SITUATIONAL PROBLEM K002071

1. COPD, severe, in the acute phase. Emphysema of the lungs.

Respiratory failure 3 degrees. Chronic pulmonary heart in the phase of decompensation. Circulatory insufficiency IIB according to the right ventricular type, 3rd functional class. Ascites.

2. The patient has exogenous risk factors for COPD – the index of a smoking person aged 25, work in a hazardous industry.

Prolonged course of the disease, manifested by a productive cough with frequent exacerbations, symptoms of irreversible obstruction of the upper respiratory tract, respiratory failure, chronic pulmonary heart with congestive heart failure of the right ventricular type. The presence of neutrophilic leukocytosis, hyperthermia, purulent sputum indicates the exacerbation phase of COPD. There are radiological signs characteristic of COPD – diffuse enhancement of the lung pattern, manifestations of pulmonary emphysema. ECG shows signs of right ventricular overload. In the clinical analysis of blood – secondary erythrocytosis, which indicates the existence of prolonged severe hypoxemia.

3. Respiratory failure 3 degrees. Emphysema of the lungs.

Secondary bronchiectasis (?)

Chronic pulmonary heart in the phase of decompensation.

Circulatory insufficiency 2b according to the right ventricular type, 3 functional class. Ascites.

Secondary erythrocytosis.

According to the mMRC scale, the patient has very severe shortness of breath, which makes it impossible to leave the house and occurs with minimal physical exertion, which corresponds to the 3rd degree of respiratory failure.

Chronic pulmonary heart in the decompensation phase is indicated by congestive heart failure, hepatomegaly, ascites, signs of overload of the right heart on the ECG. Secondary erythrocytosis indicates severe hypoxemia.

4. Leading role in the diagnosis of COPD is the study of the function of external respiration. It is mandatory to determine the following indicators: vital capacity (VC), fixed vital capacity (FVC), forced expiratory volume in the first second (FEV1) and FEV1/FVC value. The criterion for the diagnosis of COPD is the value of the ratio FEV1/FVC<70%.

Computed tomography of the chest helps to clarify not only the nature of emphysema, but also to detect bronchiectasis.

Echocardiography will clarify the state of the right heart and determine pulmonary hypertension and its severity.

Cytological examination of sputum provides information about the nature of inflammation and its activity.

It is necessary to conduct a bacterioscopic and bacteriological examination of sputum using modern techniques (PCR, DNA diagnostics).

5. In severe COPD, the basic therapy is regular treatment with long-acting bronchodilators:

formoterol, salmeterol (1 inhalation 2 times a day), indacaterol (1 inhalation 1 time per day), tiotropium bromide (1 inhalation 1 time per day), glycopyrronium (1 inhalation 1 time per day).

Since the patient has a severe course of COPD, triple therapy is indicated for him: tiotropium bromide + seretide or symbicort or foster. In the presence of viscous sputum

mucolytic therapy is indicated. Ambroxol (lazolvan) is the most effective. In connection with the exacerbation of COPD, parenteral therapy with systemic glucocorticosteroids in medium therapeutic doses (equivalent to 30-40 mg of prenisolone) is indicated for a period of not more than 2 weeks with a gradual complete withdrawal. Antibacterial therapy with respiratory fluoroquinolones (levofloxacin, moxifloxacin) is indicated. Correction of hypoxia with oxygen therapy.

Situational task 213 [K002072]

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

Main part

Patient Z., 62 years old, was delivered to the emergency room with complaints of chills, shortness of breath, lack of air, severe weakness. He fell ill acutely 3 days ago, when a chill arose, the body temperature rose to 40 ° C, he began to worry about a dry, and then a wet cough with pink sputum that was difficult to separate. Weakness, shortness of breath progressively increased, cough intensified, he did not urinate during the last 24 hours.

On examination, the condition is severe, consciousness is confused. The skin is pale, cool, cyanosis of the lips, acrocyanosis. Subicteric sclera. Body temperature – 35.8 ° C. Breathing is superficial. Respiratory rate – 44 per minute. Pulse – 118 per minute, thready. Heart sounds are muffled. BP – 80/50 mm Hg. Art. Above the lungs, shortening of the percussion tone in the posterolateral sections of the right lung. In the same departments, breathing is weakened, moist rales and pleural friction rub are heard. The abdomen is soft, the liver protrudes 3 cm from under the edge of the costal arch, the edge is soft, moderately painful. There are no peripheral edema.

Blood test: leukocytes – 21 × 109 / l, basophils – 1%, stab neutrophils – 18%, segmented neutrophils – 63%, lymphocytes – 16%, monocytes – 2%, ESR – 58 mm / h., ACT – 0, 7; ALT – 1.28; KShchS: PH – 7.5; P CO2 – 20; P O2 – 50; BE – 10.

Questions:

1. Your presumptive diagnosis.

2. Criteria for the main diagnosis.

3. What complications of the underlying disease do you suppose?

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

5. Treatment tactics, choice of drugs.

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