CASE STUDY MEDICAL HISTORY 68 yr old Caucasian male with metastatic renal cell c

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CASE STUDY MEDICAL HISTORY 68 yr old Caucasian male with metastatic renal cell carcinoma. He was a millwright for the city ater department but is now retired. He has a medical history of dyslipidemia (total cholesterol 178 mg-d' density lipoprotein cholesterol 24 mg dl', triglyceride - 774 mg dl), hypertension, and myocardial ion in August 2003. He also has a history of atrial fibrillation. In January 2005 his body mass was kg, his blood pressure was 11 0/70 mmHg, and his heart rate was 72 beats min- Current medications are ol, isosorbide dinitrate, Solu-cortef, fenofibrate, and aspirin. DIAGNOSIS In 2000 during a follow-up visit for impotency in the Department of Urology, urinetests detected micro hematuria The following year, stillhaving difficulties ofimpotency, the patient complained of gross hematus and right flank discomfort. An intravenous pyelogram tomography scan showed a right renal mass that invaded the right kidney and the inferior vena cava. He underwent a right radical nephrectomy in November 2001 for stage IIIA renal cell carcinoma. Pathology showed invasion of the renal capsule, as well as the renal vein and inferior vena cava. scopic suggested a renal mass. Results of a computed A follow-up computed tomography scan in April 2003 showed metastases in the lower lobe of the left lung These nodules were considered too small for biopsy. In May 2003 he complained of radiating pain from the right buttock to the knee. A bone scan identified widespread bone metastases. Magnetic resonance imaging showed a mass in the left posterior lateral aspect of the lumbar vertebrae. He underwent 14 d of radiotherapy in June 2003, during which his back discomfort improved. As part of a clinical trial, he also received two courses of interferon and chemotherapy. In May 2004, Mr. CB underwent surgical decompression and excision of an L3 vertebrae tumor. He began immunotherapy with interferon alpha in July 2004. Repeat magnetic resonance imaging and bone scans through January 2005 showed the disease to be stable. EXERCISE TEST RESULTS Mr. CB's most recent electrocardiogram showed normal sinus bradycardia with evidence of a previous inferior wall myocardialinfarction. Resting heart rate was 53 beats-min" An exercise stress test completed in August 2003 was mildly suggestive of ischemia, with a VO,peak of 17.6 ml. kg min-. Peak heart rate was 92 beats min,and exercise was discontinued because of mild- to moderate-grade angina. His cardiac status is now stable with Canadian Cardiovascular Society grade 2 angina. EXERCISE PRESCRIPTION During chemotherapy in 2003, Mr. CB began an exercise program. He exercised 3 or 4 d/wk at a perceived exertion of 11 to 12 (Borg scale 6-20) and at a prescribed heart rate range of 72 to 82 beats-min. This heart rate range was free of any electrocardiographic evidence of ischemia. Exercise modalities included treadmill, dualaction bike, and rower. Exercise therapy was tolerated well, without complications or symptoms. DISCUSSION QUESTIONS What effect does metoprolol have on heart rate response to exercise? Would you alter how you go about guiding exercise intensity for patients taking this drug? Fatigue and mood disturbances are common com I. both to the disease itself and to the treatments used to manage the disorder. cise should be used or withheld in and around those times when a patient are common complaints of patients with cancer, often attributable Explain whether exer-

Explanation / Answer

1.The action of metoprolol is to decrease the heart rate. During exercise normally the heart rate increases,but if you are taking metoprolol and doing exercise then heart rate instead of increasing it will decrease and you can't reach the target heart rate.

The patient may try to increase there exercise intensity to achieve their target heart rate hence patients must be advised to not to increase the intensity of exercise as it will lead to atrial fibrillation and other cardiovascular problems .

2. Exercises help to ease side effects of chemotherapy like nausea , fatigue etc . After taking the permission from the doctor only you should start exercising because some of the chemo drugs have severe effects with exercise.Low intensity exercises must be done like walking , riding bicycle,doing aerobic exercises and resistance training like isometric exercise, flexibility exercises.

If the patient is tired ,have a low HB ,TLC counts the patient should take rest and no exercise must be done. For guiding intensity the patient can be referred to physical therapist who deal with cancer patients for proper advise and guide.

When the patient have signs andsymptoms like fatigue, tingling, numbness, neuropathy, pain ataxia ,anemic and LOW TLC ,HB counts exercise should be avoided until safe levels of counts are achieved.

If the patient complains of shortness of breath, chest pain , fatigue, dizziness etc during exercise then the doctor must be consulted immediately. The effectiveness of exercise regimen will include :-

Less tiredness and mood swings

Energetic

Good sleep pattern

Better focusing

Recovery from intense environment

3. Resistance training program is increases the strength of muscles by working against a weight or force. Some of the examples are pull downs, two arms bent over rows etc . Patient must be referred to physical therapist for exercise advice. According to the test results the patient must take rest because his body can't take the workload as he is having infarction .

Resistance training exercise is one of the exercise which a cancer patient can do but before starting exercise ,monitoring of the patient blood reports,his general conditions,any medicine which interact with exercise like adriamycin (decrease heart rate) etc should be done and permission from the treating doctor must be taken to avoid complication.

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