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    Lymphoma Case Study

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    Jesse Terris, a 68-year-old male with a history of alcoholism, COPD, GERD, hypertension, and relapsed diffuse large B cell lymphoma, was admitted for hypercalcemia and hyperbilirubinemia. He had experienced weight loss of 10 pounds or 6% of his body weight over the past 2.5 months while undergoing chemotherapy. Initial interventions included supplementing with Ensure and advancing his diet. However, he later required intubation and was started on TPN due to respiratory distress and inability to tolerate enteral nutrition. Despite nutritional support, his condition continued to decline and he ultimately passed away.

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    Lymphoma Case Study

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    api-622273373
    116 views16 pages
    Jesse Terris, a 68-year-old male with a history of alcoholism, COPD, GERD, hypertension, and relapsed diffuse large B cell lymphoma, was admitted for hypercalcemia and hyperbilirubinemia. He had experienced weight loss of 10 pounds or 6% of his body weight over the past 2.5 months while undergoing chemotherapy. Initial interventions included supplementing with Ensure and advancing his diet. However, he later required intubation and was started on TPN due to respiratory distress and inability to tolerate enteral nutrition. Despite nutritional support, his condition continued to decline and he ultimately passed away.

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    Jesse Terris, a 68-year-old male with a history of alcoholism, COPD, GERD, hypertension, and relapsed diffuse large B cell lymphoma, was admitted for hypercalcemia and hyperbilirubinemia. He had experienced weight loss of 10 pounds or 6% of his body weight over the past 2.5 months while undergoing chemotherapy. Initial interventions included supplementing with Ensure and advancing his diet. However, he later required intubation and was started on TPN due to respiratory distress and inability to tolerate enteral nutrition. Despite nutritional support, his condition continued to decline and he ultimately passed away.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    116 views16 pages

    Lymphoma Case Study

    Uploaded by

    api-622273373
    Jesse Terris, a 68-year-old male with a history of alcoholism, COPD, GERD, hypertension, and relapsed diffuse large B cell lymphoma, was admitted for hypercalcemia and hyperbilirubinemia. He had experienced weight loss of 10 pounds or 6% of his body weight over the past 2.5 months while undergoing chemotherapy. Initial interventions included supplementing with Ensure and advancing his diet. However, he later required intubation and was started on TPN due to respiratory distress and inability to tolerate enteral nutrition. Despite nutritional support, his condition continued to decline and he ultimately passed away.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 16

    CASE STUDY

    Jesse Terris
    WHAT IS LYMPHOMA

    Lymphoma is a cancer that starts in the lymph system.

    There are two categories of lymphoma

    • Hodgkin lymphoma
    • Those with Hodgkin lymphoma have large cancerous cells called Reed-Sternberg (RS)
    cells.
    • Non-Hodgkin lymphoma (NHL)
    • NHL forms in either B cells or T cells within the immune system and can be fast or slow
    growing.
    DIFFUSE LARGE B CELL
    LYMPHOMA
    • Diffuse Large B cell Lymphoma is the most aggressive type of Non-
    Hodgkin Lymphoma.
    • B cells are what your bodies immune system relies on to make
    antibodies.
    • It is fast growing and is caused by abnormal B cells in the blood.
    • It affects the body’s white blood cells and its ability to fight
    infections.
    CHEMOTHERAPY
    • Prior to admission the pt was receiving chemotherapy which can cause side effects that
    affect nutritional intake.
    • Mouth sores
    • Loss of appetite *
    • Nausea
    • Vomiting
    • Constipation *
    • Change in taste
    • Metallic taste in mouth *
    THE PATIENT

    • 68-year-old male • Past medical history


    • Height: 5’10” • Alcoholism
    • Cancer: Non-Hodgkin lymphoma
    • Weight: 155 lb (70.4 kg)
    • COPD
    • BMI: 22.36 • GERD
    • Hypertension
    ADMISSION
    • Pt presented to ED with hyper calcium and
    bilirubin levels. Pt experiencing shortness of
    breath and has been “peeing blood”
    Lab 3/10/22 3/11/22
    • Pt has relapsed Diffuse Large B cell lymphoma
    and has been receiving chemotherapy. Calcium 14.6 13.3
    • Pt receiving IV NaCl and is on Decadron.
    Bilirubin 5.9 3.4
    INITIAL VISIT 3/11
    • Patient was sitting up in bed, good spirited and was able to answer questions
    • RN Admission Nutrition screen positive for weight loss 24-33 lb and decreased appetite. –
    RD consulted.
    • Decreased appetite for 2.5 months (since NFPE
    starting Chemotherapy) Subcutaneous Fat loss
    - Orbital: moderate/severe
    • Weight loss of 10 lb in last 2.5 months - Triceps: mild
    (6.0% weight loss, significant) Muscle wasting
    - Temple: mild
    • Drinks Oreo premier protein once a day at - Clavicle: moderate
    home - Shoulder: moderate
    - Interosseous: moderate
    • Willing to try strawberry or vanilla ensure Edema
    while here. - bilateral trace pitting
    ENERGY NEEDS

    • Energy Needs:
    • 1760- 2100 kcals
    • Based on 30-35 kcal/kg for repletion
    • Protein needs:
    • 84-105 gm
    • Based on 1.2-1.5 gm /kg for cancer
    • Fluid needs:
    • 1760-2100 ml
    • Based on 1 ml per kcal
    INTERVENTIONS MONITORING
    - Food and supplement intake
    1. Meals and snacks: NPO, diet advancement per
    GI. - Weight and weight changes

    2. Medical food supplements: trial Strawberry and - Diet advancement/tolerance


    Vanilla Ensure Enlive.
    - Labs/medical tests/procedures

    NUTRITION DIAGNOSIS
    1. Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by NPO.

    2. Non-severe malnutrition in the context of chronic illness related to inadequate oral intake as evidenced by
    <75% intake x 2 months, 4.3% weight loss x 2 months, and moderate/severe subcutaneous fat loss in orbitals
    and moderate muscle wasting in clavicle, shoulder, and interosseous regions.
    3/12
    - Diet advanced to Cardiac diet: 3-4 gm 3/14
    Na; Low fat - Pt has had increased needs for oxygen
    - Pt started experiencing hallucinations and and course crackles noted
    requested to have medications to help - Now NPO due to concerns for aspiration,
    him sleep. pending swallow evaluation
    - Pt became aggressive with staff and was
    placed in restraints
    - GEM team now following.
    • Moved to ICU and intubated due to increased oxygen demands,
    respiratory distress, and inability to follow demands.
    • OG tube placed in stomach, verified per KUB.

    FOLLOW UP • RD consulted for vent protocols


    • IV medication
    3/15 • Propofol at 18 ml/hr (provides 491 kcal)
    • Dextrose 5% at 125 ml/hr (provides 510 kcal)
    • Labs: Mg 1.2 – placed on replacement.
    INTERVENTIONS
    ENERGY NEEDS for
    critical care
    1. Enteral Nutrition:
    - Vital AF 1.2 at goal rate
    Kcal: 1685-1830 50ml/hr if off Propofol Increase to 65
    - Based on 23-25 kcal/kg ml/hr.
    Protein: 85-145 gm - This provides 1716 kcal, 107
    - Based on 1.2-2 g/kg gm protein, and 1158 ml free water.
    Fluid: 1685-1830 ml - Recommend 100 ml flush every
    4 hrs when IV fluids discontinue.
    - Based on 1ml/kcal
    2. Monitor BM: Last BM 3/10. Colace
    and Senokot ordered.

    PT STILL NPO AT THIS TIME


    FOLLOW UP 3/18

    • 3/17
    • Oncology spoke with the family about poor prognosis for any
    meaningful recovery.
    • Palliative care following
    • Still NPO – No TF started.
    • BM 3/16 – still receiving Colace and Senokot BID per NG tube
    • IV Medications
    • Dextrose 125 ml/hr (provides 510 kcal)
    • Propofol 18 ml/hr (provides 491 kcal)
    • Labs: Na 135, low. Ca 6.8, low
    • 3/21
    • Family visit with palliative care
    • Progressive metastatic lymphoma
    • Not a candidate for disease directed therapy
    • Family decided comfort care and liberated from life support 3/22
    • Labs: Na 133, low. Ca 6.3, low
    • 3/22
    • Patient passed away.
    CONCLUSION
    • This is a perfect example of just how quickly people can decline.
    • Although as dietitians we did everything, we could to ensure the patient could receive
    nutrition, his body was too weak to support it.
    CITATIONS
    • Sehn LH, Author AffiliationsFrom the BC Cancer Centre for Lymphoid Cancer and the University of British
    Columbia. Diffuse large B-cell lymphoma: Nejm. New England Journal of Medicine.
    https://www.nejm.org/doi/full/10.1056/NEJMra2027612. Published June 10, 2021. Accessed April 12, 2022.
    • Schmitz R, Al. E, Author AffiliationsFrom the Lymphoid Malignancies Branch (R.S., et al. Küppers R. The
    biology of Hodgkin's Lymphoma. Nature News. https://www.nature.com/articles/nrc2542. Published December
    11, 2008. Accessed April 12, 2022.
    • New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa1801445. Published August
    2, 2018. Accessed April 12, 2022.

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