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Case Presentation

FARIS MOHD NASIR


1314597

SUPERVISOR: ASST. PROF. DR. MUHAMMAD


NAIMMUDDIN ABDUL AZIH
CHIEF COMPLAINT
• Mr. New, a 64-year-old Chinese gentleman, an active smoker with no known
underlying illness, presented to ED with a complaint of shortness of breath
associated with bilateral upper limb swelling for 1 week duration.
History of Presenting Complaint
• Bilateral upper limb swelling x 1/52
 Painless
 Sudden onset, worsen over time
 Starting with dorsal of the hand, then spread to arm, then neck and around the eye
and cheek.
 No swelling anywhere else
 Worse in the morning, better in evening
History of Presenting Complaint
• Shortness of breath x 1/52
 Intermittent, worsen over time
 Initially only on exertion, prior to admission occur at rest
 Can only talk in words
 Unsure of any exacerbating factors, attacks resolve spontaneously or by rest.
 He can’t perform most of his daily activities because of this
 Can’t lie flat during sleep comfortably, but no PND
History of Presenting Complaint
• Generalized headache x 1/52
 Sudden onset
 Getting worse until the day of admission
 Unsure of any triggering or relieving factors
 Does not radiate elsewhere
 Pain score 5/10
Further questioning:
• Intermittent, non-productive cough for x 1/12
 No coughing out blood
 Worsen over the past 1 week prior to admission
 Occur simultaneously with SOB. No episode of post-tussive vomiting
 No night sweats, fever or chest pain
 No known contact with TB patients
 No LOA, unsure of any weight loss.
 He has a family history of malignancy.
 No history of difficulties swallowing, hoarseness of voice
• He has multiple hospital admission over the past 1 year. The last admission
was around 1 month ago at Hospital Dungun due to fever, shortness of
breath and feeling easily tired.

• 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

• CVS: no chest pain, palpitations

• Neuro: no muscle weakness

• GI: no abdominal pain, nausea, dysphagia, hematemesis, flatulence,


heartburn, melena

• Urinary: no frothy urine, haematuria, loin pain


Past Medical History
• He has no known underlying illness. This is his 3 rd admission in the past 1
year. He had no previous surgery
Drug and Allergy History
• He is not any medication

• He had a history of taking traditional medicine (ginseng-based)

• No known drug/food allergy


Family History
• He is the 3rd out of 7 siblings

• Both of his parents died at old age

• 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

• Besides smoking, he denied taking alcohol, taking IV drugs or involved in


sexual promiscuity
Physical Examination
• General inspection
 Alert
 Lying 45° propped-up position
 Medium built
 He is in respiratory distress, occasional cough, wearing nasal prong with flow of 3L/min
O₂
 Speak in phrases
 Hydration status is good
 Branula inserted left dorsum of the hand, infusion of normal saline
 There’s a sputum pot on the cardiac table

• 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

• Congestive heart failure


 Points for: age, SOB, oedema
 Points against: no palpitation, normal cardiovascular examination
Investigations
• FBC:
 HB: 12.2
 TWBC: 8.5
 P.C.V: 36.6
 MCV: 84.9
 MCH: 28.4
 MCHC: 32.2
 Platelet: 365

• 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

On admission Post tapping


Other investigations
• CT-Scan – to define the level and extend of the blockage, staging in case of
cancer

• Sputum Culture and AFB stain – done, but no result yet

• Bronchoscopy – to take sample for definitive diagnosis.


Final Diagnosis
Superior Vena Cava Obstruction secondary to stage IV Lung
Adenocarcinoma
Acute Managements
• General
 Resuscitation (ABC)
 O2 supplementation 3L/min, keep O2>95%
 IV access

• Pleural Tapping

• Monitoring
 Vital sign monitoring
 I/O charting
Definitive management
• IV Dexamethasone 4mg TDS

• S/C Arixtra (Fondaparinux) 2.5mg OD

• Superior Vena Cava Stenting

• Radiation therapy

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