Clinical Physiology. Introduction to the Lungs. Anatomy and Physiology

analyse the information provided to write an in-depth analysis to differentiate and diagnose the pathologies, considering the context and the key signs and symptoms. You should apply your understanding of normal and abnormal pathology to interpret, evaluate and differentiate the case study in relation to the disease processes and current literature/guidance (This is not a describing or recalling information report). This should help you to formulate various potential differential diagnoses using systematic assessment strategies and consulting relevant clinical diagnostics and guidelines. You should seek guidance from, and include references to, key health care documentation such as national standards framework/NICE guidance/academic references which are current (preferably less than 5 years old). Your references should be presented using APA 6th edition format: referencing.port.ac.uk.

Clinical Physiology
Assessment 2
Assignment brief
In this second assessment you are presented with a complex clinical case that consists of a that requires you to systematically problem solve and evaluate the clinical case in context to current clinical guidance, incorporating relevant current literature, to diagnose and differentiate the possible pathologies. 
The learning outcomes are
3. Systematically diagnose problems in clinical pathology.
4. Research and critically evaluate current literature and clinical guidance in relation to a range of pathological disease states.
Assignment instructions
The assessment should be no more than 4000 words (there is no + 10%) typed in the default word setting, ie. Calibri 11, 1.5 line spacing, margins set to 2.54 cm.
For this complex clinical case, analyse the information provided to write an in-depth analysis to differentiate and diagnose the pathologies, considering the context and the key signs and symptoms. You should apply your understanding of normal and abnormal pathology to interpret, evaluate and differentiate the case study in relation to the disease processes and current literature/guidance (This is not a describing or recalling information report). This should help you to formulate various potential differential diagnoses using systematic assessment strategies and consulting relevant clinical diagnostics and guidelines. You should seek guidance from, and include references to, key health care documentation such as national standards framework/NICE guidance/academic references which are current (preferably less than 5 years old). Your references should be presented using APA 6th edition format.
Consider the following points when analysing and writing the case study:
1. Identify and discuss the significance of any key signs/symptoms. Use relevant references to justify these.
2. Discuss the importance of any abnormal diagnostic tests. What do they mean in relation to the pathology of the disease? Use relevant references to justify these.
3. Evaluate the potential differential diagnoses given the pattern of presentation and signs / symptoms. Justify your decision using references.
4. Discuss the significance of any factors which may indicate higher risk of pathology. Use relevant references to justify these.
5. What additional questions do you need to ask the person in order to differentiate the possible diagnoses? Base these on clinical references.
6. Consider additional evidence which may add to the clinical picture and use the information to re-evaluate the significance of the signs and symptoms in context of the possible diagnosis. Use clinical guidance or academic literature.
7. Make a logical diagnosis
8. What other diagnostic test might request and why? How would they help you to differentiate your provisional diagnosis? Base these on clinical references.
9. What is the intervention, treatment and/or management? Base these on clinical references.
Case Study clinical summary:
A man aged 68 years, presents for a second opinion (first opinion 10 days ago). He complains of a six to ten month history of difficulty walking on the flat, walking up stairs and when carrying heavy items, such as bags of shopping. These activities produce breathlessness (coughing) and pain /pins and needles radiating down his left arm and are getting more frequent. The pain usually goes after a few minutes if he stops the activity. In addition, he has noticed that he is losing weight more quickly than expected despite eating his usual amount of food and is generally more fatigued. He has also noticed that he is having night sweats and that his glands in his throat swell intermittently, which he puts down to a recent virus infection.
From a social context, he is a retired long distance lorry driver who lives with his partner and young son. He has recently given up smoking (10 months ago), following a 40 pack year history of smoking. 
Overall, his goal is to be able to return to good health and to be able to do a range of activities including taking his child to the park.
Clinical Examination:
On examination, he looks tired. He is short of breath, he is pale and the capillary refill time is slow. Digits are pale and cold. There is patchy hair loss on his forearms/dorsal side of the hand and there is evidence of clubbing of the fingers. He assumes the Tripod positon on occasions.
Clinical assessments and investigations performed:
Resting Heart rate (HR) = 90 beats/min.
Pulse regular and strong.
Blood pressure 158/96mmHg.
Current weight is 90 kg, height 178 cm, BMI = 28.4Kgm2 (from notes: BMI was 32.2Kgm2 10 days ago).
Pulse oximetry: SpO2% = 96%.
Capillary refill time >3 seconds
Evidence of clubbing of fingers
Digits appear cold.
Respiratory system & dynamic Spirometry:
Short of breath, cough, rate 14bpm, regular, shallow, tripod position assumed, evidence of accessory
muscle activation.
He has a productive cough and this is occasionally blood stained.
Dynamic spirometry results:
VC = 3.0L (98% pred) 
FVC = 3.1L (100% pred)
FEV1 = 2.3L (74% pred)
Carbon monoxide detector: 3 parts per million.
Peak flow: Best blow: 340mL/min.
Walking tests
He is able to walk 200m with two rests in the best of two six minute walk tests. During the test oxygen saturation levels dropped to 92% on room air and felt very severely breathless (dyspnoea score = 7) at the end of the walk and took several minutes to recover. The pain in his chest returned, central in origin and spread to his left jaw and back of head. After several minutes resting quietly the pain and breathlessness subsided.
Biochemistry:
Fasting blood glucose test: 7.2mmol/L.
Total blood cholesterol 6.8mmol/L
Serum trigyercides 2.4mmol/L
Cardiac investigations:
12 lead ECG: A resting 12 channel ECG was performed whilst at rest. The ECG is shown below.
 
Subsequently he was referred for an exercise tolerance test (shown below). 
The ECG results are shown for A) pre-test and B) during exercise stress test. During the period of exercise (B) the patient complained of central chest pain shortness of breath which lasted several minutes post exercise (on next page).A)
 
B) 
                                                       End of case study information
Note: Please refer to the recommendations and marking criteria provided to help you write up your case study.
 Grade criteria (Level 7) – General criteria applicable to essays, reports and aspects of projects and dissertations
Level 7
80+   As below plus:
• Excellent work – able to express an original reasoned argument in a lucid manner by reviewing and critiquing a wide range of material. Original, critical thinking based on outstanding insight, knowledge and understanding of material. Material contributes to current understanding and is of potentially publishable quality in terms of presentation and content.  
• Wide reaching research showing breadth and depth of sources.
70–79
60–69 As below plus:
• Clear, balanced coherent critical and rigorous analysis of the subject matter. Detailed understanding of knowledge and theory expressed with clarity.
• Extensive use of relevant and current literature to view topic in perspective, analyse context and develop new explanations and theories.
50–59 As below plus:
• Detailed review and grasp of pertinent issues and a critical contextual overview of the literature. Thorough knowledge of theory and methods and uses this to underpin arguments and conclusions.
• Confidence in understanding and using literature.
40–49 • Demonstrates grasp of key concepts and an ability to develop and support an argument in a predominately descriptive way with valid conclusions drawn from the research.
• Familiarity with key literature which is cited and presented according to convention.
• Logical and clear structure, well organised with good use of language and supporting material.
30–39 FAIL – Some knowledge of relevant concepts and literature but significant gaps in understanding and / or knowledge. Little attempt at evaluation, conclusions vague, ambiguous and not based on researched material. Limited or inappropriate research. Deficits in length, structure, presentation and / or prose.
0–29