William Reed

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.


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 or student facilitator 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. This case focuses on occupational asthma.


FACILITATOR'S GUIDE

Learning Objectives

1. Describe the pulmonary inflammatory response to bacterial infection, including the mechanisms by which an empyema is formed.
2. Outline the methods for assessing a pleural effusion and making the diagnosis of empyema.
3. Diagram the inflammatory mechanisms that affect the lung in asthma and the rationale for anti-inflammatory therapy for asthma.
4. Summarize the causes of occupational asthma, including asthma caused by a large exposure to an irritant.
5. Explain the causes of sinusitis and describe the medical and surgical management.
6. Discuss the risk factors for pneumonia.
7. Discuss the rationale for draining an empyema mechanically vs. conservative treatment alone with antibiotics.
8. Describe the consequences of not managing empyema with mechanical drainage.
9. Outline the mechanism of action of medications commonly used to treat asthma.
10. List and define the pathophysiology of the bacteria that are common causes of pneumonia and empyema in the adult patient.
11. Describe how asthma can be worsened secondary to a pulmonary infection.
12. Outline the causes and management of anaphylactic shock.
13. Discuss the differential diagnosis of chest pain.
14. Explain the implications of newly identified high blood pressure readings.
15. Describe the mechanisms by which grain dust causes lung inflammation.
16. Outline the types of personal protective equipment available for workers exposed to grain dust and other types of organic dust.
17. Outline the recognition and management of oral candidiasis.

List of References

1. Occupational Medicine by Joseph LaDon: 1990 Appleton and Lange: ISBN: 0-8385-7207-3
2. Mandell, Douglas and Bennettÿs Principles and Practice of Infectious Diseases Chapter 51; pages 637-641 by Richard E. Bryant
3. Current opinion in Pulmonary Medicine 1997, 3:198-202, 1997 Rapid Science Publishers ISSN 1070-5287

SESSION 1

Initial Presentation

Your next patient is William Reed who is a 55 year old man who presents with complaints of cough and wheezing that wake him up at night at least 3 times a week and sometimes bothers him during the daytime.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE
Additional Information

Mr. Reed says he has had this problem intermittently for 12 years. He first became very ill with wheezing and shortness of breath after scooping moldy grain out of a bin. You had identified reversible obstruction on spirometry at the first clinic visit a month earlier.

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Office Visit Continues

Mr. Reed says he is feeling much better since you gave him a 10 day course of prednisone. He was also started on a salmeterol inhaler (2 puffs BID), prn albuterol by inhaler and an oral theophylline preparation. After the course of prednisone was completed, you started him on a fluticasone inhaler. He has had much less difficulty doing his work as a financial advisor and has been able to resume his workouts at a health club.

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Another Office Visit

He has been having a fever and has had severe pain in the right side of his chest which is worse with deep breathing. A ventilitation/perfusion scan was unremarkable at the other hospital. He is mildly short of breath at rest and is coughing up green sputum. He is worried because he has lost 12 pounds in the last 2 weeks.

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Learning Issues
Additional History

The patient was treated with 4 days of an unknown intravenous antibiotic at the other hospital. He was given Biaxin to take at home. He is otherwise healthy with the exception of having frequent bouts of sinusitis. He has smoked cigarettes. He rarely drinks alcohol.

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END OF SESSION
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.


SESSION 2

Past Medical History

Mr. Reed's past medical history is remarkable for the patient stating that he has had anaphylactic shock twice after taking aspirin and naproxin, respectively. He has suffered from sinusitis repeatedly for most of his adult life. Mr. Reedÿs most recent of several surgical procedures for sinusitis was completed on 12/6/96, at which time bilateral frontal sinus mucoceles were resected by endoscopic surgery. He has also had a left nasal lacrimal duct obstruction repaired surgically in January, 1997 which was thought to be a complication of the sinus procedure. He has had nasal fractures in the past. He is otherwise healthy, with no history of hypertension.

Social History

His social history is notable for having a 10 pack year history of smoking. He quit smoking in 1976. He rarely drinks alcohol. He lives in Lincoln, Nebraska with his wife. His favorite recreational pastime is to go trout fishing in Wyoming. He sometimes develops severe wheezing and shortness of breath while trout fishing.

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Physical Examination

The patient is an ill, weak appearing man with slightly labored breathing and a flushed face.

T = 97.7 degrees F.
P = 108
R = 18
BP = 187/76

HEENT: White patches on the oral mucosa that have an erythematous base.

Lungs: Rare wheezes. Decreased breath sounds over the right lower lobe. A friction rub is audible in that region and there as is egophony noted on auscultation of the chest.

The remainder of his physical examination is unremarkable.

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Laboratory Data

WBC = 11.9 X103/ml with 80% segmented neutrophils and 0% band forms.

Chest X-Ray

The chest X-ray reveals patchy consolidation of the right middle lobe and right lower lobe as well as a large right pleural effusion.

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You decide to evaluate the pleural fluid.

Thoracentesis: Yellow hazy fluid.
Cell differential: 100% PMNs.
Pleural fluid protein = 4.8 g/dl. Serum protein = 8.8 g/dl.
Pleural fluid LDH = 1299. Serum LDH = 376.
Pleural fluid pH = 6.84.
No organisms seen on Gram stain, culture negative (culture results available 5 days later).

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End of session

Learning Issues

Was the treatment for the pneumonia appropriate and adequate?
What does the finding on chest X-ray suggest? Should the changes from pneumonia be expected to have resolved by now?
What other laboratory tests should be ordered at this time?
What complication of pneumonia do the pleural fluid findings suggest and how should this be managed?
What is likely to happen with his asthma symptoms secondary to the acute infection and how should his asthma be managed at this time?
What link is there between sinusitis and asthma?
Do all pleural effusions complicating pneumonia have to be drained? What are the management options for pleural effusions that are empyemas?
What is the meaning of a single elevated blood pressure reading?
What should you do with the patient at this time?


SESSION 3

Clinical Course

The patient was admitted to University Hospital. Under CT scan guidance, a 16 French chest tube was placed into the right pleural cavity. Only 300 cc of fluid was drained out.

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The patient was given 100,000 units of urokinase into the chest tube daily for a total of 6 days. This caused the chest tube to drain freely. Also, the patientÿs chest pain decreased during this time.

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What would have been the likely outcome if the empyema had not been drained?
What organisms are most likely to have been responsible for causing the empyem?
What is the mechanism of action of urokinase?
What are other uses for this drug?

Follow-up

A chest X-ray done after 6 days of therapy showed no sign of residual fluid in the pleural space. He was also treated with oral Augmentin 500 mg three times daily and for 2 weeks after discharge. He was able to return to work within 2 weeks of discharge. His asthma has remained under good control.

What are possible complications of chest tube drainage?
Was Augmentin a good choice for managing this problem?

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END OF CASE



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


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.