A 52-year-old man comes to the office due to a chronic cough for the last 3 weeks. The patient says, "I haven't been coughing up phlegm, but sometimes I notice some blood on the tissue when I cough particularly hard." He has smoked 2 packs of cigarettes daily for the past 30 years and drinks 3 or 4 cans of beer on weekends. He works as a welder on an assembly line and says his father died of lung cancer at age 70. Physical examination shows right-sided face and arm swelling and engorgement of subcutaneous veins on the same side of the neck. Which of the following veins is most likely obstructed in this patient?

Question

A 52-year-old man comes to the office due to a chronic cough for the last 3 weeks.  The patient says, "I haven't been coughing up phlegm, but sometimes I notice some blood on the tissue when I cough particularly hard."  He has smoked 2 packs of cigarettes daily for the past 30 years and drinks 3 or 4 cans of beer on weekends.  He works as a welder on an assembly line and says his father died of lung cancer at age 70.  Physical examination shows right-sided face and arm swelling and engorgement of subcutaneous veins on the same side of the neck.  Which of the following veins is most likely obstructed in this patient?

Quizplus · Accepted Answer

11ec160b_3568_1efa_9249_136dc3107265_MD0001_00 This patient has symptoms consistent with an obstructed right brachiocephalic (innominate) vein. This may be the result of external compression by an apical lung tumor or thrombotic occlusion as can occur when a central catheter has been in place for an extended period. The right brachiocephalic vein is formed by the union of the right subclavian vein and the right internal jugular vein. The right external jugular vein drains into the right subclavian vein, so obstruction of the right brachiocephalic vein will also cause venous congestion of structures drained by the external jugular vein. It is important to note that the right brachiocephalic vein also drains the right lymphatic duct, which drains lymph from the right upper extremity, the right face and neck, the right hemithorax, and the right upper quadrant of the abdomen. (Choices A and E) The subclavian vein is the continuation of the axillary vein. Both drain blood from the upper extremity. Blockage at any of these 2 sites would cause unilateral arm swelling without associated facial swelling. (Choices C and D) The external jugular vein drains the scalp and portions of the lateral face. The internal jugular vein drains the brain and superficial face and neck. Obstruction of the internal jugular veins would not cause arm swelling. (Choice F) Superior vena cava (SVC) syndrome results when the superior vena cava is obstructed. The signs and symptoms of SVC syndrome are similar to those of obstructed right brachiocephalic (innominate) vein, except that both sides of the face, neck, and chest and both arms would be involved. Educational objective: The brachiocephalic vein drains the ipsilateral jugular and subclavian veins. The bilateral brachiocephalic veins combine to form the superior vena cava (SVC). Brachiocephalic vein obstruction causes symptoms similar to those seen in SVC syndrome, but only on one side of the body.

A 52-Year-Old Man Comes to the Office Due to a Chronic