1. chronic diseases
2. Presentation
2.1. heavy occupational exposure to asbestos which lead to fibrotic changes in the lung
2.2. breathlessness, vague chest pain, productive cough, cyanosis
3. Step 6
3.1. Review session 1
3.1.1. Summary of step 5
3.2. Report new knowledge
3.2.1. occupational respiratory diseases
3.2.1.1. what is common in navy
3.2.1.1.1. most of ships where using asbestos
3.2.1.2. asbestosis and mesothelioma
3.2.1.2.1. neoplasms
3.2.1.3. fibrotic lung diseases
3.2.2. pathophysiology for the process of cyanosis
3.2.3. what causes vague chest pain
3.2.3.1. not related to breathing or exertion
3.2.3.1.1. any tumor in the chest may cause chest pain
3.2.3.1.2. mainly the pain is from excessive cough and called tightness
3.2.3.2. could it be caused by lung cancer?
3.2.3.3. it could be pleural or mediastinal cause because lungs are well innervated
3.3. 40 minutes
4. Step 8
4.1. Diagnostic decision
4.1.1. fibrotic lung disease (asbestosis)
4.2. Mechanism
4.3. Supporting data
4.3.1. history and physical examination
4.3.1.1. crackles, clubbing,
4.3.1.2. reduced chest expansion
4.3.1.3. occupational exposure
4.3.2. test results
4.3.2.1. ABG
4.3.2.2. CXR
4.3.2.2.1. reticulonodular changes
4.3.2.3. CT
4.3.2.3.1. we need high resolution CT
4.3.2.4. Spriometry
4.3.2.4.1. hypoxemic with respiratory alkalosis with compensatory metabolic acidosis
4.3.2.4.2. restrictive lung disease
4.4. 10 minutes
5. Step 7
5.1. Inquiry plan and info gathering
5.1.1. History of presenting complain
5.1.1.1. history of cyanosis
5.1.1.1.1. nothing he's aware of
5.1.1.2. SOCRATES of the chest pain
5.1.1.2.1. pain distrubting sleep
5.1.1.2.2. started recently last two months
5.1.1.2.3. vague
5.1.1.2.4. no radiation
5.1.1.2.5. not related to breathing or movement
5.1.1.2.6. mild to moderate 3-4 out of 10
5.1.1.3. sputum production
5.1.1.3.1. whitish grayish sputum
5.1.1.4. fatigue
5.1.1.4.1. yes
5.1.1.5. hemoptysis
5.1.1.5.1. no
5.1.1.6. breathlessness type
5.1.1.6.1. get worse last 6 months
5.1.1.6.2. not related to activity
5.1.1.7. fever
5.1.1.7.1. no fever
5.1.1.8. weight loss
5.1.1.8.1. some weight loss
5.1.1.9. night sweats
5.1.1.9.1. no
5.1.1.10. no wheezing
5.1.2. Previous medical / surgical history
5.1.2.1. pain killers
5.1.2.2. previous surgery
5.1.2.3. hospitalization
5.1.2.4. started over last few years
5.1.2.5. ulcers can cause aspiration which by time may cause aspiration to lung
5.1.2.6. NO PREVIOUS HISTORY
5.1.3. Drug history / allergy
5.1.3.1. no allergy
5.1.3.2. didn't seek medical advice before
5.1.4. Family history
5.1.4.1. Clean family history of any diseases
5.1.5. Social / occupational history
5.1.5.1. 20 pack year smoker
5.1.5.2. retired 5 years ago
5.1.5.3. social drinker
5.1.5.4. heard that one of his collegues had a problem in breathing
5.1.5.5. no other jobs
5.1.5.6. married with two grown-up kids
5.1.5.7. symptoms affecting his daily activity especially last 6 months
5.1.5.8. lost apetite because he feels sick
5.1.5.8.1. not able to exercise
5.1.5.9. depression and scare feeling
5.1.6. worked for the last 30 years
5.1.7. Physical examination
5.1.7.1. vital signs
5.1.7.1.1. no fever
5.1.7.1.2. 25 respiratory rate
5.1.7.1.3. pulse 105
5.1.7.1.4. 150/80 BP
5.1.7.1.5. O2 88-90 %
5.1.7.2. peripheral
5.1.7.2.1. clubbing
5.1.7.2.2. cyanosis
5.1.7.2.3. no muscle wasting
5.1.7.2.4. no hypertrophic osteoarthropathy
5.1.7.2.5. JVP
5.1.7.2.6. no edema
5.1.7.2.7. no horner's syndrome
5.1.7.2.8. voice change
5.1.7.3. looks breathless, using accessory muscles for breathing, tripole positioned
5.1.7.3.1. no lymphadenopathy
5.1.7.4. chest
5.1.7.4.1. inspection
5.1.7.4.2. palpation
5.1.7.4.3. percussion
5.1.7.4.4. auscultation
5.1.8. tests results
5.1.8.1. CBC
5.1.8.1.1. little bit high hemoglobin level
5.1.8.2. ABG
5.1.8.2.1. hypoxemic with respiratory alkalosis with compensatory metabolic acidosis
5.1.8.3. CXR
5.1.8.3.1. reticulonodular changes
5.1.8.4. CT
5.1.8.4.1. we need high resolution CT
5.1.8.5. Spriometry
5.1.8.5.1. restrictive lung disease
5.1.8.6. after all this we have to consider biopsy by bronchoscopy
5.1.8.6.1. not yet done