Intern report

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Intern report

• Intern ???

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Basic data

• Name ?
• 37 y/o
• Male
• Occupation Worker
• Married
• ??

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Chief complaint

• Right neck painful swelling for 3 days

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Present illness

• 3 months ago
• 1. Bulging right lower neck mass
• 2. Body weight loss from 70kg(May,2006) to
  65kg(July, 2006)
• This month
• Intermettent chest dullness
• Orthopnea
• Difficulty in repiratoy while swallowing
• 8 days ago excisional biopsy due to right neck
  mass

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Present illness (continued)

• 3 days ago
• 1.biopsy wound erytematous, painful, farm,
  and swelling
• with radiating numbness
• 2. fever without chillness

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Past history

• Denied systemic disease
• Smoking 1 ppd for 20yrs
• Alcohol 12 bottles a day
• Betal nuts a few

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Physical examination

• Neck
• 1. right neck swelling and erythema change
• 2. trachea central position
• 3. fixed LNs 32cm at right neck zone IV/V
• Chest dilation of superficial vein and capillary
  over subclavicular area
• Lymph system no palpable axillary nodule,
• no palpable inguinal
  nodule

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Lab data

• WBC 7570
• Neutrophil seg73.5
• Lympocyte16.2

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Image finding

• Nodules in RML with interstitial pattern
• Prominent right pericardial effusion
• Confluent mass in pretracheal space, pretracheal
  space
• Right paratracheal tripe, with encasement of
  right pulmonary artery
• Swelling of soft tissue in right chest wall
• Persence of right pleural effusion with several
  nodules

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Pericardiocentesis(95.8.1)

• Indication massive pericardial effusion r/o
  metastasis
• Dark bloody effusion was drained for about 10ml
  but acute pleuric chest pain with dyspnea
  developed.
• f/u cardiac echo revealed mild to moderate amount
  of pericardial effusion and left pleural effusion
• Consult CVS for emergent management

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Operation (95.8.1)

• Operation methods
• 1. decrotication of left pleural cavity
• 2. pericardial pleural window
• 3. mediastinal tumor excision

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• Operation finding
• 1. mediastinal tumor, neck tumor with SVC
  syndrome
• 2. massive pericardial effusion s/p pigtail
  insertion with acute dyspnea, r/o heart injury
• gtnew onset of Lt hemothorax around 1100 with
  fibrin clotting over lung surface, without heart
  injury/pneumothorax

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Impression

• metastasis in mediastinum with SVC syndrome,
  origin unknown.
• Airway compression due to enlarged cervical LNs
• Right pulmonary hypertension

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Progress (95.8.2)
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Plan

• 1. Maintain airway
• Branchoscopic exam
• evaluation the indication of stent
• 2. Consult hematologist for reduce SVC syndrome
  by C/T

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Superior vena cava syndrome

• Obstruction of blood flow in the superior vena
  cava
• can be caused either by invasion or external
  compression by contiguous pathologic processes
  involving the right lung, lymph nodes, and other
  mediastinal structures

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Symptoms and signs

• Dyspnea is the most commonly reported symptom
• facial swelling or head fullness
• cough, arm edema, cyanosis
• Varicose vein of chest, neck and sublingual area
• May compress the airway

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Etiology

• Malignant tumors are responsible for 78 to 85
  percent of cases
• Lung cancer is the most common malignant cause
  of the SVC syndrome, followed by lymphoma.
• responsible for 94 percent of cases of SVC
  syndrome
• Infection and thrombosis account for most of the
  remainder.
• 60 percent of patients with SVC syndrome related
  to malignancy present without a known diagnosis
  of cancer. Such patients also require tissue
  biopsy for histologic diagnosis.

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Diagnosis - Radiography

• Chest CT preferred imaging modality. 1.defines
  the level and extent of venous blockage,
• 2. identification of the underlying cause of
  venous obstruction.

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Diagnosis - Histology

• Minimally invasive techniques
• pleural fluid cytology , bone marrow biopsies,
  biopsy of enlarged peripheral lymph node
• Bronchoscopy may be indicated when less invasive
  procedures do not provide a definitive diagnosis

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Treatment

• Treatment is directed toward control of the
  underlying disease
• With C/T or R/T

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• THANK YOU