A 45-Year-Old Man with COAD

http://www.anzca.edu.au/fellows/community-development/indigenous-health.html

This case study features a registrar who has been requested to do a ‘fitness for surgery’ review by a member of the general surgical team. The patient is a 45-year-old Indigenous man with a history of chronic obstructive airways disease (COAD).

The Teaching and Learning Program for this case study can be found on http://www.anzca.edu.au/fellows/community-development/indigenous-health.html

Questions relating to this case study include:

Are you surprised by the relationship between the patient and his relative?  How do you account for it?

Is there a more productive way to have responded to the young visitor’s behaviour?

Why has the patient developed this condition?


As a registrar in a busy city hospital, you are requested to do an in-patient anaesthetic review by the general surgical team  They would like you to assess a patient’s ‘fitness for anaesthesia’ before they book him into surgery.  The referral note indicates that the patient, a 45-year-old man, requires a laproscopic cholecystectomy and has a history of chornic obstructive airways disease (COAD).

You find the patient on the surgical ward surrounded by family and friends.  He is due to be discharged home in the next few days following an acute episode of cholecystits.  From the end of the bed you can see that your patient is an Indigenous man with a slim build As he laughs at a joke he breaks into proxysmal coughing and is obliged to spit into a cup.  The cup is half full of thick, yellow sputum, which is blue tinged.

You introduce yourself and ask for a little time to talk to the patient in private.  Most visitors leave except a young man who introduces homself as a relative of your patient and refers to him as ‘uncle’.  The visitor has green eyes and a pale complexion.

You ask the patient if he is happy for the young man to be present during your history taking and examination and he says that he is.

You conduct an initial anaesthetic review of your patient during which you notice that while he answers with simple ‘yes’ and ‘no’ responses, the young man is qucik to respond for him  You are not convinced that he can always speak accurately for his uncle and you take pains to address only your patient, at time cutting off the visitor’s responses in order to ask the next question.

Clearly frustrated by your behaviour, the visitor tells you that his uncle is a bit ‘hard of hearing”, and that he is just trying to help you out by answering all your questions.

You focus your attention on the patient’s productive cough.  The visitor is quick to point out that it is nothing new, to which your patient agrees. Despite being alifelong non-smoker, he coughs up at least half a cup of sputum a day even when he is well and that the cough has been worse over the past few days as the pain in his right upper quadrant has subsided.

The cough, like his partial deafness, has been present since childhood.  The patient tells you that he comes from “the bush” and that there wasn’t much medical care that he recalls.  He still spends most of his time out in the country, travelling into the city only to visit relatives.

Reassuringly, the patient tells you that he is normally fit enough to go spear fishing when he’s at home, and on examination you note that although there are signs of consolidation in the right lower lobe with focal wheeze and crepitations, there is no evidence of cyanosis, clubbing nor right heart failure.

You explain that you are concerned about the cough and that you need to order some tests so that you can properly evaluate the risks of the anaesthetic for your patient.

You further explain that it is important that the patient is as well as he can be before the planned surgery, and that you will be requesting a consultation with a respiratory physician.

The young man suddenly becomes very angry.  He accuses you of delaying the surgery for no good reason “just like those surgeons”.

You try to explain to him that you need to know as much as possible about his uncle’s medical condition in order to plan the safest possible anaesthetic, but he refuses to listen and eventually leaves saying that he’ss come back only when you’ve gone.

You’re deeply upset by this interaction, apoligise to your patient, and try once again to explain why you need the tests and the physician’s review.  The patient assures you that he understands that you’re just doing your job.  He is not concerend about he possible delay for his surgery.

The following afternoon you return to see the patient with the results of your investigations.  This time the young relative is absent and you have requested the presence of the hospital’s Indigenous liaison officer.

The liaison officer tells you that he had spoken to the young relative earlier that day, whose hostile behaviour had been triggered by the belief that his uncle was being denied surgery on racist grounds.  He had been trying to protect his uncle.

You sit down together with the patient, the liaison officer, they physician’s notes and the test results.  The CXR shows a normal cardiac shadow and an area of increased shadowing in the right lower zone aboue a pleural effusion. The CT image of the same area displays the typical signet-ring appearance of cylindrical bronchiectasis.

The ECG is unremarkable.

Spirometry indicates an FVC 70% of predicted but an FEV1/FVC ratio that demonstrates only mild obstruction and no reversibility.  The physician has ruled out the likelihood of an inherited disorder causing your patient’s bronchiectasis.  The patient’s sputum has grown a Pseudomonas species which is the probable cause of the original insult and of the current exacerbation.  He has added Meropenem and Prednison to your patient’s drug regime as well as a regime of intensive physiotherapy.

Given all of this additional information, you are now able to formulate an anaesthertic plan and discuss it with your patient.  The patient asks you when they can expect the surgery to go ahead.

Before you leave, you ask your patient to convey your regret to his young relative that the misunderstanding of the previous day had occurred.

The patient is happy to do so, and tells you that he’s going to take the “young fella” back home with him to “connect with country”, as soon as he is well again.