The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical and pedagogical faculty
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Theme: "Shortness of breath, choking. Differential diagnosis of diseases occurring with bronhoob struction (asthma, COPD, lung cancer).Tactics GPs. Indications for referral to a specialist or hospitalization zations in the profile department.The principles of treatment, follow-up, monitoring, and reabsorption in ilitatsii SVP or joint venture. The principles of prevention.The principles of teaching topics. "
Flow chart classes
The majority of patients with shortness of breath and suffocation, particularly with chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA) to seek medical help. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of COPD and asthma .. In the case of COPD or asthma GPs must determine the severity of the disease, it is necessary to determine the reasons obuslavlivayushie exacerbation of the disease for health care, details of where the dislocation in this group of patients and develop a plan of prevention and clinical examination. 3. Interdisciplinary communication and Intra
Anatomy, histology and cytology with embryology, biology, normal physiology, Biochemistry, Pathology, Pathological Physiology, Topographic anatomy and operative surgery, internal medicine Propedeutics, Tuberculosis, Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy, Hospital therapy, orthopedics 4. The content of classes 4.1. Theoretical part
On a practical lesson in the theoretical part includes analysis of the clinical features of the diagnosis of COPD. COPD is a distinct disease (nosological form) is the final stage of progressive course of COB, the stage at which the disease progresses is lost due to a reversible component of airflow obstruction.This attitude corresponds to the problem, and the International Classification of Diseases, 10th Revision (ICD-10), it is highlighted, under the heading J.44.8 chronic obstructive bronchitis, without further elaboration, that is part of the updated COPD.
Chronic obstructive pulmonary disease (COPD) is a leading place among the causes of morbidity and mortality in the adult population. COPD is a chronic inflammatory process is shown with a primary lesion of the distal airways.For this category of patients characterized by reduced maximum expiratory flow and slow the progressive deterioration of gas exchange function of the lungs, which reflects the irreversible airway obstruction. Biomarkers of chronic inflammation in COPD are part of neutrophils with increased activity of myeloperoxidase, elastase, an imbalance in the systems of proteolysis-antiproteoliz-oxidants and antioxidants. The main clinical manifestations of COPD are cough of varying severity, sputum production and shortness of breath. COPD relates to a group of diseases multigeneticheskih. Externally and internally etiological factors of COPD (risk factors) are separated by the significance. The main risk factor (in 80-70% of cases) COPD - smoking.Smokers have the highest mortality rates, they quickly develop irreversible obstructive changes in respiratory function and all of the known symptoms of COPD. It is believed that reflects the demographics of COPD prevalence of smoking. The most frequently (70%) the cause of COPD is chronic obstructive bronchitis, about 1% of the EL (due to a1-antitrypsin deficiency), the remaining percentage accounted for severe asthma. COB allocation in a separate nosological form is crucial from the point of early diagnosis and treatment at the stage of intact reversible component of airflow obstruction, that is, when the disease has not lost its identity and there is a real possibility of inhibition of progression of the disease by affecting the reversible component of airflow obstruction. The clinical picture of COPD depends on the stage of the disease, the rate of progression of the disease and the priority level of destruction of the bronchial tree.COPD develops in times of risk factors slowly and progresses gradually. The rate of progression and severity of COPD symptoms depend on the intensity of the impact of etiologic factors and their summation. The first signs, which patients usually go to the doctor, is a cough and shortness of breath, sometimes accompanied by wheezing with phlegm.These symptoms are most pronounced in the morning. The earliest symptom of appearing to 40-50 years of life, is a cough. By this time in the cold seasons are beginning to have episodes of respiratory infections that were not connected to the first one disease. Shortness of breath, initially perceived exertion, there is an average of 10 years after cough onset. Sputum production in a small number (rarely more than 60 mL / day) in the morning, a slimy character and becomes purulent only during infectious episodes, which are usually regarded as an exacerbation. As the progression of COPD exacerbations intervals between getting shorter. Results of physical examination of patients with COPD depends on the severity of airflow obstruction, the severity of pulmonary hyperinflation and physique.As the disease progresses to coughing joins wheezing, most notable in rapid exhalation. Often auscultation revealed rales dry raznotembrovye. Shortness of breath can vary over a wide range: from the feeling of lack of air at standard physical exercise to severe respiratory failure. As the progression of airflow obstruction and lung hyperinflation rise anteroposterior chest size increases. Limited mobility of the diaphragm, auscultation picture changes: reduced the severity of wheezing, prolonged exhalation. The sensitivity of physical methods for determining the severity of COPD is low.Among the classic signs can be called a whistling breath and extended expiration time (> 5 s), which may be indicative of bronchial obstruction. Thus, the development and progression of COPD occurs in times of risk factors characterized by a slow gradual onset.The first (the earliest) COPD symptom is a cough. Other characters join later in the progression of the disease, with a gradual acceleration of the progression of the disease. Physical examination in patients with COPD is not enough for a diagnosis of the disease, it provides only guidelines for the future direction of the diagnostic studies using instrumental and laboratory methods.Conventionally, all diagnostic methods can be divided into methods of mandatory minimum, is used in all patients (complete blood count, urine, sputum, chest radiography, the study of respiratory function (ERF, an electrocardiogram), and additional methods used for special indications. For routine clinical work with patients with COPD, in addition to general clinical tests, it is recommended ERF study (FEV1, forced vital capacity or FVC), a test with bronchodilators (b2-agonists and holinolitikami), chest X-ray.The other research methods are recommended for special indications, depending on the severity and nature of its progression. In everyday practice, patients with COPD tests used bronchodilators (b-agonists and / or holinolitikami), which to some extent the ability to characterize quickly regression bronchial obstruction in other words, the "reversible" component of obstruction.The increase in FEV1 during the test by more than 15% of the baseline conditional commonly characterized as a reversible obstruction. 1. Smoking cessation and limitation of external risk factors. 2. Education of patients. 3. Bronhodilatiruyuschee therapy. 4. Mukoregulyatornaya therapy. 5. Anti-infective therapy. 6. Correction of respiratory failure. 7. Rehabilitation therapy. In the formation of the strategy and tactics of treatment of patients with COPD is crucial to allocate two treatment regimens: non-acute treatment (maintenance therapy) and treatment of COPD exacerbations
The teacher asks students questions about classes: 1. Define the term "chronic obstructive pulmonary disease" (COPD) and asthma. 2. Tell classification of COPD and asthma. 3. List the diagnostic criteria for COPD and asthma. 4. List the laboratory and instrumental methods for the diagnosis of COPD and asthma complications and diseases. 5. Give predisposing factors of asthma and COPD. 6. Differential diagnosis of asthma and COPD. 7. Tell the wording of the diagnosis of COPD. 8. List the treatment in acute and non-acute COPD and asthma. 9. Tell the clinical manifestations, laboratory and instrumental methods of diagnosis and complications of lung tumors. Answer: 1. COPD - primary chronic inflammatory disease mainly affecting the distal airways of the lung parenchyma and the formation of emphysema and is characterized by airflow limitation to the development of irreversible (or not fully reversible) airflow obstruction caused by the productive persistent non-specific inflammatory response. The disease manifests cough, sputum and increasing shortness of breath, has been steadily progressive nature with the outcome in chronic respiratory failure and pulmonary heart. BA-disease, which is based on airway inflammation, accompanied by changes in the sensitivity and bronchial reactivity and manifested an attack of breathlessness, status asthmaticus, or, in the absence thereof, respiratory discomfort (paroxysmal cough, wheezing and shortness of breath remote), accompanied by reversible airflow obstruction against the hereditary predisposition to allergic diseases extrapulmonary allergy symptoms, blood eosinophilia and / or eosinophils in the sputum.
2. Recommended classification of COPD severity with the release of four stages is given in accordance with the latest version of the international program "Global Initiative for Chronic Obstructive Lung Disease» (GOLD, 2003). Classification of COPD severity (GOLD, 2003)
Note: FEV1 - forced expiratory volume in 1 s, FVC - forced vital capacity Classification of asthma (see theoretical part). 1. Examples of the wording of the diagnosis; A) COPD, mainly bronhitichesky type, moderate flow (stage II), remission or exacerbation, MD II, chronic pulmonary heart, the degree of heart failure. B) COPD is predominantly emphysematous type, it is extremely difficult for a (stage IV), remission or exacerbation, NAM III, chronic pulmonary heart, the degree of heart failure.
4.2. The analytical part of Case Studies:
1. A patient 50 years appealed to the GP complaining of shortness of breath, cough with purulent sputum. Smoking history of 30 years.The general state of moderate severity, cyanosis, neck veins bulging, epigastric pulsation. In lung auscultation dry and moist rales. Heart sounds are muffled, rhythmic, focus on a 2 tone. Pulmonalis.Blood pressure 130/90 mm Hg Ps -90 ud.v min.KLA-Hb 173 g / l er-3, 9-Leu 10 × 10 9 / L, erythrocyte sedimentation rate, 18 mm. HFVD-FEV 1, 45%, Index Tiffno-57%, VC-75%. 1. Determine the severity of COPD in clinical and functional criteria (GOLD, 2003); 2. Preliminary diagnosis: 3. Enter the X-ray and ECG data; 4. The tactics of the GP;
2. A patient 40 years appealed to the GP complaining of shortness of breath, breathlessness, dry cough. Deterioration of ties with the use of a pill anaprilina. The general condition of medium gravity, expiratory dyspnea, cyanosis of the lips. In the lung auscultation scattered dry wheezing.BH-30 min. Heart sounds tachycardia, muffled. AD 140 - 90 mm HgPs -100 per min.. HB-120g / l, er-4, 0 Leu-7 ,8-7 EPZs ESR-14 mm / h
1. Preliminary diagnosis: 2. Treatment of patients with asthma by desensitization; 3. Enter the pathogenetic mechanisms of aspirin asthma; 4. The tactics of the GP;
3. Patient 18 years. Complaints of choking, wheezing and shortness of breath during physical stress. In the lungs, wheezing. No history of disease was not sick. Auscultation in the lungs of hard breathing. Heart sounds are clear, rhythmic. 1. Enter the immunological and non-immunological mechanisms of asthma; 2. Informative survey methods; 3. Preliminary diagnosis: 4. The tactics of the GP;
4. A patient 57 years appealed to the GP with complaints of cough, hemoptysis, hoarseness, loss of weight. OBJECTIVE: astenik, clubbing as "drumsticks", the increase in cervical l / at the right Horner's syndrome positive right. R-graphy: atelectasis of the right upper lobe. 1. List at least five diseases for which there are the above signs and symptoms (drumsticks); 2. Preliminary diagnosis: 3. Informative survey methods; 4. The tactics of the GP;
5. An appointment with the GP patient received 50 years, complaining of frequent harassing chest pain, cough, weight loss, shortness of breath, fluctuating fever and general weakness. From history, the patient over 30 years of experience in the workshop production of asbestos. OBJECTIVE: lagging behind left rib cage in the act of breathing. Percussion: dullness of sound from left, Auscultation: from left auscultated decreased breath. Complete blood Hb - 80 g / l, Lake. - 12 000, ESR - 30 mm / s. 1.Specify the characteristic radiographic signs of this pathology; 2. Preliminary diagnosis: 3. Informative survey methods; 4. The tactics of the GP;
6. The patient was 42 years old, due to frequent inflammations of the airways complaining of hard phlegm and coughing fits, shortness of breath after minor physical activity and rapid fatigue. From history, the patient over the age of 12 suffering from bronchial asthma. To prevent the disease took a day for the 10-15mg prednisolone and did Ventolin inhalation. An objective examination of notes expiratory dyspnea, cyanosis, 30 breaths per minute. Heart rate of 120 beats per minute, blood pressure 150/90 mm Hg Percussion: there is a box sound. Auscultation: marked common wheezing. FEV1 <60%. 1. The patient what type of respiratory failure is observed; 2. Preliminary diagnosis: 3. Specify the groups bronchodilator; 4. Specify the characteristic radiographic changes; 5.Treatment. Tactics GPs and secondary prevention; __________________________________________________________________ 7. The patient was 58 years old, works as a driver, he entered the reception GP complaining of shortness of breath with minimal exertion, the lack of air, choking, cough, rapid heart beat, on the right upper quadrant. From history, repeatedly ill with pneumonia. In this regard, the colder times of the year the disease is often acute, smoking for 25 years. OBJECTIVE: Patients with severe general condition, cyanosis of the lips, the lungs are common dry and moist rales. Heart sounds are dramatically suppressed, in the pulmonary artery auscultated accent II-tone, heart rate - 1,002 bpm. per min. BP -140 / 80 mm Hg CBC HB - 182 g / l, WBC - 13 × 10 9 / L, the wand 13% neutrophils, segmented neutrophils - 62% lymphocytes, 9% monocytes -2% ESR - 22mm / s FER - FEV1 - 29%, IT - 45%.
1. List at least five diseases for which there are the above mentioned signs and symptoms; 2. Preliminary diagnosis: 3. What kind of change do you find the part of the ECG (data). 4. The tactics of the GP; __________________________________________________________________ 8. At the reception of GPs admitted patient complaining of vasomotor rhinitis, and rashes on the body, shortness of breath, a dry cough. After taking the pill tetracycline rash appeared on the body. Auscultation: in the lungs marked dry wheezing and prolonged expiration, the index Tiffno 50%. After inhalation berotokom Tiffno index was 55%, the number of eosinophils in the blood of 12%. White blood cells 11h10 9 / l.
1. Preliminary diagnosis: 2. Enter the pathogenetic mechanisms of this disease; 3. Index coefficient index Tiffno OK; 4. Treatment. The tactics of the GP; _________________________________________________________________ 9. Patient D. 50 years old, examined by GPs. Complaints of shortness of breath during the inspection at the slightest exertion, swelling in the legs. For 10 years, suffers from chronic bronchitis. In the past 5 years has increased shortness of breath, headache, worry, fatigue. OBJECTIVE: cyanosis of the face, swollen neck veins, swelling of the veins on the exhale increases, bleeding in the sclera of the eye, swelling in the legs. Respiratory rate 26 times in 1 min. In the lungs, both sides are heard, dry and moist rales. Heart sounds, rhythmic, II tone on the pulmonary artery is emphasized. HR 110 in 1min. Liver + 4 cm painful. In the blood: red blood. - 6 million, hematocrit - 65/35.
What complication has arisen? Your diagnosis? List the four diseases for which there are a complication of the above; List the typical 8 Signs for complications of the disease that are present in this patient; Methods of the research. Tactics GPs and treatment. __________________________________________________________________ 10. In the hospital the patient is 60 years old with a diagnosis of bronchial asthma, pulmonary emphysema. CAD: Angina FC III. PEAKS. Donkey.: LN III. NC II B Art. in the direction of the GP. During the last days of the patient's condition was serious. There are chest pain, hemoptysis, cyanosis, edema of the legs, shortness of breath worsened. Nitroglycerin did not remove the pain. NPV 28 in 1min. In mild diffuse dry whistling and fine moist rales unvoiced. Heart sounds, rhythmic, focus and splitting II tone on the pulmonary artery. HR 96 in 1min. Blood pressure 100/60 mm Hg Liver + 3 cm ECG showed hypertrophy of the right ventricle and right atrium. On chest radiograph: the roots of lung congestion, "a symptom of amputation," an arc of pulmonary artery bulging.
What was the reason for the deterioration of the patient? 2.List the four diseases in which there is a complication of the above; List the typical 7 features for complications of the disease that are present in this patient; Methods of the research. Treatment. __________________________________________________________________ 11. A patient 48 years old, the home inspected by GPs. Complaints about the increase of breathlessness at the slightest exertion, headache, drowsiness. Had a history of cough with a small amount of sputum. A year ago, found elevated levels of red blood cells and hemoglobin in the blood, and therefore was produced bloodletting. Somewhat retarded patient communication with him difficult. OBJECTIVE: falling asleep while sitting on a chair, dyspnea at rest, cyanosis of the lips, obesity (height 170 cm, weight 110 kg).The lungs are listened diffuse dry and moist rales. Heart sounds, stress and break down of II tone on the pulmonary artery. Blood pressure 160/90 mm Hg ECG: high and sharp tooth "P" in the II-III and AVF leads. Axis deviation to the right, in the right chest leads high R (R / S V1 greater than 1.0) in the left chest leads increases prong S (R / S V6 greater than 1.0) In the blood, red blood cells 5.5 million On radiographs: bulging arc pulmonary artery.
List the three diseases in which the above symptoms are observed; Your diagnosis; List the typical 10 signs of the disease that are present in this patient; What interpret ECG data? Tactics GPs and treatment. _____________________________________________________________________________ 12. An appointment with the GP patient turned 56 years old, accompanied by relatives complaining of shortness of breath, asthma attacks at the exit of the cold, the rise from the bed and emotional stress, cough with sputum difficult, general weakness. History of the disease: patients consider themselves to be in a few years, is on the "D" account.In the last three months of frequent attacks of breathlessness. Worked as a salesman for many years, smoking a cigarette, do not currently smoke. An objective examination: overall moderate position forced (orthopnea), skin moist and bloodshot face with cyanotic hue, swollen neck veins.Percussion over the light box sound, auscultation - hard breathing, wheezing scattered dry.Heart sounds, accent II tone of the pulmonary artery, the pulse 98 in 1 min. A A 120/70 mmHg
Tests: 1. What is not a reversible component of bronchospasm in patients with COPD: a) hypersecretion of mucus b) smooth muscle cell hyperplasia c) the swelling of the bronchial mucosa d) smooth muscle spasm e) bronchial epithelial hyperplasia
2. What is not a permanent component of bronchoconstriction in patients with COPD: a) hypersecretion of mucus b) epithelial hyperplasia c) the spasm of smooth muscles of the bronchi d) peribronchial fibrosis d) hypertrophy of smooth muscle cells of the bronchial
3. What drugs are not used in the treatment of COPD: a) expectorants b) agonists c) antibiotics g) mucolytics e) cytostatics e) beta blockers
4. Preparations for the basic treatment of bronchial asthma: a) 2-agonists, short-acting b) systemic corticosteroids c) Cromones g) inhaled corticosteroids e) anticholinergics e) Antibiotics
5. Preparations for the relief of bronchial asthma: a) cromones b) systemic corticosteroids by mouth or intravenously c) short-acting methylxanthines / in g) B-2 agonists long acting e) inhaled corticosteroids e) inhaled B-2 agonists, short-acting
6. For prolonged drug theophylline are: a) eufillin b) diafillin c) teopek g) retafil e) diprofillin e) Ditek
7. By selective adrenomimetikami (with a predominant effect on β 2 receptors) are: a) brikanil b) izadrin
c) salbutamol g) Euspiran e) berotek e) astmopent
8. The use of ipratropium bromide, as appropriate: a) for the treatment of young patients b) for the treatment of elderly patients c) in abundant sputum (bronhoree) g) with scanty sputum or no d) at sympathicotonia e) When vagotonia
9. Contraindications to ipratropium bromide are: a) glaucoma b) bradycardia c) adenoma of the prostate d) AV block 1 - degree e) bundle branch block
10. For aspirin asthma is characterized by: a) nasal polyposis b) easy for asthma c) the severity of the asthma g) is very easy for asthma d) sensitization to house dust
11. For moderate asthma is characterized by: a) sharpening 1-2 times per year b) symptom relief injections bronchodilators b) sharpening 3-4 times per year d) the presence of status asthmaticus d) repeating attacks in 2-3 days
12. Asthmatic triad includes: a) chronic sinusitis b) asthma c) non-steroidal antiinflammatory drugs intolerance d) nasal polyposis e) vasomotor rhinosinusopathy
13. Attacks of breathlessness at night (occurring in 3-4 am) to recommend to the patient better at night: a) ingalyapiyu beroteka b) teopek (teodur) inside c) 2 tablets suprastina g) inhalation Intalum d) 2 tablets prednisolone
Cluster (Cluster - bundle, the bundle) - a way of mapping information - gathering ideas around of any of the main factors to focus and define the meaning of the whole structure. Stimulates the actualization of knowledge helps freely and openly engage in new associative thinking process perspective on a topic. Acquainted with the rules of drawing up the cluster. In the center of the chalkboard or a large sheet of paper is written the name of the keyword or topic of 1-2 words. By association with the key word is credited alongside it in the circles smaller "satellite" - the words or sentences that are related to that topic. Connect their lines with the "main" word. These "satellite" can be "small satellites", etc. record goes before the expiration of the allotted time, or until they are exhausted ideas. Exchanged between clusters for discussion. 4.3. Practical part The list of skills that GPs should possess after completing training on the subject 1. Perform a visual inspection of patients with diseases soprovozhdayushihsya breathlessness and suffocation. 2. Interpretation of the analyzes, the data of laboratory and instrumental studies, radiographs of patients with diseases soprovozhdayushihsya breathlessness and suffocation (clinical and biochemical blood tests, coagulation tests, sputum examination, chest x-ray images, the results of pulmonary function, ECG, immunological research, knowledge extraction of foreign technology bodies in the upper respiratory tract). 3. Prescription of drugs depending on the etiology of shortness of breath and choking
5. TYPES OF ASSESSMENT OF KNOWLEDGE, SKILLS AND ABILITIES Orally Writing The solution case studies Demonstration of practical skills mastered
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle of "security" for the patient.
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