Guptashutosh
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14. A 47-year-old man comes to the physician because of a 3-week history of increasing facial swelling and a 1-week history of morning headaches and mild shortness of breath. He had previously felt well. He completed a course of chemotherapy 4 months ago for small cell carcinoma of the lung. His temperature is 37.2°C (98.9°F), blood pressure is 142/80 mm Hg with an 8-mm Hg paradoxical pulse, pulse is 84/min, and respirations are 18/min. Examination shows significant diffuse facial and periorbital edema. The optic discs are sharp, and ocular movements are intact. The lungs are hyperresonant bilaterally with a moderately prolonged expiratory phase. Mild rhonchi are heard on inspiration and expiration. An x-ray film of the chest shows a 10-cm mass in the right upper lobe and apex. Which of the following is the most likely explanation for these findings?
A ) Chemotherapy-induced bone marrow toxicity
B ) Chemotherapy-related cardiac toxicity
C ) Hypercoagulable state secondary to malignancy
D ) Interstitial metastatic pulmonary disease
E ) Intracranial metastases
F ) Lymphatic obstruction
G ) Malignant pericarditis
H ) Paraneoplastic syndrome
I ) Pleural metastases
J ) Soft tissue metastases
K ) Vascular obstruction
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| prathapdoctor
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vascular obstruction.
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| fox
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Vascular obstruction - SVC obstruction syndrome
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| robin082006
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K
Edited by robin082006 on 01/23/07 - 12:28 AM
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| young_doc
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H
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| CocaCola
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???
Lymphatic obstruction
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| young_doc
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haha...i'm glad we can all agree?!?
Ok so i'll say why i chose H...but of course it's just my guess. I figure the patient still has Small Cell...since small cell is not very easily treated with Chemo.
And we all know Small Cell can produce ADH and ACTH...This can explain her swollen face (cushing's)...
I don't think it's an intracranial metastasis, because there is no evidence of an intracranial mass lesion (optic disks are sharp)
SVC syndrome looks very appealing, especially with the Dyspnea. But in SVC syndrome we would typically have upper extremity edema as well...?
Anyone else?
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| prathapdoctor
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cushing syn may cause facial edema, but i dont think it will cause dyspnea and wheezing on examination.
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| dr.wad
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i think the answer is ( H ) paraneoplastic syndrome.
the facial and periorbital oedema is due cushing syndrome.
the dyspnea and wheezes are due carcinoid syndrome.
the 8 mmHg lowering of blood pressure during respiration is within the normal range
i.e (not pulsuus paradoxus ).
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| nida
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K ) Vascular obstruction
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| r_albayunen
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ill go with SVC syndrome due to SCCL ... K
A cushings edema i guess it will not be localized solely to face or orbits .. it'll be more generalized with all the cushings manifestations ..
headaches? well the drainage of the SVC is blocked .. i guess that contributes to a high ICP ..
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| Mahwish Mushtaq
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i'll go with H
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| liwei
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Pancoast cancer blocks the SVC
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| Mamay
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(F)-lymphatic obstruction
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| young_doc
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Remember from Anatomy that the Lymphatic drainage of the head is split right down the midline. So a unilateral lymphatic obstruction can't possible cause the whole face the swell....
Another reason against Vascular obstruction is that if you impede the flow coming into the heart, then you're decreasing preload..and hence decreasing Stroke Volume...Remember from Physio, this directly decreases BP. I just can't see how the patient can have a BP of 142/80 if she has her SVC obstructed?
Gupta Shutosh do you have the answer??
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| dr.wad
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what is the answer Guptashutosh.....
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