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NEUROBLASTOMA
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Patient is born term to a G2P2 (2003) mother with a twin, delivered via normal spontaneous
delivery at a local district hospital without complications. With birth weight of 2.5kg, birth
length of 44 cms and good apgar score of 9, 10. Noted good cry and good suck, no jaundice.
At 5 months old, patients folks noted a slowly growing mass at the lower back associated with
weakness of movement and eventually progressing to immobility of the lower extremities. Folks sought
consult with a private physician, and was given unrecalled medications. Patient was also referred to a
specialist which advised CT scan of the whole abdomen but was not able to comply due to financial
constraints.
At 7 months old, there was persistence of the growing mass and no resolution of the immobility. They
again sought consult and was then admitted under the department of surgery. CT of the whole abdomen
was done which showed retroperitoneal mass lesion with invasion into adjacent spinal column and
paraspinal muscles with possible involvement of the spinal cord. Malignancy primarily considered.
Biopsy of the mass was also done revealing an impression of small round cell tumor favoring
neuroblastoma.
Due to the proximity of the lesion to the spinal cord, surgery became an unlikely option. Patient was
advised and underwent chemotherapy with cyclophosphamide, etoposide, and GCSF 1 month prior to
admission.
Patient was scheduled for 2nd cycle of chemotherapy and was then admitted.
Review of Systems:
General Survey: Patient is awake and active. No signs of distress noted throughout the interview.
Patient is dressed appropriately for the environment.
Vital Signs:
Ht: 66 cms BSA: 0.33 CR: 119 bpm Temp: 36.2C
Wt: 6.3kg BMI: 14.5 RR: 23 cpm
HEENT:
The skull is normocephalic and atraumatic. No deformities nor injuries of the scalp. Scalp has no
discolorations, lesions or scaling. Anicteric sclera with pinkish conjunctiva bilaterally. Both
pupils are equally round and directly and consensually reactive to light and can accommodate.
Ears symmetrical without discharges. Nose symmetrical, no septal deviation or discharges. Oral
mucosa and gingiva pink in color. No lesions noted.
Cardiovascular:
Inspection revealed PMI located 12cm lateral to the midsternal line with irregular timing. No
thrills were felt. No bruits or thrills also in the carotid arteries. Cardiac dullness heard in the left
3rd, 4th and 5th ICS. Grade 2 murmurs were heard over the 3-5th intercostal space on the lateral
sternal border with increasing intensity over the apex. Jugular venous pressure measured 4 cm
above the sternal angle taken with head elevated 30 degrees.
Abdomen:
The abdomen was symmetric, uniformly brown in color, no areas of redness or swelling was
note. Bowel sounds with a frequency of 16/minutes were heard. No bruits or friction rubs heard.
No pain on both light and deep palpation. No masses were felt. Liver span measures 6 cm
midclavicular line and 4 cm midsternal line. Smooth liver edges and no pain during palpation.
Spleen and kidneys were not appreciated during palpation. Negative for splenic percussion sign
and negative costovertebral pain. No shifting dullness nor fluid wave.
Peripheral Vascular:
No varicosities noted on both upper and lower extremities. Extremities are warm to touch
without pitting edema and no palpable epitrochlear nodes. Color of the nail beds is pinkish and
nails without clubbing or cyanosis.
Pulses: Full
Musculoskeletal:
The patient's Temporomandibular joint is intact, it is symmetric, no atrophy, tenderness or
swelling in the muscles of mastication. The patient was able to exhibit a full range of motion in
the TMJ. Symmetric shoulder, elbow, wrist and hands bilaterally. No tenderness, swelling,
atrophy of joints bilaterally. Full range of active and passive motion on shoulder, elbow, wrist
and hands of the patient. The patient was able to exhibit a full range of motion in the spinal
column and hip joint. The patients knees were symmetric, no swelling or effusion. MCL, ACL,
PCL and LCL were all intact. The patient was able to flex and extend his knees without
restrictions and tenderness. No tenderness and were able to exhibit full range active and passive
of motion on the ankle.
Neurologic:
Mental status:
Patient sitting in bed, alert, relaxed, and cooperative. Oriented to time person place
Cranial Nerves:
I intact sense of smell,
II visual acuity intact; visual fields full;
III, IV, VI extra-ocular movements intact;
V motor-temporal and masseter strength intact, sensory-corneal reflexes present;
VII facial movements intact, sensory-sense of taste intact;
VIII-hearing intact; negative lateralization
IX, X-gag intact;
XI-strength of sternomastoid and trapezius muscles 5/5;
XII-tongue midline.
Motor System: Good muscle bulk, tone, and strength.
Cerebellar: Rapid alternating movements of the hands, finger to nose intact.
Sensory System: Pinprick, light touch, position, and vibration intact.
Reflexes: 2+ all