Scenario #A: Zack is a 12-year old boy who had been in good health with no significant medical history until 6 months ag

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Scenario #A:
Zack is a 12-year old boy who had been in good health with no
significant medical history until 6 months ago. At that time
he began to experience episodic migraine-like headaches, and with a
paternal family history of migraines, Zack was evaluated for
possible antimigraine therapy if the headaches continued.
After 3 months of increasing severity of the headaches, he
was diagnosed by CT scan with a brain tumor. Zack underwent
craniotomy for evacuation of a malignant tumor and began
chemotherapy 1 month after surgery, prior to planned radiation
therapy treatments. He has completed one cycle of
chemotherapy over 2 months and will have a second cycle prior to
radiation. He visits the oncology clinic today for evaluation
prior to his second round of chemotherapy.
Physical examination on this clinic visit reveals a pleasant
young boy in no obvious distress. Zack weighs 43.6 kg (96
lbs) and is 157.5 cm (62 in) in height. BP 92/40 mmHg, pulse
rate is 92 beats/min, respirations of 24 breaths/min, and
temperature of 37.1 C (98.8 F). Zack denies having any pain
and his neurologic examination is unremarkable except for
diminished patellar deep tendon reflexes (DTRs), graded at 1
(decreased but present; normal of 2). His white blood cell
(WBC) count is 3420/mm; Hemoglobin (Hgb) 13 g/dL; hematocrit (Hct)
36.5%; and his platelet count is 225,000. CBC is within range
expected post chemotherapy. Zack will be hospitalized for
approximately 2 days for administration of cyclophosphamide
(Cytoxan), carboplatin (Paraplatin), and vincristine (Oncovin) and
will continue to receive doses of vincristine as an outpatient and
start etoposide (VePesid) in several weeks. Because he
experienced significant nausea and vomiting with the last round of
chemotherapy, he will also be given ondansetron (Zofran) regularly
with supplemental corticosteroids IV as needed.