A 78-year-old woman presents with worsening shortness of breath. She has been a heavy smoker for most of her life and has had a couple of episodes of haemoptysis over the last week. On examination, you note that her face appears oedematous and that she has dilated veins on her upper anterior chest wall.

1. What is the most likely diagnosis?

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This patient has presented with worsening breathless and haemoptysis on a background of a long smoking history. The diagnosis, in this case, is superior vena cava obstruction (SVCO), most likely caused by a primary bronchial neoplasm.

2. Give two other signs that might be present on examination (other than those mentioned above)?

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Other signs that may be present in SVCO include the following:

  • Neck or arm swelling
  • Dilated veins and telangiectasia on arms, neck and chest wall
  • Facial flushing
  • Stridor due to laryngeal oedema
  • Cyanosis
  • Engorged conjunctiva
3. How should this patient be managed?

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This woman needs urgent referral and hospital admission. At the initial presentation, her head should be elevated and administered supplemental oxygen to provide symptomatic relief. Corticosteroids and diuretics can also be administered. She will need further investigation via CT scanning, and radiotherapy may be indicated.

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