THE MEAN EFFECT OF SUPERIOR VENA CAVA SYNDROME

A Case Study Presented to the Nutrition and Dietetics Department

Adventist University of the Philippines

A partial Fulfillment of the Requirement of the Course

Hospital field Experience

Franche, Frellyn H.

June, 2015
 Chapter 1

Background of the Study

Hospital: AMCM

A. Patient Profile

Case Number:066643

Date of Admission: April 06, 2015; 12:42 pm

Date of Discharge: May 19, 2015; 07:30 pm

Time: 12:45 PM

Service: Medical One

Provisional Diagnosis: Pleural Effusion left 2 to Arterior Mediastinal Area with Problem

Liver Metastasis

Final Diagnosis: Superior Vena Cava Syndrome (SVC) Syndrome

Related Procedure/s VATS, Biopsy of Mediastinal Tumor

B. Social History:

The patient is slim and underweight, his weight is not accurate with his height, it stands 5

feet and 10 inches and weighs about 55 kilograms. He admitted at room 200 in Medical One. He

was born on June 19, 1971 and resides at 166 San Juan St. Pasay City Manila 1300. He is
married already and God Gift them with three (3) beautiful ladies. All of them in the family are

Seventh Day Adventist and they believe in the miracle of our Lord Jesus Christ. He is working as

a Driver traveling from Cavite going here in manila. He woke up early at 3 am and went home at

11 pm in the evening. He is also particular to the food that they eat but may be because he is

always slept late at night his immune system getting slower and weak.

C. Medicinal History

Previous Admission and Diagnosis

The patient was previously hospitalized at Adventist Medical Center Manila last

December 22, 2014 due to Pulmonary Tuberculosis. He was also hospitalized in February 23,

2015 and Diagnosed of Mediastinal Neoplasm. He admitted again here in the same hospital with

the case of SVC Syndrome and after one week, the patient admitted again because he complains

of loss appetite due to pain upon ingestion of food/fluid (at thoracic area) 7/10 burning pain due

to radiotherapy. To relieve pain, the patient was prescribed Maalox Benadryl 15ml drink 15

minutes per meal three times a day.

Chief Complains on Admission

Dyspnea (shortness of breath). The patient is a known case of malignancy

(primary unknown) with anterior mediastinal and Liver involvement. Biopsy was refused, went

on Hama from AMCM (3/3/2015) with a diagnosis of SVC Syndrome. Four days prior to

admission, patient started heavy symptoms of shortness of breath and difficulty of breathing

accompany with orthopenia and back pain.

 Relevant Symptoms & Physical Findings

The patient doesnt know why he has this kind of this disease, he knows that we have

cancers cell but if we didnt take care of our self and feed the cancer cells it will trigger our body

and cause diseases to us. He knows that things already. And since it happen to him already he

doesnt know what to do so he just admitted to the hospital.

D. Relevant diagnosis test & Laboratory Findings on Admission

During the admission the patient had undergone laboratory test including

Hematology and Clinical Chemistry. These are the following result:

Hematology (April 21, 2015)

TEST NAME INTERPRETATION LABORATORY NORMAL

FINDINGS RANGES
RBC Low 4.24 10^12/L 4.60 6.20
Hematocrit Low 0.39L/L 0.40-0.54
WBC High 29.34 10^9/L 5.00-10.00
Lymphocytes Low 2% 25-40
Eosophils Low 0 1-4
Segmenters High 96% 54-75
MCH High 32..3pg 27.0-31.0

CLINICAL CHEMISTRY (April 21, 2015; 1:19 pm)

TEST INTERPRETATION RESULT NORMAL RANGES

pH Low 7.32 7.35-7.45
po2 High 155 mmHg 95-100
 BEecf Low 6.0 mmol/L 2.4-2.3
HC03 Low 20.5 mmol/L 22-26
Total C02 Low 22.0 mmol/L 24-28

Pathophysiology ( cause and progress of disease)

Superior vena cava syndrome (SVCS), is a well-defined symptom complex,

traditionally designated an oncology emergency. It is caused by obstruction of blood flow in the

superior vena cava limiting return of blood from the head, neck and upper trunk to the right

heart. This results in symptoms of face, neck, chest wall and arm swelling, prominence of neck

veins and plethora. Shortness of breath and coughing are quite common symptoms; difficulty

swallowing is reported in 11% of cases, headache in 6% and stridor (a high-pitched wheeze) in

4%. Superior vena cava syndrome (SVCS) is obstruction of blood flow through the superior vena

cava (SVC). It is a medical emergency and most often manifests in patients with a malignant

disease process within the thorax. A patient with SVCS requires immediate diagnostic evaluation

and therapy

Dietary History

The patient loves to eat fruits and vegetables also but since he is a driver he woke up

early in the morning and went to his respective places to be in line at exactly 4 am. So He just

buys boiled saba and egg on the way for his breakfast and he always went home late at night at

11 pm or beyond. In their house his niece and sometimes his wife are the one who prepare the

food for them. And before he admitted he also consumes meat per week and if theres an

occasion and seldom in fish, because he is allergy on it. They always consume rice and white

bread for their cereals sources and sometimes they ate also pasta or noodle dish in a meal. They
have also fruits and green leafy vegetables every day in their meal. He also consume Processed

meat like (tuna), he ate 1 -2 servings per meal two to three per week for their convenient

preparation. He can add eggs also in their meal aside from buying in the side of the road. He

likes to eat milk, cheese and nuts specially if theres in the table. They used canola oil for frying

and sauting vegetables. He likes to eat candy also like Mentos while he is driving for his

relaxation.

Chapter II

METHODOLOGY
 Gathering of information about the patient is not so easy, because sometimes he is not

willing to communicate with me especially when he is not in the good mood. So for me to get

more information about the patient, I patiently interviewed him including his wife, asking about

this case, interviewing the nurse on duty and reading his chart to know more about him.

Visiting him every day starting May 13- 19 is a great privilege to me, because I know

more about him and I share more about his diet and tips on how to become more healthy.

Computing his desirable body weight and give one day meal plans for him.

A. Dietary Instruction and Management

The patient was prescribed with CHIP (Complete Health Improvement Program)-

This diet is a scientifically proven lifestyle intervention program that can prevent, arrest, and

even reverse todays most common diseases.

His diet prescription was 2,450 kcal with snacks (morning and afternoon snacks) base on

his desirable body weight. The patients BMI (Body Mass Index) was 17.5 which is indication of

underweight. And because the patient is underweight he must need to add 500 calories in his diet

to meet his desirable weight for him and support his nutritional needs.

The energy allowance is then determined based on the patients height, weight, sex

and occupation or activity. People with underweight cases must need to have nutritionally

adequate calorie to support the body needs and free from other diseases. Psychological support

(Less stress), Exercise and eating behavior are added strategy to improve compliance with

caloric prescription.

A. Computation
Desirable Body Weight, Body Mass Index and Nutritional Status

Patients Height: 177.8 cm (5 feet and 10 inches)

Patients weight: 122 lbs or 55.45 kg

Activity: 35 (Light work as a driver)

Tanhaussers Method:

5x12= 60+10= 70x 2.54= 177.8 100 = 77.8 10% = 70 02 kg

Desirable Body Weight: 70 kg

Body Mass Index:

BMI = Actual weight 55kg 17.5 Underweight

Height (m) (1.778)

The patient is underweight with the BMI of 17.5, actual weight of 55kilograms

which needs to reach the desirable body weight of 70 kilogram.

Body Mass Index

Classification BMI actual weight Risk of co-morbidities

height (m)
Mild underweight < 18.50 Low
Normal range 18.50 24.99 Average
 Overweight 25.00
Pre- Obese 25.99-29.99 Increased
Obese I 30.00-34.99 Moderate
Obese II 35.00-39.99 Severe
Obese III 40.00 Very severe

Total Energy Requirements

Formula:

TER= DBW x Physical activity

TER= 70x 35 = 2450 kilo calories/day

TER= 2450 + 500 kilo calories

B. Medical plan (one day)

Food Breakfast Snacks Lunch Snacks Supper

Groups
Vegetable A As desired As desired As desired
Vegetable B 1 1 1
Fruits 2 2 2
Milk 1 1
Rice 4 2 2 2 2
Meat 2 2 2
Fat 2 2 2

Breakfast

1 slice Mango and 1 small green pear

2 cups of Brown rice

2 slice of CHIP Steamed Tofu Siomai

1 cup Boiled Baguio beans

10 pieces Cashew / Pili nuts

Am Snacks

1 cup Arrozcaldo and 2 slice Whole Wheat Bread

Lunch

1 slice papaya and 10 pieces Grapes

1 cup brown rice

1 cup white beans with camote tops

2 tsp flaxeed

PM Snacks

2 meduim pandesal with peanut butter

Supper

1 slice watermelon and 1 piece banana

1 cup brown rice

2 slice Tofu for Ampalaya

1cup Ampalaya with tofu

1 bottle Soya milk

 These is the one day meal plan that I was given to him on his first admission last April

06, 2015, since he can still tolerate big and hard foods.

B. Medical Management

First priority is to make a diagnosis: although in an emergency it is still important to have

a historical diagnosis of the tumor or obstruction before starting treatment.

For malignant lesions radiation is the treatment of choice except in small cell carcinoma

or lymphomas where chemotherapy is very effective in superior vena cava syndrome.

The patient use Incentive Spirometer is a medical device used to help patients improve

the functioning of their lungs.

Coralan ( 7.5 mg) BID

This medication is a cardiotonic agent, prescribed for angina pectoris. It helps to lower

the heart rate. Contraindicated in patients with severe heart disease, and hypersensitivity. It

should not be administered along with calcium channel blockers. Adult: PO- Initial: The

recommended dose is 5 mg twice daily. Increase if necessary to 7.5 mg twice daily after 3-4

weeks. It may be reduced up to 2.5-5 mg twice daily if needed .It comes as a tablet to take by

mouth, with food. Avoid excess dosage.

Suplenex; x 500 cc x24

Suplenex available forms, composition, doses: Injectable; Infusion; Dextrose 25 g;

Vitamin B1 (Thiamine Hydrochloride) 125 mg; Vitamin B2 (Riboflavin 5'-Phosphate

Sodium) 25 mg; Vitamin B3 (Nicotinamide) 625 mg; Vitamin B5 (D-Panthenol) 250 mg;

Vitamin B6 (Pyridoxine Hydrochloride) 25 mg; Vitamin C

 Dexamethasone ( 10 mg) OD

Is a type of steroid medication. It has anti-inflammatory and immunosuppressant effects.

Cancer patients undergoing chemotherapy are given dexamethasone to counteract certain side

effects of their antitumor treatments

Dolcet ( 3 tablets) TID

Contains Paracetamol and Tramadol, it is used to treat pain, fever and swelling.

With long-term use, it can cause some stomach problems and organ damage, however, this isn't

likely to occur if the person is only being given 3 tablets a day and up to 8 can be taken in a day.

It's usually given, as needed, every 4 to 6 hours and, since it is a regular release tablet, it can take

15 to 20 minutes, before it starts to work.

Spirulina (Food supplement) (4 tablets per meal and 1 extract per day)

(Arthrospira platensis) is a cyanobacterium that can be consumed by humans and other

animals.1 gram of spirulina is equals to 1 kg of assorted fruits and vegetables. A good

food to maintain health and it is a good aid to regain health.

 CHAPTER III

RESULTS AND DISCUSSION

This chapter shows the prognosis and the progress of the patient. It will discuss also the

result and the discussion about the patient condition.

A. Prognosis and Progress

Last May 12, 2015, the patient diagnosis of lymphoma or a small cell carcinoma, and a

tumor origin from the lungs, are less favored as of the moment until he discharge on May 19,

2015. But after one week (May 26, 2015) the patient visited the same hospital for another test

and they found out that the patient has a diagnosis of Malignant Pleural Effusion. And he is

complaining of loss of appetite due to pain upon ingestion of food/fluid (at thoracic area) 7/10

burning pain due to radiotherapy. He still losing weight because he cannot tolerate more of the

food because of the pain that he experience during swallowing of the food

These are the result of Radiological report ( May 27, 2015; 08:15 am), Follow up study of

the chest since April 27, 2015 show partial regression of the left Para cardiac pneumonia and left

Sided Pleural effusion and the patient must need to undergo 20x radio therapy.

Prognosis
Symptoms are usually relieved with radiation therapy within one month of treatment.

However, even with treatment, 90% of patients die within two and a half years. This relates to

the cancerous causes of SVC that are 90% of the cases. The average age of onset of disease is 54

years of age.
 And since the patient can no longer tolerate the food that was given to him, the doctor

prescribes these following to support his nutritional needs: These can be used for alternative

meal of a patient.

Medicine Dosage Frequency Time

Nutren Optimum 7 scoops 100 200ml of H2O (OR)
Ensure Chocolate 6 scoops in 200 ml water 3x a day 8 am- 1pm 8pm
Prosure 1 sachet (OR) 9 scoops in a glass of water 2x a day 6am 6pm
Sucralfate 1am/tab 2 tablets in 50 ml water shake to make slurry then swallow 2x a day

9:30 am-9:30 pm

Dietary instruction

As a Nutritionist and Dietician we need to consider the situation of the patient weather

they can tolerate foods in a big amount or not. So, since this patient cannot tolerate big amount of

food, he can use alternative way like blenderized the food and follow the prescribed medicine/

food for him.

One Day Meal Plan

This is the new menu for the patient since I discover that he cannot tolerate the food that

was given to him based on his desirable body weight.

Food Breakfast Snacks Lunch Snacks Supper

Groups
Vegetable A As desired As desired As desired
Vegetable B 1 1 1
Fruits 2 2 2
Milk 1 1
Rice 4 2 2 2 2
Meat 2 2 2
Fat 2 2 2

Breakfast
1 glass of fruits shakes (Carrots, 2 kinds fruits, and soymilk)
 1 cup of mechanically unpolished rice with slightly fried tofu.
AM Snacks
2 slices of white bread with flaxseed
Lunch
1 glass of fruit shakes again (vegetable B, apple & banana)
1 cup pureed unpolished rice
1 cup pureed white beans with camote tops
PM Snacks
1 cup, miswa soup
Supper
1 glass of fruits shakes (Water melon and orange fruit)
1 cup pureed unpolished lugao
1 cup blenderized vegetables (broccoli, carrots and baguio beans)
1 cup purred mongo with ginger.

IV. CONCLUSION

According to the results and intervention that I was given to the patient, the result is not good.

The doctor gave him also some medication to relieve the pain that he experience. But the patient

still losing weight and thin already. And may be because the patient still overcoming problem in

his life and the effect of the radiation to him. It really shows that he is weak and need still more

time to recover when I saw him.

 V. SUMMARY AND RECOMMENDATION

SUMMARY

The patient has diagnosed of having Superior Vena Cava Syndrome.. He was admitted

trice in the same hospital (AMCM) with different diagnosis. And for the last time he admitted

again for checkup, he diagnose of having malignant pleural effusion. The doctor gave him some

medication and treatment to at least recover the pain that he experience. But even everything has

given to him; still his body cannot tolerate it so much. So, until now the patient is still surviving .

RECOMMENDATION

Since our time is short and limited, the researcher hopes that more and more researchers

have their time in this kind of case. I recommend also more time to document all the information

needed about the patient, so that it will be easy to Intervene and focus about the case. I just hope

and pray for his health, because I know that he is really striving for his case. Hoping our God

will give miracle for him. I wish to his family to give him strength and courage to fight against

his disease. Teach the family on how to do and make the food that appropriate to the patient and

encourage him to be strong and have faith in God.

.
Glossary

Anterior mediastinum is that portion of the mediastinum anterior to the pericardium and below

the level of the clavicles.

Biopsy is a sample of tissue taken from the body in order to examine it more closely. A doctor

should recommend a biopsy when an initial test suggests an area of tissue in the body isn't

normal. Doctors may call an area of abnormal tissue a lesion, a tumor, or a mass.

Bronchogenic carcinoma is a malignant neoplasm of the lung arising from the epithelium of the

bronchus or bronchiole.

Cytokeratins are proteins of keratin-containing intermediate filaments found in the

intracytoplasmic cytoskeleton of epithelial tissue.

Mediastinal Neoplasms (Tumor) are abnormal growths of tissue that can occur in almost any

area of the body. They are also called tumors. They are most commonly linked with cancer.

Tumors that develop in the mediastinum.

Orthopnea-difficulty in breathing that occurs when lying down and is relieved upon changing to

an upright position

Plethora - Overabundance, e.g. hypervolemia when referring to blood

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a

small video camera that is introduced into the patient's chest via a scope.
References:

Patient Chart

http://www.livehealthyappalachia.org/programs-and-activities/chip/

http://nutritionstripped.com/underweight-nutrition-tips-gaining-weight/

Superior Vena Cava.Syndrome. Wikipedia Encyclopedia.

http://en.wikipedia.org/wiki/Dexamethasone

http://www.medicatione.com/?c=drug&s=suplenex#ixzz3bYfDdxEM

www.google.com.ph/search?q=pathology+of+superior+vena+cava&newwindow=1&source=