SITUATIONAL PROBLEM K000221

1. Chronic obstructive pulmonary disease, severe course (III stage), emphysematous type, exacerbation. Sop. ischemic heart disease. Angina II FC. Postinfarction cardiosclerosis (Q-former of unspecified age). Ventricular extrasystole. CHF II A. FC II.

2. The diagnosis of chronic obstructive pulmonary disease (COPD) is made on the basis of complaints of progressive shortness of breath, cough, wheezing and heaviness in the chest, long smoking history (30 years); objective data (emphysematous chest and percussion box sound, which, together with the predominance of dyspnea over cough, indicates an emphysematous type of COPD). On the radiograph, changes characteristic of COPD are emphysema and pneumosclerosis. With the help of a spirogram, we clarify the diagnosis (obstruction) and the stage – Tifno test <70% and FEV1=37% (Stage III). The presence of complaints of increased cough, increase and purulent nature of sputum, confirmed by a general sputum analysis, indicates the presence of an exacerbation. history data and

ECG indicates the presence of cardiac pathology. Smoker index – number of cigarettes smoked per day × smoking history / 20 = 20 × 30/20 = 30 pack/years.

3. Pulse oximetry to clarify the severity of respiratory failure, if possible – blood gases. General analysis of blood, urine. Blood glucose, CRP. To clarify the presence of an exacerbation of the disease, or concomitant diseases, or differential diagnosis. Microbiological examination of sputum to verify the pathogen. ECHO-CS to rule out chronic pulmonary heart disease. Control of spirography after treatment to assess the reversibility of bronchial obstruction. Peakflowmetry daily to clarify the reversibility and variability of bronchial obstruction. If necessary – CT scan (presence of bullae in the lungs).

4. Long-acting bronchodilators – primarily M-anticholinergic tiotropium bromide (Spiriva) 18 mcg (caps.) 1 time per day. It is possible to add a long-acting ß2-agonist – Formoterol (Foradil) 12 mcg (caps.) 2 times a day. As needed – Berodual inhalation through a metered dose inhaler or nebulizer. With frequent exacerbations and a good response to glucocorticosteroids, the appointment of Ingal is indicated. GKS. An effective treatment option in such cases is a combination of ICS and a long-acting ß2-agonist, such as Symbicort (Budesonide 160 mcg/formoterol 4.5 mcg). With persistent shortness of breath, theophyllines per os may be added (Teopec 2 times a day). With blood oxygen saturation <90% - long-term low-flow oxygen therapy.

5. The presence of a serious competing pathology – IHD dictates the need to take vital drugs. These drugs include the non-selective ß-blocker Sotalol, which has a side effect in the form of bronchospasm. Due to the presence of obstructive changes on the spirogram, it is recommended to replace it with a selective ß-blocker, for example, Bisoprolol.

Case study 163 [K000222]

Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS

Main part

Patient B., 35 years old, was brought to the clinic by ambulance with complaints of chest tightness, shortness of breath, especially exhalation, excruciating cough. Sick for 10 years with bronchial asthma. Prior to that, he had been observed for several years with a diagnosis

“Chronical bronchitis”. For 5 years, he took Prednisolone 2 tablets per day and inhaled Berotek for suffocation. Exacerbations of bronchial asthma 3-4 times a year, often requiring hospitalization in a hospital. The present worsening of the state connects with the abolition of Prednisolone a week ago. Allergy anamnesis – calm. Attacks of suffocation are preceded by a short episode of excruciating cough, at the end of the attack it intensifies, and viscous mucous sputum begins to stand out in a small amount.

Objectively: the patient’s condition is grave, on examination the patient’s skin is pale, with a bluish tint. The patient sits in the “orthopnea” position. A patient with increased nutrition (gained 15 kg in weight over 3 years). “Cushingoid face”, striae on thighs and abdomen. Speaks in single words, excited. The chest is in the position of a deep breath. The abdominal muscles are involved in the act of breathing.

Respiration is sharply weakened, a small amount of dry wheezing, 32 respiratory movements per minute. Percussion above the lungs box sound in all lung fields, especially in the lower sections. Heart sounds are rhythmic, muffled. Pulse – 120 beats per minute, rhythmic. BP – 140/90 mm Hg. Art., SpO2 – 85%.

During the day he received more than 15 inhalations of Berotek. The ambulance doctor has already intravenously injected 10.0 ml of a 2.4% solution of Eufillin, 60 mg of Prednisolone.

Questions:

1. Formulate a preliminary diagnosis.

2. Justify the diagnosis. How to explain the deterioration of the patient’s condition?

3. What is shown to the patient first of all in this situation?

4. What additional examination should be carried out for the patient when his condition stabilizes?

5. Has the patient received the correct therapy in recent years? Why? What basic therapy would you prescribe to the patient?

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