Roger Bean

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

Instructor(s): Von Essen, Susannna
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 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 "farmer's lung", a type of hypersensitivity pneumonitis.

FACILITATOR'S GUIDE

Case Objectives
Year Two Student Faclilitated PBL

Half of the groups for each case will be facilitated by students this fall; each group will alternate between faculty facilitators and student facilitators for each case. This is an experiment to determine if there is any significant difference between student facilitated groups and faculty facilitated groups.

Outcome measures will include case exam grades, a summary of group process, which will be completed after each case, the quantity and quality of hypotheses and learning issues generated by each group, and a survey of student attitudes at the end of the semester.

Student facilitators and faculty facilitators will both receive this facilitator's guide. To eliminate a potential bias in this study, faculty and student facilitators will not receive a case summary or references for this case. To give such data to student facilitators would put them at an advantage over their classmates, and the temptation to distribute the facilitator guides to members of their groups and the whole class would be great.

Faculty facilitators are welcome to research the case just as students will if they are uncomfortable with the content area of this case. I am sorry for the inconvenience this may cause faculty, but I believe that this is the only fair way to handle this issue for the students.

Attachments

Exhibit A: Chest x-ray
Handout: "Consultation and Referral"

Summary of ICE Session on August 29, 1994

NOTE: Some ICE small groups had female standardized patients; for the rest of the case the patient will be a male Review the following information, which should have been obtained from the standardized patients, to insure that all students have the full story.


SESSION 1

Initial Presentation

Mr. Bean is a 33 year old white male who comes to your clinic in a central Nebraska town near his home. He wants another opinion because he has been told by other physicians that he has a serious pulmonary problem.

History of Present Illness

Mr. Bean states that for the past 18 months he has had episodes of fever, chills, dry cough, and malaise. These episodes come on in the evening and can last for several days. They are associated with dyspnea on exertion. He has lost 20 pounds during this time.

Occupational History

Mr. Bean raises hogs in confinement, working together with his father and two brothers on a large farm that his father owns. He feels good if he does not work in the swine confinement unit for a few days but becomes ill when he tries to return to work. At the present time he is feeling well because he has avoided the hog barn for several days.

He has been advised by other physicians to give up farming and to choose another profession. He comes to you for another opinion regarding his medical problems and for advice about the need for him to give up farming. He also mentions being worried about medical bills because of a high deductible in his health insurance policy.

Additional History

Mr. Bean has been healthy for most of his life. He had an inguinal hernia repaired when he was two months old. Childhood diseases included chicken pox. He had been immunized against measles and mumps, and his last tetanus was 2 years ago. He lost part of the 3rd digit of his right hand in a power take-off accident at age 12. At age 17 he suffered a febrile reaction lasting about a day after removing moldy corn from a bin. He did not see a doctor about that.

Mr. Bean has never smoked, and alcohol intake consists of an occasional beer on weekends. Mr. Bean is married and has three children, ages 10, 7 and 4.

His family history is fairly unremarkable. His 7 year old son has asthma and his 9 year daughter has allergic rhinitis. His father and two brothers work with him on the farm and are healthy.

The Bean family farm is well known in the Midwest for their production of hogs to be sold as breeding stock. Roger Bean's job consists of supervising this aspect of the operation. His expertise is vital to the continued success of the business. The hog raising operation was recently expanded, using a sizable loan from the local bank. Mr. Bean has no education beyond high school. His wife also works on the family farm and serves as bookkeeper for the family business.

Physical Examination

At the current time his physical examination is normal.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


Advice for Mr. Bean

Mr. Bean is advised to come back to the physician during one of his attacks.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE


Another Attack

Mr. Bean returns to the physician when he has his next attack.

Diagnostic Tests

After performing a physical exam, pulmonary function tests during this episode reveal the presence of moderate restriction with a low diffusing capacity for carbon monoxide. The test was also interpreted as being consistent with "small airways disease".

See Exhibit A: chest x-ray

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DISCUSS THIS SECTION BEFORE YOU CONTINUE



Chest X-Ray Report

The chest x-ray was interpreted as showing evidence of pneumonia.

Other Diagnostic Tests

Mr. Bean's physician sent blood away for a "farmers lung panel" of serum allergic precipitins, which revealed antibodies to Aspergillus and pigeon serum.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE



Physician's Advice

The physician told the patient to wear paper masks in the swine confinement unit. Despite doing this he has another attack.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Pulmonary Consultation

His doctor asks him to see the pulmonary consultant who comes out from Omaha to work in his office once a month. She performed a bronchoscopy with bronchoalveolar lavage (BAL). This revealed the presence of erythematous airways with a mild increase in mucus.

Lavage cell counts were as follows (normals in parentheses):
bronchial fraction: 4.2 X 106 cells (up to 10 million)
alveolar fraction: 30.5 X 106 cells (5 - 50 million)

Cell differentials were as follows for the bronchial fraction:
neutrophils: 40% (0-20%)
macrophages: 25% (0-100%)
lymphocytes: 24% (0-8%)
eosinophils: 5% (0-5%)
ciliated cells: 3% (0-35%)
squamous cells: 2% (0-15%)

The alveolar lavage differential was as follows:
neutrophils: 10% (0-6%)
macrophages: 65% (0-100%)
lymphocytes: 23% (0-20%)
eosinophils: 2% (0-5%)
ciliated cells: 0% (0-10%)
squamous cells: 0% (0-2%)

Cytology of the BAL cells showed "inflammatory changes".

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DISCUSS THIS SECTION BEFORE YOU CONTINUE



Wrap-up
1. Hand out summary of this session AND article on "Consultation and Referral".
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

Pulmonary Consultation (continued)

The pulmonary consultant told the patient to wear an air supply helmet.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE


Follow-up

About a month later, the patient returns to the pulmonary consultant because he has had yet another bout of his illness in spite of using an air-supply helmet to filter out the hog dust. He seems angry and defensive.

She repeats the history and physical and compares what she hears now with the notes from the other physicians who have seen Mr. Bean.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE


Physical Examination

Vital signs:
T = 99.0
P = 88
R = 18
BP = 148/92

General appearance: thin but otherwise appears well
Chest/lungs: a few inspiratory rales at his lung bases to auscultation
The examination is otherwise unremarkable.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE



Review of Previously Collected Information

Careful questioning reveals that the patient has his office in the basement of his home, which is damp and has molds growing on the walls. After sealing the basement walls and removing the mold, as well as moving his office upstairs, the episodes ceased. He had hypersensitivity pneumonitis caused by mold exposure. The patient was able to stay in farming.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE


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

Case Summary

This is a combined PBL and ICE case. The first session will be held in ICE time on Monday, August 29. At that time students will interview a standardized patient and obtain physical exam results. Follow-up will be in the usual PBL format during two PBL sessions.

Mr. Bean is a 33 year old white male whose symptoms, physical examination, chest x-ray abnormalities, and pulmonary function test results point to a diagnosis of hypersensitivity pneumonitis.

Because he is a farmer who raises livestock and thus possibly has exposures to thermophilic actinomycetes (which grow in spoiled hay) and to fungal antigens such as those of Aspergillus (which grows in "moldy" grain), he is at risk for the type of hypersensitivity pneumonitis commonly called "farmer's lung". There are many other occupations where workers are at risk for this problem.

In hypersensitivity pneumonitis, fever, chills, malaise, and a dry cough begin 4-8 hours after exposure to the causative antigen. A prior exposure, followed by sensitization, is required for this reaction to take place. This is a classical delayed-type hypersensitivity reaction. The symptoms can last for days to weeks after the exposure. Particularly with repeated bouts, the patient may experience weight loss. These farmers are also at increased risk of developing chronic bronchitis.

Neutrophil recruitment to the lungs occurs via IL -1 and TNF induced releases of other cytokines, including Interleukin 8. This substance is released by both alveolar macrophage and bronchial epithelial cells. Complement activation, which leads to generation of the neutrophil chemoattractant C5a, may also play a role. After several days, neutrophil numbers fall and lymphocytes are recruited to the lung. Cytokines that cause neutrophil recruitment include IL -1 and IL -2.

There is a T cell-induced mononuclear cell accumulation of regulatory and effector T cells and macrophages. Initially, T helper cells predominate, then T suppressor cells. These lymphocytes are activated. Natural killer (NK) cells activity increased, which may be related to the pathology seen. Lymphokines and monokines are released. Granulomas often form. Interleukin 1 and tumor necrosis factor (TNF) are released from the activated macrophages, causing the fever, malaise and leukocytosis.

Physical exam findings during an acute attack can include fever, tachycardia, and rales on lung exam. Restrictive lung disease (a low vital capacity) and a low diffusing capacity for carbon monoxide (indicating compromise of the alveolo-capillary membrane) are characteristic pulmonary function test findings in the disease. Arterial blood gases likely will show hypoxemia. The complete blood count will show a leukocytosis.

Tests, which support but do not confirm the diagnosis, include testing for antibodies in the patient's serum to antigens known to cause hypersensitivity pneumonitis. These demonstrate that exposure has occurred, but they may be elevated in persons who are not ill.

Bronchoscopy with bronchoalveolar lavage (BAL) is sometimes done in hypersensitivity pneumonitis, particularly if the diagnosis is very much in doubt based on other information available. Bronchoscopy with BAL permits direct inspection of the large airways (1st through 5th generation airways) using a fiberoptic endoscope. By wedging the scope into position in a large airway, sampling of areas distal to those directly visualized can be done using saline washings followed by gentle suction. Cells recovered are counted and cell differentials are performed by light microscopy.

Fluid recovered can also be cultured to help rule out a pneumonia. BAL findings in farmer's lung include increased neutrophils acutely; this is followed by an increase in lymphocytes. Mast cells, which are not routinely quantified on BAL samples but which can be seen using special stains, are also elevated. The matter of BAL interpretation is further complicated by the fact that neutrophils are also elevated in organic dust toxic syndrome (described below) and by the observation that healthy farmers can have elevations in BAL lymphocytes numbers.

BAL fluids can also be assessed for the presence of a variety of proteins, including procollagen III peptide, a fibroblast product that is a marker for fibrogenesis. The fibroblasts are stimulated to proliferate by alveolar macrophage derived growth factor, produced by macrophages that are activated by inhalation of the offending antigen. Fibronectin and vitronectin are other macrophage products, which are elevated in BAL fluids in hypersensitivity pneumonitis and which also serve as markers of fibrogenesis.

Tissue specimens obtained by open lung biopsy or video-assisted thoracoscopic biopsy of the lung show an interstitial alveolar infiltrate with plasma cells, lymphocytes, and occasional neutrophils and eosinophils, usually with granulomas. Interstitial fibrosis may be present, particularly in chronic disease. Some bronchiolitis is often found. These findings are distinctive but not pathognomonic of hypersensitivity pneumonitis. Because of the morbidity, potential mortality and cost of such procedures, they are not usually done if there is information from the history, physical examination, and laboratory tests which points to hypersensitivity pneumonitis.

Treatment of farmer's lung consists of avoidance of further exposure. Wearing proper masks (two-strap masks designed for use in dusty environments and NIOSH approved for that purpose) may be sufficient. An air supply helmet (which filters the air) can be helpful. In other cases, the farmer may have to change his or her work practices to avoid the exposure that triggers the attacks. Oral corticosteroids shorten the duration of the symptomatic period.

This can be a serious health problem for several reasons. It commonly causes patients to feel sufficiently ill to lose time from work and therefore is of economic importance. Hypersensitivity pneumonitis can also lead to pulmonary fibrosis. When that occurs, the patient usually suffers from chronic hypoxia. This in turn causes vasoconstriction in the lung, which places stress on the right side of the heart and leads first to right-sided, then biventricular congestive heart failure. Severe hypoxemia and/or heart failure can lead to the death of patients with hypersensitivity pneumonitis.

Farmer's lung is often confused with organic dust toxic syndrome, also called toxic pneumonitis. This is an acute, influenza-like febrile illness, which follows heavy organic dust exposure, such as might be experienced while sweeping out grain bins. It is much more common than farmer's lung and does not require prior sensitization.

ICE Issues

Understand why an individual like Mr. Bean carries health insurance with a high deductible and what effect the bills created by his illness have on his life.

Possible explanations include the high cost of insurance for a family not covered by group insurance. There may be a family member who has a pre-existing medical condition, which would cause the premiums be very expensive. This could be Mr. Bean. His illness might also cause the family's policy to be canceled by an insurance carrier. Another example would be a handicapped child or a child with cancer.

In the past, farmers have not been as likely to buy health insurance, but this has changed in the past 10 years. At present, they are more likely to carry a policy with a high deductible than a person who works for a large business.

The tests ordered on this patient cost several thousand dollars. While farmers often have millions of dollars invested in land, machinery, and animals, they often do not have a great deal of cash available at times not coinciding with the sale of animals or crops. The large expenses and interest payments may make finding the resources to pay medical bills a problem. This may cause the patient to resist having further tests done.

The patient may not want to explain his thinking because of embarrassment or unwillingness to discuss his financial situation with an outsider. In small communities there are often very real concerns about confidentiality that are even greater than those in medical facilities in urban areas.

Understand the implications that leaving the farm would have for the entire family.

Mr. and Mrs. Bean may not be able to find work in their community because jobs are scarce in small towns. They may have to move away from their community to an urban area, where they likely would have to take jobs that do not pay well because neither have education beyond high school. This would change their standard of living and their sense of who they are in society.

Mr. or Mrs. Bean could go through job training or attend college, which would initially be expensive but would lead to a higher standard of living for them in the future. Mr. Bean could seek employment that would allow him to use his farming skills but would have to avoid work that would give him the same exposures that made him ill.

Leaving the family farm would no doubt change their relationship with other family members. Potential areas of conflict may be buying out Roger Bean's share of the business and his degree of responsibility for any debts for new farm buildings or animals. Others in the family may resent that they are losing the bookkeeper and hog breeding specialist whose participation was vital to the success of the business. The children may also have difficulty adjusting to an urban area, to leaving their cousins and friends, and to attending a new school.

Understand the implications of a serious chronic illness on a young individual's sense of self esteem and discuss how a rural person's reaction might be different from that of someone from an urban area.

People, especially those who are the "head of a family", draw a large part of their identity from their work. When no longer able to work in the field they have chosen, they may blame themselves or others unjustly. They may fear being completely disabled. They may be embarrassed about accepting any kind of public assistance. This can lead to conflict within a marriage as well as depression and physical and/or emotional abuse of children.

The independence and pride in self sufficiency prevalent in rural areas may keep them from seeking help for these kinds of problems. Often, they deny for as long as possible that the problem exists and may return repeatedly to the environment that makes them ill. They may deny the presence of other medical problems as well. For example, Mr. Bean had an elevated blood pressure reading in clinic and had declined treatment for hypertension in the past. Young male farmers are often particularly reluctant to visit a doctor's office. The fact that Mr. Bean has done so frequently in the past few months is a clue that he is extremely concerned about his pulmonary problem.

Understand the frustration experienced by patients who are told different things by different physicians, particularly if the information has far-reaching implications.

Patients may try to play one physician against another. The second or third physician to assess the case should avoid the temptation to voice negative opinions about the other physicians directly to the patient. Information gathered by other physicians should be reviewed carefully, if possible before the clinic visit. Additional information should be obtained directly from the other physicians if possible, rather than relying on the patient's memory. The focus should be on solving the problems at hand and not on discussing delays in diagnosis and treatment.

Point out the need to maintain an open mind about the case.

It should not be assumed that the subspecialist who also treated the patient had explored every diagnostic and therapeutic possibility. Repeating the history is very important. Patients commonly recall additional details not previously documented as they talk.

Explain the difference between a consultation and a referral. List the responsibilities of the consulting/referring physician and the physician being consulted or referred to.

The attached article is a good, short review of this topic.

Explain the importance of the occupational history in regards to its relationship to causation of illness in addition to the effect of illness on the patient's occupation.

Of course, illness affects the patient and his/her ability to work, but don't forget that the job may be a risk factor for illness or actually cause the illness. Remember to take that occupational history!

References

Curtis, JL and M Schuyler. Immunologically mediated lung disease. PP 689-731. (ATTACHED)
Consultation and referral. In An Introduction to Family Medicine. McWhinney IR. New York, Oxford University Press, 1981:173-176. (ATTACHED)
Bronchoalveolar Lavage (ON RESERVE)


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


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