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• CT-scan and pleural tap was done (unsure how many cc was drained). The
patient was unsure of the exact diagnosis at that time
• The patient is an active smoker, smokes around half pack/day. (total 25 pack
years)
Systemic Review
• Respiratory: No URTI symptoms
• One of the siblings had leukaemia, otherwise all are alive and healthy
Social History
• He used to live in Dungun, but as his health condition deteriorates, he move
here and live with his sister.
• He used to work as a car painter but stopped around 3 weeks ago due to
health reasons.
• He is single
• Vital signs
BP: 143/98 mmHg
PR: 109 bpm
RR: 20 bpm
Temperature: 37°C
Peripheral Examination
• Hand
Palm is warm, not clammy
No clubbing
No tremor
No nicotine stain
Pitting oedema over bilateral U/L up until the shoulder
No skin changes
BCG scar noted at left arm
• Head
There was no pallor or jaundice
Oral hygiene is satisfactory
No central cyanosis
Facial and neck swelling. More prominent on the cheek and periorbital.
No cervical lymphadenopathy
• Chest
On inspection, there’s multiple dilated veins over the chest area.
No structural deformity. No surgical scar
Apex beat was palpable at 5th intercostal space, lateral to mid-clavicular line
Trachea was centrally located
Chest expansion reduced on the right side
Findings are confined to right middle and lower zone of the lung
Reduced tactile fremitus
On percussion, there was stony dullness
On auscultation, reduced but vesicular breath sound
Reduced vocal resonance
No rhonchi
Back: similar findings, no sacral edema
• CVS
On inspection
No chest wall deformity, visible pulsation or surgical scars
Palpation
Apex beat located at the 5th ICS lateral to midclavicular line
No parasternal heave
No palpable thrill
Auscultation
S1 and S2 were heard
No added sound
• Lower limb
No pedal oedema
Summary
• Mr New, 64-year-old Chinese gentleman, active smoker with no known
underlying illness, presented with a history of bilateral U/L and facial
swelling associated with shortness of breath and generalized headache for 1
week duration. He also had history of intermittent non-productive cough for
1 month duration. Denied having constitutional symptoms. Known family
history of malignancy.
• On examination, there was bilateral U/L, neck and facial swelling and
multiple dilated veins on the chest. On respiratory examination, there was
reduced chest expansion, tactile fremitus, vocal resonance, air entry and
stony dullness, all confined to the left lung
Provisional Diagnosis
• Superior Vena Cava Obstruction secondary to Lung CA
SCVO outlet obstruction symptoms:
Upper limbs oedema, facial swelling, headache, dilated veins
Family history of malignancy
Smoker
Suggestive physical examination findings
Differential Diagnosis
• Pulmonary Tuberculosis
Points for: Prolonged cough, reduced air entry
Points against: no night sweats, weight loss, contact with TB patients, reduced
tactile fremitus
• ABG
pH: 7.45
pCo2: 38.7 mmHg
pO2: 80.0 mmHg
HCO3: 23
• Liver Profile
Total bilirubin: 15.6
Total protein: 65.0
Albumin: 36
Globulin: 29
ALP: 107
ALT: 12
AST:11
• Chest X-ray
• Pleural Tapping
• Monitoring
Vital sign monitoring
I/O charting
Definitive management
• IV Dexamethasone 4mg TDS
• Radiation therapy