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 3 Semester 2 – Cardiorespiratory Fitness – PBL Casebook 2006/07

9 Cardiorespiratory Fitness
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11 Medicine PBL Casebook

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13 Year 2 Semester 3
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15 Session 2009/2010
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17

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19 Name:___________________________

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21Semester Chair
22
23

25Exam Coordinator
26
27
28

29Course Content
30
31The collection of cases chosen for this semester were reviewed in 2004 and direct
32you to learning material in cardiovascular and respiratory areas considered
33appropriate for a clinician in the 21st Century. They are reviewed annually for
34accuracy.
35
36The cases presented in this semester are linked to an index of clinical situation
37from the core curriculum of the MBChB degree awarded by the University of
38Manchester. The design of the Manchester course has been guided by
39publications from the General Medical Council (GMC) and the UK Government.
40
41Your PBL tutor/facilitator has been trained to facilitate your learning through the
42PBL discussion group and is the first person you should ask for advice if you have
43problems.
44
45
46
47

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48

49Contents

50Cardiorespiratory Fitness...................................................................................2
51Medicine PBL Casebook...................................................................................2
52Year 2 Semester 3...........................................................................................2
53Session 2009/2010 ..........................................................................................2
54Name:___________________________ .........................................................2
55Contents.............................................................................................................4
56Case 1: The Stabbing......................................................................................12
57Case 2: Peak Performance..............................................................................15
58Case 4: The Downward Slope.........................................................................21
59Case 5: The Faintheart....................................................................................24
60Case 6: Too Much Pressure............................................................................27
61Case 7: Giving and Receiving.........................................................................30
62Case 9: Negative Consequences...................................................................36
63
64

65Theatre Events
66Problem-based learning curricula emphasise SELF-DIRECTED LEARNING and students’
67using a range of resources to find the information they need. The theatre events are one such
68resource. However, in the Manchester MBChB programme theatre events are NOT intended
69to be THE major way of delivering key content via didactic teaching – this is what happens in
70“old-style” lecture-based courses, not in PBL curricula.
71
72Theatre events will vary widely in style and content. This is intentional and reflects different
73types of events delivered by different groups of staff involved in Medical Education.
74
75Some speakers are CLINICIANS, usually telling you about some aspect of their clinical
76specialty. Many of these talks are designed to help you gain insight into the links between the
77basic science concepts you study in phase 1 (and phase 2) and clinical practise. Some may
78be basic summaries of an important aspect or aspects of disease or clinical practise.
79
80Some speakers are BIOSCIENTISTS engaged in teaching and research. These talks may
81summarize and wrap-up at the end of a series of linked cases, or present useful ways of
82thinking about concepts or topics commonly perceived to be difficult to grasp. Sometimes
83talks try to bring together topics which feature briefly in a number of cases – an example
84might be a talk about different kinds of drugs used to treat a particular common condition.
85
86Some speakers are BEHAVIOURAL or SOCIAL SCIENTISTS engaged in teaching and
87research. These talks may discuss the empirical evidence behind concepts or models applied
88to medicine that you will encounter in your reading and discussion. Others may use a more
89discursive style to present an argument, or different points of view of, say, an ethical question.
90Still others may look at the historical development of medicine or of treatments.
91
92To sum up: not all theatre events will be delivered in the same style. Not all are summaries.
93Not all contain core content. They are NOT “the things you need to know to pass the
94Semester test”. They are, however, designed to reinforce your understanding and to help,
95inform or interest you.
96
97

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98SSC
99
100There will no PBL cases during the SSC time.
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102Year 1 Special Study Components (SSCs)

103
104The SSC allows you to investigate a specialist topic related to medicine under the
105supervision of a member of staff. To investigate the topic you will be expected to
106search systematically for relevant literature, critically assess that literature and
107then to produce a report on your findings. The aim of this component of the
108curriculum is to encourage and active approach to learning based on curiosity and
109exploration of knowledge. Tomorrow’s doctors will need to be questioning and
110critical and this module will help you to develop these skills.
111
112You will be allocated a title by 29th January 2007. In the first few weeks of term
113you should approach your supervisor for initial guidance on your project. Over the
114following weeks you should then make use of the advice and information on
115literature searching provided by library staff, consult the literature, produce a plan
116for your report and generate a first draft based on the guidelines provided. The
117period from 13th to 22nd March has been set aside for you to finalise your report.
118There will not be any PBL cases or practical sessions during this period. It is NOT
119recommended or wise to leave all the preparation to these two weeks. The
120deadline for submitting their SSC is 5pm on 22nd March.
121
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124Weekly summary
125
Date Case PBL session 1 PBL session 2
week beginning (and finish prev
case)
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 Monday Thursday

Consequences
7th May Conclude case 9 on Bank Holiday Thursday (finish
Thursday case 9)
126
127Normal timetable
128Groups 1-16 PBL times
129Monday : 10.00-11.30 am Thursday : 9.00-10.00 am
130
131Groups 17-31 PBL times
132Monday : 11.30-1.00 pm Thursday : 11.00-12.00 pm
133
134* Exception to the timetable
135Note: due to the Monday Bank Holiday on May 7th, session three for Case 9
136(“Negative Consequences”) will take place on Thursday 10th May 2007 at the
137usual Thursday times.
138Alterations to the timing of this final session may only be made with the
139agreement of your PBL tutor.

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140You should download a complete individualised timetable for semester 2 from

141MedLea.
142First Theatre Event: Monday 29th January 2007 - 9.00 am LT2 and LT3
143First PBL session: Monday 29th January 2007

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Time MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
9.00
9.15 LT2 and LT3 Early Early DR Early PBL Euro LT2 and LT6
9.30 (31 groups) Experience Experience Experience (Groups option (31 groups)
9.45 (Groups 1-16)
10.00 (in Stopford) (ex Stopford) 9-15) (ex Stopford)
10.15 PBL Euro LT2 and LT6 LT2 and LT6
10.30 (Groups Option (31 groups) (31 groups)
10.45 1-16)
11.00 DR
11.15 PBL Euro 1MUL Early
11.30 (Groups (Groups option (Groups 13-18) Experience
11.45 PBL Euro 24-31) 17-31)
12.00 (Groups Option (in Stopford)
12.15 17-31) LT2 and LT3
12.30 (31 groups)
12.45
13.00
13.15 Microlab Early 1MUL Early 1MUL
13.30 Experience (Groups Experience (Groups 19-24)
13.45 DR 25-31)
14.00 (Groups (ex Stopford) (in Stopford)
14.15 16-23)
14.30
14.45
15.00
15.15 Microlab 1MUL 1MUL Micro-
15.30 DR (Groups (Group lab
15.45 (Groups 7-12) s 1-6)
16.00 1-8)
16.15
16.30
16.45
144

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

146 Please note that theatre events and practical sessions vary each week during the semester.
147 PBL = problem-based learning. DR = dissecting room. 1 MUL = first floor multi-user lab.
148 LT2,3 and 6 – Stopford Lecture Theatres

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149Aims for semester 2

150
151Knowledge: To promote acquisition of knowledge and facilitate the understanding of
152 cardiovascular and respiratory health and promotion, and of cardiovascular and
153 respiratory diseases, their prevention and management, in the context of the
154 individual and society.
155Skills: To develop student competence in the performance of a number of basic procedures.
156Attitudes To encourage students to develop attitudes necessary for the achievement of high
157 standards of medical practice.

158Expected learning outcomes for Semester 2

159Knowledge
160At the end of the semester, students are expected to have acquired a knowledge and understanding
161of:
162 a. the normal structures and functions of the cardiovascular and respiratory systems.
163 b. the features of major cardiovascular and respiratory diseases, their investigation,
164 prevention and treatments.
165 c. the main causes of major cardiovascular and respiratory diseases including the role of
166 processes such as inflammation, immune response, thrombosis, degeneration, and
167 trauma.
168 d. how cardiovascular and respiratory diseases present in patients of all ages, and
169 factors affecting patients reactions to illness.
170 e. the environmental, social and psychological factors affecting the development of
171 cardiovascular and respiratory diseases, historical as well as contemporary views.
172 f. the principles of disease prevention and health promotion.
173 g. the principles of therapy including the action of drugs.
174 h. the management of chronic illness including rehabilitation.
175 i. the factors influencing the effectiveness of communication in health care settings.

176 j. the organisation, management and provision of health care including ethical and legal
177 aspects, in community and in hospital.
178 k. scientific research and an ability to evaluate evidence through information presented
179 in the PBL cases and from the Student Selected Component in this semester.

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180Skills
181 a. to be able to demonstrate competently the use of a spirometer and the safe handling of
182 blood,
183 b. to be able to interpret ECGs, heart sounds, and take accurate measurements of pulse
184 and blood pressure
185 c. the ability to reflect upon different motives for studying medicine
186 d. to be able to identify stress symptoms in self and personal coping responses to stress
187 e. to be able to demonstrate best teaching methods for inhaler use to optimise adherence
188 f. to be able to assess for motivational stage of behavioural change
189 g. to be able to provide evidence based smoking cessation advice
190 h. to accurately classify individuals into socio-economic groups
191 i. to be able to provide age-appropriate information about health, illness and treatments

192
193Attitudes:
194At the end of the semester the students are expected to have acquired the appropriate
195attitudes/professional development in relation to:
196
197 a. an appreciation of the need to apply a scientific framework to biological, behavioural and
198 social sciences
199 b. a non-judgemental approach to people people’s health/illness behaviour and a mature
200 approach to discussions about the extent of an individual’s responsibility for their own
201 health
202 c. a belief in the role of health care professionals as health educators
203 d. the need to demonstrate empathy and respect for all patients
204 e. standards of behaviour expected of medical students, including the need to show respect
205 for fellow students, university staff , and healthcare workers
206 f. a critical but open mind in relation to psychological therapies
207 g. a sense of citizenship
208
209
210
211Each PBL case has been carefully designed to address detailed and specific intended learning
212outcomes.
213

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Case 1: The Stabbing

214Steven was a 19 year old student at Manchester University. At 11 o'clock one

215evening he was walking home when he was mugged by two young men. Although
216the street was busy no-one came to his assistance as he struggled to defend
217himself from a series of blows to his chest. The assailants ran off, dropping a
218bloodstained screwdriver. He phoned the police and while waiting for them
219discovered he was bleeding from the right side of his chest. On seeing his blood-
220stained shirt the police radioed for an ambulance.
221
222The paramedics found him agitated and pale but still able to talk sensibly.
223Breathing seemed to be causing him some pain. His pulse was strong but rather
224fast. They gave him oxygen via a mask and examined his chest wound, a clean
225puncture near the right nipple which was no longer bleeding. There was no
226sucking sound at the injury site as he breathed and no evidence of frothing. The
227paramedics applied a square dressing, sealed to the skin on only three sides, and
228took him to the Accident & Emergency department.
229
230The A&E doctors assessed Steven according to ATLS protocol. They noted he was
231conscious with no sign of injury to his face or mouth. He was able to talk but his
232breathing was now very laboured. He was not coughing blood and there seemed
233to be no obstruction to his airway. Examining his neck they noticed engorged
234veins and displacement of the trachea to the left of the midline. Turning to his
235chest, palpation revealed crackly swelling around the paramedics’ dressing.
236Percussion produced increased resonance on the right side while auscultation
237revealed diminished breath sounds on the right side. A doctor inserted a needle
238through Steven's chest wall via the second intercostal space in the right mid-
239clavicular line. Air came out through the needle under some pressure, confirming
240the diagnosis and making it easier for Steven to breathe.
241
242A second needle was then used to infiltrate lidocaine into the tissues of the 5th
243right intercostal space in the mid-axillary line. A chest drain (a polythene tube
244about 1cm in diameter) was inserted through an incision in the anaesthetised
245area. Air escaped vigorously through the drain and its under-water seal. The
246needle in the second intercostal space was then removed and an anterior-
247posterior chest radiograph was taken. The paramedics’ dressing was removed
248from the original stab wound which was sutured and an air-tight dressing applied.
249

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250Steven was admitted to an acute surgical ward where his chest drain was
251observed closely. The fluid level rose and fell in the transparent tube as he
252breathed and initially a lot of air bubbles were expelled every time he breathed
253out. During his first night in hospital Steven managed to sleep only for short
254periods. He was in considerable discomfort from his injuries, despite analgesics.
255The next day Steven was interviewed by the Police. They found him hesitant
256about details of the attack and confused over times and dates. He was also visited
257by two of his house mates who expressed concern about the safety of the area
258they lived in. On the third day bubbles were no longer emerging through the
259drain, a further chest radiograph (posterior-anterior) was taken and the drain was
260removed. A final chest radiograph on day 4 was satisfactory and Steven was
261allowed home. Later that month he saw his personal tutor and they discussed the
262attack and the apathy of the by-standers. She referred him to the university's
263counselling service where he received cognitive behavioural therapy (CBT) for
264post traumatic stress disorder.

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265

266Case Notes
267
268Definitions
269
270
271
272
273
274
275
276
277 ------------------------------------------------------------------------------------------------------
278Group Learning Objectives
279
280
281

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282Case 2: Peak Performance

283
1Luke O’Treen, from Bournemouth, was a 22 year old keen athlete who had
2represented his school at athletics and decided go to Manchester University
3because of the Commonwealth Games in the City in 2002. He had attended
4university athletics trials and had succeeded in getting in the running team.
5
6Competition was high and in an effort to improve his fitness he would run several
7miles each day. During the first semester the weather was cold and he found
8himself getting out of breath and feeling wheezy for several minutes despite
9having stopped running. Blaming his problems on living in a city he discussed it
10with his parents by phone who suggested he should see his GP. He told them how
11he was representing the University in athletics and trained for 2 or 3 hours on
12most days.
13
14After discussing his breathing problem with the coach he underwent some tests.
15His peak flow was measured at 500L/min. His height was measured as 1.8m. His
16symptoms persisted which prompted him to visit the GP. He informed her that he
17had asthma as a child but this had cleared by the time he was eight. He was not
18sure what might have triggered the asthma. His younger brother was asthmatic
19and used steroid and β2-agonist inhalers and his sister suffered from hay fever.
20Luke was not aware of suffering from any allergies. The GP showed him a model
21of the lungs and explained the nature of his condition. She suggested he keep a
22peak flow diary and record his attacks. She also started him on two types of
23inhalers (salbutamol and beclomethasone).
24
25Feeling better Luke returned to fitness but embarrassed to take his medication in
26front of his team mates he rarely used his inhalers. Luke had previously overheard
27one of his team mates describe his condition as ‘psycho-somatic’, saying that
28Luke could not cope with the pressure of performing. He found that his
29breathlessness returned and was much worse at night.
30
31On a visit home, he informed his parents that the GP thought he was asthmatic
32and showed them his medicines. Being at home his chest felt better. On a walk
33with his granddad, his improvement during his stay at home was put down to the
34“sea air”, or to “getting away from all that city pollution”. In a rush to get
35everything together to return back to University Luke left his medication at home.
36

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37Returning to Manchester after the Christmas holiday he continued his training,

38trials were approaching and he was eager to participate. Early in the morning
39during a jog Luke collapsed short of breath. He was taken to hospital by his
40running partner. His pulse was 100/minute, respiratory rate 22/min and PEFR 350
41L/min. Pulse oximetry gave a result of <92%. Arterial blood gases were PaO2 61
42mm Hg (predicted 90-100) and PaCO2 31 mm Hg (predicted 36-46), and pH was
437.47(predicted 7.35-7.45). Luke was given a chest radiograph at casualty.
44Treatment with a nebuliser delivering a bronchodilator over the next two hours
45eased his condition. Luke was given a week’s course of oral steroids to
46supplement his inhalers. After rechecking Luke’s PEFR, the doctor told him he
47could go home. The doctor told Luke that ‘fit young people like you can and do die
48from asthma attacks not much worse than this’ and reiterated the importance of
49taking his medication and self management. Complying with his treatment his
50asthma improved and he was able to resume training.

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Case Notes

Definitions

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Group Learning Objectives

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Case 3: Turning Blue

51Mr Boyle, a 50 year old unskilled manual labourer from Rochdale, was a regular
52visitor to the clinic. He was waiting for his appointment to discuss a chesty cough.
53Both his parents had been smokers and he had smoked since a teenager and had
54often stated that he could not get through the day without his ‘nicotine fix’. He
55was aware of being flushed and breathless after walking to the clinic. Having
56been certificated as sick by his GP he was off work long-term. His GP suggested
57that to improve his condition he should join a smoking cessation group and
58undertake some exercise. Mr Boyle found it easier to be motivated to change in a
59group than on his own. For many years he had smoked over thirty cigarettes per
60day but was down to about ten per day, mainly due to the cost.
61
62A detailed history and blood pressure were taken and spirometry performed by
63the practice nurse, and an exercise tolerance record was started. The nurse also
64asked Mr Boyle about what sort of jobs he had done and where he had worked.
65
66Spirometry demonstrated reduced FEV1 and a ratio FEV1/FVC of 60%. This did not
67change markedly on subsequent visits. Bronchodilator therapy was provided
68which he was instructed to take as required. He was referred to a specialist at the
69Primary Care Trust who diagnosed COPD. At the cessation clinic he found it
70difficult to quit but enjoyed the social side to the group. He was offered nicotine
71replacement therapy and bupropion, and his carbon monoxide levels were
72measured.
73
74He continued to attend the GP surgery and 1 year later when his ratio FEV1/FVC
75was 56% he was given a trial of a glucocorticoid. Mr Boyle responded positively
76and regular steroid therapy continued; he was again urged to undertake mild
77exercise. However, he found it difficult to walk to the end of his garden. As time
78progressed the severity of his disability meant that he required high dose
79bronchodilators and oxygen therapy.
80
81Mr Boyle now attended a “breathe easy support group”. One winter evening he
82felt very unwell and was admitted to hospital. He had a bounding pulse, and was
83pyretic and drowsy. He had dyspnoea, was cyanosed with increased wheeze, and
84had purulent sputum. Pulse oximetry showed hypoxia and he was given 40% O2
85by mask. Measurement of blood gases showed hypoxemia and hypercapnia;
86values were PaO2 6.1 kPa (predicted 12.1 SD 1.05), PaCO2 8.3 kPa (predicted 4.8-

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

88chest radiograph revealed emphysematous bullae. Cough and rust-coloured
89sputum were evident and Mr Boyle was prescribed a course of antibiotics
90(cefuroxime, erythromycin) and a course of oral steroids, and told to keep up his
91bronchodilator therapy. Later discharged he was instructed to attend an
92outpatient follow-up at 5 weeks. The SHO commented he was seeing many
93people with similar symptoms.
94
95On worsening of his symptoms he requested a home visit from his GP. He was
96again admitted to hospital, over time becoming a frequent visitor. Tests for
97arterial blood gas tensions and polycythemia were undertaken. As his symptoms
98worsened repeated pulmonary function tests were performed. He died before
99retirement age.
100

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101Case Notes
102
103Definitions
104
105
106
107
108
109
110
111
112
113 ------------------------------------------------------------------------------------------------------
114Group Learning Objectives
115
116
117

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118Case 4: The Downward Slope

119
1Mr Ahmed was born in Pakistan in 1950. As a child he had suffered a throat
2infection followed by severe malaise, a skin rash and swollen, tender joints. He
3came to Britain in 1988 and registered with a GP seven years later. When he
4visited his GP he was usually accompanied by his 14 year old daughter who
5interpreted for her father and the GP.
6
7In 2002 he reported to his GP that he was breathless on climbing a single flight of
8stairs and had begun waking up in the middle of the night with breathlessness
9leading him to sleep propped up by several pillows. On examination he had a
10pulse of 82/min, with occasional irregularities; blood pressure was 115/90 mmHg
11and auscultation of the chest revealed basal crepitations. There was a pan-systolic
12murmur at the apex, radiating towards the axilla. The GP prescribed furosemide
13and arranged for him to be seen in the open-access heart failure clinic.
14
15However, 2 days later he suddenly became severely breathless, and began to
16cough up pink frothy sputum. His daughter telephoned for an ambulance because
17she viewed these symptoms as very serious. The paramedics gave him oxygen by
18face-mask and took him and his wife to the local hospital. On arrival, Mr Ahmed
19was breathing rapidly and his lips and finger-tips were cyanosed. His ankles were
20swollen, and his liver was palpable. His pulse was ‘irregularly irregular’ at
21120/min. On auscultation, crackles could be heard over the lower two-thirds of the
22chest. An ECG showed atrial fibrillation, and an antero-posterior chest X-ray
23revealed enlargement of the left side of the heart, with central congestion of the
24lung fields. Digoxin treatment was given to control his heart rate. Oxygen
25treatment was continued and he was given intravenous furosemide, and an
26infusion of glyceryl trinitrate and he soon began to feel more comfortable. A
27troponin T test was normal.
28
29By the next morning he had produced 2 litres of urine and was no longer
30breathless. An ECG revealed his ventricular rate had fallen to 90 beats per minute.
31Echocardiography showed that the mitral valve leaflets were thickened and rigid,
32and that the left ventricular ejection fraction was low and colour Doppler flow
33analysis demonstrated marked mitral regurgitation. He was commenced on
34aspirin, furosemide, ramipril, and carvedilol and was transferred to the
35cardiothoracic ward.
36

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37The specialist registrar spoke to Mr Ahmed and his family and explained Mr
38Ahmed needed a mitral valve replacement operation. He underwent his mitral
39valve replacement whilst in hospital and his atrial fibrillation problems
40disappeared. A month later, he was able to climb two flights of stairs without
41feeling breathless. Later, he returned to full-time work. He was advised that he
42would have to take warfarin long-term and have his dosage regulated by INR
43measurements, and he would require antibiotics when undergoing dental
44treatment, or if he ever needed certain sorts of medical or surgical treatment.

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Case Notes

Definitions

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Group Learning Objectives

46
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Case 5: The Faintheart

1Mrs Khan had gained almost 20 kg since her move to the UK nearly 20 years ago.
2Her husband was a wealthy businessman and she had never needed or wanted to
3work outside the home. Her pride and joy were her three sons: the oldest had just
4graduated from medical school. Mr and Mrs Khan went for regular walks in the
5evening, although recently, she had experienced some difficulty keeping up with
6her husband on their mile long walk.
7
8At the age of 53, while walking with her husband, Mrs Khan developed intense
9pain in her chest that spread to the left side of her jaw and to her back, which
10settled when she stopped walking. During the next month the weather was
11particularly cold and walking initiated several more attacks of pain. This prompted
12a visit to her GP. Her father had died from a heart attack in his fifties.
13
14Her blood pressure was 148/94 and a resting electrocardiogram, performed in the
15GP’s surgery, was normal. The GP took a sample of venous blood for analysis of
16lipids and glucose and prescribed glyceryl trinitrate, aspirin and atenolol. The
17laboratory reported a serum cholesterol concentration of 5.1 mmol/l [desirable
18value <5.0] and low density lipoprotein (LDL) 3.2 mmol/l [desirable value <3.0],
19triglycerides were elevated at 4.4 mmol/l, and her HDL was 0.7mmol/l. Her
20glucose level was normal. The GP told her they would need to watch her blood
21pressure and cholesterol, and advised her on diet and exercise.
22
23However, 6 months later while clearing autumn leaves from the lawn she
24experienced a particularly bad attack of chest pain. When the pain had gone on
25for nearly an hour, her husband called an ambulance. In the Accident &
26Emergency department, she was pale and clammy. Her pulse was regular at 60
27beats per minute and her BP 100/60mmHg. An ECG showed elevation of the ST
28segments in her anterior leads. A blood sample taken that night showed raised
29cardiac Troponin T.
30
31Initial treatment included the administration of oxygen by mask, aspirin by mouth
32and the intravenous infusion of recombinant tissue plasminogen activator,
33diamorphine and glyceryl trinitrate. After about 3 hours in A&E she was admitted
34to the coronary care unit where she continued to complain of chest pain.
35Emergency coronary angiography was therefore undertaken, an immediate
36angioplasty was performed and coated stents placed in her circumflex and left
37anterior descending arteries. Her pain settled and she was discharged on the

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38seventh day on atenolol, glyceryl trinitrate, aspirin, clopidogrel, ramipril and

39atorvastatin.
40
41Mrs Khan was very concerned about how she could reduce her chance of having a
42further problem with her heart. Her GP talked to her about the most effective
43medical and non-medical (lifestyle) interventions, stressing the need to control
44her blood pressure and cholesterol, lose weight, and get fitter. As she was leaving
45the consultation the GP suggested that she could join a comprehensive cardiac
46rehabilitation programme. He also gave her a British Heart Foundation leaflet on
47living with heart disease. She was followed up in the cardiology clinic.
48
49

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50Case Notes
51
52Definitions
53
54
55
56
57
58
59
60
61
62 ------------------------------------------------------------------------------------------------------
63Group Learning Objectives
64
65
66

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67Case 6: Too Much Pressure

68
69Ray is a 56 year-old bus driver and lives with his daughter Janet and her teenage son Jimmy.
70With Jimmy and Janet nagging him, Ray gave up smoking four years ago after, as he says,
71“35-odd years on 20 a day”. Janet and Jimmy had been urging Ray to have a health check-
72up, so last year Ray - who was then 55 - went to see the GP. His blood pressure was 180/115
73in both arms, but after he sat talking to the doctor for ten minutes it dropped to 170/110. Ray’s
74BP was the same at two further monthly appointments. The GP sent Ray to the community
75hospital for 24 hr blood pressure monitoring and blood tests. When the results came through
76she told Ray he would need to start taking medicine to reduce his cholesterol and blood
77pressure, as well as make some lifestyle changes. Ray was rather shocked, as he had been
78generally healthier since giving up smoking and felt fine.
79
80Using her computer, the GP showed Ray a chart indicating (given his total plasma
81cholesterol:HDL cholesterol ratio of 5 and his BP of 170/110) that he had about a one in three
82chance of developing a serious cardiovascular disorder within the next 10 years. Accordingly,
83she started him on a statin and bendroflumethazide. After four weeks the thiazide had
84lowered his BP to 160/100. However, Ray decided the drugs made him want to urinate more
85often during the morning. As this was inconvenient for his work as a bus driver, he stopped
86taking the tablets after a few more weeks.
87
88Several months later, after Ray got in a heated argument with a motorist while driving his bus,
89he got a terrible headache and thought he saw flashing lights. After the headache went on for
90several days he went to see the GP, who measured his BP at 180/115. When Ray admitted
91he wasn’t taking the tablets, and explained why, the GP said she could try him on a different
92blood pressure drug, and prescribed amlodipine and a statin. She also signed him off sick.
93
94After several months on amlodipine Ray’s BP was consistently around 160/110, although he
95had swollen ankles and got troublesome headaches. When his sick leave ran out he went
96back to work, but the GP said Ray was not allowed to drive a bus with his blood pressure.
97After Ray saw an Occupational Health doctor his manager transferred him to work as a
98dispatcher, although this has meant financial difficulties for the family as the pay is not as
99good. The GP also added an ACE inhibitor to Ray’s medication, which meant more tests as
100Ray had to have his serum potassium and creatinine checked after a week on the new drug.
101Several months of the combination of ACE inhibitor and amlodipine got Ray’s BP down close
102to 150/100. However, he had a persistent dry cough he found very annoying and this
103prompted a switch from the ACE inhibitor to losartan.
104
105Ray is currently trying to lose some weight and hoping to get his blood pressure down enough
106to be able to go back to driving. He is taking amlodipine, losartan and a statin and his BP is

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107consistently just above 150/100. However, the GP tells Ray this “still isn’t where it needs to
108be”, and they are discussing, as Ray says “even more pills”.

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109Case Notes
110
111Definitions
112
113
114
115
116
117
118
119
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122Group Learning Objectives

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123Case 7: Giving and Receiving

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1Sarah’s dad was a blood donor. However, it was when her brother needed to have
2a blood transfusion that Sarah (18) decided to give blood. Her brother had been in
3an accident, and had to have emergency surgery including splenectomy. After he
4recovered, he was given several immunisations and told to take life-long
5penicillin, although he hated doing this. He was also given a card to carry in his
6wallet. It read “I have no functioning spleen”.
7
8Sarah was well known for helping people and, prompted by an advert in the
9Student Union, she went to a Blood Donor drive. She was given a questionnaire to
10complete about her fitness and life-style, and then counselled. She was warned
11that she would be tested for a range of infectious diseases including HIV, and had
12a finger-prick blood test to check she was not anaemic. After she had signed a
13consent form, Sarah was told that she would be notified to give blood about three
14times a year. Finally, she lay on a bed to give blood. This went smoothly, although
15she had to lie on the bed for about a quarter of an hour afterwards and have a
16drink of tea or orange before going. She was also advised to avoid vigorous
17exercise and alcohol that night. Several days later she was sent a card with her
18name, donor number and blood group on. Her group was AB Rh positive. Worried
19that this was different from her father’s group, which was A Rh negative, she
20looked this up on the Internet, and discovered that this was entirely possible!
21
22She continued to give blood regularly for more than ten years. However, she
23missed two sessions in her first year when, towards Easter, she began to feel very
24tired and run down. Sarah went to the Student Health Centre, who took a blood
25sample. Later she got a text message to call the Centre, where the receptionist
26told her they needed her to come in again because her sample had shown ‘some
27abnormal monocytes’. Sarah spent a couple of days worrying that she had
28something really serious, like leukaemia, but when she saw the doctor he said she
29had glandular fever. He told her it was not serious but that she would need to rest
30as much as possible over the holidays and ‘take things easier’ and ‘pace yourself’
31next semester.
32
33On one occasion in her mid-20s when she went to give blood, Sarah was told her
34haemoglobin was too low and she would not be donating blood that day but would
35be called back in twelve months. She was recommended to visit her GP. Sarah
36suffered from heavy periods and on the visit the doctor noticed that she looked
37pale. A blood test showed her haemoglobin concentration was 8.0g/dl and her

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38mean corpuscular volume 72fl. In addition her serum ferritin level was low. The GP
39considered the possible causes, and concluded that her menorrhagia was to
40blame. With this in mind he gave a hormone preparation to reduce the heavy
41periods, and ferrous sulphate, advising her to take the tablets after meals and
42carefully store them away from any children. A month later her faintness and
43tiredness subsided but she was constipated and her faeces black.
44
45At 30 years, when Sarah was pregnant with her first baby her blood group, and
46her partner’s, were again checked by the hospital. She was told that she would
47not need any intramuscular injections of Rhesus anti-D immunoglobulin. The
48midwife told Sarah they would keep an eye on her blood pressure and iron levels.
49Sarah’s baby was routinely monitored for jaundice before being allowed home two
50days after the birth.

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Case Notes

Definitions

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Group Learning Objectives

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Case 8: The Grocer

51When he left school at 16 to work in the family's grocery shop, Clive Lot was already quite
52overweight, and by his 20s he was obese. He smoked and usually had a ticklish cough. He
53was encouraged to lose weight by shop customers, including a nurse and a physiotherapist.
54But he always said he “lacked the will power” or told them it wasn’t how much he ate, just that
55he “liked the wrong food”. Clive usually had a takeaway for lunch and a large evening meal
56with his parents, as he still lived at home. By the time he was 33, he weighed 133 kg (21
57stones) although he was only 1.75 m (5ft 8in) tall.

58One day Clive strained his back badly lifting some boxes at the shop. He spent a week laid up
59in bed, with his mother bringing him his meals. After about a week his back eased a bit, and
60he could get up and about with difficulty. When he went to the toilet, feeling a bit constipated,
61and passed a motion after a fair bit of straining, he immediately had a severe crushing pain in
62his chest. He felt breathless and collapsed. His mother had to call the fire brigade to break
63down the bathroom door, and Clive was rushed to hospital by ambulance.
64
65Initially the doctors in A&E suspected a heart attack, but an electrocardiogram (ECG) showed
66only a sinus tachycardia with no signs of myocardial infarction. Physical examination revealed
67tachypnoea, normal breath sounds in the chest and engorged neck veins with prominent
68pulsations. BP was 90/65. Chest X-ray was normal. It was obvious that Clive’s right calf had a
69circumference greater (by about 3-4 cm) than the left.
70
71Analysis 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
72
73The A&E doctor ordered a full blood count, cardiac troponin, and clotting screen (all results
74came back normal). A provisional diagnosis of pulmonary embolism secondary to deep vein
75thrombosis was made, and later confirmed by a ventilation-perfusion scan.
76
77Clive was given the first of 5 daily subcutaneous injections of a low molecular weight heparin,
78and started on oral warfarin several days later. His “prothrombin time” was measured and
79used to calculate his International Normalised Ratio (INR). The daily warfarin dose was
80adjusted to stabilise his INR at a value of 3.5. He was urged by the doctors to lose weight.
81When he was discharged from hospital, he was told to attend the anticoagulant outpatient
82clinic for follow-up to check his INR value.

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83On his first visit to the clinic his INR value remains close to 3.5. Some weeks later he got a
84toothache and took some Nurofen Plus® tablets he bought from the supermarket. On next
85attending the clinic, his INR was 10. He was promptly given intravenous phytomenadione
86(vitamin K) and his warfarin was stopped for several days. Subsequently his INR value re-
87stabilised at 3.5. He was warned not to take any other drugs without telling his GP or the
88anticoagulant clinic. Clive complained to his father that the doctors at the clinic were
89interested only in his blood, not in him and his problems. This feeling worsened when he was
90asked to give another blood sample “for a research project”. Although Clive agreed to the
91extra sample, he did not understand what the doctors planned to do with it.

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92

93Case Notes
94
95Definitions
96
97
98
99
100
101
102
103
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105Group Learning Objectives
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107
108

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109Case 9: Negative Consequences

1A car was found on a country lane, with the front end embedded in a tree. The 18
2year old driver Bethan Rhys, was unconscious and her right leg was trapped
3beneath the engine. The ambulance crew found her pale, cold and clammy
4although there was little sign of external bleeding. Her pulse was weak and rapid
5and she was breathing rapidly. No blood pressure reading could be obtained. An
6airway was inserted and oxygen given by mask. With difficulty, an intravenous
7cannula was inserted and a rapid infusion of Gelofusine® was started. The fire
8brigade sent a vehicle with cutting equipment and she was freed from the car. It
9was obvious that her leg was broken but no other injuries were apparent apart
10from bruising over the lower part of the sternum.
11
12An initial assessment was carried out on arrival in the A&E department. Bethan’s
13blood pressure was 90/60mmHg, heart rate 140/min and respiratory rate 39/min.
14Her axillary temperature was 35oC. Blood samples showed a low arterial PO2 and
15haemoglobin concentration; there was both respiratory and non-respiratory
16acidosis, and a raised plasma lactate concentration. Her blood type was B, Rh
17negative. However the hospital's stock of packed cells of this type was very low.
18She was given 2 units of plasma in combination with packed cells of group O, Rh
19negative. While all this was going on the hospital tried to contact her next of kin
20for consent to treatment. Eventually the police found her mother, who was alone
21when the news of the accident was broken to her. Emergency surgery was carried
22out to repair closed fractures of the femur, tibia and fibula. During the operation
23the surgeons encountered a lot of blood oozing from the damaged soft tissues. By
24this stage, supplies of group B, Rh negative packed cells had arrived from the
25Regional Blood Centre and so this was now infused. Altogether 7 units of blood
26product were given.
27
28Bethan was then transferred, in an unconscious state, to the Intensive Care Unit
29(ICU) where arterial, Swan-Ganz and urinary catheters were inserted; her mother
30was allowed to her bedside for the first time. Data were obtained on right atrial
31pressure (RAP), pulmonary capillary wedge pressure (PCWP), cardiac output, and
32oxygen contents of systemic and pulmonary arterial blood. The cardiac pressures
33were only slightly below normal, but the cardiac output was well below the
34desired value. An ECG showed right bundle branch block. Haemoglobin
35concentration had now risen to 11.2 g/dl; fluid infusion was resumed, the rate
36being adjusted with reference to the PCWP. Over the next few hours, the cardiac
37pressures and output rose to acceptable levels. When she regained consciousness
38she was perfectly lucid and complained of pain, both in her leg and in her chest.

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39The pain was treated by adding diamorphine to the intravenous infusion. A supine
40chest radiograph showed no abnormalities.
41
42By the end of her two week stay in intensive care Bethan did not know how long
43she had been in hospital, or whether it was day or night. During this time she had
44several abnormal sensory experiences. She also became distraught at the death
45of one of the other patients. Subsequently she was transferred to an orthopaedic
46ward, where she stayed for several weeks.
47
48While still confined to bed, she began a rehabilitation programme under the
49supervision of a physiotherapist. She was encouraged to move around the ward
50and hospital corridors on crutches. She left hospital after a total stay of 2 months
51and her leg remained in plaster for a further 2 months. Bethan was able to begin a
52sedentary job after six months and could walk reasonably well by the end of a
53year. However it was nearly two years before she was able to resume playing
54tennis because of problems with moving her right knee.

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56

57Case Notes
58
59Definitions
60
61
62
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68Group Learning Objectives
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72Reflections/Additions for Portfolio

73In this section you can make notes and observations that bring together
74knowledge gained during theatre events, laboratory work (dissection and other
75skills sessions) and private study, with your thoughts and feelings from early
76experience and interactions in PBL groups. Reflection and portfolio activity will
77enable you to think about your changing knowledge, attitudes and skills. As a
78professional practitioner, you have to apply your knowledge to the benefit of the
79person who is consulting you. Clearly, this is an early stage of your training but
80as you progress, reflection will become more and more valuable. Meeting people
81as a professional can be daunting. It is valuable contribution to your experience
82to record your personal thoughts and feelings after these meetings. You need to
83get used to recording how you feel, how you react to particular situations, what
84strategies you use to cope and how successful they are. There will be debriefing
85situations and these notes may help you at these times.
86
87In particular, you might want to make brief notes here on the conduct of the PBL
88session, your role in it, whether any aspect of the case interested you and if so
89what, and whether they had looked up anything extra as a result of this. It is good
90practise to make such notes “there and then”, rather than waiting until some time
91afterwards to record your impressions.
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93
94

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95Reflections/Additions for Portfolio

80