KURSK STATE MEDICAL UNIVERSITY DEPARTMENT OF POLYCLINIC THERAPY AND GENERAL PRACTICE Head department associate professor N.V. Medvedev OUT - PATIENT MEDICAL CARD Name- Aly Goni Primary Diagnosis- Bronchial Asthma Allergic form modrate degree Concomitant DiagnosisBronchial asthma allergic form moderate dergree,Exerbation immination respiratory Failure 2nd degree , Allergic dermatitis on hand and stage remission By- Gaurav Kumar Group-03, 5th year 2ndsem Faculty-International Kursk -2021 1.Date of filling out the medical card: day month Year - 15-03-2021 2. Surname, name-Aly goni Gender: Male 3. Date of birth: 16-10-1992 4. Place of registration: Kursk District- kursk SettlementStreet, house, flat Lenina 90 city- kursk 5. Employment: Machinery Engineer 6. Place of work, position - Kursk, worker 7. Disability (group) Absent 8. Diseases for which dispensary observation is carried out Bronchial asthma chronic diasese 9. Vaccination Plan of description 1. Main complaints detailed- cough with mucopurulent sputum, rising body temp. till 830 celcius. Shortness of breath , tightness of chest ,inspiratory dyspnea during walking in usual, weezing. 2. History of the disease-patient was doing well then then he get cough during walling and physical excersize and suddnlly he get tightness of chest and difficulty of breathing. -then tempture was increase and weezing rather then patient don’t don’t have any other comlains then he hospitalize in the intensive care. 3. Life history (family, occupational, allergological history, past diseases)patient living in the kursk region patient don’t have truama and his family don’t have any disease. Occupation :-he is an engineer in macheniry company in the kursk region . Financial status:-satisfactorry Living condition :-satisfactory and patient was dressed in satisfactory condition and his dress properly according the session Meals:-satisfactory meal eaten by patient atleast 3 times in a day all the food nutrient. Body hygiene :-patient appers clean and managed. Marital status :-patient not married Familly history :-there is no history of chronic disease running in his familly. Past illness:-patient don’t have any past illness. Habits:-patient smoking 1 packet in a day and he is drinking. Allergy:-patient have allergy with the pollutent and dust. Blood trnsfussion:- no complication and he did not do this 4. Physical examination (detail):- General condition: Satisfactory condition. - Show: patient looks normal for his age. - Consciousness and stages: alert - Posture: forced. - Lock at the face: Absent - well nourished -Skin:satisfactory -Pale Color of the skin and mucous membrane (mucous coat), -No Skin eruptions (rash), -No subcutaneous hemorrhages, No ulcerations, -Nails: Normal -Hair: Normal Texture, absence of patches and brittleness - Subcutaneous fat: present -Edema: no -Decreased Muscular tension, -No Convulsions. No Tremor - Lymphatic System: -Submandibular, axillary, inguinal lymph nodes are palpated, sized 0.5-1 cm in -diameter, of soft consistency, and non-tender - Bones-satisfactory -Head: normal configuration -Nose: normal form with no septal deviation and no involvement of nose wing in breathing -Eyes: Normal sclerotic coat, with no exophthalmos or endophthalmos. Lids, sclera, conjunctivae, cornea, pupils appear normal. Patient’s vision is normal. - Lips: normal -Neck: Normal Structure. - Body temperature. 38 °С -Respiratory System - General Inspection: - the form of chest appears to be abnormal (hypochromic), - equal expansion during respiration -Type of Respiration - thoracic respiration that appears normal -rhythmical and shallow breathing. Vesicular bronchial breathing. - Palpation of the chest - surface of the chest region was normal - vocal fremitus was increased in right lower area - chest rigidity was normal Percussion -Comparative percussion- Resonance sound. In above and lower right side dull -in percussion -Topographic percussion -Altitude of apex- 3.5 cm above the upper border of clavicle. 4cm laterally from -the 7th cervical vertebra-posteriorly. -Lower border of lungs according to following topographic lines: -Parasternal - 5th interspace -Midclavicular - 6th rib -Anterior axillary - 7th rib -Mid axillary - 8th rib -Posterior axillary - 9th rib -Scapular - 10th rib -Paravertebral - T 11- spinous process -Lung mobility- mid axillary 6cm, mid clavicular 4cm and scapula 4cm. - Auscultation:- Vesicular breathing in lungs which is not auscultated on the right side down -from the scapular angle - Crepitation in rights lower area. -Rale - no rales present Cardiovascular system:-Inspection: -Region of heart - heart region appeared normal with no presence of abnormal condition, -shape or pulse, No cardiac humpback -Region of neck - No visible pulsation on the neck - No Aortic arch pulsation, No carotid arteries pulsation ("carotid shudder") -engorgement of jugular veins. Jugular venous pulse - negative -Trachea - positioned at the normal midline region -Peripheral arteries pulsation - No peripheral arteries pulsation was visible - No Quincke’s sign - No wrinkle of arteries -Epigastric pulsation - Not visible epigastric pulsation - No presence of abnormal pulsation -Hypodermic - Chest and abdominal area appear normal with no pathological changes Palpation:- Apex beat was felt at the normal spot medially by 1.5cm to the left -midclavicular line - Intensity of apex beat was normal - Peripheral arteries pulsation; pulsation of radial artery was equal on both -sides with the rate of 78/min Percussion:-Relative dullness Right-1cm lateral to right of sternum - Left-1.5cm medially from midclavicular line. - Upper-3rd intercostals space -Absolute dullness right-right margin of sternum - Left-2.5cm medially to midclavicular line(left) - Upper-4th rib - Revealed normal configuration of heart with the following parameters. ~ Right transverse line = 4cm ~ Left transverse line = 10cm Auscultation:- Normal heart sounds with no presence of murmurs - Auscultation of vessels revealed no pathology Arterial and Venous Pressure Blood pressure was measured at the brachial artery and reading was 130/80mmHg Gastrointestinal system:Inspection -Oral cavity appears normal with no offensive odor. -Teeth: normal -Gums: normal -Mucous membrane of the oral cavity: both hard and soft palate appears pale, -No ulceration -Tongue: size is normal with normal pinkish coloration -Throat: mucous membrane is pale -Tonsils: normal size -Abdomen: normal configuration of the abdominal part - Surface abdominal palpation: palpation revealed no tenderness and muscle. -tension - Stomach: no splash sound heard. -Liver and gallbladder: -No tenderness and enlargement were present. No displacement. Palpable -swellings are not observed in liver. The borders of liver are soft and surface is smooth. -Gallbladder palpation: Normal form, no tenderness, painful points were negative. -Spleen: was not palpable, no tenderness -Urinary organs: Normal skin, no swelling, painful points negative 4.-Clinical syndromes with detalization:-Bronchial obstructive syndrome :charactrized by the inflamed and collased easily and dilation and vasular constriction in the bronchus. 5.Formulation of the leading syndrome:-Bronchial obstructive syndrome -inflamatory syndrome(increase of sputum) 6.Preliminary diagnosis:-Bronchial asthma allergic form because of smoking and drinking as risk factor. 7.Survey plan (laboratory and instrumental studies, necessary specialists):Laboratory investigation :-blood analysis :-we can see level of esionophilia a type of white blood cells. Urine analysis. -Instrumental diagnosis:-Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out. Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign that your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings. Lung function tests often are done before and after taking a medication to open your airways called a bronchodilator (brong-koh-DIE-lay-tur), such as albuterol. If your lung function improves with use of a bronchodilator, it's likely you have asthma. Additional tests Other tests to diagnose asthma include: Methacholine challenge. Methacholine is a known asthma trigger. When inhaled, it will cause your airways to narrow slightly. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal. Imaging tests. A chest X-ray can help identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems. Allergy testing. Allergy tests can be performed by a skin test or blood test. They tell you if you're allergic to pets, dust, mold or pollen. If allergy triggers are identified, your doctor may recommend allergy shots. Nitric oxide test. This test measures the amount of the gas nitric oxide in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels. This test isn't widely available. Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye. Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air. ultrasound x-ray ECG 8.Survey results, their interpretation. 9.Clinical diagnosis according to the accepted classification:- Bronchial asthma allergic form modrate degree excerbation imition,respiratory failure 2nd degree,allergic dermatitis on hand and stage of rimission. 10.Substantiation of the diagnosis:-according to result and according to diagnosis method. 11.Patient management plan (diet, regimen of FA, non-drug and pharmacologicaltreatment according to clinical guidelines, standards of medical care). Diet: • Vegetables and fruits at least 400 g a day • low-fat dairy foods, which contain calcium and vitamin D • Fish, nuts, plant oils which contains Omega-3s may help relieve your joint pain and decrease morning stiffness. • Vitamin c - key element for joint health, vitamin C helps build collagen and connective tissue. Non pharmacological treatment :-Non-pharmacological approaches are an important aspect of asthma management. These approaches are used in combination with medications. Approaches include avoidance of environmental exposures, physical activity and educational interventions. High-level evidence is available for some non-pharmacological approaches. These include avoidance of tobacco smoke exposure, physical activity, healthy diet and avoidance of medications that worsen asthma. Unfortunately, high-level evidence is limited for most non-pharmacological strategies. To generate high-quality evidence, careful consideration must be made to study design and analysis. Useful guidance for non-pharmacological treatment trials is available in from the CONSORT Group (Boutron, Ann Intern Med, 2008). This presentation outlines factors that to consider when in non-pharmacological trials for asthma. Key factors include a clear statement of the research question, the choice of comparator groups, outcome measures, study blinding and patient involvement. Through careful consideration of these factors high quality research of nonpharmacological interventions is possible. Key Points: Asthma management is not just about drug treatment Many non-pharmacological strategies have been proposed in asthma management High-quality evidence for many of these interventions is limited High-level evidence is available for avoidance of tobacco smoke exposure and medications that worsen asthma and promotion of physical activity and healthy diet Quality issues in non-pharmacological studies relate to study design, selection of patient populations, recruitment, intervention approaches, outcome measures, analysis and meta-analysis A CONSORT checklist extension provides guidance for non-pharmacological treatment trials (Boutron, Ann Intern Med, 2008) When planning a study, it is important to consider whether the study is a proofof-concept (efficacy) versus an implementation study (effectiveness) Selection of the treatment comparator can be active or inactive Active comparators include current best practice, matched interventions for nonspecific components and alternative treatment Inactive comparators include placebo or sham treatment Selection of the same comparator groups as other clinical trial studies can facilitate meta-analysis It is desirable that comparator groups be matched for the level of contact with health professionals, as healthcare contact has effects on outcomes Including sufficient detail in study methods is important, to ensure reproducibility across sites and to support blinding Regulatory requirements are lacking for non-pharmacological interventions, compared to drugs and medical devices There is less ability to blind non-pharmaceutical interventions, which increases the potential for sampling bias. Blinding the specific study hypothesis can help with this concern How the intervention is described, and patient expectation of outcomes can have large effects on study outcomes In asthma studies, treatment outcomes for symptom control and exacerbations are often discordant Short-term responses do not necessarily reflect long-term safety in asthma trials Asthma symptoms are modifiable by placebo or sham treatment, but are often used as outcome measures in trials of non-pharmacological treatments Example case: A pharmacist-delivered inhaler technique education intervention resulted in improved inhaler technique, asthma control and asthma-related quality of life (Basheti et al. Patient Educ Couns, 2008) Example case: A double-blinded RCT trial of breathing technique exercises with shallow nasal breathing failed to improve asthma outcomes, when compared to non-specific exercises with no evidence of benefit (Slader, Thorax, 2006) High quality research of non-pharmacological interventions is possible using standardised outcomes, achieving blinding where possible and considering costeffectiveness Involving patients in study concept and design can be beneficial Pharmacological treatment :-Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you'll have an asthma attack. Types of long-term control medications include: Inhaled corticosteroids. These medications include fluticasone propionate (Flovent HFA, Flovent Diskus, Xhance), budesonide (Pulmicort Flexhaler, Pulmicort Respules, Rhinocort), ciclesonide (Alvesco), beclomethasone (Qvar Redihaler), mometasone (Asmanex HFA, Asmanex Twisthaler) and fluticasone furoate (Arnuity Ellipta). You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, inhaled corticosteroids have a relatively low risk of serious side effects. Leukotriene modifiers. These oral medications — including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma symptoms. Montelukast has been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if you experience any of these reactions. Combination inhalers. These medications — such as fluticasone-salmeterol (Advair HFA, Airduo Digihaler, others), budesonide-formoterol (Symbicort), formoterol-mometasone (Dulera) and fluticasone furoate-vilanterol (Breo Ellipta) — contain a long-acting beta agonist along with a corticosteroid. Theophylline. Theophylline (Theo-24, Elixophyllin, Theochron) is a daily pill that helps keep the airways open by relaxing the muscles around the airways. It's not used as often as other asthma medications and requires regular blood tests. Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack. They may also be used before exercise if your doctor recommends it. Types of quick-relief medications include: Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex, Xopenex HFA). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer, a machine that converts asthma medications to a fine mist. They're inhaled through a face mask or mouthpiece. Anticholinergic agents. Like other bronchodilators, ipratropium (Atrovent HFA) and tiotropium (Spiriva, Spiriva Respimat) act quickly to immediately relax your airways, making it easier to breathe. They're mostly used for emphysema and chronic bronchitis, but can be used to treat asthma. Oral and intravenous corticosteroids. These medications — which include prednisone (Prednisone Intensol, Rayos) and methylprednisolone (Medrol, DepoMedrol, Solu-Medrol) — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so these drugs are used only on a short-term basis to treat severe asthma symptoms. If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But you shouldn't need to use your quick-relief inhaler very often if your longterm control medications are working properly. Keep a record of how many puffs you use each week. If you need to use your quickrelief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication. Allergy medications may help if your asthma is triggered or worsened by allergies. These include: Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years. Biologics. These medications — which include omalizumab (Xolair), mepolizumab (Nucala), dupilumab (Dupixent), reslizumab (Cinqair) and benralizumab (Fasenra) — are specifically for people who have severe asthma. Bronchial thermoplasty This treatment is used for severe asthma that doesn't improve with inhaled corticosteroids or other long-term asthma medications. It isn't widely available nor right for everyone. During bronchial thermoplasty, your doctor heats the insides of the airways in the lungs with an electrode. The heat reduces the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks. The therapy is generally done over three outpatient visits. Treat by severity for better control: A stepwise approach Your treatment should be flexible and based on changes in your symptoms. Your doctor should ask about your symptoms at each visit. Based on your signs and symptoms, your doctor can adjust your treatment accordingly. For example, if your asthma is well controlled, your doctor may prescribe less medication. If your asthma isn't well controlled or is getting worse, your doctor may increase your medication and recommend more-frequent visits. Asthma action plan Work with your doctor to create an asthma action plan that outlines in writing when to take certain medications or when to increase or decrease the dose of your medications based on your symptoms. Also include a list of your triggers and the steps you need to take to avoid them. Your doctor may also recommend tracking your asthma symptoms or using a peak flow meter on a regular basis to monitor how well your treatment is controlling your asthma. 12.Examination of work ability:-due to syndrome of bronchial obstructive syndrome with the spirometery. 5. Plan of dispensary observation. 6. Rehabilitation:-Static, dynamic breathing exercises, and sound gymnastics are widely used in the rehabilitation of bronchial asthma. Yoga pays great attention to the system of breathing exercises, the so-called pranayama, which allows you to consciously influence tissue respiration. REFERENCES- (with the obligatory indication of clinical guidelines, standards ofmedical care).medscap and myoclinic and helen reddel woolcock of medical research university of sedney.
