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Lung Cancer Case Report
Lung Cancer Case Report
PRESENTATION
HISTORY
GENERAL DATA
J.A
68 y/o.
Male
Filipino
Roman Catholic
Langkaan, Dasmarinas Cavite
February 2, 1950
CHIEF
COMPLAINT Difficulty of breathing
HISTORY OF PRESENT ILLNESS
03 No febrile episode
Conscious, coherent, in
cardiorespiratory distress, weak looking
VITAL SIGNS:
BP: 100/60
CR: 120
RR: 32
Temp: 36.5 Celsius
O2: 90-91%
PHYSICAL EXAMINATION
SKIN
01
Warm to touch CHEST AND LUNGS
SCE
HEAD AND NECK Decreased breath sounds
03 R mid-base
Dry lips and oral mucosa
AS (-) wheezing
02 Pink palpebral conjunctiva decrease vocal and tactile fremitus
Noted white plaque on tongue on right
(-) NAD
(-) CLAD
(-) TPC
PHYSICAL EXAMINATION
CARDIOVASCULAR
04 AP
Tachycardic EXTREMITIES
Regular rhythm
No murmur
06 (+) Swelling Left leg
Full pulses
ABDOMINAL
Flabby
05
NABS
Soft
Non tender
NEUROLOGICAL EXAM
• Mental Status: Conscious, coherent
• Cranial Nerves:
• CN I: N/A
• CN II: 2-3 mm pupils equally reactive to light
• CN III, IV, VI: Extraocular muscles intact
• CN: V: Can clench teeth
• CN VII: No facial asymmetry
• CN VIII: Intact gross hearing
• CN IX, X: (+) gag reflex
COURSE IN THE WARD
1st day Patient is conscious but with cardiorespiratory
distress and weak looking.
BP is 100/60 HR is 120
Decreased breath sound at right mid to base
lung field
Swelling on the left leg
Urinalysis
• Color: Dark Yellow • Specific Gravity: 1.020
• Transparency: Slightly hazy • PUS cells: 0-2/HPF
• Reaction: Acidic 5.0 • RBC: 5-10/HPF
• Protein: Trace • Epithelial Cells: Rare
• Glucose: Negative • Hyaline Cast: >10/LPF
Chest AP
Previous flm not available for comparison
There is homogenenous density in the right lower lobe with suspicious
semicircmscribed density.
Right hemidiaphragm amd right costophrenic sulcus are obscured.
Heart size cannot be properly evaluated.
Aortic knob is calcified.
Other visualized structures are unremarkable.
Impression:
Consider Pleural effusion or thickening with
suspicious concomittant pulmonary mass.
Correlation with contrast enhanced chest C
T scan is suggested.
Atherosclerotic Aorta.
Sputum
Gram Stain:
Specimen Source: Pleural Fluid
Gram Stain Result: PMS (Polymorphonuclear segmenters)/PUS Cells: MOre
than 50/ HPF
No microorganism seen
No fungal elements seen
AFB STain:
Specimen Source: Pleural Fluid
Result: No AFB seen in 300 visual fields
COURSE IN THE WARD
CT Scan
CT scan of the chest with lung and mediastinal windows show the following findings:
• The previously noted soft tissue density is seen in the right lower lobe measuring ab
out 11.3 x 9.7 x 9.0 cm
• There is atelectasis of the adjacent lung.
• Basal pleural thickening is noted bilaterally.
Impression:
Right Lower lobe mass
Fibrotic changes, both lower lobes
Bibasal pleural thickening
Emphysematous changes both upper lobes
2nd day
Histologic Findings
• Edema L Leg
• Still decreased
breath sounds
COURSE IN THE WARD
8th day
7th day
• Dysuria
• Edema progressed
from grade 2 to
grade 3
COURSE IN THE WARD
12th day
10th day
• Hospital day
• No fever
• No DOB
• No chest pain
• Grade 2 edema on right leg,
with grade 3 edema on left
leg
COURSE IN THE WARD
01 17th day
• Cough
• Decreased breath • Fondaparinux was decreased to 5 mg SC once a day
sounds on right • Levopront syrup 10 ml twice a day was started
base lung field • Repeat x-ray
• Erythema • Management was continued.
• Swelling on the • Patient improved.
left leg
• Repeat PTT
COURSE IN THE WARD
01 26th day
• No difficulty of breathing
• No chest pain
• No desaturation, still with decreased breath sounds at right base
• Soft and non-tender abdomen
• Scrotum swelling
• Hyperpigmentation of left leg
• Medical management was continued
• Transfer to other hospital was considered.
INITIAL IMPRESSION
Acute Respiratory Failure Type 1 Secondary to
Pneumonia High Risk, Pleural Effusion Right; Lu
ng Cancer Stage IV (NSSCA); S/P Oral Chemot
herapy 9 Cycles (Navelbine); Hypertension; Sep
tic Shock Secondary to Community Acquired Hig
h Risk; Oral Candidiasis
DIFFERENTIAL DIAGNOSIS
• Pulmonary Tuberculosis
Rule in Rule out
3: Retro paratracheal
Station
4: Lower paratracheal
5: Subaortic
Mediastinal nodes N2
6: Para aortic (Ascending Aorta)
7: Subcarinal
8: Paraesophageal
9: Pulmonary ligament
Epidemiology
106,470 cases
Lung
Cancer • top cause of cancer-related deaths amo
ng men
• third cause of cancer deaths among wo
men
> 39 yrs. Very Low
old
50-70
yrs. old
70 yrs.
old and
Predominate
Peak age
>
above
Etiology
LUNG CANCER
Pathophysiology
History of Lung
Cancer
Cancer Cells
Metastasize
Increase capillary
Increase capillary permeability or
permeability or vascular
vascular disruption
disruption
Malignant Pulmonary
Malignant Pulmonary Effusion
Effusion
DIAGNOSTICS
HISTORY AND PHYSICAL EXAM
CHEST RADIOGRAPH
THORACOSCOPY
COMPLETE BLOOD COUNT
The patient was given medicines and CTT procedure that were directed at h
is symptomatology and thus, was palliative. Surgery is occasionally appropri
ate for highly selected patients with tumors invading the SVC, carinal or vert
ebral body involvement, or satellite nodules in the same lobe. However, surg
ery generally does not have a role in the care of patients with any tumor with
N3 disease or T4 tumors with N2 disease. Thus, the only appropriate mana
gement for the patients’ lung cancer is chemotherapy.
Patient was discharged after his expressed desire to transfer to another insti
tution.
Recommendation
Also, a copy of the biopsy would have given the physicians a clearer view as to what
type of non-small cell lung carcinoma is the patient dealing with.
The patient could also benefit from the endovascular or surgical interventions of perip
heral arterial occlusive disease such as stent placement, thrombectomy, thromboaspi
ration, embolectomy, or bypass graft thrombectomy and other similar modalities.
Review of Related Literature
According to Molina et. al (2008), lung cancer is the leading cause of cancer-related mortali
ty not only in the United States but also around the world. Over half of patients diagnosed with l
ung cancer die within one year of diagnosis and the 5-year survival is around 17.8% (Zappa & M
ousa, 2016).
A study conducted by Zappa & Mousa (2016) identified smoking as the major risk factor.
A study conducted by Zarogoulidis et. al. (2013) revealed that, radical surgery is the standar
d of care for fit stage I non-small cell lung cancer (NSCLC) patients.
Schad et. al. (2018) study revealed that one-year and three-year overall survival rates were
greater with CTx plus VA compared to CTX alone which suggest that concomitant VA is positive
ly associated with survival in stage IV NSCLC patients treated with standard CTx.
References
Molina, J. R., Yang, P., Cassivi, S. D., Schild, S. E., & Adjei, A. A. (2008). Non–Small Cell Lung Cancer: E
pidemiology, Risk Factors, Treatment, and Survivorship. Mayo Clinic Proceedings. Mayo Clinic, 83(5), 58
4–594.
Schad, F., Thronicke, A., Steele, M.L., Merkle, A., Matthes, B., Grah, C., Matthes, H. (2018). Overall s
urvival of stage IV non-small cell lung cancer patients treated with Viscum album L. in addition to
chemotherapy, a real-world observational multicenter analysis. Plos. https://doi.org/10.1371/journ
al.pone.0203058
Tan, W. W., & Karim, N. A. (2018). Non-Small Cell Lung Cancer. https://emedicine.medscape.com/article/
279960-overview
Zappa, C., & Mousa, S. A. (2016). Non-small cell lung cancer: current treatment and future advances. Tra
nslational Lung Cancer Research, 5(3), 288–300. http://doi.org/10.21037/tlcr.2016.06.07
Zarogoulidis, K., Zarogoulidis, P., Darwiche, K., Boutsikou, E., Machairiotis, N., Tsakiridis, K., … Spyratos,
D. (2013). Treatment of non-small cell lung cancer (NSCLC). Journal of Thoracic Disease, 5(Suppl 4), S3
89–S396. http://doi.org/10.3978/j.issn.2072-1439.2013.07.10