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.



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

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

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.

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DISCUSS THIS SECTION BEFORE CONTINUING

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

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.

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DISCUSS THIS SECTION BEFORE CONTINUING

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.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

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: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

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

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

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






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