Chest, Lung Medicine (COW)

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Chest, Lung Medicine

Please note the following very carefully!

   * The organization of the COB and PCL for weeks 2 and 3 of this block is different!
   * For the COB Dr. McCormack has provided Cases A and B (below) which will be used for the wrap-up on April 14. The wrap-up will be in the form of a Clinical Pathological Conference. Students are expected to work through these cases on your own over the next two weeks.
   * For PCL on April 5 this week the case is 'Susan' - see below.
   * For Week 2 of PCL, you have the opportunity to set objectives on whatever topic you wish in cooperation with your tutor - see below.

CLINICAL PATHOLOGICAL CONFERENCE - Case A

This 72-year-old gentleman presented with a two month history of weight loss, malaise, and low grade fevers. He had a cough productive of a small amount of yellow sputum each day. For the last 4-6 weeks he had noticed some streaking of blood in the sputum. Four weeks prior to admission he had been seen by his family doctor for these same complaints. A sputum culture was taken which grew Haemophilus influenzae and he was treated with two weeks of Amoxicillin. During this course of treatment his symptoms did not change substantially.

This gentleman had immigrated from India five years previously. He works as a teller in a bank. He currently smokes one pack of cigarettes per day and has a 50 pack year smoking history.

On the day before admission, he started to cough up an increasing amount of blood in his sputum and he came to the Emergency Room. In the Emergency Room he was noted to be a chronically ill-looking gentleman in no respiratory distress. His temperature was 37.8, his heart rate was 96 per minute, and his blood pressure was 120/70. Head and neck examination revealed dental caries, but no lymphadenopathy. He was clubbed. On auscultation of the chest he had good breath sounds bilaterally with some crackles at the right base, but no wheezes or rubs heard. The remainder of the physical examination was unremarkable.

His initial blood work demonstrated a hemoglobin of 140 and a white count of 11.9 with 79% neutrophils and 21% lymphocytes. His liver function tests, urea, and creatinine were normal.

A chest x-ray was performed at the time of admission and, in addition, a CT scan of his chest was also obtained. Diagnostic investigations confirmed the nature of his illness.

CLINICAL PATHOLOGICAL CONFERENCE - Case B

This 46-year-old teacher presented with a two month history of a non-productive cough associated with mild shortness of breath on exertion. His shortness of breath had progressed to the point that he found it difficult to walk up two flights of stairs, whereas six months ago this had not been a problem. He denied any problems with hemoptysis. He had felt like he had been febrile on and off over the last few weeks, although he had not taken his temperature. He complained of arthralgias, but denied any problems with skin rashes.

This gentleman had had no significant past medical history. He had no known HIV risk factors. He had been a teacher all of his working life and his only pet was a dog.

When he was seen in the clinic he was a generally well-looking man in no respiratory distress. He was afebrile and his heart rate was 80 per minute with a respiratory rate of 20 per minute and a blood pressure was 110/70. He was not clubbed and there was no lymphadenopathy. On auscultation of the chest he had good breath sounds bilaterally with scattered crackles over both lungs, predominantly over the upper lobes. There were no wheezes, or rubs heard. Cardiovascular examination was unremarkable.

Pulmonary function tests demonstrated an FEV1 at 75% of predicted, a forced vital capacity 72% of predicted, and a total lung capacity of 74% of predicted. His FEV1:FVC ratio was 82%. His diffusing capacity was 60% or predicted. On room air his pO2 was 68 with a pCO2 of 37 and a pH of 7.40. His hemoglobin was 135 g/L, his white blood count was 7.3 x 109/L with a normal differential. His liver function tests showed a normal SGOT and SGPT with a slightly elevated LDH (230, normal 91-180) and gammaGT (67, normal 0-50). His bilirubin was normal.

A chest x-ray was performed as well as a CT scan of his chest. Three 'slices' obtained during the tomography are here: A , B , and C.

Diagnostic investigations were performed to establish a definitive diagnosis in this patient.

PCL CASE - 'Susan'

Susan is a 30 year old married woman who is self-employed. She works out of her home as a business consultant. She is 7 weeks into an unplanned pregnancy. She has been smoking since she was 17 ears old and is currently smoking about one pack of cigarettes a day. She wants to quit smoking for many reasons. Her daughter is two years old and has had problems with recurrent ear infections and asthma. She tried to quit smoking the first time she was pregnant but then read warnings on the internet that "quitting cold turkey was bad for the baby" and stopped.

She tried to quit cold turkey last week but relapsed after 3 days. Her husband smokes and isn’t interested in quitting but he wants Susan to quit while she is pregnant. She knows that smokers tend to have small babies but has been told that they are easier to deliver.

How do you approach smoking cessation in Susan’s case and how do you deal with the beliefs she has about smoking and quitting smoking?

How do you convey the risks of smoking during pregnancy and after pregnancy to Susan?

Questions and comments that Susan has:

  1. "I have been told that smokers have small babies and that small babies are easier to deliver."
  2. "Quitting is really hard and I have been told that nicotine replacement isn’t safe during pregnancy."
  3. "There isn’t much point in quitting now since I am already pregnant."
  4. "If I can’t quit but I cut back isn’t that just as good?"

Besides these questions, the case can also be used to learn about motivational interviewing and to review Prochaska's stages of change model of behavioural change. If you register at this site, you can view a good lecture by Dr. Prochaska (in streaming video).

Dr. Kathy Ferguson will expect students to be able to answer the questions on the 'Susan' case for her lecture on April 13!

The impact of smoking as a world health problem can be gauged from this proportional mortality study of tobacco use in China.

In the event that some groups answer all questions to their satisfaction and wish to examine another area for the April 12 PCL session, here is another case.