Mario Hernandez

University of Nebraska Medical Center - College of Medicine
Omaha, Nebraska

Instructor(s): Von Essen, Susanna; Rhee, Kenneth
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 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 pulmonary edema.


FACILITATOR GUIDE

Major learning issues

1. Acute and chronic pesticide poisoning.
2. The differential diagnosis of vomiting and diarrhea in adults.
3. The pathophysiology of emesis.
4. The pathophysiology of diarrhea.
5. Electrolyte disturbances associated with vomiting and diarrhea
6. Clinical application of plasma and RBC cholinesterase measurements
7. Causitive organisms, symptoms and epidemiology of food-borne infectious diseases.

Minor learning issues

1. The differential diagnosis of vomiting and diarrhea in a child.
2. The pharmacologic management of vomiting and diarrhea.
3. Prevention of pesticide poisoning.
4. Long-term effects of heavy pesticide exposure.

Case Objectives

1. Outline the risks and consequences of acute and chronic pesticide poisoning.
2. Discuss the differential diagnosis of vomiting and diarrhea in adults.
3. State the pathophysiology of vomiting.
4. State the pathophysiology of diarrhea.
5. Outline electrolyte disturbances associated with vomiting and diarrhea.
6. Summarize the treatment of these imbalances.
7. Describe pharmacologic management of vomiting and diarrhea.
8. Discuss the differential diagnosis of vomiting and diarrhea in a child.
9. Develop a differential for acute pulmonary edema in an adult.
10. Discuss the organisms, symptoms, and epidemiology of food-borne infectious diseases.

List of References

1. From the Worker Health and Safety Branch, California Department of Food and Agriculture, Sacramento (Dr. O'Malley), and the Division of Occupational and Environmental Medicine, University of California,, Davis, School of Medicine (Dr. McCurdy).
2. Morgan, D.P. in: Recognition and Management of Pesticide Poisoning, EPA Publication 540/9-88-001, 4th Ed., pp 1-11, 1989


SESSION 1

Initial Presentation

Mr. Hernandez is a 28 year old Hispanic man who comes to your clinic in Madeira County, California complaining of the "stomach flu" just as you are about to close your clinic for the evening. He has been vomiting and having diarrhea for most of the day. He has barely been able to do his work harvesting tomatoes and wants you to give some medication so that he can go back to the field tomorrow

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

Additional Information

His 2 year old son (who is at home) also has diarrhea. The patient wants you to give him some medication for his little boy.

STOP
END OF SESSION

Wrap-up

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

Review Group Process

1. Did everyone get a chance to participate?
2. Did someone dominate the discussion?
3. Did someone not contribute or participate as fully as they could have?
4. What actions contributed to effective group process?
5. How can we do a better job next time?

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.


SESSION 2

Additional History
The patient has felt well until recently. Other symptoms that have been present for several hours include blurred vision and headache. He also is complaining of having excess saliva and that his eyes are watering

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
Additional History

His wife, who does field work for another grower, is healthy. The 3 older children are well. The family has not eaten out at any restaurants lately. They buy unpasteurized milk from a neighbor who has a dairy farm. They recently attended a picnic on the weekend at which barbecued pork and hamburgers as well as potato salad were served. He does not think that any of the other party guests got sick.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
More History

It is early September and Mr. Hernandez has been harvesting grapes for 2 months. He has also been helping another farmer with his turkey growing operation part-time, cleaning the barns. He dislikes the latter job because of the odor in the barns and because it makes him cough.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
Office Visit Continues

Past Medical History

Mr. Hernandez was raised in Mexico and came to the United States 5 years ago. He has been healthy all of his life. He had an appendectomy at age 16. He does not smoke cigarettes but does chew smokeless tobacco. He drinks several cans of beer when out with friends.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
Family History

His family history is notable for his father having died of unknown causes at age 55. His mother is diabetic and hypertensive.
STOP
END OF SESSION
Wrap-up

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

Review Group Process

1. Did everyone get a chance to participate?
2. Did someone dominate the discussion?
3. Did someone not contribute or participate as fully as they could have?
4. What actions contributed to effective group process?
5. How can we do a better job next time?

Tasks for Next Session

1. Summarize/review case.
2. Review and discuss learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.


SESSION 3

Office Visit Continues

Physical Exam

General: The patient is a robust individual who is diaphoretic and tremulous. He is sitting in a slumped position, blowing his nose frequently.

P = 48 bpm ( normal = 65-85)
BP = 96/70 (normal 120/80)
R = 28
T = 98.8

HEENT exam: Pupils pinpoint, reactive to light. Sclera anicteric. Oral exam notable for dental caries and copious amounts of saliva.

Lungs: Wheezes heard bilaterally. He coughs frothy pink sputum during the exam.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
Physical Exam Continues

Heart: No murmurs or gallops

Abdomen: A well healed right lower quadrant scar is present. Soft without rebound tenderness. Mild diffuse tenderness to deep palpation.

Neurologic exam: Remarkable for tremor in both hands and mild weakness of flexor and extensor groups in upper and lower extremities. He cannot stand without assistance.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE
Office Visit Continues

Suspecting that your patient has pulmonary edema, you order a chest x-ray which confirms you suspicions. SEE EXHIBIT A

Chest x-ray report : PA chest radiograph shows a normal sized heart with evidence of parenchymal consolidation consistent with pulmonary edema. Other diagnostic considerations include infection, over hydration , pulmonary hemorrhage. Correlation with clinical findings is recommended.

STOP
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.