CASE NO. 120 CARLOS CUENCA SESSION V NOTE: This case may be used during the regular PBL Sessions or as a case for Individual Process Assessment (IPA). The following Tutor Guide is for a regular PBL Session. When used during the IPA, the guidelines for the IPA of First Year students shail be followed. TUTOR GUIDE: 1 First 45 minutes Finish discussion of the leaming issues of the previous sessions. Next 1 hour and 30 minutes Let the students extract the history and physical examination findings of Carlos ‘Cuenca. Do not volunteer any information that they do not ask for. Let them make their ‘Ask for their primary hypothesis regarding the pathophysiology of the patient. impression and differential diagnosis and the rationale for each one. 2 3. 1 minutes Processing and feedback. LEARNING ISSUES: 1. Causes of prolonged cough 2. Causes of wheezing 68CASE NO. 120 CARLOS CUENCA SESSION V CHIEF COMPLAINT: Cough of 2 weeks duration CASE SCENARI Carlos Cuenca, a 32-year old male, married, Roman Catholic, working as a Coal Mill tender at the lligan Cement Corporation, sought consultation at the company clinic because of he wanted to file a sick leave due to his dry, hacking cough of 2 weeks duration. ‘According to Carlos, the cough started 2 weeks ago as dry cough accompanied by itchiness. of the throat. The cough did not bother him so much because they came occasionally. What bothered him was the itchiness of the throat. A friend advised him to use Strepsils lozenges to ease the itchiness. This relieved him of the itchiness of the throat but the cough persisted, which seemed to be more severe in the afternoon while working at the coal mill, He made a mental note then to seek consultation that week-end. However, he forgot about this because the cough seemed to have been relieved and did not bother him during the week-end ‘When he returned to work this week, he noted that the same dry cough has retumed. He took carbocisteine capsules 3 times a day as advised by a co-worker. The cough, however, persisted, becoming more frequent and more severe. Two days ago, he felt some shoriness of breath after a bout of successive dry cough which was relieved by rest. He was then advised by his supervisor to see the company physician, Aside from the cough, Carlos complains of prutitic and erythematous lesions on his arms which flare up every time he is in his work area. The itch and the redness are relieved once he washes his arms with soap and water but he wants some medicine to relieve some dark spots on his arms which he thinks are due to his constant soratching when the area is itchy. Carlos is a commerce graduate of lligan Capitol College and is married to Loma (30 years old), @ cashier at Gaisano Supermarket, with whom he has a 4-year old daughter, Angela. He does not smoke and rarely drinks alcoholic beverages. His parents are alive and are in good health. He hhas one brother, Alvin, who used to have asthma as a child but is presently in good health He started working at lligan Cement Corporation 5 years ago. He was initially assigned to the Purchasing Division and was transferred as Checker in the Warehouse Section one year ago. ‘Two months ago, there were vacances in the Production Division due to the retirement of some employees. He applied for transfer since the pay was higher and was accepted as Coal Mill Tender. ‘AS such, he was assigned to panning charooal into the kiln that cooks the cement. As a child, Carlos was never hospitalized although he always had cough, most especially when he was tired. Hence, he was never active in sports (basketball, volleyball, etc) like his friends were because he was forbidden by his parents from engaging in strenuous physical activities since fhe went into coughing fits once he started sweating. He also has allergies to seafoods and to penicilin, 69PHYSICAL EXAMINATION: General Appearance: {airy nourished, faity developed, notin respiratory distress: Vital Signs: , BP = 130/60 Temperature = 26.8°C RR = 26/min. Height = 54° PR = 85/min, Weightt = 136 tbs. HEENT: + Pinkish conjuctivae + Anicterie sclerae + No nasal discharge + No flaring of alae nasi + No tracheal deviation + Nomasses + No lymphadenopathies + No supraclavicular and suprastemal retractions + Neckveins not engorged Chest and Lungs: + Equal expansion + No intercostal retractions = (#) tactile fremitus both lungs = No hyperresonance + (#) mucoid rales over the interscapular areas = (inspiratory wheezes all lung fields with occasional expiratory wheezes. = PM at 4” interspace LMCL + Nothrils or heaves + CADisnormal = Regular rhythm, no murmurs Abdomen: + Flat, no scars + Soft, non-tender with no areas of abnormal tympany or dullness = Normoactive bowel sounds Extremities: + Lichenified plaques over both antecubital and both popliteal areas + Good, equal and strong peripheral pulses + No edemaCASE NO. 120 CARLOS CUENCA SESSION VI TUTOR GUIDE: ‘Note: if the case was used for IPA, the students have just finished Session V during the IPA. 1. First hour and 30 minutes Have the students present the case. Correct whatever misinformation they have and supply all the missing data, based on Scenario V before proceeding with your discussion Have them list down and discuss the leaming issues they have identified during the IPA (if case was used for IPA), |dentify new leaming issues. 2. Next 30 minutes Ask group about their management of the case. Introduce the Scenario and compare this with the group's management. Answer the task. Identity new leaming issues. 3. Last 15 minutes Processing and feedback. LEARNING ISSUES: |. Bronchial astnma: etiology, types, pathogenesis, clinical manifestations, management and complications. nCASE NO. 120 CARLOS CUENCA SESSION VI CASE SCENARIO: ‘You tell Mr. Cuenca to have a Complete Blood Count and a Chest X-ray (PA) done and you ask the clinic nurse to nebulize the patient using one nebule of Salbutamol 2.5 mg plus 1 ml of NSS. You instruct him to come back the following day with the results and you tell him to file his sick leave then. Before he leaves you give him a prescription for the following medications: 1. Loratadine (Claritin) 1 tablet once daily 2. Salbutamol + gualaphenesin (Ventolin Expectorant) 1 capsule TID TAS! Give the rationale for the above-mentioned orders. Are there any other tests. that you want to add?CASE NO. 120 CARLOS CUENCA SESSION VII TUTOR GUIDE: 41, First hour and 15 minutes Discuss the tasks and leaming issues of the previous session 2. Next 30 minutes, Give the scenario piecemeal, Answer the tasks and identify new leaming issues. 3. Last 15 minutes Processing and feedback. LEARNING ISSUES: 1 ‘Types, examples and mechanisms of hypersensitivity reactions (allergy) to include anaphylaxis, allergic rhinitis, arthus reaction, atopic dermatitis. Mediators of hypersensitivity reactions 3. Definition of dermatologic terms = lichenification = urticaria and angicedema = macules, papules, nodules + vesicles, bullae, wheal + keratosis = comedonesCASE NO. 120 CARLOS CUENCA SESSION VIL CASE SCENARIO: ‘Mr. Cuenca comes back the following day, bringing with him his laboratory results. Complete Blood Count: Hemoglobin = 14 g/d Hematocrit = 0.38 RBC = 43x 10°7L WC = 8,500/cu.mm, Neutrophils = 60% Lymphocytes = 32% Eosinophils = 8% ‘Chest X-Ray (PA): Essentially normal chest He reports that the frequency of his coughing has greatly diminished and that he feels ready to go back to work. He files his 3-day sick leave and you give him a Return to Work Certificate. TASK 1: ‘What advice will you give Mr. Cuenca? Are you going to give him any maintenance medications? ‘Three days later, you see Mr. Cuenca again in the clinic, this time brought in per stretcher by his co-workers. They tell you that since yesterday, the coal mill was shut down for maintenance work and they have been cleaning all its parts since that time. They noticed that Carlos started coughing then and this morning his coughing got worse up to a point when he could not breathe anymore. His co-workers became alarmed $0 they placed him on a stretcher and brought him to the clinic, You examine Mr. Cuenca and note that his face and neck are full of soot. There is flaring of the alae nasi and supractavicular retractions. Examination of chest and lungs reveal hyperresonance in lungs, intercostal retractions and inspiratory and expiratory wheezes in all lung fields. TASK 2: ‘What happened to the patient? Give the pathophysiology. How would you manage the patient? ‘You tell the nurse to give oxygen inhalation at 2 Itersiminute while she prepares the same nebulizing solution she gave Mr. Cuenca 5 days ago. This time however, you told her to incorporate ‘one respule of Budesonide solution, Nebulization takes about 10 minute, with his respiratory distress being relieved gradually. After 10 minutes, you note less flaring of the alae nasi and less intercostal retractions, but he still had plenty of wheezes. The ambulance driver, who was called by the employees, arrives. You put the Patient in the company ambulance, give him oxygen inhalation and take him to the hospital. TASK 3: Give the rationale for the above-mentioned management. 4CASE NO. 120 CARLOS CUENCA SESSION VII TUTOR GUIDE: 1. First hour and 15 minutes Discuss the tasks and learning issues of the previous session 2. Next 20 minutes. Give the scenario piecemeal. Answer the identify new leaming issues. 3. Last 15 minutes Processing and feedback LEARNING ISSUES: 1 Spirometry 2. Peak Expiratory Flow 3. Arterial blood gases and acid-base balance 75CASE NO. 120 CARLOS CUENCA SESSION Vill CASE SCENARIO: in the emergency room, approximately 15 minutes afer he was treated in the company clinic, patient is still in respiratory distress with upraciavicular and intercostal retractions and wheeses all over {he lung fields. His peak expiratory flow rate is taken: PEFR on 3 trials are 160 min, 180 Vin, and 190 Win. TASK: What is the peak expiratory flow rate? What isis use clinically? Can this be used as @ substitute for spirometry? =e _ How will you manage the patient? ‘You admit the patient with the following orders: Laboratory Tests: + CBS «Arterial blood gases (ABG) + Chest X-ray (PA) + Spirometry STAT and after nebulization Pharmacologic treatment: Nebuiize with Ipratropium bromide + salbutamol (Combivent UDV) every 8 hours. {is this better than using a metered dose inhaler?) = Oxygen inhalation at 2 Vein + DALRS 1 liter at 15 dropsimin. «Hydrocortisone sodium succinate 100 mg now via slow IV over minutes then 100 mg every 8 hours a period of 30 TASK: Give the rationale forthe treatment given. Would you ‘modify anything? 76CASE NO. 120 CARLOS CUENCA SESSION IX ‘TUTOR GUIDE: 1 2 First hour and 15 minutes Discuss the tasks and earring ssues of the previous session Next 30 minutes Give the scenario. Identify “=n eaming issues. Last 15 minutes Processing and feedback 7CASE NO. 120 CARLOS CUENCA SESSION IX CASE SCENARIO: Carlos did the spirometry test prior to nebulization. Initial FEV; is 78% of predicted value. 30 minutes after nebulization FEV; increased to 85% of predicted value. At about the same time the laboratory results arrived. Complete Blood Count: Arterial Blood Gases: Hb = 1359/1 HCO; HCt = 0.38 P.O: RBC= 4.4.x 10% P,CO, WBC = 8,500/cumm pH Neutrophils = 60% Lymphocytes = 30% Eosinophils = 8% Basophils = 2% Chest X-Ray: There is lowering and flattening of the diaphragm and increased radiolucency of the lung fields. All of the other structures are of normal configuration. TASK 4: Interpret the results. Mr. Cuenca's condition improved so that he requested that he be discharged the following morning, TASK 2: (for submission during the next tutorial) 1. How would you explain his illness to the patient? 2. What will you advise Mr. Cuenca? 3. Are you going to give him maintenance medications? (The process of discharging a patient ~ give home instructions, advice and medications - can be role played during the next session) 78