SVC Obstruction
There is prominent veins over this patient's anterior chest wall. They are tortuous and dilated. The neck veins are engorged with loss of pulsation. The face looks plethoric and suffused.
This is superior vena cava obstruction.
This patient has undergone recent radiotherapy for this medical emergency condition as evidenced by fresh radiation ink marks and skin erythema over the same area.
Any other signs to mention? How do you tie them up to form a complete diagnosis?
What are the other clinical clues to the unifying diagnosis?
Photo courtesy of Wuchereria
Labels: Quiz series, Respiratory
posted by Axonopathic @ 6/11/2007 11:43:00 PM
15 Comments:
Look for Pemberton's sign. It is positive in SVC obstruction.
Don't ever try to test for Pemberton's sign in exam. Just mention it and the reason you wont perform it.
stridor + cervical LN + right middle lobe consolidation (do complete respi exam), check other LN to exclude lymphoma
2 common causes:
bronchogenic CA (radiotherapy)
mediastinal lymphoma
Can look for upper limb edema and worsening of symptoms by bending forward.
Feel for lymphadenopathy, percuss and auscultate the lung. Suspect malignancy.
BTW, why not perform pemberton's sign in exam?
You guys did a great work listing the additional steps to be done:)
But look closely, that patient has tattoos and he's chained to the bed.
In PACES, we're expected to sum up all the clinical signs to arrive to a reasonable diagnosis, apart from eliciting the obvious ones. Bravo!
Any takers?
Wow, looks like there is a great response here!:)
It is a very distressing test for the patient! Please imagine that different PACES candidates perform test repetitively in the exam.
Secondly, please made sure that you are able to resuscitate the patient if the patient turn coma with this test!
Please check for
1.R sided horner syndrome
2.clubbing &nicotine stain
3.signs of endocarditis
Dr Sadiq
Hmm....
Another try then,correct me I am wrong.
An emergency admission of SVC obstruction with tracheal compression requiring radiotherapy means a few things to me
1. The disease is insidious/silent
2. The disease is incurable/late stage due to progression or refusal of treatment.
The patient:
He looks like a young bloke,I'll give probably in his late 20s to early 30s.
No surgical scars evident.
Patient is not cachexic.
No oxygen support line visible.
No IV line (for ?chemo) visible but the right hand is partially covered.
Tatoos could mean bloodborne infection e.g. Hep C, Hep B, HIV
HIV increases susceptibility of cancer.
My top two differentials
1. Small cell lung cancer(it causes most of SVC obstruction, unresectable, thus no surgical scar,strong association with smoking,he probably is a smoker to me:p)
2. Hodgkin lymphoma(bi-peak distribution: young adults and elderly,insidious;I assume you would run the IV chemo here)
Others:
3. Metastastatic cancer. Tatoos could mean Hep C infection,Hep C could lead to hepatoma. Against this : no visible organomegaly,?no jaundice, no visible scratch mark)
To add on, this young tattoo bloke could have endocarditis and mycotic aortic aneurysm which compresses on the SVC.
Signs of endocarditis, chest imaging and urine dipstick for hematuria will help.
just to add on from XZ,
HIV can be the cause for his lymphoma (if he has one)
Could it be disseminated fungal infection (like Histoplasmosis) involving the lungs (pulmonary fibrosis causing SVC obstruction) and the brain (encephalitis with behavioral problems needing a restrainer) in an immunodeficient AIDS patient (tattoo marks as a clue)?
HIV with lymphoma is the answer
these quizes are GREAT!! please keep you the good work! i'm hoping to sit for the exam in november...
my first fifferential would be lymphoma with underlying HIV.
Ca Lung with SVC obstuction is a pssibility though unlikely owing to his young age.
just a quest, would iv dexa help to improve symptoms?
no iv dexa will not help as compared to radiotherapy
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