Harold Hopkins

University of Nebraska Medical Center - College of Medicine
Omaha, Nebraska
Instructor(s): Von Essen, Susanna
Subject area: Health / Medicine
Department: Medicine
Level: Undergraduate Medical
Duration of exercise: 3 sessions, 5 hours total
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information
Teaching style: Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

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This Problem Based Learning Case is presented to medical students at the University of Nebraska College of Medicine. The students work through an actual case presentation of an environmental health problem. The instructor guides the discussion as the students work through the case. In an interactive question/discussion format, needed information is provided to the students to work through the differential diagnosis and arrive at the appropriate conclusion.


FACILITATOR'S GUIDE

Major Subject Areas
1. Effects of occupational exposure to asbestos.
2. Mechanisms and effects of inflammation in the lungs.

Minor Subject Areas
1. Anatomy of the thorax.
2. Pulmonary physiology.
3. Obstructive sleep apnea syndrome.
4. Familial cancer syndromes.
5. Basal cell carcinoma.
6. Atrial fibrillation.

Case Objectives
1. Discuss the etiology and physiologic mechanism of cough.
2. Outline the inflammatory events, including cytokines and chemokines that lead to pulmonary fibrosis.
3. Be able to recognize interstitial lung disease and pleural effusion on a chest x-ray and develop a differential diagnosis for each.
4. Review how the occupational history can help determine the cause of interstitial lung disease.
5. Be able to discuss the medicolegal implications of asbestos exposure in the workplace.
6. Outline the various ways asbestos exposure can affect the lung.

References
1. Occupational and Environmental Respiratory Disease (L. DeYoung, ed.), Mosby-Year Book, Inc., St. Louis, MO, 1996, pgs. 293-329
2. Harrison's Principles of Internal Medicine, Thirteenth Edition ; Sleep Apnea pgs. 168,1236-1239
3. Harrison's Principles of Internal Medicine, Thirteenth Edition; Basal Cell Carcinoma, pgs. 272,309, 1866
4. Harrison's Principles of Internal Medicine, Thirteenth Edition; Arterial fibrillation pgs. 1022-1023


SESSION 1

Initial Presentation

Mr. Harold Hopkins is a 58 year old UNMC Physical Plant employee who comes to your clinic complaining of a cough that he has had for the last 3 years. He also complains of being "tired all the time". Harold's wife is concerned because he snores loudly at night and sometimes quits breathing. She is particularly upset because he nearly fell asleep at the wheel of the car on a trip from Kansas City to Omaha the past weekend.

STOP
DISCUSS THIS SECTION BEFORE CONTINUING

• What are diagnostic consideration in the differential diagnosis of chronic cough?

Cough is produced by inflammatory, mechanical, chemical, and thermal stimulation of the cough receptors. Inflammatory stimuli are initiated by edema and hyperemia of the respiratory mucous membranes and by exudative processes. Such stimuli may arise either in the airways(as in laryngitis, tracheitis, bronchitis, and bronchiolitis) or in the alveoli (as in pneumonitis or lung abscess). Mechanical stimuli are produced by inhalation of particulate matter, such as dust particles, and by compression of the air passages and pressure or tension upon these structures. Lesions associated with airway compression may be either extramural or intramural in type. The former include aortic aneurysms, granulomas, pulmonary neoplasms or mediastinal tumors; intramural lesions include bronchogenic carcinoma, bronchial adenoma, foreign bodies, granulomatous endobronchial involvement, and contraction of airway smooth muscle (bronchial asthma). Pressure or tension on the air passages is usually produced by lesions associated with a decrease in pulmonary compliance, such as acute and chronic interstitial fibrosis, pulmonary edema and atelectasis. Chemical stimuli may result from inhalation of irritant gases, including cigarette smoke and chemical fumes. Thermal stimuli may be produced by inhalation of either very hot or cold air.


• What additional questions should be asked to characterize the cough?

• Answers to the following general questions will significantly narrow the diagnostic possibilities:
  
  Is the cough acute or chronic? Is it productive of sputum or nonproductive? A chronic productive cough may be caused by diseases such as chronic bronchitis, pulmonary tuberculosis, and pulmonary neoplasms. Are the findings on physical examination of the chest normal or abnormal? Is the chest roentgenogram normal or abnormal?
  
• What questions should be asked about workplace exposures in a UNMC Physical Plant employee?

• What is the potential significance of the snoring, cessation of breathing during sleep and excessive daytime somnolence?

History of Present Illness

Mr. Hopkins' cough is "dry" (no sputum is produced). He has not coughed up any blood. He sometimes gets short of breath at work but he has blamed this on a 30 pound weight gain over the past 3 years. His manager at work has requested that he be seen in the Pulmonary Clinic every year but Mr. Hopkins thinks his last chest x-ray and lung function tests were in 1994. He is not sure of the results of these tests. His medical records are unavailable at the time of this clinic visit.

STOP
DISCUSS THIS SECTION BEFORE CONTINUING

• Could there be a relationship between the fatigue and the pulmonary complaints?

Additional History

Mr. Hopkins has worked at the UNMC Physical plant for the past 35 years. Before that, he was in the Army where he served as a medical corpsman. His duties at UNMC have included repairing plumbing and the heating and air conditioning systems. He has also helped on many remodeling projects.

STOP
DISCUSS THIS SECTION BEFORE CONTINUING

• What exposure in the workplace might explain the cough, the pulmonary findings and the surveillance plan?
• What tests could help you find out why he is coughing and why he is tired?
• What additional formation information would you like to obtain?

Additional Information

Your nurse knocks on your door and presents you with Mr. Hopkins' chart which Medical Records has just located. Clinic notes reveal that there has been concern about evidence of progressive interstitial thickening on his chest x-ray. These findings are attributed to asbestos exposure in the report by the radiologist as well as in the note from pulmonary clinic. His spirometry results are interpreted as showing moderate restriction and a reduced diffusing capacity for carbon dioxide, findings which have been slowly progressive over the past 15 years.

STOP
END OF SESSION

• Can the diagnosis of asbestos-related lung disease be made with absolute certainty from a chest x-ray?
• How did the asbestos exposure probably occur?
• How easy is it to obtain a history of asbestos exposure from a patient?
• What might a lung biopsy of this patient look like?
• What inflammatory changes does asbestos exposure cause in the lungs?

Wrap-up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used. During session 2 or 3, each student should turn in a relevant journal article. Please review the articles, make comments, and return them to students. You may also ask students to summarize the articles.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.


SESSION 2

Clinic Visit Continues

The patient has smoked 1 pack of cigarettes per day from age 17 until age 47. He drinks 1-3 cans of beer on social occasions. Leisure activities include hunting, gardening and boating.

Mr. Hopkins' family history is significant for asthma in one of his 3 children. His father died of lung cancer at age 58. His father's sister died of breast cancer at age 52. His mother is still alive at age 87. His brother is hypertensive. One of his sisters has had breast cancer and the other has had ovarian cancer.

Mr. Hopkins currently takes no medications and has no known allergies. His review of systems is notable for the use of reading glasses and having a mild hearing loss.

You leave the examination room so Mr. Hopkins can change into a gown and tell him you will perform a physical exam when you return.

STOP
DISCUSS THIS SECTION BEFORE CONTINUING

• What does the family history of cancer suggest?

Physical Examination

Vital Signs:
T = 37.6'
P = 92, irregularly irregular
BP = 156/94
R = 16
Ht = 172 cm.
Wt = 110 kg

The patient is a 58 year old male with reddish-brown hair and freckled skin who appears his stated age. Mr. Hopkins is dozing in his chair when you come back into the room. He is not coughing during the exam.

Examination of the thorax reveals dry rales bilaterally and decreased lung sounds over the left lung base. There is a focal wheeze over the left upper lobe of the lung.

The heart sounds are irregularly irregular. There is no murmur or gallup.
There is a 2 mm raised area with pearly edges on the right side of his nose.
The remainder of the examination is normal.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

• How might you explain the pulmonary findings? What tests would you order to gain a better understanding of them?
• What is the skin lesion and how should it be assessed?
• How should the elevated blood pressure be managed?
• What disorder might explain the cardiac findings and how would you continue the assessment?
• What is the differential diagnosis for chronic fatigue in this patient and what tests should be ordered to assess this problem?
• What laboratory tests would you like to order?

Laboratory Information

The chest x-ray shows interstitial prominence not remarkably different from changes on a chest x-ray done in 1994. There is also a new 2.5 cm mass in the left upper lobe and a new, moderately large pleural effusion at the left base. SEE EXHIBIT A

An EKG shows atrial fibrillation. SEE EXHIBIT B

A diagnostic thoracentesis is performed using ultrasound guidance. Analysis of the fluid shows the following:

pH = 7.0
Protein = 4.2 g/dl (serum protein = 7.0 g/dl)
Glucose = 58 mg/dl (serum glucose = 105 mg/dl)
LDH = 200 IU/L (serum LDH = 240 IU/L)
Cytology reveals the presence of cells suspicious for malignancy

Hematocrit = 53%

TSH = Normal

You schedule Mr. Hopkins for a series of examinations including a spirogram, a polysonogram, a bronchoscopy with transbronchial biopsy and refer him to a dermatologist to have his skin lesion evaluated. You schedule him for another visit in a week when you should have the results back.


STOP
END OF SESSION

• What questions will the examinations you have ordered answer? What sorts of results do you expect at this time?
• How does asbestos exposure cause pulmonary fibrosis?
• What are the causes of pleural effusion in patients with asbestos exposure?
• What is the differential diagnosis for the elevated hematocrit?
• How should the atrial fibrillation be managed? What are long term consequences of having atrial fibrillation?

Wrap-up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used. During session 2 or 3, each student should turn in a relevant journal article. Please review the articles, make comments, and return them to students. You may also ask students to summarize the articles.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.


SESSION 3

Next Clinic Visit

Mr. Hopkins' spirogram showed a 5% decrease in the forced vital capacity. There are no signs of airway obstruction on spirometry. The diffusing capacity has decreased 8% since his previous exam in 1994.

A polysomnogram shows evidence of apnea plus hypoxia index of 65 (mean events per hour of sleep, normal less than 5), short sleep latency and repetitive decreases in his oxygen saturation to as low as 75% during his sleep.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

• What do the results of his spirometry indicate?
• What recommendations can you make to Mr. Hopkins? What is his prognosis?
• What do the results of his polysomnogram indicate? What recommendations can you make to him based on these results?

Clinic Visit Continued

The bronchoscopy with transbronchial biopsy shows the presence of adenocarcinoma in the left upper lobe. The lung tissue around the tumor show evidence of fibrosis. Bronchoalveolar lavage revealed the presence of multiple ferruginous bodies in the specimen.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

• How did the patient's family history, asbestos exposure, and the smoking history contribute to the development of Mr. Hopkins' adenocarcinoma?
• What sort of therapy will you recommend for him?
• What is his prognosis?
• What are ferruginous bodies, how are they formed and what do they mean?

Additional Information

The skin lesion was excised by the dermatologist and histological evaluation showed the presence of a basal cell carcinoma.

STOP
END OF CASE

• What was the major risk factor for Mr. Hopkins' basal cell carcinoma?

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This document was last modified on 06/14/2000 03:08:02 PM

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This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.