RS 3
Description
The patient was an elderly gentleman who was lying propped
up in bed using three pillows. He was using oxygen through a mask. He was of
average height and weight.
On examination of his head there was swelling which was not
marked. There was flaring of his alae nasi. No abnormality on examination of his
eyes. The malar region appeared reddened.
On general inspection of his upper limbs both arms appeared
swollen. The hands were swollen. There was no clubbing the skin had a dusky
tinge to it.
The veins on the dorsum of his hands were distended and
they did not flatten out when raised above the level of his head. There was no
tremor or flap.
There was an increase in the size of his neck. No goitre,
JVP difficult to assess on account of swelling of the neck, the carotids were
normal and the trachea was in the midline.
The chest looked normal in size and shape. There were
distended veins over the anterior aspect of the chest and blood flow in these
vessels was in a cephalic to caudal direction. The respiratory rate was 28
breaths per minute and respiratory movements were equal on the two sides. Vocal
resonance was normal and equal on the two sides, percussion note normal and
equal on the two sides, breath sounds were vesicular, there were no added sounds
and vocal resonance was normal and equal on the two sides.
There was cervical lymphadenopathy with firm, rubbery
discrete nodes along the line of the carotids and in the posterior triangle.
There was no spinal deformity and examination of the lungs
from the posterior aspect revealed no abnormality.
Analysis
♥
On general examination one notices that the patient is in
respiratory distress. Dyspnoea may be due to many causes
(See ACES for PACES page 245)
ª
Swollen upper limbs with distended veins that do not collapse when
they are raised above the level of the heart, suggest that the patient has
superior vena caval obstruction (See ACES for PACES
page 188)
¨
An increase in the size of the patient’s neck is further evidence
in favour of obstruction of the superior vena cava
(See ACES for PACES page 256)
§
Dilated veins over the chest with blood flow in a cephalo-caudal
direction is more evidence that the patient has obstruction of the superior vena
cava (See ACES for PACES page 259)
♥
No abnormality was found on examination of the patient’s lungs and
hence there is no other cause for breathlessness
ª
The patient has cervical lymphadenopathy. There are many causes of
cervical lymphadenopathy (See ACES for PACES page
388)
¨
The chances are that superior vena caval obstruction in this
patient is due to lymph node enlargement in the mediastinum
(See ACES for PACES page 238)
Diagnosis
§
Superior vena caval obstruction due to mediastinal lymphadenopathy
