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Text of LBM 6 RESPI SGD 15

LBM 6STEP 1 Puffy face : swealling on the face . there is udema on the face because of destroy of vascularitation Hoarse voices : changes of the voice become to rough or lost because of presure of nervus laryngeus reccurens by tumor Horners syndrom : a syndrom can decrease work of nervus sympatics cerervical from cervical 8 until thoracal 1 , the manifestation facial anhidrosis , ptosis , miosis , endoftalmopati

Ptosis : is the medical term for dropping eye lid that caused by paralisis of sympatics nervush Miosis : condition when diameter of pupil < 2 mm because of decrease of nervus sympatis Facial anhidrosis : a condition in ability to sweat normally same name with hipohidrosis its means no sweat


1. Why the man appreance puffy face ?2. Why he has hoarse voices ?3. Why he feel decrease appetite ?4. Explain about horner syndrom / bernard syndrom ?5. Why he get pain in the lower chest and tightness when breathing ?6. Why the patient cough with blood ?7. Why the relation between aktif smoker with the desease ?8. Why the patient perceived weight loss and fever ?9. Why when he runout of medicine he suffered from cough and shortness again ?10. What are the etiologys from the scenario ?11. What are the risk factor from the scenario ?12. What are the DD and Diagnose from the scenario ?13. What are the treatments from diagnose ?STEP 3

1. Why the man appreance puffy face ?

Puffy face caused of infation and supresion to vena cava superior that can puffy face , and another syndrom is feeling foolness in the had and headache There is mass or tumor can pressure VCS

2. Why he has hoarse voices ?

Because maybe is there a mass that can press nervus laryngeus that can infuence fonation Most often caaused by problem with vocal cord , when the vocal cord has inflamation they sweal and the mass common of horse voice is a call sinus infection which can usually got away within two weeks another the hoars voice doesnt go away a few weeks its can be cause of cancer3. Why he feel decrease appetite ?

Decrease apetite because of smoking there are toxic in extrapulmoner and spread to the eshopagus and make decrease apetite or disfagia4. Explain about horner syndrom / bernard syndrom ?

Is disorder because of nervus sympatic from cervical 8 until thoracal 1 ganglion superior can make manifestation ptosis (disorder from palpebra superior looks like myastenia gravis) Tumor usually a rising at the very end of the apex lungs if the metastasis 5. Why he get pain in the lower chest and tightness when breathing ? Because of mass in the bronchus make obstruction in bronchus and the patient fells dyspnea and the are disorder when gas difution Because from mass that will grow in the bronchials segments and a barrier of the air that enters the respiratory tract . manifestation that arises is a feeling of shortness of breath due to mass obstruction and there is local pain in the chest due to supression of the mass in the lung

6. Why the patient cough with blood ?

Because mass can metastasis respiratory tract make the vasculer rupture make a coughing with blood

7. What are the relations between aktive smoker with the desease ?

There is free radical from the cigarette there patogenesis proto onkogen will be onkogen because of radiation carsinogen spesifics in the substance of ciggarette can make malignation on the lung but there is factor inactivation supresor gen of tumor and the factors else there is polimorfic gen example the gen in code but endcoding interleukin 1 and the citokrom P450 cascape 8 will be apoptosis spark and there is XRCC1 will be molekul DNA repair and EFGR or epidermal growth factor receptor can be set proliferation cells apoptosis angiogenesis and infation tumor so the horners syndrom

8. Why the patient perceived weight loss and fever ?

He lost appetite so that can the patients has weight loss Fever = because of tumor press the sweat gland cant produce sweat

9. Why when he runout of medicine he suffered from cough and shortness again ?

Because of mass the lung full in the room potensial normally that room fil if we maximal inspiration but it there is mass in normal condition can make dyspnea

10. What are the DD and Diagnose from the scenario ?

DD : cardiac temponade Right ventrikular disfunction SVCS

SVCS : lung cancer , lymphoma , maligna , benigna

DIAGNOSE SVCS because SCCSCC ( Squamos Cell Carsinoma) = from the epidemiology > 57 years oldMetastasis in the principal bronchus go to hilus gland but the patient there is metastasis spread to VCS anhidrosis , puffy face

11. What are the etiologys from the scenario ?

Lung cancer Exposure iritation free radical Metastasis from breast cancer and testis cancer Aneurisma Fibrosis Mediastinitis tuberculosis Histoplasmosis

12. What are the risk factor from the scenario ?

Smoker Cateteritation Family history of lung cancer Radiation teraphy to the chest

13. What are the treatments from diagnose ? depend of etilogy Steroid : inflamation ( glukokortikoid , dexametason ) Diuretik : decrease preload Surgery Stent Imunotherapy Stop smoking Oxigen

1.Why the man appreance puffy face ?

Swelling of the face (face oedema) which may develop if a tumour presses on a main vein coming towards the heart from the head or a blockage of a main blood vessel (superior vena cava obstruction).

The leading symptoms of SVC syndrome are facial edema, distended veins in the neck and sometimes chest, arm edema, shortness of breath, cough, facial plethora/fullness, and less commonly wheezing, lightheadedness, headaches, and even confusion.

source:Introduction to Superior Vena Cava (SVC) Syndrome_Published October 25, 2008 By Dr WestNetter. atlas of human anatomyPierson DJ.Disorders of the pleura, mediastinum, and diaphragm. in horrisons principles of internal medicine, ed 12. new york:Mc-Graw Hill

A puffy face, neck, and eyelids, coupled with dilated veins of the neck, shoulder, thorax, and upper arm (i.e., superior vena cava syndrome) may constitute the rst clinical evidence of obstruction of the superior vena cava by a neoplasm of the lung. Although the causes of superior vena cava syndrome are many and diverse, at least 80 percent are attributable to a primary carcinoma of the lung . In the patient in whom an eoplasmhas evoked acute signs andsymptomsof increased systemic venous pressure that progresses rapidly (e.g.,to laryngeal edema), early diagnosis and prompt treatmentof the neoplasm can be lifesaving. The presence of Hornerssyndromeunilateral ptosis, miosis, and anhidrosisin apatient with a carcinoma of the lung suggests a pulmonarysulcus tumor with involvement of the ipsilateral sympatheticpathway within the thoraxFishmans Pulmonary Diseases and Disorders Fourth Edition Volumes 1 & 2, Alfred P. Fishman, MD

2.Why he has hoarse voices ?

Textbook of Pulmonary Medicine, Volume 1Oleh D. Behera

Sound is produced in the larynx by vibration of the vocal cords. Resonance occurs in the pharynx, nose and mouth; articulation uses the mouth and tongue. Coughing requires adduction of the vocal cords to be effective.Innervation of the laryngeal muscles is from the vagus nerve via its branches, the superior laryngeal and recurrent laryngeal nerves. The recurrent laryngeal nerve controls abduction and adduction of the vocal cords. This nerve has a long course, from the base of the skull to the mediastinum: on the left side it loops under the aortic arch and on the right under the subclavian artery.The vocal cords are subject to high forces and so are vulnerable to voice overuse or misuse.source: Meyer TK; The larynx for neurologists. Neurologist. 2009 Nov;15(6):313-8. About the voice; Lions Voice Clinic of the University of Minnesota

3.Why he feel decrease appetite ?

From Symptoms secondary to regional metastases can be esophageal compression causes dysphagia and decrease .html

The anorexia/cachexia syndrome is a multi-factorial entity. While the association between contributing factors is not clearly understood, chronic inflammation has been identified as a core mechanism. Lipolysis, muscle protein catabolism, increases in acute-phase proteins (including C-reactive protein), and a rise in pro-inflammatory cytokines (notably IL-1 [interleukin-1], IL-6 [interleukin-6], TNF [tumor necrosis factor alpha], and LIF [leukemia inhibitory factor]) are associated with the syndrome and are similar to the processes and substances found in the metabolic response to an acute injury.Inflammatory cytokines, specifically TNF, IL-1, IL-6, as well as others, may play a causative role.Anorexia may be due to the effects of inflammatory cytokines on the hypothalamus with consequent changes in the balance of neurotransmitters stimulating or inhibiting food intake. Neuropeptide Y and Agouti Related Peptide (AGRP) are appetite-stimulating neurotransmitters; conversely the Opio-melanocortin and the Cocaine Amphetamine Related Factor (CART) neurotransmitter systems inhibit food intake.In health, leptin, which is produced in fatty tissue, inhibits appetite, while ghrelin, a hormone mainly produced in the stomach, stimulates appetite; both act through their influence on the neurotransmitter systems described above. These physiologic regulators seem overwhelmed in cachectic patients(loss weight); leptin levels are low and ghrelin levels are high, but all to no avail.source:MacDonald N, Eason AM, Mazurak, et al. Understanding and managing cancer cachexia. J Am Coll Surg. 2003;197:143-161; full text.

4.Explain about horner syndrom / bernard syndrom ?

Horner syndrome (Horners syndrome) results from an interruption of the symp