Prevention of chemotherapy-induced neutropenia: Administer Neulasta 6 mg SQ 24-72 hours after completion of chemotherapy. Please see 3 for reasons to contact doctor. Also, patient should avoid taking aspirin or acetaminophen if patient experiences fever and should contact physician first.8 5. Prevention of Rituxan Infusion Reaction: Prior to chemotherapy infusion, premedicate RB with acetaminophen 650 mg po and diphenhydramine 50 mg po. Monitor patient for s/sx of serious reaction to Rituxan, which usually occur within 30-120 minutes of infusion: hypotension, angioedema, bronchospasm, hypoxia, urticaria, acute respiratory distress syndrome, MI, cardiogenic shock, and/or anaphylaxis. Slow or interrupt infusion if these more common s/sx occur: chills, fever, rigors. Once mild s/sx reside, infusion rate can be resumed at 50% reduction of the original rate.9 6. Pain Control: Meperidine 25 mg IV as needed for pain every 2-4 hours during chemo regimen. Treatment should be limited to 48 hours and do not exceed 600 mg/24 hours.9 7. Charcot-Marie-Tooth Disease & COPD: Refer to PCP.

References: 1. Non-Hodgkins Lymphomas. NCCN Guidelines. Version 1.2010 2. Adriamycin Package Insert accessed through dailymed.nlm.nih.gov on September 3rd, 2010. 3. Guideline for Maximum Adult Dose Limits of Parenteral Chemotherapy. Institute for Safe Medication Practices. 2002. 4. Jordan K, Sippel C, Schmoll HJ. Guidelines for Antiemetic Treatment of Chemotherapy-Induced Nausea and Vomiting: Past, Present, and Future Recommendations. The Oncologist 2007;12:11431150 5. Antiemesis. NCCN Guidelines. Version 2.2010 6. Cancer & Chemotherapy-Induced Anemia. NCCN Guidelines. Version 2.2011. 7. What are Signs and Symptoms of Anemia? National Heart Lung and Blood Institute. US Department of Health and Human Services. http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_signsandsymptoms.html. Accessed September 3rd, 2010. 8. Cancer Treatment Side Effect: Infections. http://www.medicinenet.com/script/main/art.asp?articlekey=21731. Accessed September 3rd, 2010. 9. Lexi Comp Online. Acessed September 3rd, 2010. 10. Coiffier B, Lepage E, Briere J, et al, CHOP Chemotherapy Plus Rituximab Compared With CHOP Alone in Elderly Patients With Diffuse Large-B-Cell Lymphoma, N Engl J Med, 2002, 346(4):235-42. 11. Myeloid Growth Factors. NCCN Guidelines. Version 1.2010