Author Topic: Case (67)  (Read 9741 times)

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Offline Dr.Habiib

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Case (67)
« on: March 10, 2011, 08:51:51 PM »
A   52- year old heavy smoker consulted his physician about an alteration of his voice, severe loss of weight, persistent cough and blood stain sputum. A distorted tracheal carina was observed during bronchoscopy. The radiograph in chest revealed   carcinoma in the upper lobe of left lung.
1. What is   your diagnosis of this case?
2. What are the predisposing   factors of this case?
3. How this cancer spread?
4. What are superficial lymph nodes would be enlarged and palpated?
5. Clarify the bronchopulmonary segments of the upper lobe of left lung?
6. What would be the cause of alteration of voice?
7. What   caused   distortion carina of trachea?
8. What are   the   complications of this case?


Ethical principles of medical professionalism:
1. Beneficence: to do good to patient.
2. Non maleficence: not to harm the patient.
3. Justice: to be fair to all patients.
4. Respect for autonomy: free decision for the patient


Offline Dr. Acromion

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Re: Case (67)
« Reply #1 on: March 11, 2011, 10:22:03 AM »
1.What is   your diagnosis of this case?
 
It would be the wise to say as already indicated in the case that the diagnosis is Carcinoma in the upper lobe of the left lung  ( Lung cancer).

2.   What are the predisposing   factors of this case?
 
The principal predisposing factor is cigarette smoking  including second hand smoking, the risk of lung cancer increases with the number of cigarettes each day and the number years smoked.  Quitting smoking at any time can significantly decrease one's chances of developing lung cancer in the future.
Exposure to certain chemicals like asbestos, radon gas can increase the risks of Lung cancer.
There is also the so  called " non-modifiable risk  factors" such as  heredity, age , sex and race may play role in lung cancer development.
Certain chronic lung diseases , for example  Chronic Obstructive Pulmonary Disease (COPD) may also increase the risks of developing lung cancer.


3. How this cancer spread?

The cancer cells spread via the bloodstream , the lymphatic vessels or by means of direct contact to the adjacent body structures.

4.   What are superficial lymph nodes would be enlarged and palpated?

Supraclaviculer lymph nodes are the most important, however a complete physical examinations should include  palpation for the anterior cervical,  posterior cervical , axillary, tonsilar, submental and submandibular lymph nodes and in advanced stages of the cancer as far as the inguinal region.


5. Clarify the bronchopulmonary segments of the upper lobe of left lung?        
Left upper lobe;      
   1 and 2. Apicoposterior bronchus
   3. Anterior bronchus
                 Lingula
   4.  Superior bronchus (lingular)
   5.  Inferior bronchus (lingular)

6.What would be the cause of alteration of voice?                                

Alteration of the voice also known as hoarse voice is do to compression of the left recurrent laryngeal nerve by the cancerous  (pancoast) tumor.


7.What   caused   distortion carina of trachea?  
The growing cancerous tumor compresses and pushes the immediate structures  such us the trachea, great blood vessels, mediastinum , th ribs leading to distortion of the carina of trachea.


8.What are   the   complications of this case?  
                                            
If the cancer spreads throughout the lungs the level of oxygen in blood drops causing shortness of breath.
 Blockage of air way by the tumor may lead to the collapse of the part of the lung that the airway supplies, a condition called Atelectasis,
 Accumulation of fluid between the lung and the chest wall...........pleural Effusion may also occur leading to sensation of breathlessness.
The cancer may also encroach into certain nerves in the neck , causing a droopy eyelid , small pupil, Sunken eye and reduced perspiration on one sid of the face..........this is called Horner's  Syndrome.
The Esophagus my be affected by the growing cancer causind difficult in swallowin food or pain while swallowing.
The heart may be affected by the lung cancer leading to arrhythmias, reduced blood flow to the heart   due to obstruction of the superior vena cava by the tumor causing facial swelling , cyanosis and dilatation of the veins of the face and neck......known as the Superior vena cava syndrome and ultimately heart failure.



Offline Dr.Habiib

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Re: Case (67)
« Reply #2 on: March 11, 2011, 02:49:11 PM »
 Thank you  Dr. Acromion for you trying.

we wait another try the answer is still ......................


   مستنيكم محاولة ثانية علشان لسه الحل ما كملش
Ethical principles of medical professionalism:
1. Beneficence: to do good to patient.
2. Non maleficence: not to harm the patient.
3. Justice: to be fair to all patients.
4. Respect for autonomy: free decision for the patient

Offline Dr. Acromion

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Re: Case (67)
« Reply #3 on: March 11, 2011, 08:18:31 PM »
Thank you Dr. Habib! looking forward to the right answers.

Offline Dr.Habiib

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Re: Case (67)
« Reply #4 on: March 12, 2011, 10:31:01 AM »
Thank you very much Dr. Acromion. You are nearest to the answer in more than one way.

I respect your answer really be because most of your answers   are correct, but the roles of cases the most of answer depends on first to diagnosis because if you diagnosis is not clear you will lose all of the case mark.

Possible to say some of our members why you say most of answers are correct and problem in diagnosis?

To be kind the case is near to dr answered and they have common factors here we need the best diagnosis, another factor part of questions not need to diagnosis because they are anatomy not pathology


ANSWERs:

1.  A part of diagnosis in the case (carcinoma) but we want only complete this into more clear term.

 Probably diagnosis is bronchogenic carcinoma.

  - First definition of carcinoma:   is a malignant tumor of epithelium.

  -Second it becomes in old age smoking there is metaplasia in bronchial mucosa    which may lead to squamous metaplasia and for long time into bronchogenic carcinoma.
 
- yes the bronchi  are   start at bifurcation  of trachea in two main bronchi which enters the lung  may be part of them, but if we back to the normal histology the lung contains alveoli not has  epithelium mucosa, so term carcinoma is exactly bronchogenic carcinoma.

2. Predisposing factors of this case (bronchogenic carcinoma):
   ► Tobacco smoking (aromatic hydrocarbons and phenol derivatives). Mainly.
   ► Air pollution with exhaust fumes of tar and diesel.
   ►Silicosis asbestosis and industrial chemicals as arsenic and nickel.
   ►Bronchiectasis.
   ►Irradiation.
   ►Genetic factors.
 
 
3. Spread:
  a. Direct with lung, to the pleura and mediastinum.
  b. Lymphatic spread to hilar, mediastinal and supraclavicular lymph nodes.
  c. Blood spread:
    - Through pulmanry artery         → metastasis in lungs.
    - Through the pulmonary veins → metastasis liver brain, bones( systemic).
 
 
4. The supraclavicular lymph nodes would be enlarged and palpated.

5. The bronchopulmonary segments of upper lobe of left lung are:
    - Apicoposterior.
    - Superior lingular.
    - Inferior lingual.
 
6.  The alteration of voice was probably due to enlargement of left bronchomediastinal lymph nodes which caused compression of left recurrent laryngeal nerve affecting the left vocal cord.
 
 
7. Spread of cancer cells from bronchomediastinal lymph nodes to tracheobronchial lymph nodes (which lie at bifurcation of trachea) caused distortion of the trachea carina observed during bronchoscopy.

8. Complications:
a. Haemoptysis:  is coughing of blood which appears frothy (mixed with air).
b. Pleural effusion:  fluid accumulating in pleural sac.
c. Bronchial obstruction.









Ethical principles of medical professionalism:
1. Beneficence: to do good to patient.
2. Non maleficence: not to harm the patient.
3. Justice: to be fair to all patients.
4. Respect for autonomy: free decision for the patient

Offline Dr. Acromion

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Re: Case (67)
« Reply #5 on: March 12, 2011, 11:24:45 AM »

Thank you Dr. Habib they say; 'Almost doesn't count.' It gave me the opportunity to refresh my knowledge on cancer.
I would kindly request you shade some light on this again, sorry for keeping you on the case; Is there any information in this case that proves that the cancer actually starts from the bronchus and not from the lungs or neighbouring structures while keeping in mind that even metastasis from other areas can lead to distortion of the normal anatomy of the bronchus?


Offline Dr.Habiib

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Re: Case (67)
« Reply #6 on: March 12, 2011, 01:38:34 PM »
 Thank you very much again and again Dr. Acromion.

When we making cases there is roles any word of the case is has a meaning so that what helps as diagnosis.
Also there is basic  clinical cases and advanced ( postgraduate clinical cases), in basic clinical cases we make simplify to be clear more and more and we list parts of investigations, on other you are doctor we don`t to be like others you must use a mind, so we make tricks to not reach answer easy.

On back to your opinion :

Let`s us to focus about metastasis:

   Metastasis: is a development of secondary malignant cancer implants, discontinuous with primary tumor.
Can occur in many routes; the most common of which lymphatics and vascular spread.
The most common sites are:  Lung, LIVER, and BONE BRAIN (2L AND 2B)

What does make metastasis in lung?

It is a malignant, makes hemorrhage and necrosis here is important we see clinically in the person dyspnea (difficult of breathing) so if we make case must see this word and if you are in your clinic you must see this problem in your patient.
In our case there is no word says there is difficult of breathing.

ON OTHER HAND DISTORTION OF VOICE:

There is many other factor can make alteration of voice so we use alteration not hoarse of voice.
This disease may lead to chances of voice:
1. Laryngeal nodule (laryngeal polyp or singer disease.
2. Squamous cell carcinoma of larynx.
3. Spread of cancer line bronchogenic.
4. And many other diseases like thyroid diseases.

Ethical principles of medical professionalism:
1. Beneficence: to do good to patient.
2. Non maleficence: not to harm the patient.
3. Justice: to be fair to all patients.
4. Respect for autonomy: free decision for the patient

Offline Dr. Acromion

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Re: Case (67)
« Reply #7 on: March 12, 2011, 01:58:07 PM »
Dr. Habiib, aad ayaad u  mahadsantahay, I appreciate.

Offline Dr.Habiib

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Re: Case (67)
« Reply #8 on: March 12, 2011, 04:21:59 PM »
My dear Dr. Acromion thank you.
 Our goals of cases is to make refreshment every one of our dear members to make updating of his knowledge day after, to comfort when he deals  our patient if we don't make this we will shock  when we will meet cases which is reality serous that makes confuse what we will make.
 
  FOR FATHER UNDERSTANDING:
LUNG METASTASIS:
 Origin:
Metastasis tumors of lung are common and may derive from:
1. Carcinomas (e.g. thyroid, breast, kidney, placental, G.I.T).
2. Melanoma.
3. Sarcomas.
4. Lymphoma.
HOW TO REACH THE LUNG?
 They reach the lungs though the blood spread.
 
1.BREAST, SKIN AND KIDNEY tumors: Tumor emboli derived this organs draining by systemic veins (vena cava) → Lung metastasis.
2.Tumors of G.IT: Tumor emboli derived from this organs drained by portal vein  → liver metastasis, futher spread from the liver gives rise of emboli that reach hepatic vein and consequently to the inferior vena cava  → Lung metastasis.

OR THEY REACH THE LUND RETROGRADE LYMPHATIC SPREAD IN CASE OF BREAST CANCER.
Ethical principles of medical professionalism:
1. Beneficence: to do good to patient.
2. Non maleficence: not to harm the patient.
3. Justice: to be fair to all patients.
4. Respect for autonomy: free decision for the patient


 

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