The patient is a woman with stage 4 lung cancer that has metastasized to her brain. She has undergone surgery and other treatments for brain tumors but still has 3 active brain metastases. She is experiencing significant pain, depression, cognitive difficulties, and denial about her terminal prognosis. The psychologist recommends more aggressive pain management, a trial of antidepressant medication, and a hospice referral to improve her quality of life during her final weeks. Comfort measures and engaging in meaningful activities and reminiscing are also advised.

1. 1
Mental Health Consultation
Patient Name: METASTATIC BRAIN TUMORS with primary lung cancer
Date: xx-xx-xx Facility: XXXX
Abbreviated Format: the following sections will not be included in this report:
Comprehensive Background Information, All Current Medications and Complete
Medical History: That information can be found elsewhere in this chart.
Reasonfor Referral: xx-year-old, white, xxxxx, female… I was asked to evaluate her
for depression. She was admitted from XXX on xx-xx-xx.
She has a history of lung cancer with brain metastases. She underwent a left craniotomy
for tumor resection on xx-xx-xx and tolerated the procedure well. She has an intractable
seizure disorder. She has been through chemo and radiation therapy. Results of the most
recent neuroimaging follow:
FINDINGS: When compared with the patient's prior exam there has been interval left craniotomy There
has been interval resection/debulking of the mass previously noted at the left posteriorfrontal convexity.
Postoperative pneumocephalus is noted.There is persistent extensive vasogenic edema within the left
cerebral hemisphere with persistent mass effect on the left lateral ventricle and mild rightward shift. There
is persistent vasogenic edema in association with the smaller metastasis noted at the right parieto-occipital
junction. The left occipital metastasis is faintly visualized on the current exam. No unexpected
postoperative finding is identified. There is no new paranasal sinus opacification.:
IMPRESSION: No unexpected finding status post resection/bulking of mass left posterior frontal
convexity. Right parietal occipital and smaller left occipital masses are unchanged on this noncontrast
enhanced exam.
FINDINGS: Since the prior study,the patient has undergone left frontal parietal craniotomy and
resectioning/debulking of a left posterior frontal lobe mass with postoperative seroma/hematoma,
pneumocephalus and persistent extensive peritumoral vasogenic edema and regional sulcal effacement.
Trace subduralblood is present along the left convexity with postoperative dural enhancement.
Redemonstrated are 2 stable hemorrhagic brain metastasis involving the right occipital and left posterior
medial parietal lobes. DWI Sequence demonstrates no evidence of acute infarct. No enhancing lesions are
noted.The ventricles and sulci are normal size and configuration. There is no hydrocephalus,midline shift,
uncal or tonsillar herniation.
IMPRESSION: Status post left frontoparietal craniotomy and resection of a left posterior frontal lobe mass
with expected postoperative changes as described.The patient has undergone left frontal parietal
craniotomy and resectioning/debulking of a left posterior frontal lobe mass with postoperative
seroma/hematoma, pneumocephalus and persistent extensive peritumoral vasogenic edema and regional
sulcal effacement. Trace subduralblood is present along the left convexity with postoperative dural
enhancement. Redemonstrated, are 2 stable hemorrhagic brain metastasis involving the right occipital and
left posterior medial parietal lobes.

2. 2
In addition to brain and lung cancer, she has Hypertension, COPD, Hypothyroidism,
GERD, Anemia, Type II Diabetes Mellitus, Generalized Anxiety Disorder, Major
Depressive Disorder, Hypokalemia, Radiation Sickness and chronic pain. Her MMSE
score on 5/19 was 23/30.
In addition to other medications, she takes Dexamethasone, Atenolol, Clonazepam 0.5mg
bid, Melatonin, Dilantin, Levothyroxine, Trazodone 50mg qhs, Oxycodone 15mg q 4hr
prn, and Morphine 170mg total qd dose (ER and concentrate).
Mental Status Exam: I found her in her room she was sitting on her bed squirming and
rocking back and forth in pain. She said she felt pain all through her right shoulder and in
her back and in her lower spine. She said the pain is continuous. “I rarely sleep; I wake
up at 2 AM and can’t get back to sleep until 6 AM and then I’m up again after one hour”.
She described her current primary problem as pain control and “I want things to be
normal… I want to go home and see my dog”. She said she wants chemo and more
treatment “only if it’s certain to help”. “I don’t want to die in the next few days… I
would like a few years”. Her speech was logical coherent and relevant. Her affect was
blunted and her mood was somewhat depressed. There were no signs of psychosis or
delirium. She was neither delusional nor hallucinated. Her insight and judgment were
limited. She exhibited some denial concerning her prognosis. On orientation questions,
she gave the year as 2016, the month incorrectly as October, the date incorrectly as the
16th and the place incorrectly as Medina Hospital.
Findings and Recommendations: Metastasis to the brain develops in 25% of all
patients with systemic cancer. 40% of patients with small cell lung cancer will develop
metastatic tumors making lung cancer the most common cause of metastatic brain cancer.
Only about 30% of these cases are suitable for surgical treatment. Average survival here
is measured in months or less. When the lung is the source of the metastasis, progression
of the disease is more rapid than when any other organ is the source. Headache, nausea
and vomiting, seizures, and altered mental status are commonly seen with these types of
brain tumors. Particular symptoms, such as focal neurologic deficits are related to the site
of the tumor and can localize the disease to a discrete area of the brain. In her case,
affected areas include: left posterior frontal, right parietal- occipital, left occipital- parietal and left
medial parietal lobes of the cerebrum. The picture is also compounded by hemorrhage and a craniotomy.
Altered mental status as a presenting symptom can range from subtle problems with
behavior, memory, and concentration to depressed levels of consciousness. As best I can
make out, she currently has at least three brain metastases and one tumor on her labia. All
procedures she has undergone so far have appear to have been done for palliative reasons.
From the indications I got, during my mental status exam and her MMSE score, the
tumors have already had a significant negative effect on her cognitive functioning
perhaps rising to the level of a dementia. She does appear to be suffering from depression
and inadequate pain control. Also she seems to be in and out of denial; “I want to live two
more years”.

3. 3
1. Would try her on Lexapro 10mg qd x two weeks then increase to Lexapro 20mg
qd. Would also be much more aggressive with her pain medications. Consider a
Hospice referral. Pain is a frequent precipitant for depression.
2. Generally dying patients are not as afraid of death as they are of suffering and
being alone during the dying process. She needs to know that she will be provided
with maximum pain relief and her family will be with her in her final moments.
3. In brief, frequent contacts allow her opportunities to verbalize her feelings about
her dying but don’t push her to talk about it.
4. Do not challenge her denial but if she shows she wants help working her way
through the following stages of grief (denial… bargaining… depression…
anger… acceptance) please contact me.
5. Ask family to bring in family photographs and objects, which are of sentimental
significance to her and place them about the room.
6. Try to create a soothing and familiar environment in her room, soft music and
dim, indirect lighting might help.
7. Gently encourage her to reminisce about important past experiences in her life.
8. Try to keep her busy and distracted. Follow her normal routine is much as
possible. For example, if she has a favorite television show, see that she has an
opportunity to watch it.
9. Arrange for her to spend time with her dog
(I recently learned that she will be discharged home with hospice care which is an
ideal outcome and one I believe she desires).
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist This document was created using voice recognition software.