McMillan

1. ONCOLOGY/HEMATOLOGY
FOCUSED
HISTORY AND PHYSICAL
Jessica McMillan, DNP, ARNP
Division of Hematology/Oncology
Mayo Clinic Florida

2. OBJECTIVES
 List the components of a basic history and
physical
 Discuss features relevant to cancer/hematologic
malignancies
 Identify cancer treatments related to
malignancies with side effects
 Assess for signs and symptoms of metastasis
 Discuss documentation

3. COMPONENTS OF BASIC
HISTORY AND PHYSICAL
 Imperative to determine status and needs of patient
and formulate an appropriate plan of care
 Create an atmosphere of comfort
 Discuss subjective data
 Review medications
 Physical assessment
 Formulate plan of care

4. ATMOSPHERE OF COMFORT
 Review chart
 Review labs, testing
 Introduction
 Shake hands
 Acknowledge everyone in the room (document)
 Look at patient

5. CHIEF COMPLAINT
 Why is the patient here?
 Type of cancer
 Treatment

6. SUBJECTIVE DATA
 Head to toe (from last visit – need starting point
 Chills, fevers, appetite, weight loss, fatigue
 Eyes, nose, mouth sores, or problems swallowing
 Dyspnea (exertional or all the time), cough, secretions,
sleeping up in a chair or on pillows
 Abnormal or rapid heart beats, heart pain, swelling
 Nausea, vomiting, diarrhea, constipation, heartburn, gas,
bloating, distention – What is the normal bowel pattern?
 Urinary frequency, urgency, flow, nightly, color, burning or
painful
 Numbing, tingling, fingers or toes, dizziness, headaches
 Skin – rashes, itching, lesions, wounds
 Weakness (where), gait (steady or unsteady), assistive
devices,

7. MEDICATIONS
 Review medications
 Allergies
 Current medications
 Include over the counter (OTC)
 Could medications account for symptoms?

8. PHYSICAL EXAMINATION
 What do you see?
 Distress, A&Ox?, NCNT, sleep, fatigue, mood
 Eyes – Pupils, EOMI, sclera,
 Nose – drainage, sores, bleeding, perforations
 Mouth – sores, dentition
 Look at the chest, listen to lung sounds anterior and
posteriorly
 Heart tones listen, are they regular – slow – fast check all
valves, murmurs, gallops, or rubs, is there a change from
last visit
 Abdomen (normal, hyper or hypo bowel sounds), soft,
tender, painful (where), palpate liver
 Skin – intact, lesions, rashes
 Motor – Ambulation (exam table or in a wheel chair). Does
the patient need assistance.
 Male and Female assessment – disease specific

9. PLAN
 Surgery
 Chemotherapy
 Radiation
 Side effects

10. CANCER TREATMENT
 Surgery
 Remove entire tumor
 Debulk tumor
 Ease of cancer symptoms
U.S. Department of Health and Human Services. National Institutes of Health. (2010). Radiation therapy for cancer. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/radiation-therapy/radiation-fact-sheet#q9.

11. CANCER TREATMENT
 Radiation Therapy
 External beam radiation
 Intensity-modulated radiation therapy (IMRT)
 Image-guided radiation therapy
 Tomotherapy
 Stereotactic radiosurgery
 Stereotactic body radiation therapy
 Proton therapy
 Internal radiation therapy
 Interstitial brachytherapy
 Radioactive isotopes
 Side effects
 Fibrosis
 Damage to bowels, diarrhea and bleeding
 Memory loss
 Infertility
U.S. Department of Health and Human Services. National Institutes of Health. (2010). Radiation therapy for cancer. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/radiation-therapy/radiation-fact-sheet#q9.

12. CANCER TREATMENT
 Chemotherapy
 Works by stopping or slowing growth
 Ease cancer symptoms
 Routes
 Oral
 IV
 Injection
 Intrathecal
 Intraperitoneal (IP)
 Intra-arterial (IA)
 Topical
 Symptoms
 Depend on drug
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Chemotherapy. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/chemotherapy

13. CANCER TREATMENT
 Immunotherapy
 Monoclonal antibodies
 Adoptive cell transfer
 Cytokines
 Treatment vaccines
 BCG
 Side Effects (most
commons)
 Pain
 Swelling
 Soreness
 Redness
 Itchiness
 Rash
 Side Effects (flu-like symptoms)
 Fever
 Chills
 Weakness
 Dizziness
 Nausea or vomiting
 Muscle or joint aches
 Fatigue
 Headaches
 Trouble breathing
 High/low blood pressure
 Sinus congestion
 Diarrhea
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Immunotherapy. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/immunotherapy

14. CANCER TREATMENT
 Targeted therapy
 Monoclonal antibodies
 Help the immune system stop cancer
 Stops signals that help form blood vessels
 Deliver cell-killing substances to cancer cells
 Cause cancer death
 Starve cancer of hormones to grow
 Side effects
 Resistant
 Diarrhea, liver, hypertension, mouth sores, nail changes,
rashes, loss of pigmentation
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Targeted Therapy. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/targeted-therapies.

15. CANCER TREATMENT
 Side effects for Men
 Hot flashes
 Decrease libido
 Weakened bones
 Diarrhea
 Nausea
 Enlarged breast
 Fatigue
 Side Effects for Women
 Hot flashes
 Vaginal dryness
 Menopause
 Decrease libido
 Nausea
 Mood changes
 fatigue
Hormone Therapy
Used to treat cancer, stop or slow growth
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Hormone Therapy. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/hormone-therapy.

16. CANCER TREATMENT
 Stem Cell Transplant
 Leukemia
 Lymphoma
 Neuroblastoma
 Multiple myeloma
 Side effects
 Bleeding
 Infection
 (Allogenic transplant) graft-versus-host disease
 Affects individuals differently depending on:
 Type
 Doses of treatment
 Type of cancer and advancement
 Health prior to transplant
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Stem Cell Transplants. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/stem-cell-transplant.

17. WHEN CANCER SPREADS
 How
 Local invasion
 Invades nearby
 Intravasation
 Walls of nearby lymph or blood vessels
 Circulation
 Lymphatic system and blood stream
 Arrest and extravasation
 Stop in capillaries in distant locations
and migrate
 Proliferation
 Multiply to form micrometastases
 Angiogenesis
 Micrometastases form new blood supply
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Diagnosis and Staging. Retrieved from http://www.cancer.gov/about-
cancer/diagnosis-staging/staging

18. WHERE DOES CANCER SPREAD
 Bladder
 Bone, liver, lung
 Breast
 Bone, brain, liver lung
 Colorectal, Stomach,
Pancreas
 Liver, lung, peritoneum
 Kidney
 Adrenal gland, bone,
brain, liver, lung
 Lung
 Adrenal gland, bone,
brain, liver, lung and
other lung
https://upload.wikimedia.org/wikipedia/commons/archive/7/7e
/20110617071751%21Metastasis_sites_for_common_cancers.s
vg
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

19. WHERE DOES CANCER SPREAD
 Melanoma
 Bone, brain, liver, lung,
skin/muscle
 Ovary
 Liver, lung, peritoneum
 Prostate
 Adrenal gland, bone,
liver, lung
 Thyroid
 Bone, liver, lung
 Uterus
 Bone, liver, lung,
peritoneum, vagina
https://upload.wikimedia.org/wikipedia/commons/archive/7/7e
/20110617071751%21Metastasis_sites_for_common_cancers.s
vg
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

20. COMMON SITES OF METASTASIS
BREAST CANCER
 Bone
 Brain
 Liver
 Lungs
By Cancer Research UK - Original email from CRUK, CC BY-SA 4.0,
https://commons.wikimedia.org/w/index.php?curid=34333556

21. COMMON SITES OF METASTASIS
BLADDER CANCER
 Bone
 Liver
 Lung
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

22. COMMON SITES OF METASTASIS
PANCREAS CANCER
 Liver
 Lung
 Peritoneum
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

23. COMMON SITES OF METASTASIS
COLON CANCER
 Liver
 Lung
 Peritoneum
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

24. COMMON SITES OF METASTASIS
STOMACH CANCER
 Liver
 Lung
 Peritoneum
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

25. COMMON SITES OF METASTASIS
LUNG CANCER
 Adrenal gland
 Bone
 Brain
 Liver
 Lung
 Other lung
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

26. COMMON SITES OF METASTASIS
MELANOMA CANCER
 Bone
 Brain
 Liver
 Lung
 Skin/muscle
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Melanoma Treatment. Retrieved from
http://www.cancer.gov/types/skin/patient/melanoma-treatment-pdq
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

27. COMMON SITES OF METASTASIS
OVARIAN CANCER
 Liver
 Lung
 Peritoneum
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

28. COMMON SITES OF METASTASIS
RENAL CANCER
 Bone
 Brain
 Kidney
 Liver
 Lung
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

29. COMMON SITES OF METASTASIS
PROSTATE CANCER
 Male reproductive
 Bone
 Bladder
 Lymph nodes
 Liver
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

30. COMMON SITES OF METASTASIS
THYROID, HEAD AND NECK CANCER
 Bone
 Brain
 Liver
 Lungs
 Mediastinum
 Skin
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

31. COMMON SITES OF METASTASIS
UTERINE CANCER
 Bone
 Liver
 Lung
 Peritoneum
 Vagina
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

32. SYMPTOMS OF CANCER METASTASIS
U.S. Department of Health and Human Services. National Institutes of Health. (2015). Metastatic Cancer. Retrieved from http://www.cancer.gov/about-cancer/what-is-
cancer/metastatic-fact-sheet

33. DOCUMENTATION
 What they tell you
 Who is in attendance
 What you see
 What you feel
 Plan of care
 For each diagnosis

34. WHAT DO YOU THINK?

35. WHAT ARE THE MOST COMMON PLACES
BREAST CANCER METASTASIS TO?
A. Bone
B. Brain
C. Liver
D. Lungs
E. Both A & C
F. All of the above

36. HOW IS CANCER TREATED
A. Surgery
B. Chemotherapy
C. Hormone therapy
D. Immunotherapy
E. Targeted therapy
F. Stem Cell Transplant
G. All of the above
H. None of the above

37. HOW WOULD YOU TREAT ACUTE SHORTNESS OF
BREATH – RULE OUT PULMONARY EMBOLISM?
A. CT Angiogram
B. CXR
C. MRI
D. Start anti-coagulants right away
E. None of the above
F. All of the above

38. QUESTIONS???

39. REFERENCES
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http://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/radiation-fact-sheet#q9.
 U.S. Department of Health and Human Services. National Institutes of Health. (2015). Chemotherapy. Retrieved from http://www.cancer.gov/about-
cancer/treatment/types/chemotherapy
 U.S. Department of Health and Human Services. National Institutes of Health. (2015). Immunotherapy. Retrieved from
http://www.cancer.gov/about-cancer/treatment/types/immunotherapy.
 U.S. Department of Health and Human Services. National Institutes of Health. (2015). Targeted Therapy. Retrieved from
http://www.cancer.gov/about-cancer/treatment/types/targeted-therapies.
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http://www.cancer.gov/about-cancer/treatment/types/hormone-therapy.
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http://www.cancer.gov/types/skin/patient/melanoma-treatment-pdq
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