Two Problem-Based Learning

Cases: Methamphetamine
Creighton University School of Medicine
Eugene Barone, M.D.
Pirzada Sattar, M.D.

November 8, 2009

These curriculum resources from the NIDA Centers of Excellence for Physician Information have been posted on the NIDA
Web site as a service to academic medical centers seeking scientifically accurate instructional information on substance abuse.
Questions about curriculum specifics can be sent to the Centers of Excellence directly.
 Two Problem-Based Learning Cases: Methamphetamine

Creighton University School of Medicine

Written by:

Eugene Barone, M.D.

Pirzada Sattar, M.D.

November 8, 2009

These curriculum resources from the NIDA Centers of Excellence for Physician Information have been posted on the NIDA Web site as a service to
academic medical centers seeking scientifically accurate instructional information on substance abuse. Questions about curriculum specifics can be
sent to the Centers of Excellence directly. http://www.drugabuse.gov/coe

 Table of Contents

Introduction ....................................................................................................................... 3

Educational Objectives ..................................................................................................... 4

Curriculum Module Components ...................................................................................... 5

Keys to Successful Implementation of PBL ...................................................................... 6

Methamphetamine: An Overview ...................................................................................... 9

Facilitator Guide Case 1 ................................................................................................. 10

Student Handouts Case 1 ............................................................................................... 35

Facilitator Guide Case 2 ................................................................................................. 47

Student Handouts Case 2 ............................................................................................... 67

PBL Session Evaluation ................................................................................................. 76

Learner Self-Assessment................................................................................................ 77

PBL Facilitator Evaluation ............................................................................................... 78

References...................................................................................................................... 79

Bibliography .................................................................................................................... 80

Pilot Information .............................................................................................................. 81

Appendix A...................................................................................................................... 83

 Introduction

This curriculum module contains two problem-based learning (PBL) cases that provide
clinical presentations of substance abuse problems. These cases can be used in
teaching situations where it may not be feasible to use clinical material or standardized
patients. The PBL cases can be used to augment lecture material about the topic of
drug abuse and dependence with clinically relevant cases that depict real-life scenarios
for students to work through––either in a small-group format or an interclerkship
seminar. The PBL cases introduce students to clinical presentations of substance abuse
problems. The cases are realistic and can be adapted for use in different courses or
clerkships. Case 1 is designed for three sessions, each approximately 60 to 90 minutes.
Case 2 is designed for two sessions, each approximately 60 to 90 minutes. Both cases
should be offered to third-year medical students or advanced second-year medical
students. First-year medical students and some second-year medical students do not
possess sufficient knowledge for participation.

This PBL module is adapted from the following two MedEdPORTAL publications:

Rosenstock, J. (2006). The Impact of Psychiatric Distress on Co-morbid Medical Illness:

A Problem Based Learning (PBL) Case. MedEdPORTAL:
http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=251

Koestler, J., Waite, E., Chietero, M., Shulman, J., Rose, S., Poliandro, E., et al. (2009).
Problem-Based Learning (PBL): Abdominal Pain in a Pregnant Woman.
MedEdPORTAL:
http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=517

The required license terms for use of this curriculum resource are available at
http://creativecommons.org/licenses/by-nc/3.0/us/

Key words: drug abuse; drug addiction; methamphetamine abuse; methamphetamine

treatment; substance abuse

 Educational Objectives

 Integrate and apply collected data to problem solving, including the generation and
prioritization of a differential diagnosis for acute psychosis and for acute chest pain.
 Develop the skills necessary for the interpretation and utilization of relevant
historical, physical examination, and laboratory information in a patient who is
acutely ill.
 Integrate the concepts of evidence-based medicine to develop an approach to an
acutely ill patient.
 Assess the impact of culture on obtaining information detrimental to the diagnosis
and management of the clinical cases.

 Curriculum Module Components

This curriculum resource module includes:
 Two student cases.
 A Facilitator Guide for each case.
 Student handouts for each case and session.
 A lecture evaluation form.
 A learner self-assessment form.
 A facilitator evaluation form.
 Pilot information.

 Keys to Successful Implementation of PBL

Requirements for PBL

 PBL facilitator.

 Student leader, reader and scribe.

 Small-group or conference room.

 Computer.

 Screen.

 LCD projector.

 Supplemental readings or reading list.

 Information about local resources for the treatment of methamphetamine

abuse/dependence.

Suggestions for PBL Facilitation

Techniques for getting members of the group to talk to one another:
 Make it clear that students should address questions to other students, not to
you. You will probably observe that the group goes silent when you begin leading
it too much.
 If you are asked a question directly, acknowledge the question with nonverbal
signs (e.g., nod and smile) and then make eye contact with others in the group to
encourage a response from the other group members.
 Be patient. Give members of the group time to think quietly about what they are
reading.

Techniques for dealing with a quiet/nonparticipating student include asking that person:
 Can you summarize the case so far?
 Do you agree with all the hypotheses/learning objectives presented?
 Do you agree with what [insert name] is saying?
 What’s going on in your mind?

Metacognitive questions that can be used for eliciting responses:

 What made you decide to say that?
 Why did you say that?
 Why did you think of saying that?
 How do you know that what you are saying is correct?
 Why do you think that is an important issue?
 What made you bring that up?
 What do you think about the importance of your statement?
 How do you feel about your idea(s), in light of the facts we have so far?
 How do you know your information is reliable?
 How do you know that textbook information is reliable?
6

  What is your confidence, on a scale from 0 to 10, that your idea is correct?

 What do you see as the problem at this point?

 What information would you like to know next?

Problem Presentation Session(s)

 At the first PBL session of the course, get acquainted with your students. For
example, ask each member of the group to introduce himself/herself and
describe why he/she is unique.
 Introduce yourself and briefly describe your interests.

Mention the following to the students:

 It’s perfectly acceptable to say what’s on your mind.
 It’s perfectly acceptable to disagree with another student.

Feel free to keep the group on the right track. You are responsible for the group, but do
not dominate the discussion. Pass out the case handout and tell students to focus
initially only on page 1.
 Ask the group to choose one person to be the scribe. Have the scribe divide the
chalkboard into three columns: Facts, Hypotheses, and Learning Objectives
(LOs).
 Sequentially read and discuss each page of the case. Make sure everyone
agrees about when it is time to proceed to the next page.
 Near the end of meeting, remind students to refine and divide up the LOs (allow
~15 minutes for this activity) to be researched and presented at the next session.
Encourage students to use visuals (e.g., slides, handouts, blackboard, computer
images) to teach the group about what they have learned. Discourage dry “book
reports.”
 All pages of the case should be read and discussed prior to the end of the
introductory session.
 At the second PBL session, review and discuss the sections of Case 1 scheduled
for this meeting.

Problem Resolution Session

 Read through the scenario again and stop to have students present their LO
materials when they are relevant to the case.
 Discuss the health problem again in light of the new information that is brought
back to the group with every step of this case.
 Ask each individual to evaluate and critique his/her sources of information. Why
did they choose to use the source(s)? Are there other sources they might
consider using in the future?

At the end of the session:

 Pass out the “official” list of LOs and discuss any major differences between this
list and the one generated by the students.
 Ask the group to evaluate the effectiveness of the just-completed PBL as a
learning experience.

 Methamphetamine: An Overview

Methamphetamine is a sympathomimetic amine in the class of compounds the

phenethylamines, which have a variety of stimulant, anorexiant, euphoric, and
hallucinogenic effects. Commonly referred to as “speed,” “meth,” “chalk,” “ice,” “crystal,”
and “glass” (National Institute on Drug Abuse [NIDA], 2009a) [Note: “Street names”
should be updated regularly to accurately reflect current slang terminology.]
Methamphetamine was first synthesized in 1893 and was widely used by German,
Japanese, and American forces during World War II to increase alertness and decrease
fatigue. For more information on methamphetamine, its mechanism of action,
prevention of use, and treatment, see
http://www.nida.nih.gov/ResearchReports/methamph/methamph.html.

Recreational use of methamphetamine and other amphetamine-derived stimulants has

reached epidemic proportions in the United States. After cannabis, which is commonly
referred to as “marijuana,” “pot,” “grass,” and “weed” (NIDA, 2009b), methamphetamine
is the most widely abused drug worldwide. According to the 2008 National Survey on
Drug Use and Health, 5 percent of the U.S. population over the age of 12 has reported
methamphetamine use at some time in their lives and 850,000 people reported use in
the past year (Substance Abuse and Mental Health Services Administration, 2009).
[Note: This curriculum resource should be updated annually as new data become
available; see http://www.oas.samhsa.gov].

 Facilitator Guide Case 1:

Diagnosis and Treatment of a Woman

With an Acute Psychotic Presentation

The main objective of PBL is to use a realistic clinical scenario to explore with students
the different causes of acute mental status changes and to streamline the diagnosis and
treatment of this condition.
Audience
This PBL case has been developed for use with second- and third-year medical
students as a way to integrate knowledge and raise awareness of important
comorbidity.
Format
Case 1: Diagnosis and Treatment of a Woman With an Acute Psychotic Presentation
comprises 11 narrative sections covered over 3 sessions. Each section is printed on a
separate sheet of paper, and students are to receive only one section at a time as
directed by the Facilitator Guide (please note that students are not to be provided with
PBL case materials prior to the first PBL session). Once a section has been reviewed in
detail, students will be given the corresponding information on the teacher’s notes and
discuss why the case was managed as it was. During these sessions students are
responsible for reading the case, identifying pertinent facts, and developing hypotheses.
At the first session each group of students will also generate its own LOs. During the
final “problem resolution” session students will also teach one another what they have
learned by presenting relevant LO materials, preferably with the assistance of visual
aids (e.g., computer images, slides, handouts). The resolution session concludes with a
discussion of any major differences between the LOs generated by students and the
LOs provided to the facilitator, which are to be distributed to students at this time.

To assist faculty facilitators in coaching the student-led discussions, notes and LOs are
provided for each step of the case. The notes are suggestions for possible discussion of
the major points presented in each section. Facilitators may expand on any portion of
the case to pursue their interests or the interests of their students.

In general, facilitators are encouraged to gradually shift from being less directive to
more directive and from less talkative to more talkative. Thus, during the first session,
the facilitator would offer fewer comments and redirection than during the second. If the
facilitator is too active or directive early on, the group will wait for cues and further input
from the facilitator. Likewise, if the facilitator becomes less involved over time, the group
may feel the facilitator is withdrawing.

It is important to not divulge any important information to the students prematurely, as

this will prevent them from analyzing the data and reaching their own conclusions.

THE FACILITATOR NOTES SHOULD NEVER BE GIVEN TO THE STUDENTS.

HANDOUTS FOR STUDENTS ARE PROVIDED.

10

 PBL Case 1 Overview: Diagnosis and Treatment of a Woman

With an Acute Psychotic Presentation

This PBL guide includes a case with 11 narrative sections, detailed process guidelines
(how to facilitate a PBL group), suggested student LOs, and substantial background
information designed to make this case useful for faculty from any specialty. Topics
include how to diagnose and treat substance use disorders (in particular,
methamphetamine) and bipolar disorder and the nature of the relationship between
these conditions and other causes of acute agitation and acute mental status changes,
such as infection, trauma, and postpartum depression. Some psychiatric diagnostic and
treatment information is included; however, the goal of this PBL case is to develop the
medical students’ understanding of the comorbidity and to prevent them from assuming
a particular case is only a psychiatric presentation, without developing an understanding
of the nuances of the case.

This PBL exercise allows learners (second- and third-year medical students) to
consolidate their educational experiences across clerkships and encourages
multidisciplinary thinking in their clinical interactions. The case, developed by faculty
from multiple clinical departments, allows learners to integrate and apply collected data
to problem solving. It also helps students develop the skills necessary for the
interpretation and utilization of relevant historical, physical examination, and laboratory
information about a patient who is acutely ill. Topics addressed in the exercise include
symptom presentation/evolution, generation of differential diagnosis, diagnostic testing,
and patient management. The exercise reiterates the clinical relevance of basic science
topics, including physiology, pharmacology, and pathophysiology. It also allows
students to address cultural differences, intimate partner violence, health beliefs,
population medicine, and evidenced-based practice. The problem-based format fosters
self-directed learning, reflection, and collaborative practice. The strength of the case is
that students are required to think outside the context of a specific clerkship and
integrate symptoms across organ systems.

A. Facilitator Notes––Introduction
This PBL involves a patient with acute mental status change who presents with
psychotic symptoms. The intent of this exercise is to encourage students to consider the
impact of psychiatric comorbidity on the pathophysiology and prognosis of the patient
and on their treatment decisions. Because the patient has multiple concurrent
conditions, students may reasonably deal with the medical, psychiatric, and substance
use conditions separately. While this approach is fine up to a point, the students must
also attend to the potential interaction among the three conditions.

It is relatively new for students to consider interdisciplinary or comorbid issues in PBLs.

Hence, interdisciplinary discussions should be encouraged. Comments to help further
such discussions could include:
 What issues are involved? Is the presentation purely related to psychiatry?
 Where else may this patient present with a similar set of symptoms?

11

  Might her psychiatric problems be contributing to her presenting complaints? If

so, how?
 Might her postpartum status be affecting her mental health? If so, how?

Another unusual facet of this PBL is that it raises ethical issues and questions that have
not been completely answered by medical research. Thus, students will be dealing with
partially resolved questions and hypotheses with incomplete empirical support. For
these LOs, students will need to consult current medical journals rather than standard
text references.

Because students are more accustomed to learning concrete facts, this exercise may
make them uncertain or uncomfortable either at the stage of defining their LOs or during
their attempts to find the answers. We hope the case does not lead down a path to a
single diagnosis and simple treatment choice but, rather, to the acquisition of knowledge
that informs students of the cross-talk among the ethics, psyche, bodily functioning, and
complexities that arise when caring for patients with comorbid medical and psychiatric
disorders.

B. Student Learning Objectives

LOs should describe actions or behaviors that students are expected to

execute/perform by the end of the PBL. The following are important LOs for this PBL,

but students should pick their own before seeing this list. LOs picked by students may

be different from those on the list below. You can share this list with students after

resolution of the case.

LO 1 Explain the diagnostic criteria for postpartum depression and psychosis.

LO 2 Explain the diagnostic criteria for bipolar disorder.

LO 3 Explain emergency management of an uncooperative and agitated

patient.
LO 4 Explain the circumstances for maintenance and breaking of confidentiality.
LO 5 Explain the symptoms of methamphetamine intoxication.
LO 6 List the symptoms of sedative withdrawal.
LO 7 Discuss the proper use of medications for the acute management of
agitation.
LO 8 Describe the standard assessment of head injury.
LO 9 Describe the laboratory workup of the acutely agitated patient.
LO 10 Explain the diagnostic criteria for substance abuse/dependence.
LO 11 Discuss treatments options for methamphetamine dependence.
LO 12 Summarize the long-term goals of a patient who is facing multiple
stressors.
LO 13 Summarize the key facts that support addiction as a medical disease, with
a cause, effect, treatment, and response.

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C. Goals
 To reintroduce basic science concepts and relate them to clinical scenarios.
 To think about cases in a multidisciplinary fashion, across specialty lines, and
from a cultural perspective.
 To introduce self-directed and life-long learning using the tools of evidence-
based medicine.

D. Session Objectives
 Integrate and apply collected data to problem solving, including the generation
and prioritization of a differential diagnosis for acute agitation/mental status
changes.
 Develop the skills necessary for the interpretation and utilization of relevant
historical, physical examination, and laboratory information for a patient who is
acutely ill.
 Integrate the concepts of evidence-based medicine to develop an approach to an
acutely ill patient.
 Assess the impact of culture/ethnicity on the healthcare delivery process.
 Recognize the medical ramifications of addictive disorders.

E. Logistics
 Review goals/objectives.
 Appoint a group leader, reader, and scribe.
 Have students list facts, hypotheses, and learning objectives.
 Keep a copy of the LOs that are generated from each interdisciplinary clinical
reasoning session.
 Ask questions to stimulate discussion only (e.g., guiding questions may be used
to get the group back on track, but you should try to let students grasp the
material on their own). Suggested guiding questions are italicized in this text.
(You should refer to these questions if the group goes off on a tangent or is at an
impasse. We suggest you refrain from using the questions too early in the
process, as the students should be encouraged and given the time to formulate
questions for themselves.)

F. Schedule
 Session 1, case parts A–D.
 Session 2, case parts E–H.
 Session 3, case parts I–K.

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 PBL Case 1:

Diagnosis and Treatment of a Woman With an Acute Psychotic Presentation

Facilitator’s Notes

Session 1: Case Parts A–D

** (Student side) ** (Faculty side)

Distribute Case 1 Part A Student Handout

Case 1 Part A Case 1 Part A

A 30-year-old Hispanic woman is The case begins with an agitated, Hispanic

brought to the emergency department female patient who is brought to the hospital
because of her agitated and restless because of aggressive and restless behavior.
behavior. The triage nurse tells you
the woman speaks little English. Significant historical facts:
The patient is a nonnative English speaker who
The history you obtain through a has limited English proficiency. She delivered a
trained interpreter indicates the baby less than 2 weeks ago. She is very
patient delivered a baby at your agitated, restless, and paranoid. She is
medical school’s OB clinic last month. threatening staff members. A quick review of
She had been attending the prenatal her medical records does not identify any
clinic on a regular basis. She ongoing medical problems.
delivered about 10 days previously
and gave birth to a healthy boy. Her The differential diagnosis of an agitated woman
previous labs obtained from the includes delirium, postpartum psychosis,
medical record were as follows: psychosis due to a postpartum infection or
other medical causes, psychosis due to
Blood type: O+, antibody screen substance intoxication, psychosis due to
negative, VDRL negative, PPD substance withdrawal, bipolar disorder, and
negative, HIV negative, hepatitis B trauma/domestic violence or head injury.
surface antigen negative, rubella
immune, maternal serum triple screen What more do you want to know?
WNL, glucose challenge test WNL, HPI: Timing, onset, and precipitating factors of
hemoglobin electrophoresis 97% agitation? Agitation relieved by? Aggravated
hemoglobin A. by? Specific psychotic features? Potential for
harm to self or others?
The patient is not willing to stay in bed
and is pushing staff members away. At this point, would you feel comfortable if
She is very agitated, loud, and you were asked to proceed with this
swearing at people around her. She is medical encounter without an interpreter?
afraid and looking behind herself Why or why not? How do you balance the
constantly. She is refusing to allow need to get information with the inability to
the nurse to examine her or to draw communicate? What are the liabilities of
blood. “making do” with a relative or a staff worker
as a stand-in translator?

14

Describe what instructions you need to give

the interpreter to optimally use his/her
services in this clinical encounter. Whom
should you talk to when using an
interpreter?

Would you be willing to intervene in the

absence of the interpreter? What if the
patient’s condition worsened and the
agitation escalated? What if the agitation
did not escalate?

Distribute Case 1 Part B Student Handout.

15

** (Student side) ** (Faculty side)

Case 1 Part B Case 1 Part B

With some effort, an interpreter is able What do you do when a patient specifically
to obtain contact information for the forbids you to contact any family members?
patient’s mother, but the agitated
patient forbids the staff to make any What do you do when the patient is offered
contact with her family. When the medications but he/she refuses?
interpreter asked her for more
information about her condition, she What are your obligations when his/her
stopped talking. When the interpreter behavior worsens to the point that he/she
insisted, she became even more may be putting himself/herself or others at
agitated. When she was offered risk?
medications to help her relax and
calm down, she became even more How does your differential diagnosis
agitated, screaming that she is not change with this additional information?
crazy and will not take any Not much; and this is a major point of this case.
medications. She threatened to kill the
medical staff and is thrashing around What more do you want to know?
to the point where she is banging her Additional history related to the case.
head against the metal side rails of
the bed. Distribute Case 1 Part C Student Handout.

16

** (Student side) ** (Faculty side)

Case 1 Part C Case 1 Part C
What are the most important points about
The patient’s mother is contacted and
this presentation?
is able to provide the following history: The mother was contacted without the patient’s
consent, as the condition was deemed to be an
The patient is a single mother with a emergency with potential risks to the patient
history of “mood swings and anger and others.
problems.” She had been on
psychiatric medications in the past, What possible diagnosis should be
but her medication adherence has considered based on the history obtained
been “sketchy.” Her mother does not from the mother?
know what medications she has been The patient has a history of “mood swings and
prescribed in the past. The patient anger problems,” which suggests a psychiatric
was following up with a psychiatrist in diagnosis. She was treated with psychiatric
the past but it may have been a while medications, but has a history of nonadherence
since her last visit. She has had to treatment. Plus, she has a lot of stress with
treatment at a local inpatient three young children, one a newborn, and a
psychiatric hospital with similar boyfriend who may not be supportive. These
agitated presentations; but according factors would increase the risk of a relapse of
to her mother, the last time this bipolar disorder, schizophrenia, or other
happened was several years ago. psychiatric disorders.

PMHx: Asthma since childhood; Asthma may or may not be relevant to the
no hospitalizations. diagnosis; but her history of possibly abusing
Occasional visits to the inhalers may explain her acute agitation, if
emergency room. She inhalers were abused prior to start of agitation.
has been prescribed
inhalers and may have She also is 1.5 weeks postpartum. This
taken more than increases the likelihood of a postpartum
recommended. She was delirium due to infection, postanesthesia, or a
told she got asthma postpartum mood or psychotic disorder.
when her mother was
sick with a cold at the She is also an immigrant who moved to the
time of her birth. Her United States at age 15. Further, if the
parents told her she relationship with her boyfriend is abusive, there
could not exercise with is a possibility of her presentation being related
other children because to a trauma-induced delirium.
she had asthma and
was sickly. She is aboutWith her past history of alcohol and drug use,
1.5 weeks postpartum. substance use may also be a very likely reason
for her presentation. Her symptoms can be
PSHx: Had Cesarean section in explained by intoxication with a stimulatory
2000 under epidural substance or withdrawals from a sedative
anesthesia. agent.

17

Psych Hx: See above. How might bias play a role in this case?
Allergies: No known drug or food It is imperative that physicians are supportive
allergies. and understanding of the lives and challenges
facing patients. Racism, ethnicism, sexism, and
Medications:Proventil multidose classism undermine the underpinning of the
inhaler prn, oath to “Do no harm.” Being aware of issues
multivitamins, iron. that are troubling to us is important in framing
Social Hx: Patient was born in the what issues are ours and what is coming from
Dominican Republic. Has the patients. Providing this patient with support
lived in the run-down part and access to services and resources may be
of town since the age of pivotal in helping her live a productive life.
15. Smokes about 1½ How should you inform the family of their
PPD, ETOH dependent, loved one’s hospitalization?
has a history of IVDA for Be brief, informative, and to the point. Offer
cocaine, support to comfort them, provide information,
methamphetamine, and address their concerns. Give them your
smokes marijuana name and/or contact number for further
periodically. Has been in contact/information.
drug treatment in the past.
Currently is unemployed, What additional questions would you want
lives with boyfriend and to ask the patient/informant?
three children, ages 1½ Students should ask additional questions to
weeks, 5 years, and 7 rule out physical trauma/abuse, recent drug
years. Her boyfriend may and alcohol use, and symptoms/signs of
be abusive. He also has a infection. Using some of the questions outlined
history of drug above, the students should find out more about
dependence. the patient’s (or her family members’)
perspective about illness and inquire about the
Family Hx: Mother 50, mild patient’s use of complementary and alternative
hypertension on medications and traditional healers.
medication. Father 55,
heart disease, What more do you want to know?
hypertension, has had A physical exam would be useful at this point,
multiple strokes, in public specifically:
housing. Sister 26,  Vital signs: increased BP and pulse
brother 22, both with may suggest an infection, trauma,
asthma. Both abuse substance intoxication or withdrawals.
alcohol and drugs. Both Increased HR associated with
have been diagnosed with fever/infection, substance use and/or
bipolar disorder and medication abuse or trauma, acute pain.
depression. Grandmother
 Lungs: given asthma history.
and grandfather on both
 Abdomen: abdominal organs,
sides have hypertension, postpartum abdomen.
heart disease CVA, and  Vagina/cervix: for blood, discharge,
have been treated for infection.

depression.
 Mental status examination: for ruling
out psychiatric symptoms, delirium, and

18

Review of Systems: Significantly psychosis.

positive for insomnia.
How would you manage this patient who
does not want to get any treatment?
Things to consider:
 Agitation.
 Potential to hurt others.
 Potential to hurt herself.
 Psychosis.
 Lack of consent.
 Diminished capacity.
 Responsibility of medical staff to keep
patient and staff safe.
 Patients should be treated in emergency
situations. If emergency situations arise,
treat the patient without his/her consent.

Options at this point, without any further

information:
 Applying restraints: justified in case of
potential harm to self or others as a last
resort, because restraining can cause
more hyperthermia from increased
muscle contractions from the agitated
patient fighting against the restraints.
 Use of involuntary medications: justified
in case of potential harm to self or
others.

Distribute Case 1 Part D Student Handout.

19

** (Student side) ** (Faculty side)

Case 1 Part D Case 1 Part D

Physical Exam How would you interpret the physical

exam?
General: Anxious-appearing woman  Vital signs: BP elevated; temperature
is very agitated. elevated; high HR associated with
fever/infection, blood loss, asthma
Vitals: 160/90 mmHg and/or medications, alcohol/drug
HR: 100 BPM withdrawal or drug intoxication, trauma,
Temp: 40° C or agitation. Increase in temperature
RR: 24 BPM suggests infection; however, some drug
Height: 165 cm use intoxication states could also
Weight: 65 kg present with hyperthermia; Ht & wt:
WNL.
Skin: Several small skin  CVS: Tachycardia, which may be
excoriations noted on the present in any of the conditions noted
cheeks and both forearms. above.
 Abdomen: No abnormality, suggesting
HEENT: Anicteric with mildly dry less chance of a postpartum abdominal
mucous membranes. Teeth complication.

with several caries.

 Pelvic: Exam could not be done.
 Extrem: WNL.
Chest: Lungs clear to auscultation  Neuro: DTRs suggest anxiety or
and percussion. substance intoxication, withdrawals.
 Psych: Mood possibly consistent with
CV: Tachycardic, Normal S1, S2. psychotic disorder, either primary or
secondary.
Abdomen: Soft, nontender, with
active bowel sounds, no Do the results of the physical exam alter
rebound or guarding. your differential diagnosis?
Given this information, the focus of the
Back: Within normal. differential diagnosis would be on ruling out
underlying medical causes of her acute
Pelvic: Not done. behavior changes and ruling out trauma,
hypertensive disorders and their
Extremities: No clubbing or cyanosis. consequences, inflammatory processes, and
infectious processes. If there is no underlying
Psych: Alert and oriented, but medical problem, the focus should be on
agitated. identifying whether the symptoms are induced
by substance use or withdrawal. If this is ruled
Neuro: Cranial nerves grossly intact. out, then a primary psychiatric diagnosis should
Full strength all extremities be considered.
and sensation grossly intact.

Deep tendon reflexes 3+.

20

MSE: Hispanic female, appears What laboratory tests would you like to
stated age, not cooperative, order and why?
appears paranoid, may be Useful laboratory tests may include the
responding to internal stimuli, following: complete metabolic panel; CBC (for
agitated, not talking to infection); LFTs to assess metabolic problems,
herself, does appear to be alcohol use; urinalysis and culture; urine drug
looking around and behind screen.
herself constantly as if she is
afraid of something, speech SUGGESTED END POINT FOR SESSION 1
is not spontaneous, does not
speak English well. MAKE SURE EACH STUDENT IS ASSIGNED
AT LEAST ONE LEARNING ISSUE TO
Unable to determine whether RESEARCH AND PRESENT TO THE GROUP
she is suicidal or homicidal; AT THE NEXT SESSION
however, she appears to
threaten staff and through the
interpreter has said she does
not want anyone to come
close to her. A Folstein
MMSE cannot be done, due
to her uncooperativeness.

21

 Session 2: Case Parts E–H

Discussion of Learning Issues From Prior Session

Most of the learning issues will be of the diagnosis or etiology type. The facilitator
should inquire of each student:
 Where did you look to find the answer to your learning issue? (e.g., textbook or
UpToDate? If you went to PubMed, did you use a review article, case series, or
control trial?).
 How difficult was it to find the answer to your learning objective?
 If you found a diagnostic article, did it actually apply to our patient (a woman who
is postpartum)? Or did it apply to making a general type of diagnosis (e.g.,
diagnosing an infection or substance use disorder) in adults, in which case we
need to decide whether we can apply it to a postpartum female? Is that OK with
the group? (Note: This is common in medicine—extrapolating data to other
patient populations: pediatrics, elderly, and the surgical patient).
 If looking at diagnostic tests, did the article mention the sensitivity and specificity
of the test? Which one is more important to the group members for the question
they looked up?
 Is there a good gold standard for diagnosing these problems?
 Examples of learning issues from previous sessions have been:
 How do we manage confidentiality with a nonconsenting individual?
 How do we manage an acutely agitated patient without his/her consent?
 What is the difference between agitation due to psychiatric conditions versus
medical/substance-induced conditions?
 Are blood/urine tests necessary for a diagnosis of acute agitation?

22

Session 2 Parts E–H

** (Student side) ** (Faculty side)
Distribute Case 1 Part E Student Handout.

Case 1 Part E Case 1 Part E

Studies: The patient is refusing to Discussion of Laboratory Results

cooperate with further Do the results of these tests alter your
examination; therefore, differential diagnosis?
she is administered IM The most likely diagnosis is infection, but the
lorazepam 4 mg, and after UA is otherwise normal. The physical exam
30 minutes of not was not suggestive of a localized infection.
responding to the
lorazepam, she is LFTs do not suggest recent alcohol use. The
administered haloperidol normal MCV does not suggest chronic alcohol
10 mg IM. She calms use. High Na levels suggest there is
down after about 30 dehydration due to some cause, whether an
minutes and goes to infection or drug-induced dehydration––
sleep. Blood is drawn at possibly methamphetamine intoxication.
this point and IV fluid
resuscitation is Alkaline phosphatase and CPK are elevated,
administered. most likely due to agitation of the patient; but
this may also occur with some cases of
Lab Data substance abuse, in particular stimulant
intoxication.
SMA7:
Na 146 mmol/l (135– The WBC count is elevated, which suggests an
145) infection; but remember that acute agitation
often occurs in certain psychiatric conditions or
K 4.6 mmol/l (3.5–5.5)
in cases of drug intoxication, in particular

Cl 1

00 mmol/l (95–108) methamphetamine intoxication, which also
Bicarb 23 mmol/l (22–32) increase the WBC level significantly due to
demargination.
BUN 14 mg/dl (6–20)
Cr 0.6 mg/dl (0.5–1.5) What additional information and/or tests do
Glucose 72 mg/dl (60–115) you want?
A CT will be helpful to rule out brain pathology
for an acute mental status change and to rule
CBC:
out trauma, especially because of her history
WBC 15,300/ul (4,800–
with an abusive boyfriend and increased BP
11,000)
and pulse. A sonogram would be useful to
Hemoglobin 10.9 (11–15)
determine whether there is any
gm/dl
abdominal/pelvic organ pathology. The results
Hematocrit 32.7% (35–47) of cultures would be important. And a urine
Platelets 167 k/ul (150– drug screen would be useful.
500)

23

LFTs:
Calcium 8.6 mg/dl (8.5–11)
Total protein 6.5 gm/dl (6.0–
8.5)
Albumin 3.0 gm/dl (3.5–5)
Alkaline 480 u/l (35–
phosphatase 125)
CPK 950u/l (<150u/l)
SGPT 40 u/l (5–65)
SGOT 31 u/l (5–50)
Total 0.6 mg/dl (0.2–
bilirubin 1.3)
Direct 0.1 mg/dl (0–0.4)
bilirubin
Amylase 97 u/l (30–
300)
Lipase 134 u/l (23–
300)

Urinalysis: Spec. gravity 1.035

Urine gram stain: WNL.

Urine C&S, cervical cultures:

Pending. Distribute Case 1 Part F Student Handout.

Urine drug screen: Pending.

24

** (Student side) ** (Faculty side)

Case 1 Part F Case 1 Part F

A CT of head is generally WNL. Discussion of Ultrasound and CT Results

The results of the ultrasound, which show
Abdominal ultrasound is WNL. No normal findings, decrease the likelihood of liver
other abnormal findings. or gallbladder disease. The normal findings on
the head CT also rule out the possibility of
acute head trauma as the cause of the acute
mental status changes/delirium.

What diagnosis ranks the highest on your

differential now?
Substance use (intoxication or withdrawal) or
postpartum psychosis or infection, secondary to
postpartum sepsis.

How would you treat this patient?

Acute management with symptomatic
treatment, reduction of the symptoms of
autonomic arousal, rehydration, and
management of agitation.

Distribute Case 1 Part G Student Handout.

25

** (Student side) ** (Faculty side)

Case 1 Part G Case 1 Part G

A presumptive diagnosis of What is your differential diagnosis now?

postpartum psychosis versus Because the temperature decreased with
methamphetamine dependence and hydration, haloperidol, and lorazepam, it
methamphetamine-induced suggests the hyperthermia was not related to
psychosis. The patient was given IM infection. The differential diagnosis includes
haloperidol (10 mg) and lorazepam (4 substance intoxication (e.g., stimulants such as
mg) earlier; however, after 4 hours cocaine or methamphetamine) and withdrawal
she is awake again and shows only from sedative agents. However, the LFTs do
partial improvement. She is getting not suggest recent or chronic alcohol use,
agitated again and is disruptive. IV which decreases the chance of her symptoms
fluids and a repeat dose of the being alcohol-withdrawal related. The
haloperidol and lorazepam are given autonomic arousal that initially resolved with
intravenously. Her fever is down to the dose of haloperidol and lorazepam––and
38.1° C. the recent worsening after 3 to 4 hours
(essentially after the effects of benzodiazepine,
Physical exam: An agitated woman which has a short half-life, wore off)––suggest
lying in bed on her right side. this presentation might be related to
substances of abuse, most likely a stimulant.
Tempmax: 38.2° C
A postpartum psychosis may also be
BP: 130–140/70–84 mmHg responsible for the presentation; the drug
screen will help decide the definitive diagnoses.
HR: 112 BPM
How would you reevaluate this patient?
RR: 24 BPM What lab/ imaging studies would you order
and why?
Chest: Lungs clear to Evaluation of fluid status, CBC, and drug
auscultation and screen; consultation with psychiatry may also
percussion. be useful.

CV: Tachycardic. Distribute Case 1 Part H Student Handout.

Abd: Nontender.

Back: CTA, WNL.

26

** (Student side) ** (Faculty side)

Case 1 Part H Case 1 Part H

Lab Data Do these results change your approach to

the patient? How would you proceed with
CBC: the management of this patient?
WBC 15,300/ul 4,800– Again, review the laboratory results reflecting
11,000 on normal values with the students and the

Hemoglobin 1

0.2 11–15 improvement of the WBC count without the use
gm/dl of any antibiotics, the resolution of the

Hematocrit 3

1.4% 35–47 temperature with hydration, the resolution of

Platelets
118 k/ul 150– the agitation with the haloperidol and
500 lorazepam, and the positive findings on the
urine drug screen.
Urine culture (from admission): WNL.
What diagnosis ranks the highest on your
Cervical culture: Gonorrhea differential diagnosis now?
negative; chlamydia negative. The most likely diagnosis is methamphetamine
dependence and methamphetamine-induced
Abdominal-pelvic ultrasound: WNL. psychosis. There is still the possibility of the
symptoms being due to a postpartum
Urine drug screen: + for psychosis, but a careful history from the patient
methamphetamine. or collateral sources should clarify that.

SUGGESTED END POINT FOR SESSION 2

MAKE SURE EACH STUDENT IS ASSIGNED

AT LEAST ONE LEARNING ISSUE TO
RESEARCH AND PRESENT TO THE GROUP
AT THE NEXT SESSION

27

 Session 3: Case 1 Parts I–K

Discussion of Learning Issues From Prior Session

Today there may be a mix of diagnostic and treatment types of learning issues.
Examples of learning issues that have been raised include:
 How do you diagnose the cause of acute mental status changes in a postpartum
patient?
 How do you differentiate mental status changes that are secondary to medical
conditions such as infections, trauma, substance use/withdrawal, or primary
psychiatric conditions?
 What medications can be used to control acute agitation?

 What are the criteria for using physical restraints?

 What are the criteria for administering involuntary medications?

 How quickly should agitation resolve?

28

Session 3: Cases 1 Parts I–K

** (Student side) ** (Faculty side)

Distribute Case 1 Part I Student Handout.

Case Part I Case Part I

Based on these results, a Diagnosing Methamphetamine Abuse

presumptive diagnosis of Versus Dependence
methamphetamine dependence and For the patient in this case, ask the students to
methamphetamine-induced psychosis identify which of the Diagnostic and Statistical
is made. Manual of Mental Disorders (4th ed.) (DSM-IV­
TR) criteria for abuse versus dependence are
met.

Dependence is the more severe of the two, and

in the presence of dependence, abuse should
not be diagnosed.

The patient in this case meets the criteria for

dependence because:
 Her mother reports the patient uses IV
methamphetamines, which may be a
sign of tolerance. Generally, individuals
start with snorting and progress to IV
use due to their tolerance.
 The patient has been in a drug rehab
program in the past, which shows a
desire or attempt to decrease or stop
use.
 She has severe psychiatric effects from
the drug use, which have occurred
before; but she continues to use despite
knowledge of these adverse effects.

The limited information that is available is

enough to make a presumptive diagnosis of
methamphetamine dependence.

Review the DSM-IV-TR criteria for abuse and

dependence in Appendix A.

Distribute Case 1 Part J Student Handout.

29

** (Student side) ** (Faculty side)

Case 1 Part J Case 1 Part J

The patient received two doses of Discuss the responsibility of informing

haloperidol and lorazepam. social services, child protective services,
referral for battered spouses. Specifically,
She responds to the second dose of what supports would students recommend
the medications and is stabilized. Her given this patient’s sociocultural history.
agitation and psychotic symptoms are
controlled. She is cooperative and is Discuss how to elicit information from the
willing to participate in treatment for patient in a nonjudgmental manner:
her illness. The Explanatory Model of Illness, advanced by
Arthur Kleinman, is an excellent tool for eliciting
the patient’s perspective of his/her illness
(Kleinman, 1978). Kleinman’s model offers a
nonjudgmental approach for encouraging the
patient to explain his/her understanding of the
illness. Although derived from anthropologic
and cross-cultural research, the model is useful
for understanding any patient’s perspective on
his/her illness, including the personal and social
meaning he/she attaches to illness, the
expectations about what will occur and what
the doctor will do, and the patient’s own
therapeutic goals.

What would be your next steps in treating

this patient?

Symptom management:
 The pharmacologic treatment entails
symptom management and supportive
measures.
 For the patient in the case, the agitation
requires management with
benzodiazepines and/or atypical
antipsychotic agents.
 Oral medications should be used before
the use of intravenous or intramuscular
medications as much as possible.
 However, due to the patient’s agitation
and unwillingness to take any
medications orally, intramuscular
medications are the only option.

30

  This treatment should follow general

treatment principles of using the smallest
possible dose for the shortest possible
time.
 Haloperidol, as well as other
antipsychotic agents, is excellent in the
acute management of severe agitation.
However, their use is risky because of
the side effects possible with this class
of medications, including lowering the
seizure threshold, neuroleptic malignant
syndrome, tardive dyskinesia, akathisia,
prolongation of the QT interval, torsades
de pointes, and extra-pyramidal
movements.
 Use of lorazepam, which is a sedative-
hypnotic medication, minimizes the use
of haloperidol. If used alone, excessive
doses of lorazepam may be needed,
which in itself can cause delirium,
confusion, and respiratory depression.

Referral for further substance use

assessment and/or drug treatment.

 Distribute Case 1 Part K Student

Handout.

31

** (Student side) ** (Faculty side)

Case 1 Part K Case 1 Part K

The patient is put on a scheduled For this patient, outpatient medications were
dose of ziprasidone (Geodon) 20 mg prescribed to help control underlying
po BID and sent to the psychiatric unit psychiatric symptoms. She is being referred for
for stabilization and further treatment outpatient substance treatment with
of her substance abuse. psychotherapeutic interventions.

Treatment of methamphetamine
dependence: Treatment requires a long-term
approach that must include treatment of
underlying medical and/or psychiatric
conditions, supportive and motivational
enhancement therapies (METs), and
behavioral interventions. Treatment should
also be individualized to patient’s
abilities/preference/resources.

Pharmacological options for

methamphetamine treatment:
 No approved pharmacotherapy.

Nonpharmacological treatment options (i.e.,

psychotherapy treatment options):
 Matrix Model (Rawson, 2004), a
comprehensive behavioral treatment
approach that combines behavioral
therapy, family education, individual
counseling, 12-step support, drug
testing, and encouragement for
nondrug-related activities. More
information is available at:
http://www.nida.nih.gov/BTDP/Effective/
Rawson.html).
 MET or motivational interviewing
- Uses a nonconfrontational approach.
- Identifies contradictions between
what an individual is saying and
what is happening in his/her life.
- Utilizes rolling with the resistance.

32

  Cognitive behavioral therapy

- Identifies thoughts that trigger
thoughts of using drugs.
- Identifies behaviors that can be used
in lieu of drug use whenever
thoughts of using drugs arise.
- Provides opportunities to practice
these behaviors and offers followup.
 Contingency management (Petry et
al., 2005)
- Uses system of offering a tangible
reward for consistently staying drug
free.
- Uses multiple strategies to help the
individual stay sober, fight cravings,
etc.
 Family education
- Explains effects of drug use on the
family system.
- Involves family members in
treatment to offer support and
monitor drug use, cravings, etc.
 Group therapy
- Involves individual with others who
have drug-use and/or mental-health
issues
- Uses group dynamics to support the
individual’s strengths against using
drugs.
 Self-help groups
- Based on the 12-Step philosophy.
- Offers flexibility of availability, cost,
etc.

33
 Conclusion of PBL Session

Leave 15 minutes at the end of the session to give feedback to and receive it from the
group. Remind students of the goals and LOs and review with them how well they did in
achieving the goals. You could also address with the students this patient’s discharge
planning and followup. Give students feedback on their performance as a group. Ask
the students to evaluate themselves. How do they think they did in fulfilling the LOs?
How did the interdisciplinary clinical reasoning case process of self-directed learning
work for them? Did they enjoy the process?

34

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part A

Session 1

A 30-year-old Hispanic woman is brought to the emergency department because of her

agitated and restless behavior. The triage nurse tells you that the woman speaks little
English. The history you obtain through a trained interpreter indicates the patient
delivered a baby at your medical school’s obstetrics and gynecology clinic last month.
She had been attending the prenatal clinic on a regular basis. She gave birth to a
healthy boy about 10 days previously. Her previous labs obtained from the medical
record were as follows: blood type O+, antibody screen negative, VDRL negative, PPD
negative, HIV negative, hepatitis B surface antigen negative, rubella immune, maternal
serum triple screen WNL, glucose challenge test WNL, and hemoglobin electrophoresis
97% hemoglobin A.

The patient is not willing to stay in bed and is pushing staff members away. She is very
agitated, loud, and swearing at people around her. She is afraid and looking behind
herself constantly. She is refusing to allow the nurse to examine her or draw blood.

35

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part B

Session 1

With some effort, an interpreter is able to get contact information for the patient’s
mother, but the agitated patient forbids staff to make any contact with her family. When
the interpreter asked her more information about her condition, she stopped talking.
When the interpreter insisted, she became even more agitated. When she was offered
medications to help her relax and calm down, she became even more agitated,
screaming that she is not crazy and will not take any medications. She threatened to kill
the medical staff and is thrashing around to the point where she is banging her head
against the metal side rails of the bed.

36

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part C

Session 1

The patient’s mother is contacted and able to provide the following history. This is a
single mother with a history of “mood swings and anger problems.” She had been on
psychiatric medications in the past, but her medication adherence has been “sketchy.”
Her mother does not know what medications the patient has been prescribed in the
past. She was following up with a psychiatrist in the past but it may have been a while
since her last visit. She has had treatment at a local inpatient psychiatric hospital with
similar agitated presentations; but according to her mother, the last time this happened
was several years ago.
PMHx: She has had asthma since childhood, but no hospitalizations. There have
been occasional visits to the emergency room. She has been prescribed
inhalers and may have taken more than recommended. She was told that
she got asthma because her mother was sick with a cold at the time of her
birth. Her parents told her she could not exercise with other children
because she had asthma and was sickly. She is about 1.5 week
postpartum.
PSHx: Had Cesarean section in 2000 under epidural anesthesia.

Psych HX: See above.

Allergies: No known drug or food allergies.

Medications: Proventil multidose inhaler prn, multivitamins, iron.

Social Hx: Patient was born in the Dominican Republic. She has lived in the run­
down part of town since the age of 15 years. She smokes about 1½ PPD,
is ETOH dependent, has a history of IVDA for cocaine and
methamphetamine, and smokes marijuana periodically. She has been in
drug rehab in the past. She is currently unemployed, lives with her
boyfriend and three children, ages 1½ weeks, 5, and 7. Her boyfriend may
be abusive. He also has a history of drug dependence.

Family Hx: Mother 50, mild hypertension on medication. Father 55, heart disease,
hypertension, has had multiple strokes, in public housing. Sister 26,
brother 22, both with asthma, both abuse alcohol and drugs, both have
been diagnosed with bipolar disorder and depression. Grandmother and
grandfather on both sides have hypertension, heart disease CVA, and
have been treated for depression.

Review of systems: Significantly positive for insomnia.

37

 Student Handout Case 1: Diagnosis and Treatment of a Woman with

an Acute Psychotic Presentation

Case 1 Part D
Session 1

Physical Exam

General: Anxious appearing woman very agitated.

Vitals: 160/90 mmHg

HR: 100 BPM

Temp: 40° C

RR: 24 BPM

Height: 165 cm

Weight: 65 kg

Skin: Several small skin excoriations noted on the cheeks and both forearms.

HEENT: Anicteric with mildly dry mucous membranes. Teeth with several caries.

Chest: Lungs clear to auscultation and percussion.

CV: Tachycardic, Normal S1, S2.

Abdomen: Soft, nontender, with active bowel sounds, no rebound or guarding.

Back: Within normal.

Pelvic: Not done.

Extremities: No clubbing or cyanosis.

Psych: Alert and oriented, but agitated

Neuro: Cranial nerves grossly intact. Full strength all extremities and sensation

grossly intact. Deep tendon reflexes 3+.

38

MSE: Hispanic female, appears stated age, not cooperative, appears paranoid,
may be responding to internal stimuli, agitated, is not talking to herself,
does appear to be looking around and behind herself constantly as if she
is afraid of something, speech is not spontaneous, does not speak English
well. Unable to determine whether she is suicidal or homicidal; however,
she appears to threaten staff and through the interpreter has said she
does not want anyone to come close to her. A Folstein MMSE cannot be
done due to her uncooperativeness.

39

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part E

Session 2

Studies: The patient is refusing to cooperate with further examination; therefore, she is
administered IM lorazepam 4 mg. After 30 minutes the patient remains agitated, so
haloperidol 10 mg is given. She calms down after about 30 minutes and goes to sleep.
Blood is drawn at this point and IV fluid resuscitation is administered.

Lab Data
SMA7
Na 146 mmol/l 135–145
K 4.6 mmol/l 3.5–5.5
Cl 100 mmol/l 95–108
Bicarb 23 mmol/l 22–32
BUN 14 mg/dl 6–20
Cr 0.6 mg/dl 0.5–1.5
Glucose 72 mg/dl 60–115

CBC
WBC 15,300/ul 4,800–11,000
Hemoglobin 10.9 gm/dl 11–15
Hematocrit 32.7% 35–47
Platelets 167 k/ul 150–500

LFTs
Calcium 8.6 mg/dl 8.5–11
Total protein 6.5 gm/dl 6.0–8.5
Albumin 3.0 gm/dl 3.5–5
Alkaline phosphatase 480 u/l 35–125
CPK 950u/l <150u/l
SGPT 40 u/l 5–65
SGOT 31 u/l 5–50
Total bilirubin 0.6 mg/dl 0.2–1.3
Direct bilirubin 0.1 mg/dl 0–0.4
Amylase 97 u/l 30–300
Lipase 134 u/l 23–300

Urinalysis: Spec. gravity 1.035

Urine gram stain: WNL
Urine C&S, cervical cultures: Pending
Urine drug screen: Pending

40
 Student Handout Case 1: Diagnosis and Treatment of a Woman With
an Acute Psychotic Presentation

Case 1 Part F
Session 2

A CT of head is generally WNL.

Abdominal ultrasound is WNL. No other abnormal findings.

41

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part G
Session 2

The patient receives a presumptive diagnosis of postpartum psychosis versus

methamphetamine dependence and methamphetamine-induced psychosis. The patient
was given IM haloperidol (10 mg) and lorazepam (4 mg) earlier; however, after 4 hours
she is awake again and shows only partial improvement. She is getting agitated again
and is disruptive. IV fluids are continued and a second dose of the haloperidol and
lorazepam is given intravenously. Her fever is down to 38.1° C.

Physical exam: An agitated woman lying in bed on her right side.

Tempmax: 38.2° C

BP: 130–140/70–84 mmHg

HR: 112 BPM

RR: 24 BPM

Chest: Lungs clear to auscultation and percussion.

CV: Tachycardic.

Abd: Nontender.

Back: CTA, WNL.

42

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part H

Session 2

Lab Data

CBC
WBC 15,300/ul 4,800–11,000
Hemoglobin 10.2 gm/dl 11–15
Hematocrit 31.4% 35–47
Platelets 118 k/ul 150–500

Urine culture (from admission): WNL.

Cervical culture: Gonorrhea negative; chlamydia negative.

Abdominal-pelvic ultrasound: WNL.

Urine drug screen: + for methamphetamine.

43

 Student Handout Case 1: Diagnosis and Treatment of a Woman with

an Acute Psychotic Presentation

Case 1 Part I

Session 3

Based on the lab results, a presumptive diagnosis of methamphetamine dependence

and methamphetamine-induced psychosis is made.

44

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part J

Session 3

The patient responds to the second dose of the haloperidol and lorazepam and is
stabilized. Her agitation and psychotic symptoms are controlled. She is cooperative and
willing to participate in treatment for her illness.

45

 Student Handout Case 1: Diagnosis and Treatment of a Woman With

an Acute Psychotic Presentation

Case 1 Part K

Session 3

The patient is put on a scheduled dose of ziprasidone (Geodon) 20 mg po BID and sent
to the psychiatric unit for stabilization and further treatment of her drug use.

46

 Facilitator Guide Case 2:

Diagnosis and Treatment of a Middle-Aged Man With Chest Pain

The main objective of this PBL is to use a realistic clinical scenario to explore with
students the different causes of chest pain and to streamline the diagnosis and
treatment of this condition.

Audience

This PBL has been developed for use with second- and third-year medical students as a
way of integrating knowledge and raising awareness of important comorbidity.

Format

Case 2: Diagnosis and Treatment of a Middle-Aged Man with Chest Pain is comprised
of nine narrative sections covered over two sessions, each lasting between 60 and 90
minutes. Each section is printed on a separate sheet of paper and students are to
receive only one section at a time as directed by the Facilitator Guide (please note that
students are not to be provided with PBL case materials prior to the first PBL session).
Once a section has been reviewed in detail, students will be given the corresponding
information on the teacher’s notes and discuss why the case was managed as it was.
During these sessions students are responsible for reading the case, identifying
pertinent facts, and developing hypotheses. At the first session each group of students
will also generate its own LOs. During the final “problem resolution” session students
will also teach one another what they have learned by presenting relevant LO materials,
preferably with the assistance of visual aids (e.g., computer images, slides, handouts).
The resolution session concludes with a discussion of any major differences between
the LOs generated by students and the LOs provided to the facilitator, which are to be
distributed to students at this time.

To assist faculty facilitators in coaching the student-led discussions, notes and LOs are
provided for each step of the case. The notes are suggestions for possible discussion of
the major points presented in each section. Facilitators may expand on any portion of
the case to pursue their interests or the interests of their students. It is important to not
divulge any important information to the students prematurely, as this will prevent them
from analyzing the data and reaching their own conclusions.

THE FACILITATOR NOTES SHOULD NEVER BE GIVEN TO THE STUDENTS.

HANDOUTS FOR STUDENTS ARE PROVIDED.

47

 PBL Case 2 Overview:

Diagnosis and Treatment of a Middle-Aged Man With Chest Pain

This PBL guide includes a case with nine narrative sections, detailed process guidelines
(how to facilitate a PBL group), suggested student LOs, and substantial background
information designed to make this case useful for faculty from any specialty. Topics
include diagnosis and treatment of substance use disorders, in particular
methamphetamine abuse, and the relationship between substance use disorders and
other causes of acute chest pain such as anxiety, stress, etc. There is a significant
amount of psychiatric diagnostic and treatment information given. However, the goals of
this PBL case are to develop the medical student’s understanding of the comorbidity
and to prevent the student from assuming that a particular case is only a psychiatric
presentation without developing an understanding of the case’s nuances.

This PBL exercise allows the learners (second- and third-year students) to consolidate
their educational experiences across clerkships and encourages multidisciplinary
thinking in their clinical interactions. The case allows learners to integrate and apply
collected data to problem solving. It also helps students develop the skills necessary for
the interpretation and utilization of relevant historical, physical examination, and
laboratory information in a patient who is acutely ill. Topics addressed in the exercise
include symptom presentation/evolution, generation of a differential diagnosis,
diagnostic testing, and patient management.

The exercise reiterates the clinical relevance of basic science topics, including
physiology, pharmacology, and pathophysiology. It also allows students to address
patient reluctance in talking about things that may be considered pejorative. The
problem-based format fosters self-directed learning, reflection, and collaborative
practice. The strength of the case is that students are required to think outside the
context of a specific clerkship and integrate symptoms across organ systems.

A. Facilitator Notes––Introduction
This PBL, which evolves over two sessions, describes the course of a middle-aged man
who comes to the emergency department with acute chest pain. The intent of the
exercise is to encourage students to consider the impact of psychiatric “comorbidity”
(history of anxiety) on the pathophysiology and prognosis of the patient and on the
students’ treatment decisions.

Because the patient has multiple concurrent conditions, students may reasonably deal
with the medical, psychiatric, and substance use conditions separately. While such an
approach is fine up to a point, the students must also attend to the potential interactions
among the three conditions.

It is relatively new for students to consider interdisciplinary or comorbid issues in PBLs.

Hence, interdisciplinary discussions should be encouraged. Comments to help further
such discussions could include:

48

  What issues are involved? Is the presentation purely related to medicine or

psychiatry?
 Where else may this patient present with a similar set of symptoms?
 Might his psychiatric problems be contributing to his presenting complaints? If so,
how?

Another unusual facet of this PBL is that it raises cultural issues and questions that
have not been completely answered by medical research. The issue of social stigma
associated with drug use and the impact it has on the patients’ honest reporting of their
histories have not been adequately addressed in medical research.

B. Student Learning Objectives

LOs should describe actions or behaviors that students are expected to

execute/perform by the end of the PBL. The following LOs are important for this PBL,

but students should pick their own. LOs picked by students may be different from the list

below. Feel free to share this list with the students after the resolution of the case.

LO 1 Explain the history taking for acute management of chest pain.

LO 2 Explain the diagnostic workup of a patient with acute chest pain.

LO 3 Explain the psychiatric factors that may impact the presentation of a

patient with acute chest pain.

LO 4 Explain the impact of stimulants, in particular methamphetamine, on the
presentation of acute chest pain.
LO 5 Explain the diagnostic criteria for methamphetamine abuse/dependence.
LO 6 Explain the symptoms of methamphetamine intoxication.
LO 7 Discuss the proper use of medications for the acute management of chest
pain.
LO 8 Discuss treatments for methamphetamine dependence.
LO 9 Summarize the long-term goals of a patient who has serious medical
complications because of his/her drug use.
LO 10 Discuss ways of overcoming barriers that prevent substance abuse
patients from seeking appropriate care, such as severe social stigma.
LO 11 Summarize the key facts that support addiction as a medical disease, with
a cause, effect, treatment, and response.

C. Goals
 To reintroduce basic science concepts and relate them to clinical scenarios.
 To think about cases in a multidisciplinary fashion, across specialty lines, and
from a cultural perspective.
 To introduce self-directed and life-long learning using the tools of evidence-
based medicine.

49

D. Session Objectives
 Integrate and apply collected data to problem solving, including the generation
and prioritization of a differential diagnosis for acute chest pain.
 Develop the skills necessary for the interpretation and utilization of relevant
historical, physical examination, and laboratory information in a patient who is
acutely ill.
 Integrate the concepts of evidence-based medicine to develop an approach to an
acutely ill patient.
 Assess the impact of culture/stigma on the diagnosis and management of acute
medical conditions.
 Recognize the medical ramifications of addictive disorders.

E. Logistics
 Review goals/objectives.
 Appoint a group leader, reader, and scribe.
 Have students list facts, hypotheses, and learning objectives.
 Keep a copy of the LOs that are generated from each interdisciplinary clinical
reasoning session.
 Ask questions only to stimulate discussion (e.g., guiding questions may be used
to get the group back on track, but you should try to let students grasp the
material on their own). Suggested guiding questions are italicized in this text.
(You should refer to these questions if the group goes off on a tangent or is at an
impasse. We suggest you refrain from using the questions too early in the
process, as the students should be encouraged and given the time to formulate
questions for themselves.)

Schedule
 Session 1, case parts A–D.
 Session 2, case parts E–I.

50

 PBL Case 2:

Diagnosis and Treatment of a Middle-Aged Man With Chest Pain

Facilitator’s Notes

Session 1: Case 2 Parts A–D

** (Student side) ** (Faculty side)

Case 2 Part A Case 2 Part A
Significant historical facts:
A 43-year-old white male comes to the
emergency department with a 4- to 5­ The students need to know the right
hour onset of nontraumatic chest pain. questions to ask to get a history that
will help them rule in or rule out cardiac
pathology.
However, they should be aware of
other differential diagnoses for this
patient in order to fully understand and
treat his illness.
Differential diagnosis of chest pain
includes:
 Angina secondary to coronary
artery disease.
 Pulmonary pathology.
 Vascular pathology.
 Trauma.
 GI disturbances.
 Emotional/psychiatric conditions.
 Substance use intoxication and
withdrawals.
This is by no means a complete list of
differential diagnoses.
What more do you want to know?
 HPI: Timing, onset, and
precipitating factors of chest
pain?
 Pain relieved by? Aggravated
by?
 Specific nature and degree of
pain?
 Associated symptoms that
suggest underlying pathology?

Distribute Case 2 Part B Student

Handout.

51

** (Student side) ** (Faculty side)

Case 2 Part B Case 2 Part B

Presenting information: Questions to Consider

 The patient’s chest pain radiates

to his left arm.

How does your differential diagnosis
 He has tingling sensations in his change with this additional
left arm. information?
 He has difficulty breathing and
Not much, which is a major point of this
feels short of breath.
case.

 On initial exam, the patient

appears in moderate discomfort, This patient provides a history that

describing “10 out of 10” is suggestive of chest pain from a
substernal chest pressure. cardiac origin. At this point, does
 He states that he was spending the etiology of the chest pain
time with some friends and all of
matter?
a sudden he noticed the pain.

 He became anxious that it may Is the management of this patient

be related to his heart. Because going to be different if the origin
he is a “type A” personality, he was noncardiac versus cardiac?
wanted to make sure that he Not much; this is a major point of this
took care of it right away.
case.
 The patient also described a

constant pain, which increased What more do you want to know?

with exertion and was
Additional history related to the case.
associated with radiation to his

left arm, dyspnea, mild Distribute Case 2 Part C Student

lightheadedness, nausea, and
Handout.
diaphoresis.

52

** (Student side) ** (Faculty side)

Case 2 Part C Case 2 Part C

Additional History What are the most important points

about this presentation?
PHX: The patient does not There does not appear to be any
have a previously established history of cardiovascular
diagnosed history of any problems, nor is there any previous
cardiovascular condition. history of chest pain from any other
He does not give a source.
previous history of chest
pain (including chest pain His previous history of anxiety and
from heart disease, depression is important to note.
heartburn, or anxiety). Moreover, there is history of
However, on previous nonadherence to recommended
visits to his doctor, he has treatment.
been told he needs to “do
more or he will get heart He states that he has a high-stress job.
problems.” He does not He smokes and drinks, and he has a
specify what was meant history of using drugs. He is also
by this. adamant that he has not used recently.
However, research suggests the risk of
PSHX: No history of any relapse is always there, especially in
surgeries. the presence of stressors.

Psych HX: He has a history of His family history is positive for cardiac
depression and anxiety. conditions.
He has been prescribed
medications for this; What possible diagnoses should be
however, he is not taking considered based on the history
these medications as obtained?
prescribed.  MI.
 Aortic dissection.
Allergies: No known drug or food
allergies. What cues are present that suggest
the patient may not be providing all
Medications: None that he is the information that is relevant to
taking. this case?
 The patient talks about having
Social Hx: He is single, working full been told to “do more” to
time as a car salesman decrease his risk of
and states that his job is cardiovascular problems,
stressful. He reported an suggesting there is something
approximately 25-pack else he has not shared in his

53

 per year smoking history. history.

He drinks alcohol socially  O2 saturation.
on weekends. He also  The patient swears he has not
said he used drugs in the used drugs recently.
past, but swears he has  He has a history of depression
not used recently. and anxiety but is not taking
medication.
Family MHX: The patient’s family
history was significant for What more do you want to know?
his father who had a A physical exam would be useful at this
myocardial infarction at point, specifically:
age 50 and underwent  Vital signs: Although high BP,
coronary artery bypass high HR, and pulse may suggest
graft (CABG) at age 60. cardiac distress, they are not
The patient’s sister specific, as these may be
suffered from a heart increased in any acute condition
attack at age 24 and including medical and
subsequently died of psychiatric conditions such as
cancer. He stated that he substance use or withdrawal.
has three healthy children  Chest: Findings on percussion
from different and/or auscultation of chest may
relationships. help identify significant
underlying pathology.
 Abdomen: Findings on
palpation, percussion, and/or
auscultation of abdomen may
help identify several abdominal
causes of the acute
presentations.
 Mental status examination:
For ruling out psychiatric
symptoms, anxiety, and/or panic
attacks that might help identify
the underlying cause of the
acute presentation.

Distribute Case 2 Part D Student

Handout.

54

** (Student side) ** (Faculty side)

Case 1 Part D Case 1 Part D

Physical Exam How would you interpret the

physical exam?
General: Anxious and slightly  Vital signs: BP elevated;
agitated appearing middle- Temperature WNL; HR:
aged man in moderate elevated; RR: elevated, Ht &
distress secondary to pain. Wt: WNL; O2 Saturation: low.
 Skin: several skin excoriations
Vitals: 165/96 mmHg; HR: 102  HEENT: dilated pupils
BPM; temp: 36.1° C; RR: bilaterally.
20 BPM; O2 saturation of  CV: WNL.
90% on room air.  Chest: WNL.
 Abdomen: No abnormality.
Height: 165 cm  Extrem: WNL.
 Neuro: WNL.
Weight: 65 kg
 Psych: Mood possibly
consistent with anxiety, panic
Skin: Several 5 to 8mm small
attacks.
areas of excoriation on left

forearm.

Do the results of the physical exam

alter your differential diagnosis?
HEENT: Anicteric, dilated pupils
Given this information, the focus of
bilaterally with dry mucous
the differential diagnosis has not
membranes, and jugular
really changed. A further workup is
venous pressure of 6 cm.
required before noncardiac causes
can be considered for the acute
Chest: Lungs clear bilaterally,
management of this condition. Even
without any rales or
though with this patient's presentation
rhonchi.
a diagnosis of panic attacks and
anxiety could be considered, one of
CV: Normal S1, S2, no
the requirements of making this
murmurs, rubs or gallops.
diagnosis is that the underlying
medical conditions that could present
Abdomen: Active bowel sounds;
with these symptoms be ruled out
no rebound or guarding.
first.
Back: Within normal.
What laboratory tests would you
like to order and why?
Rectal: Heme-negative stools.
Useful laboratory tests may include
the following: complete metabolic
Extremities: No clubbing or cyanosis.
panel, cardiac enzymes, and CBC
(for infection); LFTs to assess

55

Psych: Alert and oriented, hyper- metabolic problems, alcohol use;

verbal, slightly agitated, urinalysis and culture; urine drug
and anxious. screen.

Neuro: Cranial nerves grossly

intact. Full strength in all
extremities and sensation
grossly intact.

––SUGGESTED END POINT FOR SESSION 1––

MAKE SURE EACH STUDENT IS ASSIGNED AT LEAST ONE LEARNING

OBJECTIVE TO RESEARCH AND PRESENT TO THE GROUP AT THE NEXT
SESSION

56

 Session 2: Case 2 Parts E–I

Examples of Learning Issues From Previous Session

 How do we diagnose acute chest pain?

 How do we manage acute chest pain?

 At what point can we start exploring psychiatric conditions that may be the cause

of the presenting problems?

 Are blood/urine tests necessary for a diagnosis of acute chest pain?

Discussion of Learning Issues From Prior Session

Most of the learning issues will be of the diagnosis or etiology type. The facilitator
should inquire of each student:
 Where did you look to find the answer to your learning issue? (e.g., textbook,
UpToDate? If you went to PubMed, did you use a review article, case series, or a
control trial?).
 How difficult was it to find the answer to your learning issue?
 If you found a diagnostic article, did it actually apply to our patient (i.e., a man
with chest pain), or did it apply to making a general type of diagnosis in adults
and we now have to decide whether we can apply it to a middle-aged man? Is
that OK with the group? (Note this is common in medicine—extrapolating data to
other patient populations: pediatrics, elderly, and the surgical patient).
 If looking at diagnostic tests, did the article mention the sensitivity and specificity
of the test? Which one is more important to the group for the question they
looked up?
 Is there a good gold standard for diagnosing these problems?

57

Session 2: Case 2 Parts E–I

** (Student side) ** (Faculty side)

Case 2 Part E Case 2 Part E

Additional Tests Discussion of laboratory results:

Generally, the blood tests are within
EKG: Normal sinus rhythm with normal limits and do not help identify
normal intervals. There were the specific underlying pathology that
no ischemic ST-T wave may be the cause of this patient’s chest
changes. pain.

Chest x ray: A portable chest x ray study Urine drug screen: Results pending.
showed clear lungs with no
evidence of pulmonary edema Do the results of these tests alter
or airspace disease. your differential diagnosis?
Not really.
Lab Data
What additional information and/or
SMA7: tests do you want?
Na 136 mmol/l 135–145 The most important tests needed to rule
K 3.9 mmol/l 3.5–5.5 out an underlying cardiac pathology are
Cl 100 mmol/l 95–108 the cardiac enzymes, the EKG, and an
Bicarb 23 mmol/l 22–32 echocardiogram. Only after these tests
BUN 14 mg/dl 6–20 are complete could other pathology be
Cr 0.6 mg/dl 0.5–1.5 considered as a cause of this patient’s
Glucose 72 mg/dl 60–115 symptoms.

CBC: When would you begin treatment?

As the patient’s condition is being
WBC 9,300/ul 4,800–
worked up, it is important to
11,000
presumptively start the treatment of this
Hemoglobin 12.9 gm/dl 11–15
patient’s chest pain. This is important to
Hematocrit 36.7% 35–47
decrease the mortality and morbidity of
Platelets 167 k/ul 150–500 this patient.
LFTs:
Calcium 9.6 mg/dl 8.5–11
Total protein 7.5 gm/dl 6.0–8.5
Albumin 4

.0 gm/dl 3.5–5
Alkaline 120 u/l 35–125
phosphatase
SGPT
40 u/l 5–65
SGOT
1 u/l
3 5–50
Total 0.6 mg/dl 0.2–1.3
bilirubin

58

Direct 0.1 mg/dl 0–0.4

bilirubin
Amylase 97 u/l 30–300
Lipase 134 u/l 23–300
CPK 96 ng/ml 52–200

Urinalysis: Spec. gravity 1.015 Distribute Case 2 Part F Student

Handout.

Urine drug screen: Pending.

59

** (Student side) ** (Faculty side)

Case 2 Part F Case 2 Part F

A presumptive diagnosis of Angina Pectoris It is important to stress that

is made. management should start before the
diagnosis is made.
Initial While we have a list of differential
management: The patient was initially diagnoses, patients’ treatment should
treated with oxygen, IV start even before a definitive diagnosis
lopressor, aspirin 325 mg, and is made.
three sublingual nitroglycerine
tablets, which had no effect on Distribute Case 2 Part G Student
his chest symptoms. He was Handout.
then given 8 mg of IV
morphine, which reduced his
pain to “8 out of 10.”

60

** (Student side) ** (Faculty side)

Case 2 Part G Case 2 Part G

Cardiac enzymes: Peak troponin I of What is your differential diagnosis

0.5 and a CK-MB of 470 with an MB now?
fraction of 3. The results of the cardiac enzymes are
not confirmatory for cardiac tissue
The patient eventually required IV damage.
nitroglycerine to control his pain, as
well as additional morphine. A second With these results, the origin of this
EKG showed no significant change. chest pain is still not known. While
further tests would confirm the etiology,
Further management is being treatment should already have begun
determined. Patient is being scheduled to prevent possible MI and further
for an echocardiogram and a damage.
cardiology consultation.
How would you re-evaluate this
Following lopressor administration for patient? What lab/imaging studies
his hypertension, his blood pressure would you order and why?
was 178/110. Cardiac catheterization and
echocardiogram.
Urine drug screen: Pending.
Distribute Case 2 Part H Student
Handout.

61

** (Student side) ** (Faculty side)

Case 2 Part H Case 2 Part H

An echocardiogram was performed, Echocardiogram suggests hypokinesis of the

which showed an ejection fraction of inferior septal wall of the myocardium.
78% with mild inferoseptal hypokinesis Further workup should include admission to
and mild mitral regurgitation. the hospital, a cardiology consult, and
perhaps a cardiac catheterization if
recommended by cardiology.

What diagnosis ranks the highest on your

differential now?
Possible recurrence of anxiety disorder,
possibility of gastrointestinal complaints,
local inflammation, and substance
use/intoxication may be reasons for the pain.

Some substance use toxicity or withdrawal

symptoms may also lead to autonomic
arousal and could potentially cause chest
pain. Stimulant substances can produce
myocardial ischemia by one of the following
mechanisms: (1) coronary artery vasospasm,
(2) thrombus formation, (3) increased
myocardial oxygen demand, or (4) direct
myocardial toxicity. It is of interest that
skeletal muscle necrosis (rhabdomyolysis)
has been proposed as a mechanism of
noncardiac chest pain after cocaine use, and
this complication may be a factor in chest
pain associated with methamphetamine use.

The elevated vital signs suggest a possibility

of a hyperadrenergic state and the possibility
of substance use or toxicity should be
entertained. The results of the urine drug
screen would help resolve this possibility.

Distribute Case 2 Part I Student Handout.

62

** (Student side) ** (Faculty side)

Case 2 Part I Case 2 Part I

Urine drug screen: + for The results of the urine drug screen dispute
methamphetamine. the patient’s response earlier in the
assessment to the question about his drug
The patient’s cardiac workup is use. This proves the importance of getting a
essentially within normal limits. The urine drug screen as part of the assessment of
treating physician referred the patient an acute presentation.
to the substance use disorders
Several possible reasons that might explain
program. The patient later
the patient’s reluctance to be honest:
acknowledged methamphetamine use
and stated that he has struggled with  The bias that is present in society
methamphetamine use for a while and against drug use and drug users might
has tried to stop. make it difficult for an individual to
divulge information about his/her drug
use.
 The patient may want to hide the
information from his/her significant
other, family members, employers, or
legal professionals.
 Sometimes the patient may also be in
denial about his/her own use and
minimize it by saying it was “just a little
bit,” “it really isn’t that much,” “it isn’t like
I’m buying it myself,” etc.

How would you discuss a positive urine

drug screen with the patient?
 Present the results in a matter-of-fact
way, in conjunction with other medically
relevant information.
 Re-administer the test if the patient
believes the result showed a false
positive.
 If the second biological test results are
positive, offer a brief intervention and
referral for additional assessment and
possible treatment.

Diagnosing methamphetamine abuse

versus dependence:
For the patient in this case, ask the students to

63

identify which of the criteria for abuse versus

dependence are met (see Appendix A).

 The patient reports that he has a

problem with methamphetamine abuse
and has been using repeatedly. There is
not enough information to determine
whether he has developed a tolerance
to the drug or has increased the amount
or duration of use.
 He has tried to stop his drug use, which
shows a desire or attempt to decrease
or stop using.
 He has had severe medical
problems/effects from the drug use, but
may not be aware that his drug use
caused these problems.
 There is not enough information about
any consequences he has suffered
resulting from his drug use.

The limited information that is available is

not enough to make a presumptive
diagnosis. Screening for drug use may
provide additional information as to the risk
level of the patient. The NM ASSIST—NIDA-
Modified Alcohol, Smoking, and Substance
Involvement Screening Test
(http://ww1.drugabuse.gov/nmassist/) is a
Web-based interactive tool (modified from the
WHO ASSIST questionnaire) that guides
clinicians through a short series of screening
questions that, based on the patient’s
responses, generates a substance
involvement score that suggests the level of
intervention needed.

What are your next steps in treating this

patient?
 Use MET to encourage the patient’s
recognition of the problems he is having
in his life due to drug use.
 Refer the patient for further assessment
and/or treatment, if indicated by the
results of the NM ASSIST screen.

64

Summary
For the patient in this case, the chest pain
required ruling out or treating underlying
cardiac conditions

Oral medications should be used before the

use of intravenous or intramuscular
medications as much as possible. This
treatment should follow general treatment
principles of using the smallest possible dose
for the shortest possible time.

Because there was insufficient information to

make a diagnosis of abuse or dependence,
additional questions were asked using the NM
ASSIST to determine the patient’s risk level
and needed intervention.

65

 Conclusion of PBL Session

Leave 15 minutes at the end of the session to give feedback to and receive it from the
group. Remind students of the goals and LOs and review with them how well they did in
achieving them. You could also address with the students this patient’s discharge
planning.

66

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part A
Session 1
A 43-year-old white male comes to the emergency room with a 4- to 5-hour onset of
nontraumatic chest pain.

67

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part B

Session 1

Presenting Information

 His chest pain radiates to his left arm.

 He has tingling sensations in his left arm.

 He has difficulty breathing and feels short of breath.

 On initial exam, the patient appears in moderate discomfort, describing “10 out of

10” substernal chest pressure.

 He states he was spending time with some friends and all of a sudden he noticed
the pain.
 He became anxious that it may be related to his heart. Because he is a “type A”
personality, he wanted to make sure he took care of it right away.
 The patient also described a constant pain, which increased with exertion, and
was associated with radiation to his left arm, dyspnea, mild lightheadedness,
nausea, and diaphoresis.

68

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part C

Session 1

Additional History

PHX: The patient does not have a previously diagnosed history of any
cardiovascular condition, nor does he have chest pain from any other
sources, such as heartburn or cardiac. However, on previous visits to his
doctor, he has been told he needs to “do more or he will get heart
problems.” He does not specify what was meant by this.

PSHX: No history of any surgeries.

Psych HX: He has a history of depression and anxiety. He has been prescribed
medications for this; however, he is not taking these medications as
prescribed.

Allergies: No known drug or food allergies.

Medications: None that he is taking.

Social Hx: He is single, working full time as a car salesman and states that his job is
stressful. He reported an approximately 25-pack per year smoking history.
He drinks alcohol socially on weekends. He said he used drugs in the
past, but swears he has not used recently.

Family MHX: The patient’s family history was significant for his father, who had a
myocardial infarction at age 50 and underwent CABG at age 60. The
patient’s sister suffered from a heart attack at age 24 and subsequently
died of cancer. He stated that he has three healthy children from different
relationships.

69

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part D

Session 1

Physical Exam

General: Anxious and slightly agitated appearing middle-aged man in moderate

distress secondary to pain.

Vitals: 165/96 mmHg, HR: 102 BPM, temp: 36.1° C, RR: 20 BPM, O2 Saturation
of 90% on room air.

Height: 165 cm

Weight: 65 kg

Skin: Several 5 to 8mm small areas of excoriation on left forearm.

HEENT: Anicteric, dilated pupils bilaterally with dry mucous membranes, jugular
venous pressure of 6 cm.

Chest: Lungs clear bilaterally, without any rales or rhonchi.

CV: Normal S1, S2, no murmurs, rubs, or gallops.

Abdomen: Active bowel sounds; no rebound or guarding.

Back: Within normal.

Rectal: Heme-negative stools.

Extremities: No clubbing or cyanosis.

Psych: Alert and oriented, hyper-verbal, slightly agitated, and anxious.

Neuro: Cranial nerves grossly intact. Full strength in all extremities and sensation

grossly intact.

70

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part E

Session 2

Additional Tests

EKG: Normal sinus rhythm with normal intervals. There were no ischemic ST-T
wave changes.

Chest x ray: A portable chest x ray study showed clear lungs with no evidence of
pulmonary edema or airspace disease.

Lab Data
SMA7
Na 136 mmol/l 135–145
K 3.9 mmol/l 3.5–5.5
Cl 100 mmol/l 95–108
Bicarb 23 mmol/l 22–32
BUN 14 mg/dl 6–20
Cr 0.6 mg/dl 0.5–1.5
Glucose 72 mg/dl 60–115

CBC
WBC 9,300/ul 4,800–11,000
Hemoglobin 12.9 gm/dl 11–15
Hematocrit 36.7% 35–47
Platelets 167 k/ul 150–500

LFTs
Calcium 9.6 mg/dl 8.5–11
Total protein 7.5 gm/dl 6.0–8.5
Albumin 4.0 gm/dl 3.5–5
Alkaline phosphatase 120 u/l 35–125
SGPT 40 u/l 5–65
SGOT 31 u/l 5–50
Total bilirubin 0.6 mg/dl 0.2–1.3
Direct bilirubin 0.1 mg/dl 0–0.4
Amylase 97 u/l 30–300
Lipase 134 u/l 23–300
CPK 96 ng/ml 52–200
Urinalysis: Spec. gravity 1.015
Urine drug screen Pending.

71
 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged
Man With Chest Pain

Case 2 Part F

Session 2

A presumptive diagnosis of Angina Pectoris is made.

Initial Management

The patient was initially treated with oxygen, IV lopressor, aspirin 325 mg, and three
sublingual nitroglycerine tablets, which had no effect on his chest symptoms. He was
then given 8 mg of IV morphine, which reduced his pain to “8 out of 10.”

72

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part G

Session 2

Cardiac enzymes: Peak troponin I of 0.5 and a peak CK-MB of 470 with a MB fraction

of 3.

The patient eventually required IV nitroglycerine to control his pain, as well as additional

morphine. A second EKG showed no significant change.

Further management is being determined. Patient is being scheduled for an

echocardiogram and a cardiology consultation.

Following lopressor administration for his hypertension, his blood pressure was

178/110.

Urine drug screen: Pending.

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 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part H

Session 2

An echocardiogram was also performed, which showed an ejection fraction of 78% with
mild inferoseptal hypokinesis and mild mitral regurgitation.

74

 Student Handout Case 2: Diagnosis and Treatment of a Middle-Aged

Man With Chest Pain

Case 2 Part I

Session 2

Urine drug screen: + for methamphetamine.

The patient’s cardiac workup is essentially within normal limits. The treating physician
referred the patient to the substance use disorders program. The patient later
acknowledged his methamphetamine use and stated he has struggled with it for a while
and has tried to stop.

75

 PBL Session Evaluation

Please indicate your year: M2 M3

Please respond to the following items by using the scale provided:

Strongly Strongly
Agree Neutral Disagree
Agree Disagree

1. The case held my interest. 5 4 3 2 1

2. The case was realistic. 5 4 3 2 1

3. The case was targeted to my learning level. 5 4 3 2 1

4. The case provided me with new information

5 4 3 2 1
about methamphetamine abuse and addiction.

5. The size of the group was appropriate. 5 4 3 2 1

6. The length of each case section was

5 4 3 2 1
appropriate.

7. Please comment on aspects of the PBL session that worked well:

8. Please comment on aspects of the PBL session that could be improved or enhanced:

76

 Learner Self-Assessment

Please indicate your year: M2 M3

As a result of this session, I am able to:

Strongly Strongly
Agree Neutral Disagree
Agree Disagree
1. Explain history taking for the acute 5 4 3 2 1
management of chest pain.
2. Explain the diagnostic workup of a patient 5 4 3 2 1
with acute chest pain.
3. Explain the psychiatric factors that might
impact the presentation of the patient with 5 4 3 2 1
acute chest pain.
4. Explain the impact of stimulants, in particular
methamphetamine, on the presentation of 5 4 3 2 1
acute chest pain.
5. Explain the diagnostic criteria for 5 4 3 2 1
methamphetamine dependence.
6. Explain the symptoms of methamphetamine 5 4 3 2 1
intoxication.
7. Discuss the proper use of medications for the 5 4 3 2 1
acute management of chest pain.
8. List the major pharmacologic treatments of 5 4 3 2 1
methamphetamine dependence.
9. List the major nonpharmacological
treatments of methamphetamine 5 4 3 2 1
dependence.
10. Summarize the long-term goals of a patient
who has serious medical complications due
to drug use and is facing severe social 5 4 3 2 1
stigma for drug use that prevents him/her
from seeking appropriate medical care.
11. Integrate and apply collected data to problem
solving, including the generation and 5 4 3 2 1
prioritization of a differential diagnosis for
acute chest pain.
12. Integrate and utilize relevant historical,
physical examination, and laboratory 5 4 3 2 1
information in a patient who is acutely ill.
13. Integrate the concepts of evidence-based
medicine to develop an approach to an 5 4 3 2 1
acutely ill patient.
14. Assess the impact of culture/stigma on the
diagnosis and management of acute medical 5 4 3 2 1
conditions.

15. Comments (use the back if necessary):

77

 PBL Facilitator Evaluation

Please indicate your year: M2 M3

My facilitator for this session:

Strongly Strongly
Agree Neutral Disagree
Agree Disagree
1. Encouraged critical thinking and inquiry. 5 4 3 2 1
2. Encouraged students to ask questions without
5 4 3 2 1
fear of embarrassment.
3. Demonstrated sensitivity and respect for
5 4 3 2 1
students.
4. Struck a balance between providing
5 4 3 2 1
information and actively involving students.
5. Provided feedback when appropriate. 5 4 3 2 1
6. Facilitated participation of all members of the
5 4 3 2 1
group.
7. Refocused the group when discussion was
5 4 3 2 1
wandering.
8. Encouraged and valued contributions from
5 4 3 2 1
students.
9. Encouraged student responsibility for the
5 4 3 2 1
learning objectives.
10. Questioned and probed the reasoning process. 5 4 3 2 1
11. Encouraged critical appraisal of information. 5 4 3 2 1
12. Encouraged students to assume leadership
5 4 3 2 1
responsibilities.
13. Overall, my facilitator was effective. 5 4 3 2 1

14. Comments about your facilitator (use the back if necessary):

78

 References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental

Disorders: DSM-IV-TR. Washington, DC: Author.

Kleinman, A. (1978). Culture, illness and care: Clinical lessons from anthropologic and
cross-cultural research. Annals of Internal Medicine, 88, 251–258.

National Institute on Drug Abuse. (2009a).

http://www.nida.nih.gov/DrugPages/Methamphetamine.html accessed 9-16-09.

National Institute on Drug Abuse. (2009b.

http://teens.drugabuse.gov/facts/facts_mj1.php accessed 9-16-09.

Substance Abuse and Mental Health Services Administration. (2009). Results from the
2008 National Survey on Drug Use and Health: National Findings (Office of Applied
Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD:
Author. http://www.oas.samhsa.gov accessed 9-16-09.

Petry, N. M., Peirce, N. M., Stitzer, J. M., Blaine, M. L., Roll, J. M., Cohen, A., et al.
(2005). Effect of prize-based incentives on outcomes in stimulant abusers in outpatient
psychosocial treatment programs: A national drug abuse treatment clinical trials network
study. Archives of General Psychiatry, 62(10), 1148–1156.

Rawson, R. A., Marinelli-Casey, P., Anglin, D., Dickow, A., Frazier, Y., Gallagher, C., et
al. (2004). A multi-site comparison of psychosocial approaches for the treatment of
methamphetamine dependence. Addiction, 99, 708–717.

79

 Bibliography

Cole, S. A., & Bird, J. (2000). The Medical Interview: A Three Function Approach (2nd
ed.). Mosby Year Book Inc., St. Louis, MO.

Hser, Y. I., Evans, E., & Huang, Y. C. (2005). Treatment outcomes. Journal of
Substance Abuse Treatment, 28, 77–85.

Winslow, B. T., Voorhees, K. I., & Pehl, K. A. (2007). Methamphetamine abuse.

American Family Physician, 76, 1169–1174.

80

 Pilot Information

Pilot Implementation: PBL Case 2: Facilitator’s Guide Case 2: Diagnosis and

Treatment of a Middle-Aged Man With Chest Pain.

Length of Session: This case requires two sessions, each approximately 60 to 90

minutes.

Results of Pilot Implementation: The Principal Investigator held a pilot PBL

session on December 11, 2008. Six students participated in the session. The
group included one first-year medical student, three second-year medical
students, and two third-year medical students.

The session followed the case and guide closely, although due to the
voluntary, pilot nature of the exercise, the case was discussed over a single
90-minute session rather than two sessions.

81

 Problem-Based Learning:

Session Evaluation Summary Report

Pilot Session Delivered to M1s, M2s, and M3s on 12/11/2008

Demographics:
M1 M2 M3
1 3 2

Please respond to the following items by using the scale provided

(Strongly Agree = 5, Strongly Disagree = 1):
Strongly Strongly
Agree Neutral Disagree N Mean SD
Agree Disagree
The case held my
3(50)* 2(33) — 1(17) — 6 4.17 1.17
interest.
The case was realistic. 1(17) 5(83) — — — 6 4.17 .41
The case was targeted
3(50) 2(33) 1(17) — — 6 4.33 .82
to my learning level.
The case provided me
with new information
about — 1(17) 4(67) 1(17) — 6 2.17 .98
methamphetamine
abuse and addiction.
The size of the group
3(50) 3(50) — — — 6 4.50 .55
was appropriate.
The length of each case
3(50) 2(33) 1(17) — — 6 4.33 .82
section was appropriate.
*N(%)

Please comment on aspects of the PBL session that worked well:

 Could have teaching points on meth after case.
 The step-by-step approach to the case.
 I liked getting each set of new info separately because it made it more like
solving a puzzle.
 Flow of info was good. Information was given as needed and not all at once.
 I enjoyed how each part was presented: Handed out at different times.

Please comment on aspects of the PBL session that could be improved or enhanced:
 The pace could have been faster in order to maximize time spent talking about
the substance abuse (implications, treatments, etc.).

82

 Appendix A
The DSM-IV-TR Criteria for Abuse
The DSM-IV-TR criteria for abuse require a maladaptive pattern of substance use
leading to clinically significant impairment or distress, as manifested by one (or more) of
the following, occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at
work, school, home (e.g., repeated absences or poor work performance related
to substance use; substance-related absences, suspensions, or expulsions from
school; neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous (e.g.,
driving an automobile or operating a machine when impaired by substance use).
3. Recurrent substance-related legal problems (e.g., arrests for substance-related
disorderly conduct).
4. Continued substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance
(e.g., arguments with spouse about consequences of intoxication, physical
fights).
The symptoms in this case never met the criteria for Substance Dependence for this
class of substances.
The DSM-IV-TR Criteria for Dependence

The DSM-IV-TR criteria for dependence require any three of the following seven to be
present in a 12-month period:
1. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the substance to achieve
intoxication or desired effect.
b. Markedly diminished effect with continued use of the same amount of
substance.
2. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndromes for the substance.
b. The same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than was
intended.
4. There is a persistent desire or unsuccessful efforts to cut down or control

substance use.

5. A great deal of time is spent in activities to obtain the substance, use the

substance, or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced

because of substance use.
7. The substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (e.g., continued drinking despite recognition that
an ulcer is made worse by alcohol consumption).

83