1. HSS CBL Health Problems Winter 2010

2. Welcome Get to know your peers and tutor… 1.5 hour session 2.5% participation 2.5% quiz (multiple choice) … and enjoy!

3. To become familiar with case based learning as a teaching methodology To develop communication skills, problem solving skills and teamwork skills To review the anatomy and physiology of the respiratory system To understand the pathophysiology of the discussed respiratory condition To understand the clinical aspect as well as social aspect of the discussed condition Learning Objectives

4. 51 year old white male presents to family doctor with a productive cough and a headache. The patient experiences dyspnea on effort and tires easily. Case Presentation

5. Presentation Continued… Cough sputum has moved from mucoid to purulent during the last 10 - 14 days Dyspnea and wheezing have worsened significantly Occasional tension in the chest

6. Possible Causes? Formulate hypothesis in pairs As we go through the case narrow this list (may also add to the list) Discuss how you would test your various hypothesis Discuss what further information you would like to obtain

7. History Medical Hx Wheezing and coughing have persistently worsened over the past 2-3 years Has smoked half a pack a day for the past 30 years Patient wakes up frequently during the night First time reporting these symptoms to a physician

8. History Continued… Social Hx Has lived in large cities his whole life Drinks within moderation Has a spouse who has smoked for the past 30 years Occupational Hx Has spent most of his life working in the construction industry, including welding

9. T o : 38.2 o C BMI: 27 BP: 140/90 mmHg RR: 25 breaths/minute HR: 86 bpm Physical Exam (vitals)

10. Rales can be heard using a stethoscope The length of time for expiration is longer than average Barrel Chest Patient often coughs up thick mucus, particularly in the morning Physical exam of all other organs were normal Physical Exam (respiratory)

11. Sputum Test A sample of the patients sputum was taken and revealed a bacterial infection: Streptococcus pneumoniae

12. What are the possible diagnoses? What tests should now be ordered to narrow the differential diagnosis? Differential Diagnosis

13. ABG Measures the oxygen level in blood from an artery, often in one’s radial artery (in most cases)  this can assist in determining the severity of the damaged lung Assessed by pH of the blood, partial pressure of carbon dioxide, oxygen and bicarbonate level.

14. Results for ABG Normal RangePatient Values pH 7.35 – 7.45 7.28 PCO 2 35-45 mmHg 55 mmHg HCO3 CO 2 + H 2 O  H 2 CO 3  HCO 3 - + H + 21–28 mEq/L30 mEq/L

15. Imaging Technique Which imaging technique(s) is/are most appropriate? MRI X-Ray PET Scan CT Scan Microscopy Spirometry

17. Investigation- Test Results Spirometry TestNormal ValuesPatient Values FEV13.4 L1.8 L FVC4.0 L3.6 L FEV1/FVC %80 - 85%50% When the patient is given a short-lasting bronchodilator such as ventolin and tested again, no significant improvement is found.

18. Result for Imaging

19. Pink Puffer Blue Bloater

20. Final Diagnosis?

21. Diagnosis! -Chronic Obstructive Pulmonary Disease -- with developing chest infection

22. Pathological Findings Emphysema Chronic Bronchitis

23. Possible Complications -Infection -Cor pulmonale -Secondary polycythemia -Bullous lung disease -Acute or chronic respiratory failure -Pulmonary hypertension -Malnutrition -Pneumothorax -Poor sleep quality -Arrhythmias

24. Treatment General Measures? Smoking cessation Aggressive treatment of infections Pulmonary rehabilitation Appropriate vaccinations Outpatient treatment is usually adequate. Acute respiratory failure may require mechanical ventilation.

25. Treatment continued… Surgical Measures In selected cases: lung reduction surgery or lung transplantation Activity As tolerated. Full activity should be encouraged. Diet A well balanced, high protein diet is suggested.

26. Medications Corticosteroids Ex. fluticasone Bronchodilator drugs (includes sympathomimetics) Ex. salbutamol Sympathomimetics Ex. albuterol (Proventil, Ventolin) Antibiotics Ex. penicillin

27. Other recommendations.... (apart from quitting smoking) Environment Rehabilitation Programs Traveling at high altitudes Any other recommendations?

28. Prognosis/Follow up FACT: 3 in 4 people with COPD survive for 1 year after diagnosis, but less than 1 in 20 survives beyond 10 years. (CMA) Patient monitoring Home oxygen Nocturnal oxygen

29. Evaluation Please finish the quiz independently After finishing the quiz fill the course evaluation form Tell us what you thought Don’t forget to hand everything in