1. COPD, bronchitis type, extremely severe bronchial obstruction (GOLD 4), with severe symptoms (CAT – 28), high risk of exacerbations, (group D). Chronic pulmonary heart. DN 3 tbsp. CHF IIB, FC III (NYHA).
2. The diagnosis of COPD was established on the basis of complaints of cough with sputum production and shortness of breath, a history of a risk factor (smoking), the presence of signs of bronchial obstruction (dry wheezing, a decrease in FEV1 / FVC <0.7 and a decrease in FEV1), radiological data. The severity of bronchial obstruction was established on the basis of spirometry data (FEV1=30% of predicted values), the risk of exacerbations was established by spirometry data (FEV1=30% of predicted values) and history of previous exacerbations (1 hospitalization for exacerbation in the past year). The combination of these signs corresponds to clinical group D (severe symptoms, high risk). Bronchitis type is established on the basis of complaints and chest x-ray data, characteristic of chronic bronchitis. Cor pulmonale was diagnosed on the basis of ECG data and clinical signs of right ventricular failure (enlargement of the liver, swelling of the lower extremities, swelling of the neck veins), the stage of heart failure - on the basis of symptoms (edema in the legs, enlargement of the liver, swelling of the neck veins), ECG. The degree of respiratory failure was determined based on the severity of shortness of breath (with little physical exertion) and pulse oximetry data.
3. Since the patient belongs to group D, he is preferably shown one of the treatment options:
1) combination therapy with inhaled glucocorticoids and long-acting beta-agonists (for example, Fluticasone 500 mcg + Salmeterol 50 mcg or Budesonide 320 mcg + Formoterol 9 mcg – 2 inhalations per day);
2) long-acting anticholinergics (for example, Tiotropium bromide 18 mcg 1 inhalation per day), or
3) their combination. An alternative therapy is the combination of an inhaled glucocorticoid + a long-acting beta-agonist with a phosphodiesterase-4 inhibitor (Roflumilast tablets 0.5 mg once a day),
or a combination of a long-acting anticholinergic drug with a phosphodiesterase-4 inhibitor,
or a combination of a long-acting anticholinergic drug with a long-acting beta-agonist.
Short-acting beta-agonist bronchodilators (eg, Formoterol) or anticholinergics (eg, Ipratropium bromide) may be given as required.
For the treatment of CHF, an ACE inhibitor (eg, Lisinopril 5 mg/day) or an angiotensin receptor blocker (eg, Candesartan 8 mg/day), a beta-blocker (one of 4 possible drugs – metoprolol succinate, bisoprolol, carvedilol, or nebivolol in very low doses, for example, bisoprolol 1.25 mg / day) and diuretics (torasemide 2.5-5 mg / day).
4. A patient with extremely severe COPD is shown to be examined by a local therapist once every 3 months, by a pulmonologist once every 6 months, and by other specialists (otorhinolaryngologist, dentist, psychotherapist) according to indications. The following diagnostic studies are recommended: anthropometry, large-frame fluorography, ECG, clinical blood count, general sputum analysis with a study on mycobacterium tuberculosis, sputum culture for flora and sensitivity to antibiotics, spirometry with a study of the reversibility of bronchial obstruction, pulse oximetry, test with a 6-minute walk . Additionally (optional studies) shows the study of carbon dioxide in the exhaled air, the study of nitric oxide in the exhaled air.
5. The patient is shown a referral to the bureau of medical and social expertise, as he has signs of permanent disability: severe respiratory dysfunction (DN 3 st.) and circulatory function (CHF st. IIB), as well as a violation of the ability to move and self-service 1 degree.
CASE STUDY 42 [K003095]
Instructions: READ THE SITUATION AND GIVE DETAILED ANSWERS TO THE QUESTIONS
A 52-year-old patient addressed a district physician with complaints of a systematic cough with a scanty amount of mucous sputum, mainly in the morning, shortness of breath with difficulty exhaling during normal physical exertion, and weight loss.
He smokes from the age of 20 (30 cigarettes a day), works as a typesetter in a printing house. Over the previous 5 years, chronic cough has been bothering her; in the last 2 years, progressive shortness of breath when walking has joined, which significantly limits physical performance and weight loss. Two months ago, he suffered from a cold, against which he noted a significant increase in cough and shortness of breath, and took azithromycin on an outpatient basis. The state of health has improved, but severe shortness of breath persists, in connection with which he turned to the clinic. During the last year, there were no similar episodes of colds with increased cough and shortness of breath, except for the indicated one.
Past diseases: right-sided pneumonia at the age of 40, appendectomy in childhood. Allergy anamnesis is not burdened.
The general condition is satisfactory. Reduced nutrition, height 178 cm, weight 56 kg. The skin is of normal color, no edema. The chest is barrel-shaped, on percussion of the lungs – a box sound, on auscultation – diffusely weakened vesicular breathing, respiratory rate – 18 per minute, SpO296%. Rhythmic heart sounds, pulse 88 per minute, accent II tone over the pulmonary artery. BP 130/80 mmHg The abdomen is soft and painless. The liver protrudes from under the edge of the costal arch by 4 cm.
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Draw up and justify a plan for an additional survey.
4. Assign and justify the treatment.
5. Make a plan for dispensary observation.