MEDICINE POSTING

Phase IIIB
Case Summary
Name

: TAY TUN KHONG

Matrix number : MEM 120191

Group

:5

Name : NELMAWATI BINTI KADINAN

Gender
: FEMALE
Age : 57
Race : MALAY
IC
: 590309-71-5120
RN
: 28720199
History
My patient, Madam Nelmawati, a 57 years old Malay lady, presented to hospital
with chest discomfort for 4 days prior to admission.
Madam Nelmawati was diagnosed with stage 4 Diffuse Large B-Cell Lymphoma
on the February of 2016 after presented with multiple nontender, firm mass
which progressively enlarge at the gluteal area for 3 months and later at the
scalp of the left side of the head. She is currently on the 4 th cycle of R-CHOP
(rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)
chemotherapy.
4 days prior to admission, she experienced a left sided chest discomfort which is
heavy in nature. The chest heaviness was worsened while she was lying down
and relieved by sitting up right. Due to the chest discomfort, she has to prop
herself up to 45 degrees while sleep. She also felt light-headedness while
walking. However, she denied any exertional dyspnoea and limitation of activities
as she still able to walk 2 flight of stairs as usual. The chest heaviness was nonprogressive.
She denied symptoms of fever and coughing. There is also no chest pain,
diaphoresis, nausea vomiting or palpitation, as well as orthopnoea (although she
cannot lie flat, it was due to the chest heaviness), paroxysmal nocturnal
dyspnoea and leg swelling. The is no Tuberculosis contact, and the symptoms of
night sweat which start few months ago has stopped after she started
chemotherapy. She also denied having arthralgia, myalgia, retro-orbital pain or
rashes.
On the other hand, she has suffered from the side effects of chemotherapy such
as alopecia, lethargy, dry mouth, loss of appetite. She also lost 10 kg over the
course of 6 months.
She has one hospital admission during the 2 nd cycle of her chemotherapy. She
was presented with lethargy and fever and was diagnosed with parapneumonic
effusion with neutropenic fever
She went to day-care centre in UMMC to undergo her 4 th cycle of chemotherapy
on the day 4 of illness. She told doctor about her symptoms and was admitted to
the haematology ward.
She has dyslipidaemia and was on statin which was stopped after she started
chemotherapy. Otherwise, there is no other co-morbidity.
She has no known food allergy or drug allergy. There is no usage of traditional
complementary medicine.

She was a non-smoker and does not consume alcohol. She worked as a hawker
who sells soya bean drinks and had retired. Her husband passed away 4 years
ago and currently she stays with her only son. She is full independent performing
Activities of Daily Living (ADL). She is financially constraint due to the high cost
of chemotherapy and she is not eligible for free treatment.

Summary
Madam Nelmawati, a 57-year-old Malay lady presented with left sided chest
heaviness which was aggravated by lying down and relieved by sitting. She was
diagnosed with stage 4 Diffuse Large B-Cell Lymphoma and currently on 4 th cycle
of R-CHOP chemotherapy. Other issues include dyslipidaemia and financial
difficulty.

Physical examination (Day 1 of Admission, 26/8 4.00pm)

On general inspection, patient is alert and orientated. There is no sign of pallor,
jaundice and cyanosis. There is no cervical lymphadenopathy.
Vital signs:
Pulse
Respiratory rate
Blood pressure
Temperature
Sp 02

: 110/min (tachycardia) , regular rhythm and good volume

: 24 breaths/min (tachypnoea)
: 109/70 mmHg
: 38.0 degrees celcius
: 99%

Chest examination
The notable finding is in the lower zone of left posterior lung. There is reduce
chest expansion, stony dullness percussion, reduced vocal resonance and reduce
breath sound, which suggestive of left sided pleural effusion.
Trachea is not deviated, no raised jugular venous pressure, no parasternal heave
and palpable P2.
Skin examination
There is a 7cm x 4 cm non-tender, hard lump over the gluteal region. It does not
attached to the skin. There is no overlying skin changes.
There is a 3cmx2cm non-tender soft lump over the scalp of left parietal region.
There is crusting of skin.
Cardiovascular, abdomen and neurological examination are normal.

Provisional Diagnosis
Left-sided pleural effusion due to health-care associated pneumonia

Differential Diagnosis
Left-sided pleural effusion secondary to lung metastasis
Pulmonary Tuberculosis
Dengue in critical phase

Investigations
1. Full blood count, liver function test, renal function
Date
Hb
Platelet
WBC
Neutrophil

26/9
108
152
2.3
0.92

27/9

29/9
103
179
7.1
3.62

Na+
K+
Urea
Creatinine

135
2.8
1.8
51

139
3
4.8
47

139
3.6
1.8
45

Total Protein
Albumin
Total Bilirubin
ALP
ALT
Ca+
Mg+

33
10
156
37
2.34
0.7

64
37
8
163
27
2.2
0.7

Patient has mild normochromic normocytic anaemia possibly due to marrow

suppression. She has low neutrophil counts 920/mm3, which is neutropenic.

2. Chest X-Ray PA (25/8)

Findings:
Comparision made with previous CXR dated 11.8.16.
The previously seen left pleural effusion is unchanged.
Atelectatic changes seen over the left lower zone.
Unable to comment on heart size.
No suspicious bone lesion
3. Pleural Fluid Analysis (Failed due to dry tap)
Exudative fluid would suggestive of bacterial pneumonia or tuberculosis.
Acid fast smear and culture & sensitive should be performed to rule out
tuberculosis.

4. Blood Culture and Sensitivity No growth

5. CT Thorax, Abdomen, Pelvis (on 29/1/2016)
Impression:
1. Features are in keeping with a malignant soft tissue mass arising from
right gluteus maximus muscle with adjacent bony infiltration as well as
enlarged enhancing right inguinal lymph nodes. Differentials include soft
tissue sarcoma. Suggest HPE correlation.
2. Multiple small lung nodules I the right and left lower lobes. Lung
metastasis cannot be excluded. Suggest follow up

Discussion
For patient like Madam Nelmawati who has underlying stage 4 DLBCL undergoing
cytotoxic therapy, it is common to have neutropenia. Her neutrophil count at
day-care was 920/mm3. Besides, her vitals sign upon admission was also fulfilled
4 out of 4 criteria of SIRS, as she was febrile, tachycardia and tachypnoea.
Febrile neutropenia is defined as single oral temperature of 38.3 C OR a
temperature 38.0 C for 1 hour; while neutropenia defined as neutrophil count
of <500 cells/mm3, or count of ,1000 cells/mm3 with predicted decline to <500
cells/mm3. Hence, Madam Nelmawati has neutropenic sepsis.
Symptomatically, she only has chest heaviness without chill. This is not
uncommon; as inflammatory response may be minimal especially in severely
neutropenic patient. Usually, in pleural effusion, patient will have progressively
worsening dyspnoea and minimal cough. Causes of pleural effusion may be due
to TB, parapneumonic effusion, lung metastasis, or even plasma leakage in
critical phase of dengue. Unfortunately, pleural fluid analysis was unable to be
performed as there is dry tap.
Actually, Madam Nelmawati was admitted to hospital 3 weeks ago due to
neutropenic fever secondary to parapneumonic effusion. During that admission,
pleural fluid culture showed Pseudomonas growth and her blood culture showed
Kleibsiella pneumoniae growth. However, blood culture is negative during this
admission.
Efforts have been made to formulate risk-stratification models for neutropenic
patiens, and one of the most used models is Multinational Association of
Supportive Care in Cancer (MASCC) Risk Scoring Index to identify low risk
patients as they may be considered for outpatient management. Madam
Nelmawati scored 28/30, which is considered as low risk patient.
Madam Nelmawati was started on IV Tazocin, considered that she has a previous
Pseudomonas infection. She improved clinically, although there is still left sided
pleural effusion on imaging. Her white cell count also normalized and she was no
longer neutropenic. She was discharged after hospitalized for 5 days and was
prescribed with oral Augmentin.