Management of Delirium
Management of Delirium
Ms. B is a 44-year-old married African-American female who was diagnosed with locally advanced right breast cancer in 2002. Immunohistochemistry in the original tumor was estrogen- and progesterone-receptor-negative, HER2-positive. Her past medical history is significant for hypertension and miscarriage in 1995.
After surgical consultation, it was decided that preoperative chemotherapy and radiation would be administered. Ms. B was started on doxorubicin/cychlophosphamide, followed by docetaxel (Taxotere). She underwent a modified radical right mastectomy with axillary dissection in 2003. She was found to have 2 positive nodes out of 14 and extensive necrosis of 7 additional nodes. After recovery from surgery, she underwent external-beam radiation therapy.
Ms. B did well until late 2004, when she was found to have progression in her left neck. Magnetic resonance imaging (MRI) revealed multiple masses in the supraclavicular region. She was started on single-agent capecitabine (Xeloda), as her tumors were noted to be HER2-negative.
Unfortunately, her disesase progressed on capecitabine and she was enrolled in a clinical trial in early 2005 using a tyrosine kinase inhibitor. She did well until mid-2005, when her cancer progressed further. She then received vinorelbine and her disease stabilized.
In spring 2006, she underwent an elective left mastectomy and bilateral breast reconstruction. Multiple infections and other complications after surgery resulted in postponement of chemotherapy during the summer. In fall 2006 her cancer was restaged and was found to have progressed in her neck and to have metastasized to the cerebellum and temporal lobes of the brain.
Ms. B developed simple partial seizures at home and was admitted to begin dexamethasone 4 mg every 6 hours and levetiracetam (Keppra) 500 mg bid. She was discharged after consultation with neurosurgery for treatment with gamma knife and surgical resection, which she declined. She instead received a course of whole-brain radiation. Her steroids were gradually tapered. In December 2006 she was admitted to the neurology ICU in status epilepticus. An MRI showed a decrease in previous lesions with a new parietal lesion and minimal edema without midline shift.
Ms. B was stabilized with phenytoin 100 mg tid, levetiracetam 1,000 mg bid, valproic acid 500 mg bid, and dexamethasone 4 mg every 6 hours, and transferred to oncology.