Mansoura Student Case Book

Cardiorespiratory Fitness

Medicine PBL Casebook

Year 2 Semester 3

Session 2009/2010

Name:___________________________

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Semester 2 – Cardiorespiratory Fitness – PBL Casebook 2006/07

Semester Chair

Exam Coordinator

Course Content

The collection of cases chosen for this semester were reviewed in 2004 and direct

you to learning material in cardiovascular and respiratory areas considered

appropriate for a clinician in the 21st Century. They are reviewed annually for

accuracy.

The cases presented in this semester are linked to an index of clinical situation

from the core curriculum of the MBChB degree awarded by the University of

Manchester. The design of the Manchester course has been guided by

publications from the General Medical Council (GMC) and the UK Government.

Your PBL tutor/facilitator has been trained to facilitate your learning through the

PBL discussion group and is the first person you should ask for advice if you have

problems.

© The University of Manchester 2

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Contents

Case 1: The Stabbing.....................................................................................11Case 2: Peak Performance............................................................................14Case 3: Turning Blue......................................................................................17Case 4: The Downward Slope........................................................................20Case 5: The Faintheart...................................................................................23Case 6: Too Much Pressure………………………………………………………26Case 7: Giving and Receiving........................................................................29Case 8: The Grocer........................................................................................32Case 9: Negative Consequences...................................................................35

Theatre EventsProblem-based learning curricula emphasise SELF-DIRECTED LEARNING and students’ using a range of resources to find the information they need. The theatre events are one such resource. However, in the Manchester MBChB programme theatre events are NOT intended to be THE major way of delivering key content via didactic teaching – this is what happens in “old-style” lecture-based courses, not in PBL curricula.

Theatre events will vary widely in style and content. This is intentional and reflects different types of events delivered by different groups of staff involved in Medical Education. Some speakers are CLINICIANS, usually telling you about some aspect of their clinical specialty. Many of these talks are designed to help you gain insight into the links between the basic science concepts you study in phase 1 (and phase 2) and clinical practise. Some may be basic summaries of an important aspect or aspects of disease or clinical practise.

Some speakers are BIOSCIENTISTS engaged in teaching and research. These talks may summarize and wrap-up at the end of a series of linked cases, or present useful ways of thinking about concepts or topics commonly perceived to be difficult to grasp. Sometimes talks try to bring together topics which feature briefly in a number of cases – an example might be a talk about different kinds of drugs used to treat a particular common condition.

Some speakers are BEHAVIOURAL or SOCIAL SCIENTISTS engaged in teaching and research. These talks may discuss the empirical evidence behind concepts or models applied to medicine that you will encounter in your reading and discussion. Others may use a more discursive style to present an argument, or different points of view of, say, an ethical question. Still others may look at the historical development of medicine or of treatments.

To sum up: not all theatre events will be delivered in the same style. Not all are summaries. Not all contain core content. They are NOT “the things you need to know to pass the Semester test”. They are, however, designed to reinforce your understanding and to help, inform or interest you.

SSC

There will no PBL cases during the SSC time.


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Year 1 Special Study Components (SSCs)

The SSC allows you to investigate a specialist topic related to medicine under the

supervision of a member of staff. To investigate the topic you will be expected to

search systematically for relevant literature, critically assess that literature and

then to produce a report on your findings. The aim of this component of the

curriculum is to encourage and active approach to learning based on curiosity and

exploration of knowledge. Tomorrow’s doctors will need to be questioning and

critical and this module will help you to develop these skills.

You will be allocated a title by 29th January 2007. In the first few weeks of term

you should approach your supervisor for initial guidance on your project. Over the

following weeks you should then make use of the advice and information on

literature searching provided by library staff, consult the literature, produce a plan

for your report and generate a first draft based on the guidelines provided. The

period from 13th to 22nd March has been set aside for you to finalise your report.

There will not be any PBL cases or practical sessions during this period. It is NOT

recommended or wise to leave all the preparation to these two weeks. The

deadline for submitting their SSC is 5pm on 22nd March.


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Weekly summary

Date

week beginning

Case PBL session 1

(and finish prev

case)

PBL session 2

29th January 1 The stabbing Monday Thursday

5th February 2 Peak performance Monday Thursday

12th February 3 Turning blue Monday Thursday

19th February 4 The downward slope Monday Thursday

26th February 5 Faintheart Monday Thursday

5th March 6 Ray’s blood pressure Monday Thursday

12th March SSC Monday (finish case

6)

19th March SSC submission deadline

22nd March (see page

5)

16th April 7 Giving and Receiving Monday Thursday

23rd April 8 The Grocer Monday Thursday

30th April 9 Negative

Consequences

Monday Thursday

7th May Conclude case 9 on

Thursday

Bank Holiday Thursday (finish

case 9)

Normal timetable

Groups 1-16 PBL times

Monday : 10.00-11.30 am Thursday : 9.00-10.00 am

Groups 17-31 PBL times

Monday : 11.30-1.00 pm Thursday : 11.00-12.00 pm

* Exception to the timetable

Note: due to the Monday Bank Holiday on May 7th, session three for Case 9

(“Negative Consequences”) will take place on Thursday 10th May 2007 at the

usual Thursday times.


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Alterations to the timing of this final session may only be made with the

agreement of your PBL tutor.

You should download a complete individualised timetable for semester 2 from

MedLea.

First Theatre Event: Monday 29th January 2007 - 9.00 am LT2 and LT3

First PBL session: Monday 29th January 2007


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Time MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY9.00

LT2 and LT3(31 groups)

Early Experience

(in Stopford)

Early Experience

(ex Stopford)

DR

(Groups9-15)

EarlyExperience

(ex Stopford)

PBL(Groups 1-16)

Eurooption


9.159.309.4510.00

PBL(Groups 1-16)

Euro Option



10.1510.3010.45

DR

(Groups 24-31)

11.00PBL(Groups 17-31)

Eurooption

1MUL(Groups 13-18)

EarlyExperience

(in Stopford)

11.1511.30

PBL (Groups 17-31)

Euro Option

11.4512.00


12.1512.3012.4513.00

Microlab EarlyExperience

(ex Stopford)

1MUL(Groups 25-31)

Early Experience

(in Stopford)

1MUL(Groups 19-24)

13.1513.30

DR (Groups 16-23)

13.4514.0014.1514.3014.4515.00

Microlab 1MUL(Groups 7-12)

1MUL(Groups 1-6)

Micro-lab

15.15DR (Groups 1-8)

15.3015.4516.0016.1516.3016.45

GENERAL TIMETABLE FOR CARDIORESPIRATORY FITNESS – SEMESTER 2 (2006/07)

Please note that theatre events and practical sessions vary each week during the semester.PBL = problem-based learning. DR = dissecting room. 1 MUL = first floor multi-user lab.

LT2,3 and 6 – Stopford Lecture Theatres


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Aims for semester 2

Knowledge: To promote acquisition of knowledge and facilitate the understanding of

cardiovascular and respiratory health and promotion, and of cardiovascular and

respiratory diseases, their prevention and management, in the context of the

individual and society.

Skills: To develop student competence in the performance of a number of basic procedures.

Attitudes To encourage students to develop attitudes necessary for the achievement of high

standards of medical practice.

Expected learning outcomes for Semester 2Knowledge

At the end of the semester, students are expected to have acquired a knowledge and understanding

of:

a. the normal structures and functions of the cardiovascular and respiratory systems.

b. the features of major cardiovascular and respiratory diseases, their investigation,

prevention and treatments.

c. the main causes of major cardiovascular and respiratory diseases including the role of

processes such as inflammation, immune response, thrombosis, degeneration, and

trauma.

d. how cardiovascular and respiratory diseases present in patients of all ages, and factors

affecting patients reactions to illness.

e. the environmental, social and psychological factors affecting the development of

cardiovascular and respiratory diseases, historical as well as contemporary views.

f. the principles of disease prevention and health promotion.

g. the principles of therapy including the action of drugs.

h. the management of chronic illness including rehabilitation.

i. the factors influencing the effectiveness of communication in health care settings.

j. the organisation, management and provision of health care including ethical and legal

aspects, in community and in hospital.

k. scientific research and an ability to evaluate evidence through information presented in

the PBL cases and from the Student Selected Component in this semester.

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Skills

a. to be able to demonstrate competently the use of a spirometer and the safe handling of

blood,

b. to be able to interpret ECGs, heart sounds, and take accurate measurements of pulse

and blood pressure

c. the ability to reflect upon different motives for studying medicine

d. to be able to identify stress symptoms in self and personal coping responses to stress

e. to be able to demonstrate best teaching methods for inhaler use to optimise adherence

f. to be able to assess for motivational stage of behavioural change

g. to be able to provide evidence based smoking cessation advice

h. to accurately classify individuals into socio-economic groups

i. to be able to provide age-appropriate information about health, illness and treatments

Attitudes:

At the end of the semester the students are expected to have acquired the appropriate

attitudes/professional development in relation to:

a. an appreciation of the need to apply a scientific framework to biological, behavioural and

social sciences

b. a non-judgemental approach to people people’s health/illness behaviour and a mature

approach to discussions about the extent of an individual’s responsibility for their own

health

c. a belief in the role of health care professionals as health educators

d. the need to demonstrate empathy and respect for all patients

e. standards of behaviour expected of medical students, including the need to show respect

for fellow students, university staff , and healthcare workers

f. a critical but open mind in relation to psychological therapies

g. a sense of citizenship

Each PBL case has been carefully designed to address detailed and specific intended learning

outcomes.


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Case 1: The Stabbing

Steven was a 19 year old student at Manchester University. At 11 o'clock one

evening he was walking home when he was mugged by two young men. Although

the street was busy no-one came to his assistance as he struggled to defend

himself from a series of blows to his chest. The assailants ran off, dropping a

bloodstained screwdriver. He phoned the police and while waiting for them

discovered he was bleeding from the right side of his chest. On seeing his blood-

stained shirt the police radioed for an ambulance.

The paramedics found him agitated and pale but still able to talk sensibly.

Breathing seemed to be causing him some pain. His pulse was strong but rather

fast. They gave him oxygen via a mask and examined his chest wound, a clean

puncture near the right nipple which was no longer bleeding. There was no

sucking sound at the injury site as he breathed and no evidence of frothing. The

paramedics applied a square dressing, sealed to the skin on only three sides, and

took him to the Accident & Emergency department.

The A&E doctors assessed Steven according to ATLS protocol. They noted he was

conscious with no sign of injury to his face or mouth. He was able to talk but his

breathing was now very laboured. He was not coughing blood and there seemed

to be no obstruction to his airway. Examining his neck they noticed engorged

veins and displacement of the trachea to the left of the midline. Turning to his

chest, palpation revealed crackly swelling around the paramedics’ dressing.

Percussion produced increased resonance on the right side while auscultation

revealed diminished breath sounds on the right side. A doctor inserted a needle

through Steven's chest wall via the second intercostal space in the right mid-

clavicular line. Air came out through the needle under some pressure, confirming

the diagnosis and making it easier for Steven to breathe.

A second needle was then used to infiltrate lidocaine into the tissues of the 5th

right intercostal space in the mid-axillary line. A chest drain (a polythene tube

about 1cm in diameter) was inserted through an incision in the anaesthetised

area. Air escaped vigorously through the drain and its under-water seal. The

needle in the second intercostal space was then removed and an anterior-

posterior chest radiograph was taken. The paramedics’ dressing was removed

from the original stab wound which was sutured and an air-tight dressing applied.


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Steven was admitted to an acute surgical ward where his chest drain was

observed closely. The fluid level rose and fell in the transparent tube as he

breathed and initially a lot of air bubbles were expelled every time he breathed

out. During his first night in hospital Steven managed to sleep only for short

periods. He was in considerable discomfort from his injuries, despite analgesics.

The next day Steven was interviewed by the Police. They found him hesitant

about details of the attack and confused over times and dates. He was also visited

by two of his house mates who expressed concern about the safety of the area

they lived in. On the third day bubbles were no longer emerging through the

drain, a further chest radiograph (posterior-anterior) was taken and the drain was

removed. A final chest radiograph on day 4 was satisfactory and Steven was

allowed home. Later that month he saw his personal tutor and they discussed the

attack and the apathy of the by-standers. She referred him to the university's

counselling service where he received cognitive behavioural therapy (CBT) for

post traumatic stress disorder.


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Case Notes

Definitions

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Group Learning Objectives


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Case 2: Peak Performance

Luke O’Treen, from Bournemouth, was a 22 year old keen athlete who had

represented his school at athletics and decided go to Manchester University

because of the Commonwealth Games in the City in 2002. He had attended

university athletics trials and had succeeded in getting in the running team.

Competition was high and in an effort to improve his fitness he would run several

miles each day. During the first semester the weather was cold and he found

himself getting out of breath and feeling wheezy for several minutes despite

having stopped running. Blaming his problems on living in a city he discussed it

with his parents by phone who suggested he should see his GP. He told them how

he was representing the University in athletics and trained for 2 or 3 hours on

most days.

After discussing his breathing problem with the coach he underwent some tests.

His peak flow was measured at 500L/min. His height was measured as 1.8m. His

symptoms persisted which prompted him to visit the GP. He informed her that he

had asthma as a child but this had cleared by the time he was eight. He was not

sure what might have triggered the asthma. His younger brother was asthmatic

and used steroid and β2-agonist inhalers and his sister suffered from hay fever.

Luke was not aware of suffering from any allergies. The GP showed him a model

of the lungs and explained the nature of his condition. She suggested he keep a

peak flow diary and record his attacks. She also started him on two types of

inhalers (salbutamol and beclomethasone).

Feeling better Luke returned to fitness but embarrassed to take his medication in

front of his team mates he rarely used his inhalers. Luke had previously overheard

one of his team mates describe his condition as ‘psycho-somatic’, saying that

Luke could not cope with the pressure of performing. He found that his

breathlessness returned and was much worse at night.

On a visit home, he informed his parents that the GP thought he was asthmatic

and showed them his medicines. Being at home his chest felt better. On a walk

with his granddad, his improvement during his stay at home was put down to the

“sea air”, or to “getting away from all that city pollution”. In a rush to get

everything together to return back to University Luke left his medication at home.


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Returning to Manchester after the Christmas holiday he continued his training,

trials were approaching and he was eager to participate. Early in the morning

during a jog Luke collapsed short of breath. He was taken to hospital by his

running partner. His pulse was 100/minute, respiratory rate 22/min and PEFR 350

L/min. Pulse oximetry gave a result of <92%. Arterial blood gases were PaO2 61

mm Hg (predicted 90-100) and PaCO2 31 mm Hg (predicted 36-46), and pH was

7.47(predicted 7.35-7.45). Luke was given a chest radiograph at casualty.

Treatment with a nebuliser delivering a bronchodilator over the next two hours

eased his condition. Luke was given a week’s course of oral steroids to

supplement his inhalers. After rechecking Luke’s PEFR, the doctor told him he

could go home. The doctor told Luke that ‘fit young people like you can and do die

from asthma attacks not much worse than this’ and reiterated the importance of

taking his medication and self management. Complying with his treatment his

asthma improved and he was able to resume training.


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Case Notes

Definitions

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Case 3: Turning Blue

Mr Boyle, a 50 year old unskilled manual labourer from Rochdale, was a regular

visitor to the clinic. He was waiting for his appointment to discuss a chesty cough.

Both his parents had been smokers and he had smoked since a teenager and had

often stated that he could not get through the day without his ‘nicotine fix’. He

was aware of being flushed and breathless after walking to the clinic. Having

been certificated as sick by his GP he was off work long-term. His GP suggested

that to improve his condition he should join a smoking cessation group and

undertake some exercise. Mr Boyle found it easier to be motivated to change in a

group than on his own. For many years he had smoked over thirty cigarettes per

day but was down to about ten per day, mainly due to the cost.

A detailed history and blood pressure were taken and spirometry performed by

the practice nurse, and an exercise tolerance record was started. The nurse also

asked Mr Boyle about what sort of jobs he had done and where he had worked.

Spirometry demonstrated reduced FEV1 and a ratio FEV1/FVC of 60%. This did not

change markedly on subsequent visits. Bronchodilator therapy was provided

which he was instructed to take as required. He was referred to a specialist at the

Primary Care Trust who diagnosed COPD. At the cessation clinic he found it

difficult to quit but enjoyed the social side to the group. He was offered nicotine

replacement therapy and bupropion, and his carbon monoxide levels were

measured.

He continued to attend the GP surgery and 1 year later when his ratio FEV1/FVC

was 56% he was given a trial of a glucocorticoid. Mr Boyle responded positively

and regular steroid therapy continued; he was again urged to undertake mild

exercise. However, he found it difficult to walk to the end of his garden. As time

progressed the severity of his disability meant that he required high dose

bronchodilators and oxygen therapy.

Mr Boyle now attended a “breathe easy support group”. One winter evening he

felt very unwell and was admitted to hospital. He had a bounding pulse, and was

pyretic and drowsy. He had dyspnoea, was cyanosed with increased wheeze, and

had purulent sputum. Pulse oximetry showed hypoxia and he was given 40% O2

by mask. Measurement of blood gases showed hypoxemia and hypercapnia;

values were PaO2 6.1 kPa (predicted 12.1 SD 1.05), PaCO2 8.3 kPa (predicted 4.8-

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6.1), pH 7.33 (predicted 7.35-7.45), and [HCO3] 32 mM (predicted 23-29 mM). A

chest radiograph revealed emphysematous bullae. Cough and rust-coloured

sputum were evident and Mr Boyle was prescribed a course of antibiotics

(cefuroxime, erythromycin) and a course of oral steroids, and told to keep up his

bronchodilator therapy. Later discharged he was instructed to attend an

outpatient follow-up at 5 weeks. The SHO commented he was seeing many

people with similar symptoms.

On worsening of his symptoms he requested a home visit from his GP. He was

again admitted to hospital, over time becoming a frequent visitor. Tests for

arterial blood gas tensions and polycythemia were undertaken. As his symptoms

worsened repeated pulmonary function tests were performed. He died before

retirement age.

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Case Notes

Definitions

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Case 4: The Downward Slope

Mr Ahmed was born in Pakistan in 1950. As a child he had suffered a throat

infection followed by severe malaise, a skin rash and swollen, tender joints. He

came to Britain in 1988 and registered with a GP seven years later. When he

visited his GP he was usually accompanied by his 14 year old daughter who

interpreted for her father and the GP.

In 2002 he reported to his GP that he was breathless on climbing a single flight of

stairs and had begun waking up in the middle of the night with breathlessness

leading him to sleep propped up by several pillows. On examination he had a

pulse of 82/min, with occasional irregularities; blood pressure was 115/90 mmHg

and auscultation of the chest revealed basal crepitations. There was a pan-systolic

murmur at the apex, radiating towards the axilla. The GP prescribed furosemide

and arranged for him to be seen in the open-access heart failure clinic.

However, 2 days later he suddenly became severely breathless, and began to

cough up pink frothy sputum. His daughter telephoned for an ambulance because

she viewed these symptoms as very serious. The paramedics gave him oxygen by

face-mask and took him and his wife to the local hospital. On arrival, Mr Ahmed

was breathing rapidly and his lips and finger-tips were cyanosed. His ankles were

swollen, and his liver was palpable. His pulse was ‘irregularly irregular’ at

120/min. On auscultation, crackles could be heard over the lower two-thirds of the

chest. An ECG showed atrial fibrillation, and an antero-posterior chest X-ray

revealed enlargement of the left side of the heart, with central congestion of the

lung fields. Digoxin treatment was given to control his heart rate. Oxygen

treatment was continued and he was given intravenous furosemide, and an

infusion of glyceryl trinitrate and he soon began to feel more comfortable. A

troponin T test was normal.

By the next morning he had produced 2 litres of urine and was no longer

breathless. An ECG revealed his ventricular rate had fallen to 90 beats per minute.

Echocardiography showed that the mitral valve leaflets were thickened and rigid,

and that the left ventricular ejection fraction was low and colour Doppler flow

analysis demonstrated marked mitral regurgitation. He was commenced on

aspirin, furosemide, ramipril, and carvedilol and was transferred to the

cardiothoracic ward.

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The specialist registrar spoke to Mr Ahmed and his family and explained Mr

Ahmed needed a mitral valve replacement operation. He underwent his mitral

valve replacement whilst in hospital and his atrial fibrillation problems

disappeared. A month later, he was able to climb two flights of stairs without

feeling breathless. Later, he returned to full-time work. He was advised that he

would have to take warfarin long-term and have his dosage regulated by INR

measurements, and he would require antibiotics when undergoing dental

treatment, or if he ever needed certain sorts of medical or surgical treatment.

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Case Notes

Definitions

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Case 5: The Faintheart

Mrs Khan had gained almost 20 kg since her move to the UK nearly 20 years ago.

Her husband was a wealthy businessman and she had never needed or wanted to

work outside the home. Her pride and joy were her three sons: the oldest had just

graduated from medical school. Mr and Mrs Khan went for regular walks in the

evening, although recently, she had experienced some difficulty keeping up with

her husband on their mile long walk.

At the age of 53, while walking with her husband, Mrs Khan developed intense

pain in her chest that spread to the left side of her jaw and to her back, which

settled when she stopped walking. During the next month the weather was

particularly cold and walking initiated several more attacks of pain. This prompted

a visit to her GP. Her father had died from a heart attack in his fifties.

Her blood pressure was 148/94 and a resting electrocardiogram, performed in the

GP’s surgery, was normal. The GP took a sample of venous blood for analysis of

lipids and glucose and prescribed glyceryl trinitrate, aspirin and atenolol. The

laboratory reported a serum cholesterol concentration of 5.1 mmol/l [desirable

value <5.0] and low density lipoprotein (LDL) 3.2 mmol/l [desirable value <3.0],

triglycerides were elevated at 4.4 mmol/l, and her HDL was 0.7mmol/l. Her

glucose level was normal. The GP told her they would need to watch her blood

pressure and cholesterol, and advised her on diet and exercise.

However, 6 months later while clearing autumn leaves from the lawn she

experienced a particularly bad attack of chest pain. When the pain had gone on

for nearly an hour, her husband called an ambulance. In the Accident &

Emergency department, she was pale and clammy. Her pulse was regular at 60

beats per minute and her BP 100/60mmHg. An ECG showed elevation of the ST

segments in her anterior leads. A blood sample taken that night showed raised

cardiac Troponin T.

Initial treatment included the administration of oxygen by mask, aspirin by mouth

and the intravenous infusion of recombinant tissue plasminogen activator,

diamorphine and glyceryl trinitrate. After about 3 hours in A&E she was admitted

to the coronary care unit where she continued to complain of chest pain.

Emergency coronary angiography was therefore undertaken, an immediate

angioplasty was performed and coated stents placed in her circumflex and left

anterior descending arteries. Her pain settled and she was discharged on the

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seventh day on atenolol, glyceryl trinitrate, aspirin, clopidogrel, ramipril and

atorvastatin.

Mrs Khan was very concerned about how she could reduce her chance of having a

further problem with her heart. Her GP talked to her about the most effective

medical and non-medical (lifestyle) interventions, stressing the need to control

her blood pressure and cholesterol, lose weight, and get fitter. As she was leaving

the consultation the GP suggested that she could join a comprehensive cardiac

rehabilitation programme. He also gave her a British Heart Foundation leaflet on

living with heart disease. She was followed up in the cardiology clinic.

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Case 6: Too Much Pressure

Ray is a 56 year-old bus driver and lives with his daughter Janet and her teenage son Jimmy.

With Jimmy and Janet nagging him, Ray gave up smoking four years ago after, as he says,

“35-odd years on 20 a day”. Janet and Jimmy had been urging Ray to have a health check-

up, so last year Ray - who was then 55 - went to see the GP. His blood pressure was 180/115

in both arms, but after he sat talking to the doctor for ten minutes it dropped to 170/110. Ray’s

BP was the same at two further monthly appointments. The GP sent Ray to the community

hospital for 24 hr blood pressure monitoring and blood tests. When the results came through

she told Ray he would need to start taking medicine to reduce his cholesterol and blood

pressure, as well as make some lifestyle changes. Ray was rather shocked, as he had been

generally healthier since giving up smoking and felt fine.

Using her computer, the GP showed Ray a chart indicating (given his total plasma

cholesterol:HDL cholesterol ratio of 5 and his BP of 170/110) that he had about a one in three

chance of developing a serious cardiovascular disorder within the next 10 years. Accordingly,

she started him on a statin and bendroflumethazide. After four weeks the thiazide had

lowered his BP to 160/100. However, Ray decided the drugs made him want to urinate more

often during the morning. As this was inconvenient for his work as a bus driver, he stopped

taking the tablets after a few more weeks.

Several months later, after Ray got in a heated argument with a motorist while driving his bus,

he got a terrible headache and thought he saw flashing lights. After the headache went on for

several days he went to see the GP, who measured his BP at 180/115. When Ray admitted

he wasn’t taking the tablets, and explained why, the GP said she could try him on a different

blood pressure drug, and prescribed amlodipine and a statin. She also signed him off sick.

After several months on amlodipine Ray’s BP was consistently around 160/110, although he

had swollen ankles and got troublesome headaches. When his sick leave ran out he went

back to work, but the GP said Ray was not allowed to drive a bus with his blood pressure.

After Ray saw an Occupational Health doctor his manager transferred him to work as a

dispatcher, although this has meant financial difficulties for the family as the pay is not as

good. The GP also added an ACE inhibitor to Ray’s medication, which meant more tests as

Ray had to have his serum potassium and creatinine checked after a week on the new drug.

Several months of the combination of ACE inhibitor and amlodipine got Ray’s BP down close

to 150/100. However, he had a persistent dry cough he found very annoying and this

prompted a switch from the ACE inhibitor to losartan.

Ray is currently trying to lose some weight and hoping to get his blood pressure down enough

to be able to go back to driving. He is taking amlodipine, losartan and a statin and his BP is

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consistently just above 150/100. However, the GP tells Ray this “still isn’t where it needs to

be”, and they are discussing, as Ray says “even more pills”.

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Case 7: Giving and Receiving

Sarah’s dad was a blood donor. However, it was when her brother needed to have

a blood transfusion that Sarah (18) decided to give blood. Her brother had been in

an accident, and had to have emergency surgery including splenectomy. After he

recovered, he was given several immunisations and told to take life-long

penicillin, although he hated doing this. He was also given a card to carry in his

wallet. It read “I have no functioning spleen”.

Sarah was well known for helping people and, prompted by an advert in the

Student Union, she went to a Blood Donor drive. She was given a questionnaire to

complete about her fitness and life-style, and then counselled. She was warned

that she would be tested for a range of infectious diseases including HIV, and had

a finger-prick blood test to check she was not anaemic. After she had signed a

consent form, Sarah was told that she would be notified to give blood about three

times a year. Finally, she lay on a bed to give blood. This went smoothly, although

she had to lie on the bed for about a quarter of an hour afterwards and have a

drink of tea or orange before going. She was also advised to avoid vigorous

exercise and alcohol that night. Several days later she was sent a card with her

name, donor number and blood group on. Her group was AB Rh positive. Worried

that this was different from her father’s group, which was A Rh negative, she

looked this up on the Internet, and discovered that this was entirely possible!

She continued to give blood regularly for more than ten years. However, she

missed two sessions in her first year when, towards Easter, she began to feel very

tired and run down. Sarah went to the Student Health Centre, who took a blood

sample. Later she got a text message to call the Centre, where the receptionist

told her they needed her to come in again because her sample had shown ‘some

abnormal monocytes’. Sarah spent a couple of days worrying that she had

something really serious, like leukaemia, but when she saw the doctor he said she

had glandular fever. He told her it was not serious but that she would need to rest

as much as possible over the holidays and ‘take things easier’ and ‘pace yourself’

next semester.

On one occasion in her mid-20s when she went to give blood, Sarah was told her

haemoglobin was too low and she would not be donating blood that day but would

be called back in twelve months. She was recommended to visit her GP. Sarah

suffered from heavy periods and on the visit the doctor noticed that she looked

pale. A blood test showed her haemoglobin concentration was 8.0g/dl and her

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mean corpuscular volume 72fl. In addition her serum ferritin level was low. The GP

considered the possible causes, and concluded that her menorrhagia was to

blame. With this in mind he gave a hormone preparation to reduce the heavy

periods, and ferrous sulphate, advising her to take the tablets after meals and

carefully store them away from any children. A month later her faintness and

tiredness subsided but she was constipated and her faeces black.

At 30 years, when Sarah was pregnant with her first baby her blood group, and

her partner’s, were again checked by the hospital. She was told that she would

not need any intramuscular injections of Rhesus anti-D immunoglobulin. The

midwife told Sarah they would keep an eye on her blood pressure and iron levels.

Sarah’s baby was routinely monitored for jaundice before being allowed home two

days after the birth.

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Case 8: The Grocer

When he left school at 16 to work in the family's grocery shop, Clive Lot was already quite

overweight, and by his 20s he was obese. He smoked and usually had a ticklish cough. He

was encouraged to lose weight by shop customers, including a nurse and a physiotherapist.

But he always said he “lacked the will power” or told them it wasn’t how much he ate, just that

he “liked the wrong food”. Clive usually had a takeaway for lunch and a large evening meal

with his parents, as he still lived at home. By the time he was 33, he weighed 133 kg (21

stones) although he was only 1.75 m (5ft 8in) tall.

One day Clive strained his back badly lifting some boxes at the shop. He spent a week laid up

in bed, with his mother bringing him his meals. After about a week his back eased a bit, and

he could get up and about with difficulty. When he went to the toilet, feeling a bit constipated,

and passed a motion after a fair bit of straining, he immediately had a severe crushing pain in

his chest. He felt breathless and collapsed. His mother had to call the fire brigade to break

down the bathroom door, and Clive was rushed to hospital by ambulance.

Initially the doctors in A&E suspected a heart attack, but an electrocardiogram (ECG) showed

only a sinus tachycardia with no signs of myocardial infarction. Physical examination revealed

tachypnoea, normal breath sounds in the chest and engorged neck veins with prominent

pulsations. BP was 90/65. Chest X-ray was normal. It was obvious that Clive’s right calf had a

circumference greater (by about 3-4 cm) than the left.

Analysis of an arterial blood sample taken while breathing air showed:

PaO2 10.4 kPa normal value 12.1 [SD 1.05]

PaCO2 4.9 kPa normal range 4.8 - 6.1

pH 7.43 normal range 7.35 - 7.45

The A&E doctor ordered a full blood count, cardiac troponin, and clotting screen (all results

came back normal). A provisional diagnosis of pulmonary embolism secondary to deep vein

thrombosis was made, and later confirmed by a ventilation-perfusion scan.

Clive was given the first of 5 daily subcutaneous injections of a low molecular weight heparin,

and started on oral warfarin several days later. His “prothrombin time” was measured and

used to calculate his International Normalised Ratio (INR). The daily warfarin dose was

adjusted to stabilise his INR at a value of 3.5. He was urged by the doctors to lose weight.

When he was discharged from hospital, he was told to attend the anticoagulant outpatient

clinic for follow-up to check his INR value.

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On his first visit to the clinic his INR value remains close to 3.5. Some weeks later he got a

toothache and took some Nurofen Plus® tablets he bought from the supermarket. On next

attending the clinic, his INR was 10. He was promptly given intravenous phytomenadione

(vitamin K) and his warfarin was stopped for several days. Subsequently his INR value re-

stabilised at 3.5. He was warned not to take any other drugs without telling his GP or the

anticoagulant clinic. Clive complained to his father that the doctors at the clinic were

interested only in his blood, not in him and his problems. This feeling worsened when he was

asked to give another blood sample “for a research project”. Although Clive agreed to the

extra sample, he did not understand what the doctors planned to do with it.

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Case 9: Negative Consequences

A car was found on a country lane, with the front end embedded in a tree. The 18

year old driver Bethan Rhys, was unconscious and her right leg was trapped

beneath the engine. The ambulance crew found her pale, cold and clammy

although there was little sign of external bleeding. Her pulse was weak and rapid

and she was breathing rapidly. No blood pressure reading could be obtained. An

airway was inserted and oxygen given by mask. With difficulty, an intravenous

cannula was inserted and a rapid infusion of Gelofusine® was started. The fire

brigade sent a vehicle with cutting equipment and she was freed from the car. It

was obvious that her leg was broken but no other injuries were apparent apart

from bruising over the lower part of the sternum.

An initial assessment was carried out on arrival in the A&E department. Bethan’s

blood pressure was 90/60mmHg, heart rate 140/min and respiratory rate 39/min.

Her axillary temperature was 35oC. Blood samples showed a low arterial PO2 and

haemoglobin concentration; there was both respiratory and non-respiratory

acidosis, and a raised plasma lactate concentration. Her blood type was B, Rh

negative. However the hospital's stock of packed cells of this type was very low.

She was given 2 units of plasma in combination with packed cells of group O, Rh

negative. While all this was going on the hospital tried to contact her next of kin

for consent to treatment. Eventually the police found her mother, who was alone

when the news of the accident was broken to her. Emergency surgery was carried

out to repair closed fractures of the femur, tibia and fibula. During the operation

the surgeons encountered a lot of blood oozing from the damaged soft tissues. By

this stage, supplies of group B, Rh negative packed cells had arrived from the

Regional Blood Centre and so this was now infused. Altogether 7 units of blood

product were given.

Bethan was then transferred, in an unconscious state, to the Intensive Care Unit

(ICU) where arterial, Swan-Ganz and urinary catheters were inserted; her mother

was allowed to her bedside for the first time. Data were obtained on right atrial

pressure (RAP), pulmonary capillary wedge pressure (PCWP), cardiac output, and

oxygen contents of systemic and pulmonary arterial blood. The cardiac pressures

were only slightly below normal, but the cardiac output was well below the

desired value. An ECG showed right bundle branch block. Haemoglobin

concentration had now risen to 11.2 g/dl; fluid infusion was resumed, the rate

being adjusted with reference to the PCWP. Over the next few hours, the cardiac

pressures and output rose to acceptable levels. When she regained consciousness

she was perfectly lucid and complained of pain, both in her leg and in her chest.

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The pain was treated by adding diamorphine to the intravenous infusion. A supine

chest radiograph showed no abnormalities.

By the end of her two week stay in intensive care Bethan did not know how long

she had been in hospital, or whether it was day or night. During this time she had

several abnormal sensory experiences. She also became distraught at the death

of one of the other patients. Subsequently she was transferred to an orthopaedic

ward, where she stayed for several weeks.

While still confined to bed, she began a rehabilitation programme under the

supervision of a physiotherapist. She was encouraged to move around the ward

and hospital corridors on crutches. She left hospital after a total stay of 2 months

and her leg remained in plaster for a further 2 months. Bethan was able to begin a

sedentary job after six months and could walk reasonably well by the end of a

year. However it was nearly two years before she was able to resume playing

tennis because of problems with moving her right knee.

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Reflections/Additions for Portfolio

In this section you can make notes and observations that bring together

knowledge gained during theatre events, laboratory work (dissection and other

skills sessions) and private study, with your thoughts and feelings from early

experience and interactions in PBL groups. Reflection and portfolio activity will

enable you to think about your changing knowledge, attitudes and skills. As a

professional practitioner, you have to apply your knowledge to the benefit of the

person who is consulting you. Clearly, this is an early stage of your training but as

you progress, reflection will become more and more valuable. Meeting people as

a professional can be daunting. It is valuable contribution to your experience to

record your personal thoughts and feelings after these meetings. You need to get

used to recording how you feel, how you react to particular situations, what

strategies you use to cope and how successful they are. There will be debriefing

situations and these notes may help you at these times.

In particular, you might want to make brief notes here on the conduct of the PBL

session, your role in it, whether any aspect of the case interested you and if so

what, and whether they had looked up anything extra as a result of this. It is good

practise to make such notes “there and then”, rather than waiting until some time

afterwards to record your impressions.

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Reflections/Additions for Portfolio

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Mansoura Student Case Book

Documents

pbl cases

pbl curricula

semester chair

pbl tutorfacilitator

semester test

university of manchester

pbl discussion group

manchester course