CASE NO. 121 FORTUNATO TAN SESSION X TUTOR GUIDE: 1. First 45 minutes, Discuss learning issues of previous sess 2. Next hour Have the students extract the history and physical examination findings of Fortunato ‘Tan. Have students formulate their hype Identify leaning isssues. 3. Last 15 minutes Processing and feedback. LEARNING ISSUES: 1 Chronic Obstructive Lung Disease :ypes. etiology, reisk factors, pathophysiology, Glinical manifestations, differential d agnosis. management 2. Tobacco smoking: effects of smokinginicotine, clinical correlations, strategies for cessation of smoking,CASE NO. 121 FORTUNATO TAN SESSION X CHIEF COMPLAINT: Shortness of breath CASE SCENARIO: Fortunato Tan, a 54-year old male, Catholic, residing at Villa Verde, working as a supervisor for JOC Engineering and Construction Co., sought consultation because of shortness of breath first noted 1 month ago. (One month prior to consultation, Tony, as he is called by his friends, first noticed that he was short of breath after climbing two flights of stairs. He did not really mind this because he thought this to be part of the cough and colds he has been experiencing that week. About 3 weeks ago, he went to Cebu to visit his daughter and her family and at the same time attend the festivities of the Fiesta of the Sto. Nifio. There, he again experienced shortness of breath when he joined the procession, so that he had to stop and go home instead. When his daughter urged him to go to the hospital for check-up, he refused saying that this was just due to the heat and decreased circulating air because of so many people, Moreover, he said that his breathlessness was relieved after resting ‘One week prior to consultation, he noted that he easily gets tired and short of breath even after walking a short distance. He noted that the symptoms were more severe when he is around ‘workers who are mixing cement and sand. His cough also recurred and was productive of thick, yellowish sputum. He denies having fever. He started taking carbocisteine 4 days ago but it did not ‘seem to help. Last night, he had difficulty sleeping because he could not breathe well when lying flat on bed, He had to prop up his back with 2 pillows to be able to breathe. He finally fell asleep at around 12 midnight but woke up gasping for breath around 3 a.m. (because he fell off his pillows). He resolved to seek consultation first thing in the morning Tony is a commerce graduate, but could not get a job so he started working as a security guard for various small stores; he was 25 years old then. When he was 28, he got married to Thoima, a secretary in one of the establishments where he worked as security guard. When he was 30 years old, he applied at JOC Engineering and Construction Co. and was accepted as an apprentice, working at odd jobs and at the same time leaming some skills in masonry, carpentry and plumbing. Two years later, he became a regular employee (as a construction laborer), where he frequently worked the night shifts, since the pay was higher. He was promoted to the rank of supervisor § years ago. Currently, the construction company is the contractor in charge of building a shopping center here in lligan City. They are very busy, because the target date for the opening is just two months away. Tony is in good health except for his chronic cough which he said started about 5 years ago. His cough was always productive of whitish to yellowish sputum and would last for almost a month. Initially he took various medications, some prescribed by their company doctor and others were recommendations of friends; Amoxicillin, Solmux, and Mucosolvan are the ones he could recall. The medicines relieved his cough, but after'a month or so the cough retums. Later, he gave up taking ‘medicines and just takes plenty of juice every time his cough recurs, He has no allergies to food or medicine and was never hospitalized before. He smokes a pack of cigarettes daily, a habit he developed when he started working as a security guard and which progressed when he was working the night shift, apparently to keep himself awake. He also drinks 80beer regularly with friends on week-ends. He used to play basketball regularly with friends on week- ends which is always followed by a “beer-drinking session", where he consumes 3-5 bottles of beer. However, since five years ago, he stopped playing basketball with them, because he easily gets tired than he used to, attibuting this to his advancing age. He just joins them for the beer session. He has 4 children, who are all in good health. His father died at the age of 60 of tuberculosis and pneumonia. His mother, 70 years old, is stil alive and is hypertensive and has heart disease. PHYSICAL EXAMINATION: General Survey: ‘well developed, overweight, well-oriented, not in acute respiratory distress. You ‘ote thal the patient keeps his answers short and that he seems to catch his breath in between sentences. Vital Signs: Height = 5 ft. 5 inches Temperature = 36.2°C + No flaring of alae nasi * Mild nasal mucosal congestion Dusky lips + Some yellow staining of the teeth + Mild halitosis, NECK + No tracheal deviation + Nolymphadenopathies + Nothyroid enlargement CHEST & LUNGS Inspection: + No supraclavicular intercostal or subcostal retraction + No increase in antero posterior diameter of the chest wall + Chest expansion is equal an both sides ‘+ There is prolongation of expiration with bulging of the interspaces during expiration + Forced expiration lasts for 7 seconds Palpation + Decreased tactile fremitus over the lung bases and peripheral lung fields + Rhonchal fremitus present over interscapular Areas which disappears after a cough Percussion: + Dullness over the right lower lung fields Auscutation: + Coarse rhionchi and wheezes all over which change in intensity after coughing + Coarse rales over peripheral lung fields at+ No heaves, no theills = CAD not enlarged = Regular rhythm, = Nomurmurs ABDOMEN + Globular, no scars = Soff, non-tender = Normoactive bowel sounds EXTREMITIES + Yellowish stains in nails ‘+ No clubbing of the fingers TASKS: (For submission during the next tutorials) 1. Write the medical history and physical examination findings of the patient. 2. Give your primary impression and differential diagnosis. State the basis of the diagnosis. 3. Give your plan of management. 82CASE NO. 121 FORTUNATO TAN SESSION XI TUTOR GUIDE: 1. 4st hour Have a student present the case, to include the primary impression, differential diagnosis. Have the group discuss the pathophysiology of the patient. Discuss the leaming issues of the previous session. 2. Next hour Give the case scenario. Discuss the plan of management of the students and compare it with that in the scenario, 3. Last 15 minutes, Processing and feedback, LEARNING ISSUES: Pulmonary tuberculosis: etiology, pathophysiology, clinical manifestations, management Aspergillosis: etiology, pathophysiology, clinical manifestations, management Lung Cancer: types, etiology, pathophysiology, clinical manifestations, management Pulmonary cystic fibrosis: etiology, pathophysiology, clinical manifestations, management eeNea 83CASE NO. 121 FORTUNATO TAN SESSION XI CASE SCENARIO: In the emergency room, you determine Tony's pulmonary function with a peak flow meter and you get the following results with 3 trials: 180 L.min..; 200 Limin.; and 190 Limin. ‘You nebulize the patient with salbutamol and 30 minutes later, you do another determination of his peak expiratory flow rate. With 3 tials PEFR are 200, 210 and 210 Limin. Since there is no significant improvement after bronchodilator therapy, you decide to admit him to the hospital for further work-up. Therapeutic Objectives: + Alleviate the dyspnea + Establish a definite diagnosis Laboratory Requests: = Complete blood count + Chest X-ray (PA) + Electrocardiogram ‘+ Sputum exam for acid-fast bacilli + Gram stain of sputum + Arterial blood gases = Spirometry Pharmacologic Intervention = Oxygen inhalation at 2 Limin = Azithromycin 500 mg 4 tablet now then once daily TASK: Give the rationale for the above-mentioned orders 84CASE NO. 121 FORTUNATO TAN SESSION XII Discuss the leaming issues of the previous session. 2. Next hour Give the case scenario. Answer the task if possible. Identity new leaming issues. 3. Last 15 minutes Processing and feedback.CASE NO. 121 FORTUNATO TAN SESSION XII CASE SCENARIO: ‘The laboratory results come in later that afternoon: Complete Blood Count: Hemoglobin = 16 g/dl Hematocrit = 0.50 RBC = 68x 10"/cu. mm. WBC = 12,500 cellsicu mm, Neutrophils = 68% Lymphocytes = 20% Eosinophils = 5% Basophils = 1% Monocytes = 6% Arterial Blood Gases: HCO; = 25 meq/. P.O) = 60 mmHg P.CO; = 50 mmHg pH = 7.35 Chest Xray (PA) Fibronodutar densities noted over the left upper lobe Haziness of the right lower lung fields = Increased radiolucency of the other lung - Suspicious hilar densities noted in the right lung Cardiac sithouette appears normal Impression: Suspected tuberculous inftrates inthe eft upper lobe ‘Suggest apicolordotic view. Hilar densities may be enlarged lymph nodes. Malignancy cannot be ruled out. Right pleural effusion, moderate. Gram Stain of Sputum: Sputum Exam for Acid-fast Bacill negative 86TASK: Spirometry: Parameters Values Interpretation reduced Fve 1.88 (55% of predicted value) FEV, 1.23 (45% of predicted value) | reduced reve [0s Tredeed Electrocardiogram: Non-specific ST-T wave changes, otherwise within normal Limits Interpret the laboratory results and give your plan of management. 87CASE NO. 121 FORTUNATO TAN SESSION XiIl TUTOR GUIDE: 1. 1st hour Discuss the learning issues of the previous session, 2. Next hour Give the case scenario. Identify new leaming issues, if any. Give Learning Objectives. 3. Last 15 minutes Processing and feedback 88CASE NO. 121 FORTUNATO TAN SESSION XIII CASE SCENARIO: You give the following orders: 1. Nebulize with the following solution every 8 hours: ipratropium 1 unit dose vial (UDV) + salbutamol 1 nebule. 2. Take PEFR readings every moming prior to nebulization, TASK: Give the rationale for the above-mentioned orders. PEFR determinations over the next 3 days showed gradual improvement. On the 4" hospital day, Tony has no more dyspnea and physical examination reveals clear breath sounds ‘Subsequently, he is discharged on the following medications and instructions. 1. Tiotropium (Spiriva) inhalation capsules, 1 capsule (inhaled through the handihaler) once daily 2. Salmeterol/futicasone (Seretide Metered Dose Inhaler) 25/250 2 inhelations twice daily 3. Cessation of smoking 4. Follow-up after 1 month, 89CASE NO. 121 FORTUNATO TAN SESSION XIV TUTOR GUIDE: FINISH ALL LEARNING ISSUES 90