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    CASE STUDIES CASE STUDIES Presentation Transcript

    • DR Awadhesh kr sharma,SR DEPTT OF MEDICINE MLB MEDICAL COLLEGE JHANSI(UP) Two Case studies
    • CASE - I
      • Mr. Durga Prasad 70 years ,Male, farmer by occupation presented with chief complaints of –
      • Productive cough for 8 months.
      • Loss of appetite for 8 months.
      • Loss of weight upto 25% for 8 months.
        • Negative History –
        • No history of…..
        • High grade fever
        • Haemoptysis
        • Foul smelling sputum
        • Exertional dyspnoea
        • Chest pain
        • Orthopnoea
        • PND
        • Pedal edema
        • Engorgement of neck veins
        • Ascitis
        • Rt hypochondriac tenderness
        • Oligurea
        • Burning micturation
    • Past history – no h/o DM, HTN & TB. Personnel history – Patient is chronic bidi smoker for 48 years, he used to smoke 30 bidi per day. Smoking index = 48 x 30 = 1440 i.e. > 300
    • General examination – Built – Average PR – 82/min BP- 110/80 mm of Hg RR – 16 / min Temp – afebrile Pallar--- ++ Cyanosis – absent Clubbing – absent Icterus – absent Lymph node enlargement – absent JVP – not raised
      • On respiratory system examination -----
      • Trachea is central.
      • In right inframammary, lower axillary, inter and infra scapular region –
      • diminished chest movement
      • increased tactile vocal fremitus, vocal rasonace
      • impaired percussion note
      • bronchial breath sound
      • Examination of other systems is with in normal limit.
    • On the basis of above history, examination and investigations the presumptive diagnosis is------ Right middle and lower lobe consolidation with cavitation
      • Cause?
      • Pulmonary Kochs
      • Lung carcinoma
      • Lung abbcess
      • Points against pulmonary Kochs –
      • No h/o fever with evening rise of temperature.
      • Right lower lobe involvement – an unsual site
      • Sputum microscopy negative for AFB.
      • No response to ATT.
      • Points against lung abcess –
      • No h/o high grade fever.
      • No h/o copious amount of foul smelling sputum.
      • No tachycardia & tachypnea.
      • Total leucocytes count are normal.
    • So we think in terms of lung malignancy, & go for HRCT which shows –
    • Then we done USG guided FNAC of the lesion which confirms it to be squamous cell carcinoma involving rt middle & lower lobe of lung.
      • Discussion
      • Primary carcinoma of the lung is the leading cause of death in both men and women, accounting for 1.18 million deaths from lung cancer worldwide in 2007.
      • The relative risk of developing lung cancer is increased about thirteen fold by active smoking and about 1.5 fold by long term passive exposure to cigarette smoke.
      • About 15% of lung cancers occur in individuals who have never smoked. The majority of these are found in women.
      • Radiation is another enviromental cause of lung cancer.
      • Four major cell types make up 80% of all primary lung neoplasms according to WHO there are –
            • Squamous or epidermoid CA
            • Small cell (oat cell) CA
            • Adenocarcinoma (including bronchioloalveolar)
            • Large cell CA
      • Most frequent histologic subtype is adenocarcinoma.
      • Major treatment discussion are made on the basis of wheather they are classified as a small cell lung CA or non small cell lung cencer.
      • At presentation, SCLCs usually have already spread such that surgery is unlikely to be curative and are managed primarily by chemotherapy with or without radiotherapy.
      • NSCLC that are clinically localized at the time of presentation may be cured with either surgery or radiotherapy.
      • Squamous and small cell cancers usually present as central masses with endobronchial growth, while adenocarcinomas present as peripheral masses.
      • Squamous cell CA cavitate in 10-20% of cases.
      • Although 5-15% of patients with lung cancer are identified while they are asymptomatic usually as a result of routine CXR or through the use of screening CT scan, most patients presents with some sign or symptom.
      • Central/endobronchial growth- causes cough, hemoptysis, wheeze, stridor, dyspnoea and post obstructive pneumonitis.
      • Peripheral growth- Pancoast or superior sulcus syndromes
      • SVC syndrome
      • Extrathoraccic metastatic disease
      • Paraneoplastic syndromes
      • Skeletal connective tissue syndrome
      • The role of screening high risk patients (for example current or former smokers >50yrs of age) for early stage lung cancers is debated.
      • Low dose, non-contrast, thin slice, helical or spiral CT has emerged as a possible new tool for lung cancer screening.
      • Once sign, symptoms or screening studies suggest lung cancer, a tissue diagnosis must be established .
      • Tumour tissue can be obtained by a bronchial or trans bronchial biopsy during fiberoptic bronchoscopy, by fine- needle aspiration of thoracic or extrathoracic tumour masses using CT guidance or by percutanecus biopsy of enlarged lymph node, soft tissue mass.
      • According to TNM staging, our patient belongs to T3 NoMo i.e. stage IB.
      • Stage IB, IIA and IIB who can tolerate operation, the treatment of choice is pulmonary resection.
      • The role of adjuvant chemotherapy for stage IB disease is undefined, subset analysis of all the randomized studies showed no benefit in patient with stage IB.
    • CASE – II
      • Mrs. Leelawati 75 years, Female, Housewife, resident of Oraiya, admitted with chief complaints of –
      • Cough with progressively increasing breathlessness for 5 months.
      • Acute exaggravation of breathlessness with bilateral pedal edema for 10 days.
      • Negative history –
      • No history of –
      • chest pain, perspiration
      • PND
      • Fever
      • Drugs intake
      • Intermittent claudication
      • DVT
    • Past history – no h/o DM, HTN, TB Personnel history – Non bidi smoker Family history – not significant On Examination PR – 100/min, regular, normovolumic, normal in character without any radiofemoral and radioradial delay. BP – 90/60 mmHg in right arm in supine position. RR – 22/min, regular, thoracoabdominal Temp – N SpO2 – 86% without O2 Pallar-absent Cyanosis-absent Clubbing-absent Icterus-absent Lymphadenopathy-absent JVP – raised, cv wave present Pedal edema--- +
      • Cardiovascular system examination
      • apical impulse is in 5th ICS at MCL
      • palpable & loud second sound (P2)
      • Left PSH of grade II/III
      • Pansystolic murmur of grade III/VI in tricuspid area which increases in intensity on inspiration.
      • Respiratory system ----
      • Bilateral coarse basal crepts present on auscultation.
      • Abdominal system examination----
      • Tender hepatomegaly 2 cm below costal margin.
      • So,
      • Clinical diagnosis –
      • Severe pulmonary artery hypertension with severe TR with congestive heart failure stage C cause ?
      • Cor pulmonale
      • Pulmonary thromboembolism
      • Primary pulmonary artery HTN
      • On investigation
      • Routine investigations
      • ECG
      • CXR PA view
      • USG abdomen
      • D- dimmer assay
      • PFT
    • So, final diagnosis is pulmonary hypertension associated with lung disease and or hypoxemia cause COAD.