Akute Luftnot, Schluckbeschwerden und Brustschmerzen

Acute dyspnoea, dysphagia, and non-specific chest pain in a smoker

R Som, foundation year 2 doctor¹, A Li, specialist trainee in cardiology¹, R McIntosh, research registrar¹, G W Lloyd, consultant cardiologist¹

¹ Department of Cardiology, Eastbourne District General Hospital, Eastbourne BN21 2UD

Correspondence to: R Som rsom@doctors.org.uk

Case history

A 59 year old man with a history of heavy smoking presented to casualty with two days of acutely worsening shortness of breath on a background of progressive breathlessness over three months. He had noticed his voice becoming hoarse and a lump appearing above his left clavicle, with worsening dysphagia and non-specific chest pain. On examination he had no fever, blood pressure 97/64 mm Hg, and regular heart rate of 105 bpm, with oxygen saturation of 92% on air. He had clubbing with generalised facial and neck swelling, with suffused conjunctivae and a jugular venous pressure to the jaw raised to 15 cm. Bilateral supraclavicular lymphadenopathy was noted. His heart sounds were muffled and, apart from a hyperexpanded chest, his lungs were clear to auscultation. Abdominal examination showed no organomegaly. A 12 lead electrocardiogram showed sinus tachycardia with low voltage complexes, and a chest radiograph showed a widened mediastinum with an enlarged globular cardiac silhouette.

Questions

1 What is the differential diagnosis?

2 What investigation is most urgent?

3 What is the most likely underlying cause for this man’s presentation?