ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH

YEAR LEVEL 7
PULMONARY MODULE 2018
SMALL GROUP DISCUSSION 2
October 10, 2018
1:30 TO 4:30 PM
Student Guide

OBJECTIVES OF THE ACTIVITY:

The students should be able to:

1) identify the salient data from the history and physical examination findings of patients
with this presenting manifestation
2) integrate the knowledge of anatomy, physiology, pathology, histology and radiology in
the discussion of the case
3) provide differential diagnoses of the case based on pathophysiology
4) explain to the patient the indication of diagnostic procedures necessary for the case and
the expected risks and complications of each procedure/ test; and the consequences if
patient does not agree to undergo the procedure
5) offer a diagnostic approach keeping in mind the patient’s psycho-socio-cultural-
economic concerns
6) explain the general principles of management of the case (pharmacologic and non-
pharmacologic)
7) provide the natural course the condition may take if with or without treatment
8) explain to the patient the prognosis of the condition
9) decide when the patient will need a referral to a sub-specialist

MECHANICS OF THE ACTIVITY:

1. The student facilitator reads the case and poses questions to the group during key
segments of the discussion.
2. Students provide answers to the questions posed.
3. Each student is encouraged to participate, and to contribute his/her insights during the
course of the discussion.
4. At the end of the discussion, each student is asked to summarize at least one important
learning point as a personal take-home message.
5. The students will be evaluated individually.

Questions:

1. What are points in the history and P.E. that needs clarification or additional information?
 Fever onset, duration, etc
 Night sweats?
 Weight loss w/ weight?
 Lymphadenopathy?
 Amount of bleeding?
  Asthma/COPD?
 Primary complex? Prior PPD?
 HIV?
 PSHx – work, house
 FHx – comorbids
2. What are the salient features of this case? (pertinent signs and symptoms)
3. What are the differential diagnoses of this patient’s case?
 Pneumonia (bacterial
o Constitutional symptoms
o Productive cough
o Crackles
 TB
o Endemic area
o Long history of constitutional symptoms
o Weight loss
o Crackles
 TB w/ cavitations
o Possible empyema
o Possible lung abscess formation
o
 Malignancy
o Hemoptysis
o Weight loss
o R/O
 Non-smoker
4. What diagnostics procedures would you like to request for to arrive at the diagnosis? What
is your interpretation?
 CXR
 CBC
 GS/CS
 AFB Smear
 DSSM
 GeneXpert
 ABG
 CD4?
5. What is the most likely diagnosis?
 TB
6. What are the general principles of management of this case?
 TB regimen of 2HRZE/4HR
 Drinking habits decrease
 Flu vaccine and pneumococcal vaccine
o Prevnar (PCV13)
7. How would you prognosticate the patient’s condition?
 OPD = mortality is less than 1%
 Admission = mortality is almost 10%
o 50% is attributed to pneumonia (Lecture)
8. How would you inform the patient and family about the patient’s condition?
CLINICAL CASE

Mang Jun, a 69 year old male from Floodway, Taguig consulted at the outpatient department for
cough.
He has had cough productive of greenish sputum for the past month, productive of whitish phlegm.
This was associated with malaise, poor appetite and gradual weight loss.

2 weeks PTC, he started to have undocumented fever usually in the afternoon with persistence
of cough now productive of yellowish phlegm.

He consulted with a private MD and was given Ciprofloxacin 500 mg/tab and carbocisteine taken
for 1 week but with minimal improvement.
In the last 2 days, he had blood tinged phlegm hence this consult.

Mang Jun is a non-smoker but drinks 1 bottle of beer almost daily. He is a plumber who also
works as a barber during his spare time. He lives in a house with his 4 children, 2 of whom are
married with children.

P.E
Vital signs: BP= 100/70 mm Hg CR-96 beats/min RR-20 breaths/min Temp = 38.6 C
Ambulatory, Awake, communicative
Equal chest expansion, no intercostal retractions, resonant on all lung fields
(+) crackles from mid to basal lung fields, bilateral, no wheezing
Distinct heart sounds, regular rhythm, no murmurs
Flat soft abdomen, non-tender
Full pulses, no edema

Foul-smelling sputum
Wife (+) TB w/ treatment
Diabetes, metformin 500mg qd non-compliant
No fhx of malignancy
No asthma/COPD
No prior TB
Previous weight is 50kg; >5% BW loss (he is now 45kg) in the past 6 months?

CXR
Diffuse fibrohaziness
Areas of cavitation
Upper lung fields

AFB = +6 (two specimens)

GS/CS = 34-36, epithelial 37, 2+, 2+, culture blood = no growth.

GeneXpert =

CBC 141/42/16.3WBC/258platelets/92neutrophils
BUN = 30
Crea = 102
ALT = 52

ABG
pH = 7.538 (metabolic alkalosis, partial compensation)
pO2 = 89.9
pCO2 = 39.9
HCO3 = 33.8
92% O2