G R O U P 1

PALLIATIVE CARE PRESENTATION

HODGKIN’S LYMPHOMA• AHMAD SALAHAUDIN B.

MUSTAFA• BADRUL AZNIL B. ISMAIL• AHMAD FARIS B. MOHD ARIFF• DAHIYAH AISYAH BT. RUSLAN

AFFENDY• NUR AMALINA BT. ELLIAS• NUR FATIHAH BT. ZULKAFLI

CHIEF COMPLAIN

•Miss N, 22 years old Malay student with underlying Hodgkin’s Lymphoma since 2 years ago.

SEQUENCE OF EVENTS

2012• She was diagnosed to have Hodgkin’s Lymphoma

in Hospital Ampang due to the complaint of progressive increase in size of neck swelling.

• It was also associated with cough, shortness of breath and whitish productive sputum.

• She also complaint of loss of appetite and significant loss of weight.

• Had already completed 11 chemo cycle. Last given was on July 2012.

SEQUENCE OF EVENTS

Medication prescribed :• IV cefepime 1g BD• IV Tramal 50mg BD• T. Bromhexine 8mg TDS• IV dexamethasone 4mg BD• IV Ranitidine

SEQUENCE OF EVENTS

• After that she defaulted the next follow up. • Patient still continued her studies until

finished her diploma programme. She graduated on December 2013. • She does not take any medication including

the prescription from the hospital. They were no active complaints throughout the year.

SEQUENCE OF EVENTS

21 July 2014• She was admitted to Hospital Ampang with

progressive shortness of breath, cough and fever for two days. At that time, there were chest x ray done which shows that there is opacity at the right lung. She was treated as pneumonia and chest drain was done.• At that time she was offered to do chemotherapy

but patient refused.• She was referred to palliative care - Hospis

I.C.E.

• Idea : patient and family understands about the illness• Concern : she is worried of her future as she had

this disease in her young age. Patient and her mother does not want further chemotherapy because they claimed that it does not improve patient’s condition. Patient suffers from bad experience, where she had skin and nail problems, vomiting and loss of hair due to chemotherapy. They also claimed that doctor said failure rate is high even after chemotherapy.

I.C.E

• Expectation : to find the best alternative treatment other than hospital management. They hope Hospis can supply them handy oxygen tank as she is dependent on the oxygen tank. Currently she use her uncle oxygen tank which is weighty and difficult to move.

HISTORY

Past Medical History• She does not have any other underlying illnes. • Never done any surgery before• No known allergy towards any food or medicationFamily History• Her father passed away due to motorvehicle

accident at the age of 55 years old. Her mother is 50 years old and is healthy.

• She is the youngest out of 4 siblings. Others are well.

• There is no history of malignancy in the family.

HISTORY

Social History• She finished her diploma and planning to

continue study in Degree of Science Social however due to the illness, she had to postpone it. She does not smoke, not consume alcohol or any drugs for pleasure.

PHYSICAL EXAMINATION

GENERAL EXAMINATION

• She was lying in supine position, with the bed propped up to 45o and supported by one pillow.• She looked lethargic, irritable and was in

respiratory distress.• There was a nasal prong connected to a 3L

oxygen tank.• She looked thin and her nutritional and

hydrational status were moderate.• She was able to speak in full sentences.• She was graded ECOG 3.

EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG)

Grade ECOG0 Fully active, able to carry on all pre-

disease performance without restriction

1 Restricted in physically strenuous activities, but ambulatory and able to carry out work of a light or sedentary nature

2 Ambulatory and capable of all selfcare, but unable to carry out any work activities. Up and about more than 50% waking hours.

3 Capable of only limited selfcare, confined to bed or chair more than 50% waking hours

4 Completely disabled. Cannot carry on selfcare. Totally confined to bed or chair.

5 Dead.

VITAL SIGNS

• Temperature : Afebrile• Respiratory rate : 24 breaths per minute• SpO2 : 98%• Blood Pressure : 128/82mmHg• Pulse Rate : 84 beats per minute

GENERAL EXAMINATIONHands Her palms were pink and warm, there

were no signs of peripheral cyanosis, no finger clubbings. The skin appears to be dry.

Face There is no conjunctival pallor, no scleral discoloration. Tongue and mucosa is moist with good oral hygiene.

Neck On inspection, there was a generalised swelling which is more prominent on the left side. The size was about 10x10 cm. There was no discharge, with the underlying skin normal, no ulcerations and no dilated veins.On palpation, the swelling was non tender, was not warm, firm in nature and well circumscribed margin. There is a single nodule which Is non mobile.On auscultation, there was no carotid bruit heard.

Legs No bilateral edema was noted

SYSTEMIC EXAMINATION

• Other systems such as respiratory, cardiovascular and abdominal were unable to be done as patient was irritable and refused to be examined.

SUMMARY

Miss N, a 22 years old Malay student known to have Hodgkin’s Lymphoma for two years presented with cough, fever and shortness of breath for two days.

On examination, she looked lethargic, was irritable and in respiratory distress. Neck examination revealed a significant generalised swelling.

ISSUES

1) Patient does not want to continue hospital treatment and prefer alternative Islamic treatment. Their family is very religious and believed in qada’ and qadar.

2) Financial issues as her mother is the sole bread winner of the family. She was only receiving pensions from the government and earns about RM1000 per month.

ISSUES

1) Patient defaulted chemotherapy because patient was told that the failure rate is high. Hodgkin lymphoma is a potentially curable lymphoma. SEER data report an 84.7% overall 5-year survival rate from 2002-2008.

IMPACT TOWARDS PATIENT

• Physically• Patient can’t live without the oxygen tank.

She looked thin and tired.• Unable to perform daily activities and was

dependent on her mother.• Psychological• She was worried that she might have financial

issues due to her treatment.

IMPACT TOWARDS PATIENT

• Psychosocial: • She was depressed as she felt that she was

putting her mother in a lot of hardships.• She was unable to socialize with her friends

and can’t continue her studies.

TREATMENT

• She was given syrup Bromhexine as she was having cough at the time of visit.• She was waiting for her new oxygen tank to arrive.