Holly Granger

Case 1 Day 1
2017-2018

Restriction of Use: The School of Medicine considers all PBL cases

and supporting materials to be secure and intended solely for the
educational purposes of the students and faculty of the University of
Texas Medical Branch. Students should not access the PBL cases
prior to release on the course website. At no time should the PBL
cases and supporting materials be copied or distributed. Individuals
violating these policies are subject to disciplinary action.

Slide 1 of 29
Introduction
Group Discussion
Each of you are about to embark in your clinical rotations and move
further into your medical career. You will work with a variety of
professionals who share a common goal to provide quality
healthcare to patients.

Thinking about your past experiences or even perceptions that you

have made over time, discuss the following:

1) What is a PA and why are PAs vital to healthcare?

2) What is your understanding of the working relationship between

a physician and a PA?

3) How does PA education compare to medical school?

Department Name Goes Here 2 Slide 2 of 29

History of Present Illness

Ms. Granger is a 41 year-old woman who presents to your

office. She tells you she has a history of “lupus”. She
appears weak and tired. She describes her problem as:

“For the past 2 weeks, I have continually felt tired. I just

don’t have any energy. Sometimes my muscles ache and
other times my joints ache. I have also been having bouts
of pain in my stomach. I feel feverish a lot, but I don’t
always take my temperature.”

Begin Problem List on the whiteboard

Slide 3 of 29
Tasks

1. What are your initial thoughts about Ms.

Granger’s symptoms?
2. What additional information is needed from the
patient’s history?

Discuss the above tasks before proceeding to next slide.

Slide 4 of 29
Additional History
Present Illness: You ask Ms. Granger the following questions:

What kind of activities do you do in a typical day? Have you had enough energy
lately to do these?

“I don’t do anything that requires a whole lot of effort. I try to walk several blocks after
dinner, but lately, I just don’t have enough energy and my joints have been hurting worse.”

Tell me more about the pain you experience recently. Has your pain level changed?

“Like I was saying, it’s worse than it used to be. And now my muscles ache all the time too.
Some days are better than others, but I think it is just from my lupus. Lately I have started
also having pain in my stomach and I have noticed that it is worse on the left right under my
ribs when I take a breath.

Continue Problem List on the whiteboard including current medications

Slide 5 of 29
 Other Medical History
Do you still have fever?

“It comes and goes, I haven’t noticed any patterns. The few times I have taken my
temperature, it was as high as 101.3. Sometimes, I wake up in the middle of the night and I
am just drenched in perspiration. Of course, I really don’t sleep well, and I just feel
depressed.”

Ms. Granger continues:

“I was diagnosed with lupus 5 years ago. The main problems I have are with the
arthritis in my joints.”

(Her chart indicated a non-deforming arthritis with arthralgia, proteinuria, leukopenia and
positive anti-nuclear antibodies. She has been taking Prednisone 10 mg daily for over three
years with generally good symptom control. She is taking no other medicines.)

“I was diagnosed with depression 2 years ago, but I’ve never been on any anti-
depressant medications. I have also had a heart murmur since I was a child.”

Task: Discuss before proceeding to the next slide

Slide 6 of 29
Tasks

1. Based on your current information, what do you

think is going on with Ms. Granger?
2. What information on Physical Examination is
needed?
3. Summarize and discuss the 11 clinical and
laboratory criteria for SLE diagnosis?
4. What are your Learning Issues?

Discuss the above tasks before proceeding to next slide.

Slide 7 of 29
Family History

• Mother 62 alive and diagnosed with SLE,

hypertension and chronic renal failure on dialysis

• Father 63 alive and well with controlled hypertension

• Sister 36 alive with rheumatoid arthritis

• Brother 32 alive with controlled hypertension

Task: Continue Problem List on the whiteboard if needed

Slide 8 of 29
Social History
• Ms. Granger is a petroleum engineer working in Houston and
living in the Clear Lake Area

• She has 2 daughters aged 12 and 8 both alive and well

• Husband is a self employed CPA

• Occasional alcohol

• Non/never smoker

• Used marijuana in college but none now

Task: Continue Problem List on the whiteboard if needed. STOP and discuss information
before advancing to next slide. What would you want to learn from physical exam?

Slide 9 of 29
Physical Exam
VITAL SIGNS: Temperature 37.8 C. Respirations 20/min. Pulse 100/min
and regular BP 152/88 mm Hg, Ht. 62”, Wt. 132 lbs.
GENERAL: Ms. Granger appears to be tired.
HEENT: Pupils are equally round
and reactive to light.
Fundoscopic examination
(left eye) is shown. Nares are
patent. Oropharynx is free of
exudate, erythema, or any
lesions.
NECK: Supple without adenopathy,
thyromegaly, or masses.
Trachea is midline.
Carotids 2+ without bruits.

Discuss the above before proceeding to next slide.

Slide 10 of 29
Physical Exam continued

BREASTS: No masses, tenderness, or discharge.

HEART: PMI in the 5th ICS in the MCL. Regular rate and rhythm,
with a normal S1, an S2 that splits with respiration, and no
S3 or S4. A grade III/VI blowing holosystolic murmur is
heard best at the apex with radiation to the axilla. No
pericardial rubs are heard.
CHEST: Symmetric expansion, resonance to percussion, and fine
basilar crackles on auscultation in L base. No pleural rub is
auscultated.
ABDOMEN: Bowel sounds normal. Soft abdomen, with mild LUQ
tenderness. Liver span 8 cm in the right MCL. No
splenomegaly, masses, or bruits.

Discuss the above before proceeding to next slide.

Slide 11 of 29
Physical Exam continued
BACK: Normal without tenderness.

EXTREMITIES: No cyanosis, clubbing, or edema. No joint

erythema, effusion, deformity or increased
warmth.

GENITAL/RECTAL: No rectal masses. Normal sphincter tone. Brown

stool, guaiac negative. Pelvic exam reveals no
adnexal tenderness or masses.

SKIN: No erythema or lesions.

Discuss the above before proceeding to next slide.

Slide 12 of 29
Tasks

1. How does this new information affect your

thinking about this patient?
2. What Laboratory Tests would you order now and
why?

Discuss the above tasks before proceeding to next slide.

Slide 13 of 29
Actions Taken

You ordered initial laboratory studies.

Since you did not judge Ms. Granger to be in need

of urgent intervention, you ask her to return to see
you in one week.

Task: Continue Problem List on the whiteboard including current

medications

Slide 14 of 29
Step-Up Task

Students will take 2-3 minutes to review the

following topic related question.

Each student will take a turn discussing:

• The correct answer to the question
• And why the other answers are incorrect

Following student driven discussion your facilitator

will inform you if you are correct. If incorrect, please
set the Step-Up task as a learning issue.

Slide 15 of 29
Step-Up Task

Which disease presents with predominantly

tubulointerstitial involvement?

a. Essential mixed cryoglobulinemia

b. Rheumatoid arthritis
c. Sjogren’s syndrome
d. Systemic lupus erythematosus

Slide 16 of 29
Initial Laboratory Data (received after she was sent home)

White Blood Cells 3400/mm3 (4,000-10,000/mm3 )

Hemoglobin 10.9 g/dL (11.5-15.5 g/dL)
Hematocrit 34% (34-45%)
MCV 84fL (80-96fL)
Platelets 195,000/mm3 (150,000-400,000/mm3)
WBC Differential
Neutrophils 54% (40-73%)
Lymphocytes 32% (18-53%)
Monocytes 11% (4-12%)
Eosinophils 3% (0-6%)
BUN 11 mg/dl (7-23 mg/dl)
Creatinine 1.0 (0.4-1.4 mg/dl)
Complement component C3 105 mg/dl 83-177 mg/dl
Complement component C4 30 mg/dl 15-45 mg/dl

Discuss the above information before proceeding to next slide.

Slide 17 of 29
Laboratory Data cont.

Urinalysis: 2+ protein
2+ blood
0-2 WBC/hpf
20-30 RBC/hpf
No bacteria or cellular casts

CXR: Mild bibasilar atelectasis, otherwise normal

ECG: Sinus tachycardia; otherwise normal

Discuss the above information before proceeding to next slide.

Slide 18 of 29
Tasks

1. Discuss normal and abnormal lab values. How

does this additional information influence your
thinking?
2. What additional information is needed?
3. List your Learning Issues.

Discuss the above tasks before proceeding to next slide.

Slide 19 of 29
Step-Up Task
Anti-double-stranded DNA antibodies are most likely to be found in which
one of the listed individuals?

a. A 28-year-old female with arthritis and a bimalar photosensitive,

erythematous rash on her face
b. A 29-year-old female who presents with trouble swallowing and
sclerodactyly
c. A 35-year-old female who presents with dry eyes, a dry mouth, and
enlarged salivary glands
d. A 47-year-old female who presents with periorbital lilac discoloration
and erythema on the dorsal portions of her hands
e. A 65-year-old female who develops Congo red–positive extracellular
deposits in her liver

Slide 20 of 29
 Additional Information
Ms. Granger returns in one
week and appears acutely ill.
She tells you….
“I am sweating all the time
now and have a difficult time
catching my breath. I am so
week, I can’t get out of bed
most of the time.”
Her physical examination now
shows a tachycardia of 120
beats/minute, tachypnea of
20/minute, a third heart sound,
worsening of her basilar
pulmonary crackles (now
bilateral), and the following Photograph of Ms. Granger’s fingers.
finding on her extremities.

Slide 21 of 29
Tasks

1. What is the basis for the cardiovascular

hemodynamic changes seen on today’s visit?
2. What additional studies, if any, would you
recommend?
3. In retrospect, should you have sent Ms. Granger
home after her initial visit?

Discuss the above tasks before proceeding to next slide.

Slide 22 of 29
Additional Information
Ms. Granger is hospitalized and the following tests are
performed.

Blood cultures: Pending

Chest X-ray: Diffuse hazy opacities consistent with
pulmonary edema or atelactasis

EKG: next slide.

Task: Continue Problem List on the whiteboard including current

medications Slide 23 of 29
EKG

1. Calculate Vent. rate,

PR interval, QRS
duration, QT/QTc and
P-R-T axes.
2. Interpret the EKG. l
3. Do the EKG results fit
your expectations
based on her original
heart examination?
Explain your
rationale.

Discuss the above tasks before proceeding to next slide.ation, QT

Slide 24 of 29
EKG Findings

Discuss the above tasks before proceeding to next slide.

Department Name Goes Here 25 Slide 25 of 29

Tasks continued

1. What pharmacologic measures can be used to

improve her cardiovascular status?
2. Should she be treated with antibiotics and, if so,
which ones?
3. List your learning issues.

Discuss the above tasks before proceeding to next slide.

Slide 26 of 29
Step-Up Task

Which of the following arterial pulse waveforms is

consistent with severe left ventricular impairment?

a. Bisferians pulse
b. Dicrotic pulse
c. Hyperkinetic pulse
d. Parvus et tardus pulse
e. Pulsus alternans

Slide 27 of 29
Virtual Microscopy

Make sure your device is compatible with virtual

microscopy which will be used on Wednesday, April
19. See course announcement about virtual
microscopy.

Test your device by viewing this

slide: https://vmed02.utmb.edu/dsb/webViewer.ph
p?snapshotId=1445364680

Slide 28 of 29
End Day 1

Please unplug your computer from

the wall mount.
Thank you!

Slide 29 of 29