SITUATIONAL PROBLEM K000222

1. Bronchial asthma, endogenous form, severe persistent course, exacerbation. Chronical bronchitis. Pneumosclerosis. Donkey Asthmatic status I st. ODN II Art. Exogenous hypercortisolism.

2. The diagnosis of “bronchial asthma, endogenous form, severe persistent course” is made on the basis of complaints of frequent asthma attacks, frequent coughing, chest tightness; history data (previous chronic bronchitis, the effect of treatment with corticosteroids and bronchodilators, frequent exacerbations of asthma requiring hospitalization). In this case, the absence of an allergic anamnesis. The patient developed a severe complication of BA – asthmatic status I stage. (prolonged asthma attack, orthopnea, tachypnea, tachycardia, decreased blood oxygen saturation, weakened breathing in the lungs). SpO2 – 85% indicates ODN II st. The presence of obesity, “Cushingoid face”, striae on the body against the background of long-term use of Prednisolone per os indicates exogenous hypercorticism. The deterioration of the patient’s condition is most likely due to the complete abolition of Prednisolone and the lack of basic therapy.

3. Inhalation of oxygen – 4 l / min. Berodual inhalations through a nebulizer (preferably on O2) 3 times in 1 hour, after – 1 time per hour until the condition stabilizes. Corticosteroids IV (Prednisolone 60-120 mg or Hydrocortisone 200 mg). The daily dose of corticosteroids in / in in terms of Prednisolone (Metipred) up to 600-700 mg. Preparations of the 2nd line – Eufillin in / in drip, adrenaline n / c, in / in, Magnesium sulfate in / in.

4. Pulse oximetry to clarify the severity of respiratory failure (performed daily). General analysis of blood, urine. Blood glucose, CRP. General analysis of sputum, if possible, microbiological examination of sputum. Spirography. Peakflowmetry. X-ray of the OGK. ECG.

5. In recent years, the patient received incorrect therapy: systemic corticosteroids should not be prescribed to patients with BA as basic therapy. The patient did not receive a drug from the main group of basic therapy – inhaled corticosteroids, as well as a prolonged bronchodilator. The presence of signs of exogenous hypercortisolism is explained by the long-term use of Prednisolone.

The patient should be prescribed inhaled corticosteroids + long-acting bronchodilators (ß2-agonists), better fixed drugs (Symbicort 160/4.5, 2 breaths 3 times a day or Seretide 25/500, 2 breaths 2 times a day). Taking into account the severity of BA and the presence of chronic bronchitis, add the long-acting M-anticholinergic Tiotropium bromide (Spiriva) 1 capsule (18 mcg) per day to the treatment. With persistent shortness of breath, it is possible to add theophyllines (Teopec or Teotard). Against the background of basic therapy, a gradual decrease in the dose of Prednisolone is necessary, if possible until cancellation or to the minimum dose at which there is no deterioration in the condition. It is possible to revise the basic therapy taking into account the principle of stepwise therapy and the patient’s condition.

Case study 164 [K000223]

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

Main part

Patient N., 30 years old, came to the clinic with complaints of general weakness, dry mouth, polyuria, blurred vision, numbness, paresthesia in the lower extremities, and frequent hypoglycemic conditions (at night and during the day). I have been suffering from diabetes since the age of 15. Diabetes manifested as ketoacidosis. Receives Humulin NPH – 20 IU in the morning, 18 IU in the evening and Humulin Regulator – 18 IU / day. Leads an active lifestyle, trained in self-control techniques.

Objectively: the general condition is satisfactory. Physique, male pattern hair. BMI – 19 kg / m2. The skin is dry and clean. In the corners of the mouth jams. There are no peripheral edema. The thyroid gland is not enlarged, in the lungs – vesicular breathing, no wheezing. Rhythmic heart sounds, pulse – 82 beats per minute. BP – 120/80 mm Hg. Art. The abdomen is soft and painless. The liver and spleen are not enlarged. The skin of the legs and feet is dry, there are areas of hyperkeratosis on the feet, the pulsation on the arteries of the rear of the foot is satisfactory.

The results of the examination: fasting blood glucose – 10.4 mmol/l, 2 hours after eating – 14.5 mmol/l. Urinalysis: specific gravity – 1014, protein – traces; leukocytes – 1-2 in the field of view. Optometrist: fundus – single microaneurysms, hard exudates, macular edema.

Podiatrist: decreased vibration, tactile sensitivity.

Questions:

1. Formulate a preliminary diagnosis.

2. Justify your diagnosis.

3. Draw up and justify a plan for additional examination of the patient.

4. Name and justify the target level of glycosylated hemoglobin in this patient.

5. Carry out and justify the correction of hypoglycemic therapy.

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