BRONCHOGENIC CARCINOMA CHALLENGES IN EVALUATION
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1 BRONCHOGENIC CARCINOMA CHALLENGES IN EVALUATION GRAND ROUND WARD 7C DATE: 25 TH MARCH 2015 PRESENTER: DR E. SAYO FACILITATOR: DR J MECHA
2 DEMOGRAPHIC DATA NAME : CM AGE: 69 YEARS ADDRESS : KIAMBU OCCUPATION: SECURITY GUARD MARITAL STATUS : MARRIED
3 PRESENTING COMPLAINTS COUGH Rt. CHEST PAIN 1 year DIFFICULTY IN BREATHING 2/12
4 HPI Pt was last well in December 2013 (15 months ago) A chronic smoker (20 pack yrs) with cough productive of whitish sputum. Cough occurs throughout the day and sputum is not foul smelling nor blood stained. Increase in the severity of cough affecting both day time activity and sleep noted over the past year. Rt. side chest pain, worse when coughing with no known relieving factors. Pain is dull in character, severe and but non radiating.
5 HPI cont. Progressive dyspnea with limitation of physical activity noted over the past 2/12. No report of dyspnea at rest. Other symptoms: weight loss, loss of appetite, hoarseness of the voice, fever and generalized body malaise. No known TB contact Pt was seen at a district hospital and started on anti TB medications in Jan 2014 (based on CXR). Symptoms persisted even on completion of his 6 m course.
6 HPI.cont. Review of systems : non- contributory No - Blurred vision, seizures, limb weakness, Bone pains, Polyuria, Facial swelling, Arm swelling, difficulty in swallowing, Abdominal pain, lower limb swelling, joint pains /swellings. Re- evaluated for the cause of the persistent symptoms in Nov 2014 (5 months after completing anti TB medication).
7 Past medical History None significant Family/ Social History No known FamilyHx of chronic illness Parents died of unknown causes 3 Siblings, only one with HTN SMOKING 20 PACK YRS (stopped 10 yrs ago). Stopped alcohol 15 yrs ago. No history of illicit drug use
8 Drug History No known drug allergies Occupational History No known exposure to asbestos or industrial hazards.
9 EXAMINATION GENERAL: Sick looking, wasted No dehydration, pallor, peripheral LN, cyanosis, jaundice, or fever. HANDS: No Finger clubbing No nicotine stains FACE: No ptosis or miosis. NECK: No- distended veins, enlarged thyroid, SVC obstruction.
10 RESPIRATORY SYSTEM RR - 18 bpm, symmetrical No - resp. distress, abnormal breathing pattern, chest wall deformity. Trachea central, normal chest expansion, tactile vocal fremitus equal both sides. Percussion notes normal on both sides Breath sounds vesicular with no rhonchi or crepitations Normal vocal resonance and whispering pectoriloquy.
11 OTHER SYSTEMS CNS : Normal higher functions no peripheral weakness no nerve palsies CVS : BP- 118/70mmHg, PR- 95bpm. Normal volume, regular rhythm. JVP not raised S1, S2 normal No pericardial rub No murmurs
12 OTHER SYSTEMS cont.. ABD: Not distended, no tenderness, Liver span 12cm Spleen, kidneys - not palpable bowel sounds normal M/S: No joint swellings or deformity Normal joint movements. PERFORMANCE STATUS: PS 1 (East Coast Oncology Group)
13 SUMMARY A 69 yr old chronic smoker (20 pk yrs.), who presented with productive cough, chest pain for 1 year. Progressive dyspnea for 2/12. Completed course of anti TB meds with no clinical improvement. Severe wasting Respiratory examination - unremarkable No other significant systemic findings.
14 LABORATORY REPORT (26/02/15) WBC HB PLT ESR UREA CREAT K Na Ca INR ALT AST ALB TP ALP GGT TBIL DBIL LDH RBS ESR LDH NOT DONE Ca PO4
15 OTHER LABORATORY RESULTS SEROLOGY HIV- negative HBsAg negative Hep C Ab negative SPUTUM ANALYSIS Sputum for AAFB- negative Gene xpert (sputum) negative Sputum cytology not done
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18 CHEST CT SCAN RESULT 26 JAN 2015 There is a 4.9cm X 5.8cm mass on the right middle lobe with an irregular outline. There is obstruction of the right lower lobe with brochiectactic changes. Enlarged lymph nodes at the right mediastinal and subcarinal regions. Liver, Spleen, pancreas, adrenals and bones are normal CONCLUSION: Features are highly suggestive of bronchogenic carcinoma with obstruction of the right lower lobe. NB- Biopsy and histology recommended
19 BRONCHOSCOPY DONE 6/03/15
20 BRONCHIO- ALVEOLAR LAVAGE 13 /03/15 Hemorrhagic fluid with scattered mononuclear inflammatory cells. ZN stains for acid fast bacilli are negative. Malignant cells are not represented in this fluid.
21 TISSUE BIOPSY 13/03/15 Morphological features are in keeping with a moderately differentiated squamous cell carcinoma. STAGE : T2b, N2, MX Non- bulky stage III A
22 CURRENT STATUS Cardio thoracic review Haemato- oncology review.
23 PATIENT CHALLENGES First noted to be unwell 15 months ago. Commenced anti TB meds January Completed course in June months elapsed before referral to KNH (Nov 2014) KNH initial evaluation Nov 2014 to final Diagnosis march WHATS NEXT?
24 THANK YOU
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