Breathlessness and weight loss in a 58-year-old man

Problem 34 Breathlessness and weight loss in a 58-year-old man



Hubertus P.A. Jersmann




A 58-year-old accountant presents with 3 months of progressive breathlessness on exertion. He has no associated chest pain or wheeze but has had a smoker’s cough for years. He has lost 5 kg over the last 3 months but says that his appetite is normal. He complains of a ‘frog in his throat’ for the last 6 weeks, which he has put down to his smoking. His breathlessness has progressed to such an extent that he has been unable to work for the last few days and was only able to walk up the one flight of stairs to your clinic with difficulty. Apart from feeling generally lethargic, he reports no other symptoms.

He has a history of hypertension for which he takes ramipril. He smokes 20–30 cigarettes a day; his alcohol consumption is regular and has never exceeded an average of 20 g a day. He is in his second marriage and has two young children aged 9 and 14.



Q.1


What other information would you like from the history? What will you look for on examination?


On examination he is slightly plethoric and has signs of recent weight loss. He has a hoarse voice. His pulse is 80 bpm, his blood pressure is 155/95 mmHg and he is afebrile. He is tachypnoeic with a respiratory rate of 25 breaths per minute and appears to be centrally cyanosed. Cardiovascular examination is normal.


His trachea is in the midline and the chest is not obviously over-inflated. The percussion note is dull in the lower zone of the right chest. The breath sounds are reduced in this area and there is an associated increased vocal resonance. There is a widespread polyphonic wheeze throughout both lung fields. There are no other clinical signs on full examination.



Q.2


What are the possible diagnoses?


The man looks unwell and dyspnoeic and you decide to admit him to hospital for further management.



Q.3


What investigations will you order?


You receive the results shown in Investigation 34.1.



Investigation 34.1 Summary of results

image


Q.4


What do these results tell you?


A chest X-ray is shown in Figure 34.1.


image

Figure 34.1



Q.5


What does the chest X-ray show? How are you going to manage this patient?



Q.6


What further investigations should now be considered?


A further radiological investigation is performed. Two representative films are shown (Figures 34.2 and 34.3).


image

Figure 34.2


image

Figure 34.3



Q.7


What do these CT scans show?


A bronchoscopy is performed. The right vocal cord is adducted and does not move. A tumour is found obstructing the right main bronchus. The right middle lobe and the right lower lobe bronchi could not be entered. Biopsy of this tumour reveals a poorly differentiated adenocarcinoma.



Q.8


What treatment options are open to you at this stage? What will you tell the patient?


Five days after admission you are called to see him on the ward. He has become confused over the past 24 hours. A decision has been made not to proceed with chemotherapy or radiotherapy. The nurses report that he has not opened his bowels for 4 days.


On examination he is mildly confused with a GCS of 13. Despite his humidified oxygen he has dry mucous membranes and has decreased skin turgor. He is afebrile. The examination is otherwise unchanged since admission.



Q.9


What are the possible causes for his confusion? What would you like to do?


Some serum biochemistry had been performed earlier that day. The results are shown in Investigation 34.2.



Investigation 34.2 Summary of results

image


Q.10


What is the problem and what would you like to do now?


He received rehydration and a single dose of pamidronate. This was associated with clearing of his confusion and after discussion with his wife he elected to be transferred to inpatient hospice care. His hypercalcaemia rapidly recurred and he died peacefully surrounded by his family 3 weeks after his initial presentation.



Answers


A.1 Find out the following:


• The nature and severity of his shortness of breath. After how much exertion does he get short of breath? How rapidly did this develop? Does it occur at rest, during the night or when he lies flat? How many pillows does he sleep with?

• The nature of his cough. Has it changed? Is it productive and if so is it purulent? Has he coughed up any blood?

• Has he had any other symptoms to explain his weight loss? Has he had fevers or night sweats?

• Enquire further about his smoking history. How long has he smoked? Express the smoking history in ‘pack-years’ where 20 cigarettes a day for 1 year is 1 pack-year. Thus a comparative figure can be derived for overall consumption of tobacco measured in terms of the total number of pack-years.

• Are there any other risk factors for lung disease such as industrial exposure to asbestos in the past? Does he keep birds? Has he had any recent foreign travel? Is there a family history of pulmonary disease? Has he had previous cancers or is there a family history of cancers such as colon cancer? Has he had any previous blood clots?

On examination you should look for signs or evidence of the following:


• Respiratory distress, e.g. tachypnoea, cyanosis and the use of accessory respiratory muscles.

• Chronic lung disease, wheeze and hyperinflated lungs.

• Pneumonia, e.g. fever and lobar consolidation.

• Malignant lung disease, e.g. clubbing, pleural effusions, lymphadenopathy, hepatomegaly and ascites.

• Anaemia.

• Cardiac disease, e.g. cardiomegaly, raised jugular venous pressure, atrial fibrillation or peripheral oedema.

In addition you should measure oxygen saturation via pulse oximetry and perform spirometry.


A.2 His smoking history makes it likely that he is suffering from a degree of chronic obstructive pulmonary disease (COPD). Patients with severe COPD often suffer from weight loss and become cachectic but this is usually in the context of a reduced intake due to severe dyspnoea at rest.


He may be suffering from an infective process but the length of the history makes it unlikely that this is bacterial in nature. The presence of weight loss raises the possibility of tuberculosis and you should ask about risk factors.


Other intrinsic lung diseases such as fibrosing alveolitis are possibilities but the presence of weight loss, the problems with his voice and his smoking history all make this a less likely diagnosis.


Cardiac failure leading to weight loss (cardiac cachexia) is unlikely in the absence of paroxysmal nocturnal dyspnoea or orthopnoea.


Anaemia may explain his shortness of breath, lethargy and, depending on the cause, his weight loss.


By far the most likely diagnosis in this man, who is a heavy smoker, has experienced recent weight loss and shortness of breath and has localizing pulmonary signs, is lung cancer. The hoarseness of his voice is an extremely sinister symptom and may be due to malignant infiltration of the recurrent laryngeal nerve by a hilar tumour causing a vocal cord paralysis.


A.3 Perform these investigations:


• Complete blood picture: look for evidence of anaemia or infection (leucocytosis).

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Breathlessness and weight loss in a 58-year-old man

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