Draft 2

Running head: ACADEMIC CLINICAL SOAP NOTE 1

Academic Clinical Soap Note

Grand Canyon University

ANP 650

September 25, 2019

ACADEMIC CLINICAL SOAP NOTE

SUBJECTIVE

Chief Complaint:

Patient is in clinic today for second peptide receptor radionuclide treatment (PRRT)

with Lutathera treatment.

Background:

This is a pleasant 47-year-old female with a history of metastatic pancreatic

neuroendocrine tumor. She was initially diagnosed in October 2016 presenting with

pneumonia with an incidental lung nodule noted. Biopsy demonstrated low-grade

neuroendocrine of 1%. She then was noted to have metastatic disease in the right breast

biopsy proven in February 2017. Somatostatin analog therapy was initiated then. When the

patient progressed in September 2017 she was transitioned to Afinitor. A right thyroid nodule

was noted and biopsied in December 2018 with benign findings. That due to Tait scan in

January 2019 showed progression of disease. She was transitioned to Capoten for one cycle

with recurrence of pancreatitis as well as development of splenic vein thrombus in February

2019. She had persistent pancreatitis in March 2019 on CT imaging. After, GI tumor board

review at Stony Brook University Hospital she was found to be metastatic low-grade

neuroendocrine tumor more likely pancreatic origin. Because of persistent abdominal pain

she underwent celiac plexus block in May 2019. She was subsequently referred for peptide

receptor radionuclide therapy/ Lutathera and received first dose on 7/17/2019. She has

recently moved to Florida 3 weeks ago and presents to reestablish for continuation of

Lutathera treatment at Moffitt Cancer Center.

Family History:

Father died of prostate cancer in 1998. Mother had diabetes, heart disease, and

hypertension, she passed in 2010. Patient state she had several uncles that died from cancer,

but she does not recall which cancer they had.

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ACADEMIC CLINICAL SOAP NOTE

Medication:

 Insulin (Lantus) glargine 20 unit(s), SubQ, DAILY.

 fluticasone nasal (Flonase 50 mcg/inh nasal spray) 2 spray(s), NASAL, DAILY.

 pancrelipase 6000 units oral delayed release capsule, PO, QID.

 Simvastatin 10 mg, 1 tab(s), PO, Bedtime

 Metoprolol 50 mg, 1 tab(s), PO, Daily

 NIFEdipine 30 mg, 1 tab(s), PO, Daily

 Losartan (losartan 100 mg oral tablet) 100 mg, 1 tab(s), PO, AS NEEDED.

 Multivitamin (Multi Vitamin+) PO, DAILY

 Vitamin C lozenge 500 mg, 1 tab(s), PO, Daily

 Multivitamin with iron (Iron 100 Plus) PO, DAILY.

 Multivitamin (Vitamin B Complex oral capsule) 1 cap(s), PO, Daily

 Biotin (biotin 5000 mcg oral tablet, disintegrating) PO, DAILY

Review of Systems:

Constitutional: She has a long-term history of fatigue. Weight loss of 30lb since beginning

of 2019. No fever, no chills, no weakness, no decrease activity.

Eye: No recent visual problem, No double vision.

Ear/Nose/Mouth/Throat: No dry mouth, No nasal congestion, No mouth sores, No

mucositis.

Respiratory: No shortness of breath, No cough, No sputum production.

Cardiovascular: No palpitations, No bradycardia, No tachycardia.

Breast: No nipple discharge.

Gastrointestinal: Occasionally nausea with no vomiting. She has constipation alternating

with diarrhea. Stomach pain 4 on scale 0-10. Last bowel movement today.

Genitourinary: No dysuria, No hematuria.

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ACADEMIC CLINICAL SOAP NOTE

Gynecologic: Negative.

Hematological/Lymphatics : No bruising tendency, No bleeding tendency.

Endocrine : No cold intolerance, No heat intolerance.

Immunologic : No recurrent fevers, No recurrent infections.

Musculoskeletal : No claudication.

Integumentary : No rash.

Neurologic: Alert and oriented X4.

Psychiatric: Not delusional, No hallucinations.

OBJECTIVE

Vital Signs:

Temperature: 98.65 Heart Rate: 74, Blood Pressure: 112/74, Respiratory Rate: 14,

SpO2: 100%, Weight: 57.3kg, Height: 5 ft 6 in and BMI: 21.1

Physical Examination:

General: Compared weight chart and noted a 30lb weight loss. Alert and oriented, No acute

distress.

HEENT: Oropharynx clear, Normocephalic, Oral mucosa is moist.

Cardiovascular: Normal rate, Good pulses equal in all extremities.

Respiratory: Lungs are clear to auscultation, Symmetrical chest wall expansion.

Gastrointestinal: Pain elected on lite palpation soft. Non-tender, Non-distended.

Hematological/Lymphatics: Lymphatic exam: Right, Submandibular, 10 mm ( By 10 mm ).

Extremities: Normal range of motion, No deformity, Normal gait.

Integumentary: Warm, Intact.

Neurologic: Normal sensory, No focal defects.

Cognition and Speech: Speech clear and coherent, Functional cognition intact.

Psychiatric: Cooperative, Appropriate mood & affect

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ACADEMIC CLINICAL SOAP NOTE

Labs/Imaging/ Diagnostic Test Result:

Abnormal Labs: Glucose- 219 H: Mean Cell Volume: 94.2 H: RDW: 52.7 H:

Diagnostic Data: Detailed review of the PET/CT: demonstrates numerous metastatic

avid lesions within the soft tissues and osseous structures involving bilateral breasts, liver,

pancreas, metastatic lesion in the left peritoneum and irregular mass in the left pelvis and

persistent multiple osseous metastasis.

ASSESSMENT/CLINICAL IMPRESSIONS

Health Problems:

1. Neuroendocrine Tumor D3A.8

2. Pancreatitis K85

3. Diabetes E23.2

4. Hyperlipidemia E78.49

Differential Diagnosis:

ICD-10 K29: Zollinger-Ellison Syndrome- is characterized by gastric acid

hypersecretion resulting in severe acid-related peptic disease and diarrhea. The tumors are

thought to emerge from the delta cells that are found in the pancreas and it was founded to

account for about 25% to 40% of gastrinomas. The rest of the endocrine tumors to include the

50- 70% of abnormal cells were found in the small digestive tract, while about 5% emerge

from other intra-stomach area. “Gastric not only directly stimulates parietal cell secretion but

also causes expansion of the mass of parietal cells. The increase in parietal cells results in an

increase in basal acid output and maximal acid output. This substantial secretion of acid

results in gastroesophageal reflux disease (GERD) symptoms and damage to the mucosal

lining of the GI tract, causing peptic ulcers. In addition, the acid inactivates pancreatic

enzymes, which contributes to the diarrhea, steatorrhea, and malabsorption of lipid-soluble

nutrients (www.epocrate.com.2019).”

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ACADEMIC CLINICAL SOAP NOTE

ICD-10 E34.0: Carcinoid Syndrome- progress in some people with carcinoid tumors

and is identified by cutaneous flushing, abdominal cramps, and diarrhea. There are a number

of symptoms relevant to CS that healthcare work looks for such as the abnormal labs are the

first to investigate then there are the physical manifestations. Carcinoid syndrome is seen in

individuals who have an underlying carcinoid tumor that has spread to the liver. Carcinoid

syndrome is a rare condition that effect about 10% of the population. “Carcinoid syndrome

may be more prevalent than suspected because diagnosis is difficult and sometimes

overlooked; some patients may not exhibit all three of the hallmark symptoms of flushing,

wheezing, and diarrhea (www.raredisease.org. 2019).”

ICD-10 D35.00: Pheochromocytoma- Is the type of “tumor arising from

catecholamine-producing chromaffin cells of the adrenal medulla that classically presents

with headaches, diaphoresis, and palpitations in the setting of paroxysmal hypertension

(www.epocrate.com 2019).” This disease secrete adrenaline in an uncontrolled manner and

can cause severe medical issues including heart disease, stroke, and ultimate this can lead to

death.

PLAN COMPONENT MANAGEMENT:

Research has shown that there are few neuroendocrine tumors that may not have a

clear primary tumor site and these tumors will be treated based on the histology. Many

neuroendocrine tumors tend to poorly differentiated and may grow and spread rapidly. In

order to get a better understanding of the tumor dynamic imaging studies a long with scopes

to see the internal area of the tumor body will be utilized by the provider. EUS and biopsy

may be done to confirm the cell type. The initially diagnostic test can start with the CT of the

chest, abdomen, and/ or pelvis, MRI, FDG_PET/ CT scan, and biochemical testing. The

patient that has a poorly differential neuroendocrine tumor the treatment option ideally

utilizes a combination of options. The doctor will decide which treatment will work best, for

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ACADEMIC CLINICAL SOAP NOTE

the patient at that time; “one treatment option is the surgical option this will include resection

+ adjuvant chemotherapy +/- radiation therapy. There is locoregional surgical option that

involves radiation therapy and chemotherapy given at the same time or one treatment after

the other or just chemotherapy only. If the neuroendocrine tumor is metastatic than the

treatment option is chemotherapy and every three months the patient will come into the clinic

and have his/ her lab drawn and CT or MRI completed to check the progression of the

treatment and at the time the provider and patient will decide based on the diagnostic report

how to proceed (www.nccn.org. 2019).”

Providers at the Moffitt cancer center have used peptide receptor radionuclide therapy

(PRRT) with great success. “The FDA approval of Lutathera, a peptide receptor radionuclide

therapy (PRRT), on January 26, 2018, for a new era in treatment options for the

neuroendocrine tumor (www.newRx.org. 2016).” When PRRT is use it was found to

manifest long term effectiveness to the treatment of neuroendocrine tumor while also

allowing the patient to maintain a high-quality lifestyle. The patient can use PRRT repeatedly

with very little side effects and rarely these patients were dialysis dependent.

“All PRRT candidates must first be seen by an Oncologist in order to be evaluated for

treatment. The requests for PRRT treatment should be for a GI oncology consult (De Visser,

M., 2008).” Cost associated with the PRRT can be costly but patient who do not have

insurance, Medicare/ Medicaid there are programs that can help with getting qualified for

therapy. The PRRT drug can be offered free to the patient that do not have insurance but there

will be costs for medications to help with the side effect of PRRT such as nausea and

vomiting, and there will be costs to the institution and medical personnel providing the

service.

Disposition/ Discharge Plan:

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ACADEMIC CLINICAL SOAP NOTE

“Peptide Receptor Radionuclide Therapy uses radiation to kill cancer cells, this mean

that this medication works differently than other cancer drugs. PRRT is given in a hospital

setting and have two components to the therapy (Thang. S. P., et.al 2018).” There is the tumor

targeted part that finds the cancer cell with a receptor called somatostatin. Then there is the

radioactive component that actually kills the cancer cell. This cancer infusion is given up to

four times and eight weeks apart from each infusion. Once the infusion has completed the

patient will be given an injection of long acting octreotide to decrease the cancer from

growing or spreading. The patient will be given anti-nausea medication, amino acid hydration

solution medication, and then 45 minutes later the patient will receive the PRRT treatment.

The nurse will explain during the discharge planning that it is imperative that the

patient must drink a lot of fluids/ water and urinate frequently before, during and after

treatment because this will help the radiation to leave the body. Patient should also limit close

contact with pregnant women, children, and immune compromised patient for the first two

weeks after therapy to prevent exposure and the patient must practice good hand hygiene with

soap and water often. Expected outcome of PRRT is to “reduce the risk of cancer spreading,

growing, or getting worse by 79% compared to a larger than normal dose of long-acting

octreotide (www.carcinoid.org. 2019).”

Health Education/ Promotion and Disease Prevention:

Patient education/ health promotion include “minimize radiation exposure during and

after treatment with PRRT-consistent with institutional good radiation safety practices and

patient management procedures, monitor blood cell counts because of myelosuppression;

treatment may be placed on hold, dose educed, or permanently discontinue PRRT treatment

based on negative reaction to treatment, hepatotoxicity can cause a decrease in blood levers

therefore monitor transaminases, bilirubin and albumin. Due to neuroendocrine hormonal

crisis patient must be monitored for flushing, diarrhea, hypotension, bronchoconstriction or

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ACADEMIC CLINICAL SOAP NOTE

other signs and symptoms, embryo-fetal toxicity can occur with PRRT in which the fetal

harm can come about. Advise females and males of reproductive potential of the potential

risk to a fetus and to use effective contraception and PRRT can cause infertility

(www.carcinoid.org. 2019).” Patient are also instructed to make sure they continue to update

their medication list to prevent adverse reaction. Disease prevention focus is on consuming

half the patient body weight in water daily, eating a healthy diet that consist of fresh fruit and

vegetable, avoid white pasta and rice, organic meats, fruits, and vegetables is considered a

better choice (think rainbow colors when it comes to healthy eating). Maintaining a healthy

weight and BMI. Patient are instructed to work out 150 minutes per week about 3 to 4 times

in that week, stress reduction is another prevention option, and finally getting enough rest so

that the body can fight off the cancer cell that is circulating in the body.

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ACADEMIC CLINICAL SOAP NOTE

References

Carcinoid Syndrome. (2019). Retrieved from https://rarediseases.org/rare-diseases/carcinoid-

syndrome/

de Visser, M., Verwijnen, S. M., & de Jong, M. (2008). Update: Improvement strategies for

peptide receptor scintigraphy and radionuclide therapy. Cancer Biotherapy &

Radiopharmaceuticals, 23(2), 137-57.

doi:http://dx.doi.org.lopes.idm.oclc.org/10.1089/cbr.2007.0435

Neuroendocrine cancer; long-term experience supports efficacy and safety of PRRT for

treating neuroendocrine tumors. (2016, Nov 06). NewsRx Health Retrieved from

https://lopes.idm.oclc.org/login?url=https://search-proquest-

com.lopes.idm.oclc.org/docview/1832797816?accountid=7374

Pheochromocytoma. (2019). Retrieved from

https://online.epocrates.com/diseases/16332/Pheochromocytoma/Risk-Factors

Thang, S. P., Mei, S. L., Kong, G., Hofman, M. S., Callahan, J., Michael, M., & Hicks, R. J.

(2018). Peptide receptor radionuclide therapy (PRRT) in european neuroendocrine

tumour society (ENETS) grade 3 (G3) neuroendocrine neoplasia (NEN) - a single-

institution retrospective analysis. European Journal of Nuclear Medicine and

Molecular Imaging, 45(2), 262-277.

doi:http://dx.doi.org.lopes.idm.oclc.org/10.1007/s00259-017-3821-2

Treatment Guideline: Neuroendocrine Tumors. (2019). Retrieved from

https://www.nccn.org/patients/guidelines/neuroendocrine/88/

What is LUTATHERA®? (2019). Retrieved from https://www.carcinoid.org/wp-

content/uploads/2018/07/AAA_Lu177_US_0058_LUTATHERA_lutetitum_Lu177_d

otatate_Patient_Fact-Sheet_Final-July-2018.pdf

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Zollinger-Ellison syndrome. (2019). Retrieved from

https://online.epocrates.com/diseases/40824/Zollinger-Ellison-syndrome/Etiology27,

2018, from https://www.atsjournals.org/doi/citedby/10.1513/pats.200604-099SS

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