Bioethics LUIV 2015

Case No. 2
General Data
This is the case of RR, a 31 y.o. female, married, a Jehovas Witness from
Calamba, laguna, admitted in PGH for the 1 st time on June 2015 for the chief
complaint of difficulty of breathing.
History of Present Illness
Three months PTA, patient developed cough productive of yellowish phlegm. She
likewise noted generalized body weakness and anorexia. She consulted a private
physician and chest x-ray revealed pneumonia. She was started on Moxifloxacin
for two weeks, which resulted to partial relief. She had 3 episodes of bloodstreaked sputum which prompted consult at another private clinic. A repeat chest
x-ray allegedly was noted to show a pulmonary mass at the left upper lobe. She
was then advised to take co-amoxiclav 625 mg caplet BID for 1 week and to seek
further consult at a tertiary care hospital for the said chest x-ray findings. The
cpough and hemoptysis were relieved; hence, the patient deferred the hospital
consult.
One month PTA, the patient had productive cough associated with high-grade
fever (39oC) along with anorexia and generalized body weakness. Hemoptysis
recurred also which prompted consult at a private hospital for the pulmonary
mass. A biopsy of the mass revealed multinucleated giant cells and epitheloid
cells. She was then started on Myrin Forte (an anti-TB medication) which she
took for only 2 weeks.
Two days PTA, she developed cough productive of greenish foul smelling phlegm
with associated fever for which she self-medicated with co-amoxiclav. She
subsequently experienced dyspnea and weakness which prompted admission to
our institution.
Review of systems
(+) weight loss of 20% in 3 months
(+) chest pain (pleuritic chest pain)
(+) anorexia

(+) fever
(+) malaise
(+) pallor

(+) easy fatigability

Past medical history
Previous tonsillectomy, bilateral, due to chronic hypertrophic tonsillitis at Chinese
General Hospital in 2010. No known medical illness.

Family medical history

(+) PTB father, treated with anti-Kochs regimen for 6 months who does not live
with the patient but regularly visits the patients household. No history of
heredofamilial diseases.
Personal/social history
Patient finished a 2-year secretarial course and is married to a teacher with
whom she has a 2-year old daughter. Around ten years ago, she worked for a
period of 1 year at a factory for microchip computers wherein she had exposure
to chemical acids and metal.
She is a non-smoker but exposed to secondhand smoke (patients mother). She
is a non-alcoholic beverage drinker and denies use of any illicit drugs.
Obstetric/gynecologic history
Menarche at the age of 11 tears, subsequent menstruation coming at regular
monthly interval lasting for 3 days and using 4 pads per day. She is a G1P1
(1001). Her pregnancy was delivered full term via spontaneous vaginal route with
no perinatal complications.
Physical Examination
General: awake, coherent, slightly dyspneic, fairly developed, fairly nourished
with a BMI of 18.2.
Vital signs: BP=90/60, CR=96 bpm, RR-24 cpm, T = 38oC
HEENT: pale conjunctiva, anicteric sclerae, (-) neck vein engorgement, no
cervical lymphadenopathy, (+) dental caries 1st upper premolar
CVS: distinct heart sounds, good S1 and S2, normal rate and regular rhythm,
apex beat at 5th ICS left mid clavicular line, no murmurs

Lungs: equal chest expansion, slightly decreased breath sounds at the left upper
lung filed, increase vocal fremiti and true fremiti at the left upper lung field, no
crackles or wheezes
Abdomen: flabby, soft, no fluid wave, no masses/tenderness/guarding,
normoactive bowel sounds, liver edge barely palpable, intact Traubes space
Musculoskeletal: full and equal pulses, pink nail beds, no edema/cyanosis, no
gross deformities, no petechiae/ecchymosis/hematoma
Course in the hospital
Patient was admitted at the ER and provided with oxygen support via nasal
cannula at 2-3 liters/min.

Laboratory examinations
CBC: Hb = 119, Hct = 0.367; WBC = 12.7, Neut = 82, Lym = 9, Platelet = 350
Blood chemistry: RBS = 2.68, BUN = 2.55, Crea = 79, Calcium = 2.14, Mg =
0.81, Na = 147, K = 3.6, Cl = 104
Protime: Control = 12.0 secs, Patient = 13.2 secs; Activity = 0.72; INR = 1.14
PTT: Control = 36.3 secs; Patient = 39.5 secs
Chest x-ray and chest plain CT scan were also done revealing an 8x8x10 cm
spherical mass at the left upper lobe with cavitations and air fluid level, with
surrounding infiltrates, (+) enlarged pretracheal, prevascular lymph nodes.
Patient was started on IV antibiotics: Ceftazidime 1 g IV q 8 hours and
Clindamycin 300 mg capsule q 6 hours. Sputum AFB examination (3 daily
exams) was also done and yielded negative results, nonetheless, she was
started on Anti-Kochs regimen.
On the 3rd hospital day, bronchoscopy with biopsy was done with the following
findings: left upper lobe with fish mouth and fleshy mass and left lingual with 80%
obstruction and with fleshy mass. Broncoscopy fluid collected was sent for
GS/CS and TB PCR.

Bronchial washing Gram stain

PMN (-)
Epithelial cells (-)
Gram (+) in pairs > 25/hpf
Gram (-) bacilli 3-5/hpf
Culture > 100,000 colonies of Pseudomonas and E. chloacal
Bronchial washing
AFB (-)
TB PCR (+)
Biopsy histopathology revealed: Non small cell carcinoma, poorly differentiated
(lung CA). Result was initially disclosed to the patients husband then to the
patient herself. They were advised to pursue surgical intervention left upper
lobectomy or possible pnuemectomy. A repeat chest x-ray revealed pleural
effusion. Metastatic work-up was proposed to include ultrasound guided
thoracocentesis, and liver and adrenal ultrasound. The patient agreed to the
ultrasound but refused performance of thoracocentesis despite the counseling ot
the physician regarding the benefits of the procedure. She was also receptive
regarding the option of surgery however; she was not amenable to the possibility
of blood transfusion. She opted to look for another institution, which offers
bloodless surgery and thus, she was discharged on the 28 th hospital day after
completion of antibiotic regimen. She was advised to continue the anti-TB
regimen for 6 months as well as to return for outpatient follow up at the Cancer
Institute.
Discharge diagnosis
Non small cell CA, probably SCC, poorly differentiated, left upper lung lobe
Central necrosis with secondary bacterial infection, resolved
PTB III, ongoing treatment