Professorial group B

IWC 3
MFC 864 - 873
CASE HISTORY
70 year old lady
previously healthy
cough and sputum stained with bright
red blood 3 Weeks
Right sided pleuritic type chest pain.
One week later developed SOB
while walking 20-30 m.
Impairment of ADL
++
Differential diagnosis based on
presenting problems
Common
Tuberculosis
Malignancy-primary or secondary
Bronchiectasis



LESS PROBABLE

Wegeners granulomatosis
Goodpastures syndrome
Pulmonary oedema
Pulmonary embolism



FURTHER MORE.
LOA & LOW during the last two months.

No fever

No night sweats or contact history of TB.


FURTHER MORE.
No wheeze/ stridor or hoarseness.

No history of passing red coloured urine.

No history of ankle swelling, orthopnoea
or PND.
Systemic review
No difficulty in swallowing/nausea or vomiting/acid
reflux/ dyspepsia/ abdominal pain/ bloating/ bleeding
PR/ altered bowel habits
No headache/ loss of consciousness/ fits/
paralysis/numbness/diplopia
No dysuria/ loin pain/ haematuria / frothy urine/ stress
incontinence
No postmenopausal bleeding, vaginal discharge
No other bleeding manifestations

No positive findings ..
PAST MEDICAL \ SURGICAL
HISTORY
No past history of similar episodes/
Tuberculosis/ Malignancies/ Bleeding
disorders/ recurrent chest infections

No past history of DM/ Hypertension/
IHD/ BA/ epilepsy


PAST MEDICAL \ SURGICAL
HISTORY
No history of exposure to radiation,
chemicals or cytotoxic drugs.

Bilateral cataract surgery - 2 years back.


FAMILY HISTORY

Positive family history of Bronchial
asthma, stroke
No positive family history of TB or
malignancies (especially respiratory tract,
breast & GIT)

Social History
3 children, husband died 10 years ago
Lives with daughter
Employed as a house maid previously
Not a smoker but had exposed to passive
smoking for more than 20 years.
No exposure to asbestose.

Examination
General examination
Emaciated, mildly dehydrated, small built
elderly lady.
Gross clubbing but no Hypertrophic pulmonary
osteoarthropathy.
Dyspnoeic but afebrile. Not pale, icteric or
cyanosed. No lympadenopathy.
Poor oral hygiene, No features of Horners
syndrome, no small muscle wasting of hands.
No ankle oedema.
Respiratory System
RR 28/min
Reduced chest wall movements on right
side. No use of accessory muscles.
Trachea deviated to left.
Tactile vocal fremitus impaired on right
lower zone.
Stony dull on right lower zone.

Respiratory System
No breath sounds in R/ lower zone,
Vesicular breathing . No added sounds.

Vocal resonance impaired on right lower
zone.


OTHER RELAVANT SYSTEMS
No abnormality detected in other
systems except for blood pressure of
150/110 mmHg.

Breast and thyroid examination normal.

SUMMERY
70 year old lady presented with cough &
haemoptysis for 3 weeks , she is also
having LOA, LOW but no fever or night
sweats
She is dyspnoeic, has gross clubbing
and right sided pleural effusion.
PROBLEMS
1. R\s pleural effusion
2. Hypertension
3. Loss of appetite, poor nutrition.
4. Widow, dependent on children.




DIFFERENTIAL DIAGNOSIS
Tuberculosis

Lung malignancy


INVESTIGATIONS
BASIC
ECG
FBC AND BLOOD PICTURE
CXR
ESR
UFR
FBS
GROUPING AND DT
CLOTTING PROFILE
BLOOD UREA / SERUM CREATININE /
ELECTROLYTES


RESULTS
1. ECG - no ischemic changes

2. Full blood count
1. Hb 12.5 g/dl
2. WBC 17500 / mm
3
3. N - 80%
4. L - 10%
5. PLT 400,000 / mm
3

3. ESR 80 mm 1
st
hour
4. CXR R/s massive pleural effusion
5. FBS 100 mg/dl
6. Clotting profile
o PT- 11.6 seconds INR 0.97
7. RFT results were not available



SPECIFIC
INVESTIGATIONS
Sputum for AFB and mantoux
Pleural fluid aspiration / post asp. CXR
Pleural biopsy
Contrast CT- thorax
Bronchoscopy
Bruishings
Washings
Biopsy

RESULTS
Sputum negative for AFB
Pleural fluid
Full report
Blood stained
Blood clots +
Pus cells ++
Red cells moderately field full
Protein 4.5 g/dl

AFB negative
Culture no growth seen
Post aspiration CXR
R/s Hilar mass + - could be TB, malignancy or lymphoma

RESULTS ..ctd
Bronchoscopy






Tumour seen
Brushings taken for cytology
Inoperable
Refer to oncologist with the report




INVESTIGATIONS FOR
SECONDARIES
1) LFT elevated liver enzymes liver
secondaries
2) Alkaline phosphatase
3) Serum calcium - elevated in bone 2
ry
or
small cell carcinoma PTH
4) X- ray spine look for lytic lesions
5) USS abdomen - look for secondaries in
liver
6) Radio nucleoid Bone scan

MANAGEMENT
Confirm diagnosis
If Neoplasm..
Breaking bad news - SPIKES
Discuss about treatment options
Multidisciplinary approach
physician, surgeon, oncologist, radiotherapist,
terminal care nurse



DEFINITIVE THERAPY
If operable Grading and staging

Curative surgery

C/I for surgery
I. Tumour within 2 cm of the carina
II. Malignant pleural effusions
III. Superior vena cava syndrome
IV. Extrathoracic distant metastasis
V. Vocal cord or phrenic nerve palsy
DEFINITIVE THERAPY.ctd
Radiotherapy
small cell carcinomas are radiosensitive

Chemotherapy
etoposide + cisplatin given every three weeks

supportive therapy
o Antiemetics
o Monitoring blood counts
o Maintaining hydration

MANAGEMENT OF OUR PATIENT
Non Operable
Supportive Care and improving quality of life
Pain relief
If recurrent pleural effusion pleurodesis
Maintaining nutrition
Hydration
Control of BP
If superadded infection antibiotics

Address other psychosocial and legal aspects
MANAGEMENT OF OUR PATIENT
Refer to a family doctor
To address
pain
vomiting
constipation,.. etc.