C09988782 / invoice 10000

Full bloods    Vital Signs    

Diagnosis: Relapsed nodal lymphoma (previously B cell) Other relevant history/comorbidities: - Hepatopathy prior to treatment which worsened during CHOP, liver nodules/masses on US, cytology inconclusive. Improved with chemo breaks, d/c CHOP August due to worsening hepatopathy. Suspect cyclophosphamide related hepatotoxicity and since restarting vincristine/doxorubiin ALT has been stable. - Accidental vincristine overdose 24/7. Hospitalised for one week - GI signs, neutropenia, suspected secondary pneumonia. - Chronic cough - may have been exacerbated by pneumonia but suspicious for chronic airway disease. - Heart murmur, echo NSF- Corneal ulcer 16/10 resolved, 20/11 bilateral ulcers which had not resolved after 1 week of treatment. Resolved at check 11/12, STT consistent with decreased tear production bilaterally R worse than L, started Optimmune. - On 18/12/2025, azotaemia was noted (Urea 21.8, Creatinine 150) with bacteriuria (Strep. canis), which was treated with amoxicillin-clavulanate. - Renal values improved by 31/12/2025 (Creatinine 139, Urea 13.2) but have progressively worsened over January and February 2026 (UREA 24.6, CREA 210). Seen by medicine 09/02, probable IRIS stage 2 CKD, prehypertensive, nonproteinuric. AUS did not identify pre or post renal causes. Has since improved with only mild ongoing UREA elevation after commencing renal diet.Chemo protocol: Vincristine (x2) /doxorubicin x 4 cycles - elected to eliminate cyclophosphamide as very good response to vincristine and cyclophosphamide is the most likely cause of hepatopathy History since last visit:-     Appetite normal-     Thirst normal-     Urination normal-     Defecation normal-     Vomiting none-     Other clinical signs. O reports increased frequency of coughing this week, no breathing changes. More ocular discharge.-     Medications given eye drops, denamarin, gabapentin. Physical examination: Weight 10.4kg BSA 0.481m2 BCS: 6/9 T: 38.4 P: 116 RR: 36 MM colour: Pink CRT: <2s Eyes: Pigmented cornea R eye, lens opacities L eye STT 9mm R in 60sec, > 15 in 30 seconds on LEars: Normal on general exam Nose: Normal on general exam Oral: Not examined Lymph nodes: SM and popliteal LN palpate normally, LPS not palpable due to large SQ mass, inguinal not palpable due to large SQ mass Integument: Multiple SQ masses as previously Respiratory: Normal Cardiac: Grade II-III/VI cardiac murmurAbdominal palpation: Tenses on palpation Rectal examination: Not performed Urogenital/mammary: Normal on general exam MSK: NormalNeurological: NormalLaboratory:UoM Bloods:Haematocrit L/L 0.45 0.37 – 0.55 NPlatelets x 109/L 643 200 – 500 HNeutrophils x 109/L 11.6 3.0 – 11.5 HPotassium mmol/L 7.5 3.8 – 5.6 H *was 6.3 last week, historically throughout treatment has ranges from 5.43-5.9, with only occasional 4.6 which was last noted in July 2025*Chloride mmol/L 118 102 - 117 HCalcium mmol/L 2.91 2.30 – 3.00 N*has been ranging between 2.75-2.99, upper end RR throughout treatment, with the lowest at 2.65 in July 2025*Urea mmol/L 13.3 3.0 – 8.7 HCreatinine µmol/L 135 40 – 140 HCholesterol mmol/L 12.2 3.9 – 7.8 HALT U/L 405 3 – 83 HALP U/L 5418 0 – 170 HGGT U/L 174 <12 HCRP mg/L <11 <11 NBlood gas:K 5.5 H (3.6-4.6) HCl 121 H (106-120) H ICa 1.48 (1.13-1.33) HAssessment:Tumour response:  CRToxicity from previous chemo: Nil -Coughing: Does have history of chronic pulmonary changes suggestive of airway disease. Imaging (CXR) recommended ideally however given mild neutrophilia, not unreasonable to consider an antimicrobial trial. -CKD: stable to last week, ongoing resolution of creatinine with mild UREA elevation-Progressive hyperkalaemia on UoM bloods however stable on blood gas. Gizmo has historically always had high normal potassium to mild elevations, with no historical comparison on a blood gas. This could be spurious due to EDTA contamination, however given his recent worsening azotaemia we are unable to exclude a renal or post renal cause (not evident on recent AUS). Given that he is currently clinically well, a reassessment in 1 week has been recommended. -Newly identified hypercalcaemia, however the significance of this is unknown. Gizmo has historically has had a calcium on the upper end of the RR on UoM bloods since commencing treatment, with ionised calcium assessment. The hypercalcaemia is mild and unlikely to be the cause of his azotaemia in the absence of PUPD. Treatment:Butorphanol 0.3mg/kg IMDoxorubicin 1mg/kg IV (10.4mg, 5.2ml) IV Amoxyclav 200mg PO BID x 7 days -> for worsening cough, discussed CXR but elected to trial treatment Maropitant 24mg PO SID x 4 daysProkolin 5ml PO BID x 4 days Next visit:Revisit in 7 days for full bloods (nurse collection)Recheck every 6-8 weeks for lymph node palpation and bloods.Ongoing follow ups with Medicine as required.Client Communication:NVS discussed K and Ca findings with Veronica, does not change how we proceed today. However any development of signs warrant reassessment with Medicine.    Vital Signs    MMColour: pink;       Weight: 10.4;       Temperature: 38.4;       HeartRate: 116;       RespirationRate: pant;