Robert J. Reynolds

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

Instructor(s): Von Essen, Susanna
Subject area: Health / Medicine
Department: Medicine
Level: Undergraduate Medical
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 first and second year 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

Case Objectives

1. List the differential diagnosis/causes (including occupational causes) of: 2. Tobacco use:3. COPD (emphysema and chronic bronchitis):4. Sleep apnea syndrome:

SESSION 1

Initial Presentation

Robert J. Reynolds is a 55 year old white male who comes to your Internal Medicine clinic in Kearney, Nebraska, complaining of gradually increasing shortness of breath.

Mr. Reynolds was last seen in the office about two weeks ago. At that time, his wife stated that "he snores loudly and stops breathing during his sleep."

A polysomnogram was done. The apnea plus hypopnea index = 63. The arousal plus wake index (myoclonus index) = 12. All apneic and hypopneic events recorded are obstructive in nature. The results of the test have not yet been given to Mr. Reynolds; his scheduled appointment was for next week.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


What is a polysomnogram? How is it done? What are apnea/hypopnea indices?What are the risk factors/causes for sleep apnea?
History of Present Illness

The shortness of breath has become much more severe during the past 2 days and is such that he has difficulty walking more than 1/4 mile without resting. He was so short of breath last night that he slept in his recliner chair. He has also noticed recently that his ankles are swollen at the end of the day.

He also has a chronic cough, which is much worse after he has spent the afternoon in a sale barn. He works as a cattle buyer for a feed lot. His cough is usually productive of thick sputum, which is usually white but sometimes yellow. The sputum has occasionally contained flecks of blood recently.

Mr. Reynolds states that he started smoking at age 12 and currently smokes 2 packs of cigarettes per day. He has attempted to quit using nicotine gum but was not successful.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


What is the differential diagnosis of shortness of breath?Why does he have ankle edema?
What are the causes of chronic cough?
What is the significance of his hemoptysis?What anatomic alterations are often present in the lungs as a consequence of many years of smoking?
What is the role of nicotine substitution preparations in smoking cessation?
Physical Examination

The patient is an obese man who appears somewhat short of breath at rest and very dyspneic as he walks down the hall. He brings up purulent sputum during the examination.

Vital signs: T = 37o, P = 88, R = 28, BP = 150/92, hgt = 70 inches, wgt = 90 kg
Lungs: Diffuse wheezing
Heart: Right ventricular heave, loud P2, systolic murmur best heart at the left upper sternal border
Abdomen: Hepatojugular reflux is present, mild hepatomegaly
Extremities: Mild cyanosis, 2+ pedal edema

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Discuss the mechanisms for the abnormal physical findings.What other tests would be valuable at this time?

Laboratory Data

A spirogram is performed, and the values are as follows:
FVC = 2.44 L
FEV1 = 0.94 L

A chest x-ray shows bronchial wall thickening

The arterial blood gases (on room air) are as follows:
pH = 7.26
pCO2 = 62
pO2= 41

Thyroid function studies are as follows:
T4 = 3.8 (5-12 ng/dL)
TSH = 40 (0.3-5.0 mcIU)

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


What are FVC and FEV1? How are the done? How do his FVC and FEV1 compare to expected values for his age, gender, and height?
What does the chest x-ray mean?
Describe the acid-base status of the patient. What is his A-a gradient, and what is the predicted value, given his age?
Does the patient need oxygen? If so, how much and why?
What do the thyroid values mean? How should this condition be treated? Are there any precautions to treating this patient?
What other questions should be asked during the history?


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.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

STOP
END OF THIS SESSION


SESSION 2

Additional History

The patient's additional medical problems include a history of hypercholesterolemia, hypertension, peptic ulcer disease, and non-Hodgkin's lymphoma, which was treated with chemotherapy in 1974. He has been having some chest tightness with exertion for the past 6 months.

The patient was a farmer until 1975, when he took the job as a cattle buyer. His social history is relevant for serving in the Army during the Korean War. He drinks alcohol occasionally at social functions.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Could the past history of treatment for Iymphoma be contributing to his shortness of breath? Which chemotherapeutic agents used to treat lymphoma have pulmonary toxicity? What pulmonary lesions do they cause?
What other problem(s) caused by tobacco use, hypertension, and hypercholesterolemia may be contributing to his shortness of breath? Is there a role for empirical antibiotic therapy in this patient? Why or why not?
What are likely cause(s) for this exacerbation of COPD? What bacteria commonly cause this? What viruses?
What would you do with the patient? Does he need to be hospitalized?


Hospital Course

You admit the patient to a regular room in the hospital for treatment of his shortness of breath.

Theophylline is started as a continuous infusion. He is given 125 mg of methylprednisolone IV every 6 hours. Albuterol solution and ipratropium bromide solution are administered by nebulizer every 4 to 6 hours. He is given 40 mg of furosemide for the peripheral edema. Supplemental oxygen at a flow rate of 3 L per minute is given by nasal cannula.

You ask for arterial blood gases 1 hour after the oxygen is added, and they are as follows: pH = 7.11, pCO2 = 75, and PO2 = 65.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Should he receive antibiotics at this time? If yes, what should be done before antibiotics are started?
Explain the rationale for each medication used.
Why did the patient's CO2 rise? What is his acid-base status? Is the pH dangerously low? Will he require mechanical ventilation?


A Request from the Nurse

After the nurse gives you the blood gas results, she tells you that "he doesn't look very good" even though the patient tells her that his breathing is improved.

His blood pressure is now 96/62, his pulse rate is 128 beats per minute, and the rhythm is irregular. He has had 1800 cc diuresis. She states that the patient is somnolent and confused and that you should transfer the patient to the Adult Intensive Care Unit now.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Could any of the medications have caused the changes in the pulse rate, cardiac rhythm, blood pressure, or in his behavior?
What are the side effects of the medications he received during this admission? Why might there be an electrolyte problem?
Should you listen to the nurse and have the patient moved to the Intensive Care Unit? Why? What is likely to happen soon if the therapy is not changed?


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.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.


STOP
END OF THIS SESSION


SESSION 3

Transfer to Adult ICU

You agree with the nurse's recommendation, and the patient is transferred to AICU and is intubated. A portable CXR reveals collapse of the RLL and RML.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Do you agree with the intubation?
What could cause the lobes of his lungs to collapse? What would you do for this condition?


Hospital Course

Large quantities of mucus are removed by therapeutic bronchoscopy. Later, his course in ICU is complicated by a pneumothorax and multifocal atrial tachycardia.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Why did he produce large amounts of mucus? What drugs can be used to treat this?What is multifocal atrial tachycardia? What are the risk factors for this?


Hospital Course(continued)

His current treatment regimen consists of IV theophylline, methylprednisolone 125 mg IV every 6 hours, a broad spectrum antibiotic, and albuterol aerosol treatments.

On day 5 of the ventilation, his sputum grows Pseudomonas aeruginosa resistant to all antibiotics but amikacin.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


What are the complications of high dose IV Corticosteroids?
Why did he become infected with a highly resistant Pseudomonas? What are risk factors for nosocomial pneumonia?
Does he need nutritional support while in the ICU? If so, which form is best?


Follow-up and Discharge

After 6 days on the ventilator, he is finally extubated. The patient leaves the hospital after 14 days of therapy. Supplemental thyroid was initiated at low doses and titrated without complications during his hospitalization.

At this point, his room air arterial blood gases are as follows: pH = 7.38, pCO2 = 47, pO2= 54. His FEV1 has increased to 1.53 L on the day of discharge. He is scheduled to attend pulmonary rehab as an outpatient.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Discuss the blood gases and FEV1.
How can he monitor his pulmonary function at home?
Of what should his home therapy consist, both medications and other modalities?
What does pulmonary rehab consist of?
What other pulmonary function studies might be helpful, besides spirometry, to determine if the patient has emphysema? Why?Does he need home oxygen? Will this help him to live longer?
Summary and Integration of Learning
1. Hand out summary of this session.
2. Review objectives for this case.
3. What did we learn?
4 Could we have gone through the case more efficiently?

If Indicated, 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?

PBL Written Evaluation

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.