PROBLEM BASED

LEARNING (PBL) 6th

Semester

CASE SECTION

MKK PULMONOLOGI
& KEDOKTERAN

RESPIRASI Session 2

Faculty of Medicine

Universitas Brawijaya
TA 2023/2024
Scenario:
Diesel and Dust: Examination

Bagus is a GP in a Town in Sulawesi and sees Mr. Andi Agam on Saturday morning. He is a
46-year-old plant operator at the open-cut mine and says “Sorry to bother you about this, Doc,
My wife’s been on at me for ages to come and see you, but you know what a worrier she is.
I’m just here to keep the peace. I get a bit short of breath sometimes, but not much really. I just
put it down to not being 20 anymore. I suppose the middle age spread doesn’t help, does it?”
Bagus asks Mr. Andi Agam when he gets short of breath, and he says that it is only when he
works hard, “like changing the tire the other day – I haven’t had to do that for ages. I had to
rest a couple of times. I was well-buggered for the rest of the day. The same thing happened
last week when I dug some new garden beds.”
History

Bagus asks Mr. Andi Agam some specific questions about his recent health and the history
has been clarified. He has been having some breathlessness on exertion for about
eighteen months. He thinks it is fairly constant but never happens at rest and never
disturbs his sleep. He said that he often hears a wheezing sound when he breathes. He has
had a cough for as long as he can remember, worst in the mornings, but also periodically
during the day. He brings up 'about a teaspoon' of brownish sputum during his morning
coughing but He has never coughed up any bright blood.
He has gradually gained weight (about 10 kg) over the last three or four years. He puts this
down to a less active job.
Bagus reviews his history: Smokes: 30–40 cigarettes a day since his late teens; Alcohol: 4
pots of beer on Friday nights.
Past medical history: usually has 'bronchitis' each winter, requiring one or two courses of
antibiotics. No other history of note. Family history: nil of note.
Occupational history: He has worked in the mining industry since the age of 16 years, in
Western Australia, Northern Territory, and currently in Moura for 12 months. He has never
worked underground. When not working in the mining industry, he has done contracting work
for councils or builders. He has had occupational exposure to gold, silver, and copper –
although mostly to 'diesel and dust!' he says. To his knowledge, he has never been exposed
to uranium, asbestos, or nickel.
Examination

He is a slightly overweight man, not cyanosed, and with no finger clubbing. You note that he
is using accessory muscles of respiration while sitting quietly.
Respiratory system:

RR 20/min at rest, with a slightly prolonged expiratory phase. His chest is barrel-shaped.
Percussion of his chest reveals an inferior displacement of his diaphragm. On auscultation of
his lungs, you note that his breath sounds are reduced throughout both lung fields. There are
no wheezes or other abnormal sounds.
Cardiovascular System:

BP 150/80 mmHg, HR 88/min and regular. Heart sounds normal, with no added sounds. JVP
is not elevated. Abdominal examination does not reveal any abnormality and he has no
lymphadenopathy.
Bagus is in no doubt that some investigations are in order and writes out the request forms
while Mr. Andi Agam dresses.

Investigation Result:

Mr. Andi Agam will return for spirometry the next day, after work, bringing his films with him.
Bagus will receive his blood results from the lab.
Learning Resources

1. Grippi M A, Elias J A, Fishman J A, Kotloff R M, Pack A I, Senior R M, Fishman’s

Pulmonary Diseases and Disorders, 6th Edition, Department of Medicine
Pulmonary, Allergy, and Critical Care Division Perelman School of Medicine at the
University of Pennsylvania Chief Medical Officer, GSPP Specialty Hospital
Philadelphia, Pennsylvania, 2022.
2. Pedoman Diagnosis & Penatalaksanaan Penyakit Paru Obstruktif Kronik (PPOK)
di Indonesia. Pokja PPOK Perhimpunan Dokter Paru Indonesia, 2023
3. Global Strategy For Prevention, Diagnosis And Management Of COPD: 2023
Report
4. Felson’s Principles of Chest Roentgenology, A Programmed Text, 5 th ED.,
McGraw-Hill
5. Pujan H. Patel; Vincent S. Mirabile; Sandeep Sharma. Wheezing. 2023.
https://www.ncbi.nlm.nih.gov/books/NBK482454/