Case Presentation. Dr.N.Bhanu teja Final year postgraduate Department of pulmonology

Transcription

1 Case Presentation Dr.N.Bhanu teja Final year postgraduate Department of pulmonology

2 A 60 year old male patient resident of miryalguda referred to pulmonary medicine outpatient department with complaints of: cough with expectoration for 3weeks left sided chestpain for 2weeks fever for 10days

3 History of Presenting illness Cough-insidious in onset,gradually progressive, persistent cough since 3weeks associated with sputum production which is copious, colourless, non offensive not associated with aggrevating or relieving factors or postural variations. Chest pain-gradual in onset, over anterior chest on the left side,stabbing type,non radiating,increasing on deep inspiration, relieved by lying on left side since 2weeks Fever- continuous,high grade since 10days, not associated with chills and rigors

4 Generalized weakness, and loss of appetite were associated with the above complaints No history of trauma nasal discharge, throat clearing, hemoptysis, shortness of breath

5 H/O PAST ILLNESS No similar complaints in the past No history of diabetes, hypertension, asthma, epilepsy, tuberculosis, cardiovascular diseases, malignancies

6 Family history- not significant Personal history- Diet-mixed Appetite-decreased Sleep-disturbed Bowel and bladder habits regular chronic smoker(20 pack years) and chronic alcoholic for 40years

7 Differential diagnosis basing on the above history could be left sided pneumonia with parapneumonic effusion, PulmonaryTuberculosis Malignancy

8 General physical examination Conscious,coherent,cooperative oriented to time,place and person asthenic built,poorly nourished with a BMI 16.5 Pallor and Clubbing of grade 3(drum stick appearance) present No icterus,cyanosis, peripheral lymphadenopathy, edema, no visible swellings

9 Head to toe examination-normal VITALS: pulse:84 bpm measured in the right radial artery,normal in rhythm,character,volume,no radio radial delay,no radio femoral delay,all peripheral pulses felt blood pressure:100/70 mm hg supine position,measured in right brachial artery. respiratory rate:20cycles/min, abdomino thoracic temperature-afebrile.

10 Respiratory examination INSPECTION: upper respiratory tract-poor oral hygiene noted,nicotine staining on teeth present, Nose, nasal cavity,pharynx normal lower respiratory tract: chest is bilaterally symmetrical, transversely elliptical in shape spine normal(no kyphosis, scoliosis). Movements appears to be diminished on left side. trachea appears to be central in position. Apical impulse not visible. No use of accessory muscles of respiration and intercostal retractions. skin over the chest wall normal.

11 Palpation no local tenderness or local rise of temperature Movements are diminished on left side: chest expansion 1.5cm on the left, 2.5cm on the right trachea is central in position apexbeat not palpable tactile vocal fremitus- diminished in left side all areas

12 Percussion- direct percussion over clavicle dull on the left side, over sternum- dull Dull percussion note on left side in all spaces No shifting dullness Obliteration of kronig s isthmus left side Normal resonant note on right side in all spaces

13 Auscultation-low intensity vesicular breath sounds on left side in all areas No added sounds present Vocal resonance dimnished on left side in all areas

14 Provisional diagnosis Mass lesion in left lung Unresolved pneumonia

15 investigations Necessary investigations: CBC showed anaemia(normocytic normochromic) Sputum for afb was negative Sputum for culture sensitivity showed no growth Sputum for malignant cytology- negative Serum protein 5.2 g/dl(low), serum albumin 2.4g/dl ESR- 45mm RFT: within normal limits. LFT: Within normal limits CT, BT: Within normal limits PT,Aptt,INR: Within normal limits Viral markers: negative

16 Chest xray

17 Treatment Tab. Cefixime 200mg/ BD Tab Pantop 40mg/OD/BBF Tab PCM 650mg/TID Syp ambroxol 2tsp/TID Tab Orofer XT/BD

18 USG chest showed ill defined mass with areas of necrosis and central cystic spaces. Suggested CECT chest USG neck and abdomen : no sonological abnormality noted.

19 CT CHEST

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22 CECT chest : large solid mass with areas of necrosis in left hemithorax. Most likely malignant lung mass with features of mediastinal invasion. Ultrasound guided FNAC of lung mass was done from multiple sites of the mass but the results were inconclusive due to large areas of necrosis within the mass.

23 So video assisted flexible bronchoscopy was done for the patient.

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26 BRONCHOSCOPY

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30 Smears from TBNA specimen sent for cytology which was reported features suggestive of non small cell carcinoma possibly adenocarcinoma

31 FINAL DIAGNOSIS Anatomical : left lung Pathological: mass lesion Etiological: adenocarcinoma TNM classification: T4N0M0 corresponding to stage IIIA (IASLC 8 th edition)

32 Thank you