Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
Department of Internal Medicine TRAINING GPs with CLINICAL
Allergology
CASE – TECHNOLOGY
Юлдашева Х.Ю., Мавлянов С.И.
For Education on "Syndrome: shortness of breath, choking. Differential
diagnosis of diseases that occur with bronchial obstruction "
CASE
solve the problem of determining the causes bronchoobstructical
syndrome and the development of measures to eliminate or
alleviate it with certain tactics GPs
TASHKENT-2012
2
Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
Department of Internal Medicine TRAINING GPs with CLINICAL
Allergology
CASE - TECHNOLOGY
For Education on "Syndrome: shortness of breath,
choking. Differential diagnosis of diseases that occur with
bronchial obstruction "
CASE
solve the problem of determining the causes
bronhooobstruktivnogo syndrome and the development of
measures to eliminate or alleviate it with certain tactics GPs
ТАШКЕНТ – 2012
3
CASE TECHNOLOGY
for Education on "Shortness of breath, choking. Differential diagnosis of diseases that
occur with bronchial obstruction (asthma, COPD, and lung tumors). Tactics GPs.
case
teaching abstract
The subject: Internal Medicine
Section: "Shortness of breath, choking"
Topic: "The differential diagnosis of diseases that occur with bronchial obstruction (asthma,
COPD, and lung tumors). Tactics GPs.
Course: 6th year of the medical faculty
The purpose of this case: deepen and broaden students' knowledge of diseases involving BOS
syndrome, their classification, the development of practical skills in analyzing the situation and
make informed decisions in the presence of wheezing, breathlessness. Skills select tactics,
diagnosis, emergency care.
Expected learning outcomes: for performance with case students learn how to:
- Evaluation and assessment of the practical situation and the general condition of the patient;
-informed decision-making in the differential diagnosis of diseases associated with shortness of
breath, choking;
- Selecting the right algorithm for the diagnosis of action
- Self-emergency care when necessary, to the hospital for treatment.
For the successful resolution of the case study students should have knowledge of the
pathogenesis, etiology, risk factors, diseases associated with shortness of breath, choking, their
classification, clinical presentation, diagnostic criteria and differential diagnosis, the main
survey methods and principles of therapy.
This case reflects the artificial situation.
The object is a case study in COPD (personality).
Sources of information case:
1.Убайдуллаев А.М.., Нафас органлари касалликлари. » нашриёт-матбаа акциядорлик
компанияси бош мухаририяти. Тошкент – 2004 й.
2.Путов Н.В., Федосеева Г.Б. Руководство по пульмонологии. Ленинград ”Медицина”
Ленинградское отделение 1984 г.
3.Чучалин А.Г. Хронические обструктивные болезни легких. Москва, ЗАО «Издательство
БИНОМ» 2000 г.
4.Туев А.В., Мишланов В.Ю. Бронхиальная астма (иммунитет, гемостаз, лечение). Пермь
2001 г.
5.Баранов В.Л., Куренкова И.Г., Казанцев В.А., Харитонов М.А. Исследование функции
внешнего дыхания. «Элби-СПб» Санкт-Петербург 2002 г.
6.Чучалин А.Г., Абросимов В.Н. Кашель (патофизиология, клиническая интерпретация,
лечение).Рязань, 2002 г.
7.Добротина И.С. Диагностика и лечение бронхообструктивного синдрома. Издательство
НГМА, Нижний Новгород, 2002 г.
8.Убайдуллаев А.М. Функциональные методы диагностики в пульмонологии. Ташкент –
1997 г.
9.«Умумий амалиёт врачлари учун маърузалар туплами» /А.Гадаев. 2010.
4
10.«Умумий амалиёт врачлари учун амалий куникмалар туплами» /А.Гадаев,
Х.Ахмедов. 2010.
11.«Критерий пошаговой оценки медицинского консультирования студентов с учетом
синдромального подхода» /А.Г.Гадаев. 2008.
12.Нормативные документы по деятельности сельского врачебного пункта/1-часть.
//Ташкент 2009.
13.Энциклопедия клинического обследования больного // Денисов И.Н., Ивашкин В.Т.,
Княжев В.А. и др. 2001.
14.Общая врачебная практика по Джону Нобелю//М. 2005.
Дополнительная
1.Воробьева И.И. Двигательный режим и лечебная физкультура в пульмонологии.
Москва, Медицина.,2000 г.
2.Тейлор Д. “Трудный диагноз”. М., 1995 г.
3.Хеглин Р. “Дифференциальная диагностика внутренних болезней”. Медицина 1997 г.,
8-том.
4.Денисов И.Д. Энциклопедия клинического обследования больного, ГЭОТАР, Москва,
Медицина.,1998
Characteristics of case study according to the typological features: This case is classified as a
desk, scene. It is short, structured questionnaires, contains a set of facts.
For didactic purposes Case refers to illustrate the problem, training analysis and assessment,
make informed decisions.
Case presented in print.
Case can be used to discipline internal medicine.
CASE
"Shortness of breath, choking"
Introduction.
The majority of patients with dyspnea and suffocation, particularly in 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 causes of exacerbation of the disease to provide medical care, clarify locations of
this group of patients and plan preventive measures and medical examination.
On practical training in the theoretical part series discusses the clinical features of diagnosis of
COPD, asthma, lung tumors.
COPD - a distinct disease (nosological form) is the final stage of the progressive course of
COB, the stage at which the disease progresses is lost due to the reversible component of airway
obstruction and pulmonary hypertension develops.
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and
mortality in the adult population. The predominant age - over 40. Predominant sex - male.
Etiology and risk factors: smoking - inhibits the function of alveolar macrophages, which
destroys the lung surfactant, slow transport of mucus, increases the release of lysosomal
enzymes. The adverse effects of the environment (including professional). A-antitrypsin
deficiency - increases the sensitivity of lung tissue to autolyze own proteases and leads to the
destruction of the walls of the alveoli, ie to the progression of emphysema. Frequent viral
infections. Alcohol abuse.
COPD refers to a group of diseases multigeneticheskih.
5
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 the demography of bronchial
obstruction in COPD reflects the prevalence of smoking.
COPD is a chronic inflammatory process appears with a primary lesion of the distal airways.
For this category of patients is characterized by reduction in peak expiratory flow rate and a
slow gradual deterioration of pulmonary gas exchange function, which reflects the irreversible
airway obstruction. Biomarkers of chronic inflammation in COPD are involved with elevated
neutrophil myeloperoxidase, elastase, an imbalance in the systems of proteolysis-antiproteolizoxidants and antioxidants. The main clinical manifestations of COPD are cough varying
severity, sputum production and shortness of breath.
COB allocation as a separate nosological form is crucial from the point of early diagnosis and
treatment under Reg reversible component of airway obstruction, ie if there is a real possibility
inhibition of disease progression by affecting the reversible component.
The clinical picture of COPD depends on the stage of the disease, the rate of progression of the
disease and the priority level of the lesion bronchial tree. COPD develops in terms of the risk
factors slowly and progresses gradually. The rate of progression and severity of COPD
symptoms depend on the intensity of the influence of etiological factors and their summation.
The first sign that 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 symptoms that to 40-50 years of life, is a cough. By this time in the
cold seasons are beginning to have episodes of respiratory infection, does not bind to the first
one disease. Shortness of breath, initially perceived exertion, there are on average 10 years after
the appearance of cough.
Sputum production in a small number (rarely more than 60 ml / day) in the morning, has a slimy
character and becomes purulent only during infectious episodes, which are usually regarded as
an exacerbation.
As the progression of COPD exacerbations spacing becoming shorter.
Results of the physical examination of patients with COPD depends on the degree of airway
obstruction, the severity of lung hyperinflation and physique. As the disease progresses to
coughing joins wheezing, most notable for rapid exhalation. Often auscultation revealed
raznotembrovye dry rales. Shortness of breath may vary very widely: from a sense of lack of air
at standard physical exercise to severe respiratory failure. As the progression of airflow
obstruction and lung hyperinflation increase anteroposterior size of the chest rise. Limited
mobility of the diaphragm, auscultation picture changes: reduced the severity of wheezing,
prolonged exhalation.
Sensitivity of physical techniques to determine the severity of COPD is low. Among the
classical symptoms include wheezing breath and elongate expiration (> 5 sec), which may
indicate 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 is a sign of a cough. Other characters join
later in the progression of the disease, with a gradual acceleration of the disease progression.
Physical examination in patients with COPD is not enough for a diagnosis of the disease, it
provides a benchmark 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, used in all patients (general analysis of blood, urine, sputum, chest
radiography, the study of respiratory function (ERF) and ECG), and additional methods used for
special indications.
6
For clinical work with patients with COPD, in addition to general clinical tests recommended
ERF study (FEV1, forced vital capacity and vital capacity) test with bronchodilators (b2agonists and holinolitikami), chest X-ray. The remaining methods are recommended for special
indications, depending on the severity and nature of its progression.
In everyday practice, patients with COPD used tests with bronchodilators (b2-agonists and / or
holinolitikami), which to some extent the ability to fast regression of bronchial obstruction, in
other words, a "reversible" component of obstruction. The increase in FEV1 during the test by
more than 15% from baseline values are commonly characterized as a reversible obstruction.
Tactics GPs.
1. Smoking cessation and limitation of external risk factors.
2. Patient education.
3. Bronchodilatory therapy.
4. Mukoregulyatornaya therapy
5. Antiinfective therapy.
6. Correction of respiratory failure.
7. Rehabilitation therapy.
In forming the strategy and tactics of treatment of patients with COPD is crucial to allocate two
regimens: treatment without exacerbation (maintenance therapy) and treatment of COPD
exacerbations.
Asthma.
Chronic inflammatory disease of the airways characterized by bronchial hyperreactivity, a
common reversible bronchial obstruction. The leading role in inflammation belongs
eosinophils, mast cells and lymphocytes.
The prevalence of the disease, 3% of the total population, up to 7% - in children. Predominant
sex children under 10 years old, male, adults - women.
Risk Factors
Heredity
Allergens products house dust mites, mold spores dander, hair, fibers dried saliva and urine of
domestic animals, bird feathers, food and drug allergy, smoking (active and passive).
Provocateurs (triggers) BA.
Infectious (usually ARI)
Air pollutants-SO2, NO2, etc.
Exercise.
Pungent smells.
Cold air.
Admission B-blockers.
Sinusitis.
Gastro - esophageal reflux.
Clinic-choking or difficulty breathing, expiratory dyspnea, cough, tachycardia, dry wheezing,
worse on the exhale and listens as auscultation, and at a distance (eg, remote wheezing),
percussion - box sound (gipervozdushnost lung tissue) .
Classification of asthma.
Etiologic
Predominantly allergic - atopic asthma.
Non-allergic asthma.
Mixed asthma.
Unspecified asthma.
7
Depending on the severity.
Mild intermittent (episodic) form less than one attack per week, nocturnal symptoms at least 1
time per month, short relapse (from several hours to several days), normal lung function in the
interictal period FEV1 and peak
Volumetric expiratory flow (PIC) is greater than 80% predicted, variations PIC 20%.
Mild persistent form - symptoms more than 1 time per week, but not daily, nocturnal symptoms
more than 3 times per month, the exacerbation can disrupt activity and sleep, the PIC and / or
OFV1st more than 80% of predicted, variations POS to 30%.
Moderate to severe persistent form - daily symptoms, nighttime symptoms more than 1 time per
week, acute violate activity and sleep, daily use of inhaled B-agonists, PIC, FEV1 60 to 80% of
predicted, variations
PIC-20-30%.
Severe persistent form - persistent symptoms and frequent exacerbations, frequent nocturnal
symptoms, limitation of physical activity, POS and / or FEV1
less than 60% predicted, variations PIC over 30%.
Special forms of asthma.
Aspirin-intolerant characterized by aspirin and other
NSAIDs, as well as products containing natural salicylates, manifested severe asthma, until the
development of asthma status, often associated with recurrent polypous rhinosinusitis.
Asthma in pregnancy Laboratory - instrumental investigations.
KLA-eosinophilia, sputum microscopy - is dominated by eosinophils, crystals Charcot Leyden, spiral Kurshmana.
Pikfluometriya - reducing PIC below 80% of normal for the patient's values.
Spirometry - reduced FEV1 below 80% of normal for the patient znacheniy.Obratimost
obstruction-PIC iOFV1 increase after administration of bronchodilators by 15% or more.
Skin tests - positive for certain allergens.
Chest X-ray - gipervozdushnost lung tissue
Tactics GPs.
Eliminating or limiting exposure to allergens and triggers.
Diet - hypoallergenic.
Patient education, monitoring the condition, the frequency of use of an inhaler and other drugs.
Treatment of exacerbations.
Clinical supervision.
Drug therapy Bronchodilators-B2-agonists: short (fenoterol, salbutamol, in acute and prior to exposure to the
provoking factors) and long-acting (salmeterol, Volmax, to prevent attacks, including night,
anticholinergics, Atrovent (ipratropium bromide), berodual (combined preparation of fenoterol
and Atrovent) in severe bronhoree to treat an attack;
methylxanthines, aminophylline in / or / m-acute attack, drugs theophylline sustained release
(teotard, teopek etc.) inward to prevent nocturnal attacks.
Anti-inflammatory therapy
GCS-inhalation-beclomethasone dipropionate, Flixotide, etc., in / in and inside-prednizalon
dexamethasone.
Membrane of mast cell stabilizers (cromolyn sodium, nedocromil sodium, ditek-inhalation,
ketotifen and others in the table., To prevent attacks.
Leukotriene receptor-zefirlukast, montelukast.
Theoretical survey can be carried out using the "Brainstorming"
8
The method of "Brainstorm"
Purpose: This method is used to stimulate the exchange of ideas, increases the degree of
involvement of the participants, teaches argue and defend their point of view, to find the best
solution in this situation.
The teacher asks students questions about the activity:
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 predispose to the development of COPD and asthma factors.
6. Differential diagnosis of asthma and COPD.
7. Tell wording diagnosis of COPD.
8. List the treatment during acute exacerbations of COPD and beyond and BA.
9. Tell 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 with the development of an irreversible (or not fully reversible) bronchial obstruction
caused by persistent productive nonspecific inflammatory response. The disease is manifested
by coughing, sputum and increasing shortness of breath, has been steadily progressive nature of
the outcome of the 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 asthma, status asthmaticus, or, in its absence,
respiratory discomfort (paroxysmal cough, wheezing and shortness of distance), accompanied
by reversible airflow obstruction against the hereditary predisposition to allergic diseases,
extrapulmonary symptoms of allergies, 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)
Stage
The main clinical signs
Functional indicators
I: light
cough, sputum production, usually, but not always.
• FEV1/FVC (IT) <70%
80% of the predicted value
II: Moderate
• Persistent cough, most pronounced in the morning, scanty sputum usually, but not always
Shortness of breath on mild exertion
• FEV1/FVC (IT) <70% FEV1 <80% predicted value.
9
III: severe
persistent cough, sputum, shortness of breath
• IT <70% • 30% <FEV1 <50% predicted value.
IV: Very Severe
cough, sputum, shortness of breath
• IT <70%
• FEV1 <30% predicted value or FEV1 <50% predicted value in combination with chronic right
heart failure or NAM
Note: FEV1 - forced expiratory volume in 1 s, FVC - forced vital capacity
Classification of asthma sm.teoreticheskuyu part.
Examples of formulations diagnosis:
A) COPD mainly bronhitichesky type, moderate flow (stage II), remission or exacerbation, MD
B) COPD, predominantly emphysematous type, very heavy flow (stage IV), remission or
exacerbation, NAM III, chronic pulmonary heart, the degree of heart failure.
The purpose of this case study is to deepen and broaden the students' knowledge of the issues of
timely diagnosis for shortness of breath, choking, caused asthma, COPD or lung tumors, the
development of practical skills in analyzing the situation and make informed decisions on the
management and treatment of COPD, asthma.
The solution proposed case study will allow students to achieve the following learning
outcomes:
- Develop skills in analysis of practical situations, the ability to select the right algorithm for the
diagnosis of action
Ability to work off-informed decision-making in patients with COPD and asthma;
- Develop clinical reasoning.
Situation.
An appointment with a GP, accompanied by relatives turned 32 years old patient with
complaints of asthma is difficult to breath when entering the cold air, rising from the bed and
nervous tension, cough with difficult scanty sputum, weakness, insomnia.
From history-sick for 20 years, as a child hives and shortness of breath when going out of town.
Asthma attacks in the past 10 years. Exacerbation of the disease is often in the spring and early
summer. Suppresses seizures inhaled salbutamol, aminophylline injection, is in "D" account. In
the last 3 months of frequent attacks, 1-2 times a week at night worried. Works as a shop in the
grocery store. Smoked 6 years, in the last 5 years does not smoke.'s Mother and brother
allergodermia.
An objective examination: moderate condition, the position of orthopnea, cyanosis of the lips,
hands, breathing with minor muscle and extended expiration. Over light percussion lung sounds
of the boxed color. Auscultation: a weakened vesicular breathing, scattered dry wheezing. Heart
sounds are muffled, accent II tone of the pulmonary artery. Pulse 88 in 1 min. Blood pressure
120/70 mm Hg. Abdomen soft and painless. Regular chair. The liver was not enlarged. Diuresis
b / o. Symptom effleurage negative on both sides.
KLA.
7% monocytes, 7%, ESR 16 mm / h
OAM. 0.033% 0 protein, leukocytes 1-2/1, 0-1/1 epitope, erythema 0-1/1.
10
Sputum-character-mucosa, leukocytes-1-2, alveolar macrophages - 3-4, eosinophils, 7-8, Charcot-Leyden
crystals, spiral Kurshmana, BC and abnormal cells - no.
LHC. Sugar 5.3 mmol / L, total cholesterol 5.5 mmol / L, ALT 0.3 mmol / L, AST, 0.2 mmol / L, bilirubin 13.1
mmol / L, creatinine 0.05 mmol / L, urea 7.2 mmol / l.
Coagulation. PTI 85%. Fibrinogen 300 mg%.
ECG revealed sinus rhythm, correct. HR 88 v1min. EOS denied the right, P-pylmonalae. Incomplete right bundle
branch block.
Chest X-ray - lung fields promoted luchepronitsaemosti,
Questions and tasks:
1.On your opinion, what abnormalities to make a differential diagnosis?
2.What to the emergence of this disease?
3.Vash diagnosis. Justify it.
4.Specify tactics GP.
A training material for students:
"Differential diagnosis of COPD and asthma"
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 with the
development of an irreversible (or not fully reversible) bronchial obstruction caused by
persistent productive nonspecific inflammatory response. The disease is manifested by
coughing, sputum and increasing shortness of breath, has been steadily progressive nature of the
outcome of the 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 asthma, status asthmaticus, or, in its absence,
respiratory discomfort (paroxysmal cough, wheezing and shortness of distance), accompanied
by reversible airflow obstruction against the hereditary predisposition to allergic diseases,
extrapulmonary symptoms of allergies, blood eosinophilia and / or eosinophils in the sputum.
Framework for the diagnosis of any disease with bronchial obstruction is a well-built and well
conducted anamnesis. In unclear cases a sputum and respiratory functions, test with
bronchodilator. Tactics of diagnosis determines the sequence of the following schematic to
address key issues: the identification of risk factors, determining the intensity and duration of
their impact on patients, especially allergoanamneza, onset than provoked by shortness of
breath, choking, whether they are paroxysmal in nature or not, what complications are attached,
the changes identified in the laboratory and instrumental examination of the patient, bronchial
obstruction and the degree of reversibility.
II. Methodical instructions student
The problem: determination of the cause of bronchial obstruction and development of
measures to eliminate or alleviate it with certain tactics GPs.
Instructions for independent work in the analysis and solution of practical situations.
№
1.
2.
Stages of work
Recommendations and advice
First, read the case studies.
Familiarization with case

Reading, Do not try to analyze the
situation.
Once again, read the information. Highlight those
paragraphs that seemed important to you. List the
Acquaintance with a given factors set forth in the description of the event.
situation.
Try to describe the situation. Identify what it
important and what is secondary.
11
3.
4.
5.
6.

Trying to understand the wealth of
information available to you, "do not drown" in
it, try to identify the main.
Identification, creation and Problem: The determination of the cause of
study key issues and sub- bronchial obstruction (RF, the allergens that
problems.
trigger
Factors irritants) and development activities and to
facilitate the relief of breathlessness, suffocation
with certain tactics GPs.
Diagnostics and analysis
When analyzing the situation, answer the
following questions:
1. Disease, the main clinical symptoms are
shortness of breath and asthma? Much different
pathogenesis, clinical bronchial obstruction at
them?
2. What risk factors contribute to the development
of COPD, asthma, lung tumors?
3. Which diagnostic methods must be applied,
make a plan and justify the level survey hovercraft
or SP, CRH?
4. What specialized diagnostic methods are
necessary to confirm the diagnosis?
5. Determine whether emergency aid.
6. The basic principles of non-drug and drug
treatment of COPD, asthma.
7. Diagnosis and service category for a given
situation?
Selection and justification of
ways and means to solve the
problem.
Development of measures for
implementation of the proposed
resolution of the problem
situation.
List all the possible ways and means of addressing the
situation.
Put diagnosis. Develop measures to eliminate the risk
factors and identify methods of dealing with them.
Solve the problem in a hovercraft, joint venture or a
specialized department of the clinic.
Instructions for group work to analyze and solve practical situation.
Stages of work
Recommendations and advice
Reconciliation of the situation and the
problem.
Discuss and agree on various representations of the
group members about the situation, the problem and
the subproblems.
Discuss and evaluate the proposed options and ways to
address the problem. Select the priority, in your
opinion, the idea of solving the problem.
Analysis and evaluation of the
proposed methods and means of
solving problems, the choice of priority
the idea to solve the problem.
Develop mutually acceptable solution
to the problem and detailed design
implementation.
Prepare a presentation
Develop a mutually acceptable solution to the problem
and the detailed design implementation.
Make the results in the form of an oral
12
presentation on behalf of the group. Discuss and
decide the question of who will represent the
results of the group work: the leader of the whole
group, or with the division between the
participants (co-reports), depending on the tasks to
be solved by them in the course of analyzing and
solving problems.
Prepare illustrative materials in the form of
posters, slides or multimedia.

In the preparation of reports, especially
mark the rough outline of what you say, do not go
into the details!
Sheet analysis and problem solving
The name of the stage with a The content of work stage
briefcase
Acquaintance with a given situation Review given the particular situation and
in a case
determination essential to solving the problem of
information.
When analyzing the situation, answer the
following questions:
The situation analysis
1.How disease is most often accompanied by
shortness of breath, asthma.
2. Risk factors for COPD.
3.For what disease is characterized by a history
of allergic reactions?
4.Faktory risk of asthma in this patient.
5. For what disease is characterized by springsummer season of acute illness?
6.Stepen effective bronchodilator therapy.
7.Naibolee informative methods are needed to
confirm the diagnosis, and which ones can be
realized in a hovercraft and SP.
8.How do more consultation is needed for a final
diagnosis?
substantiation is
Choice of alternatives addressing
Development and justification of
solution
Justification of the problem and its key components.
Formulation of alternatives solutions situational
problem.
Detailed development and justification of a particular
decision.
13
Table assessment of individual work with case
The
Evaluation criteria and indicators
participants
Analysis of
the current Substantiation
situation
is max 0,5
max 1,0
Detailed
Choice
of development
methods and of measures The overall
means
of to
score
addressing
implement
(max 2,5) *
max 0,5
the decision
max 0,5
1.
2.
№
* 2.0 - 2.5 points - "excellent", 1.5 - 2.0 points - the "good"
1.0 - 1.5 points - "satisfactory"
less than 1.0 points - "unsatisfactory"
The evaluation system options group decision problem.
1. Each group is given two evaluation points. It can give them all at once to one embodiment of
the decision or split into two (1:1 0,5:1,5, etc.), not including the assessment of their own
solutions.
2. All the scores for each alternative solutions are added. The winner is the solution with the
highest number of points. In disputed cases, you can take a vote.
Table evaluate options group decision problem, the score
Groups
Alternative solutions to problems
1
2
3
№
1.
2.
№
total
Оценка презентации предлагаемого решения
Group Completen
ess
and
clarity of
presentatio
n (1 - 20)
Visibility
of
representat
ion of the
universe of
presentatio
n (1 - 20)
Mass
susceptibi
lity and
activity of
members
of
the
group (1 20)
Originalit
y
proposed
decision
(1 - 20)
Admissibility
of
the
legislative
standards
(1 - 20)
The total
amount
of points
(max
100)
14
1.
2.
№
Option III solutions case study teacher-keysolog
1. What range of common diseases, accompanied by shortness of breath, asthma.
• COPD
• Asthma
• Lung Tumors
• PE
• Pulmonary tuberculosis
• Heart failure
• Spontaneous pneumothorax
• bronchiectasis
• Pneumoconioses
2. Which diagnostic methods should be applied? Plan Survey by categories 3.1 and 3.2.
• History
• blood pressure, pulse, temperature
• These physical examination (Systems)
• ECG, KLA, OAM,
• Pikfluometriya
• General analysis of sputum, sputum culture
• Coagulogram, hematocrit
• The gas composition and acid-base balance of blood
• Chest X-ray
• Spirography
• Bronhodilyatatsionny test
• allergy tests
• echocardiography,
Lecture dif.diagnoz.
Given these situational problems - asthma, when entering the cold air, exertion, seasonal
exacerbations, the presence of risk factors, physical examination findings (wheezing) is
necessary to differentiate between asthma, COPD, lung tumors.
Non-pharmacological treatment.
Medication.
IV. Case Study Technology for practical training.
Model of learning technologies
Theme:
Number of hours - 6.5
Form of studies:
Plan Workshops:
Differential diagnosis of dyspnea in
patients with COPD and asthma, asthma
and lung tumors
Number of students - 9.
Exercise increase knowledge of asthma and
COPD, practical skills and determination of
the patient tactics
1. 1. Introduction to the training
15
The purpose of the training session:
Tasks the teacher:
- To consolidate and deepen the students'
knowledge about the differential. diagnosis
of asthma and COPD, to develop students'
skills of self-informed decision-making for
shortness of breath and choking.
- To develop the skills of the patient:
- A culture of debate, communication skills
Teaching methods:
Learning Tools:
Offer
Learning conditions:
Monitoring and evaluation
session
2. 2. actualization of knowledge
3. 3. Working with case studies in
small groups
4. 4. Presentation of the results
5. 5. Discussion, evaluation and
selection of the best options strategy
6. Execution skills
Conclusion. Evaluation of the
groups and students, the degree of
achievement of lesson.
Consolidation, deepening and expanding
students' knowledge of the issues of timely
diagnosis for shortness of breath and
asthma, the development of practical skills
in analyzing the situation and make
informed decisions in the treatment of
asthma and COPD
Learning outcomes:
- Classify, characterize the clinical features
of asthma and COPD, explain the
significance of risk factors in the
development of the disease;
- Analyze the situation presented in the
case;
- Allocate and formulate the problem,
objectives, situation;
- Based on the analysis of the situation to
make informed decisions to resolve it activities carried out in the treatment of
asthma and first aid;
- Make a final conclusion, rightly defend it;
- Carry out practical skills.
Case studies, discussion, practical skills
Case, student guidance, flip chart
Individual, front, group work
Audience, work with a group, a hospital
ward, room
Observation, quiz, presentation, evaluation
Technological map of lesson
Этап работы
Содержание деятельности
16
Teachers
Phase
I
- 1.1. Calls subject classes, its purpose,
Introduction
to objectives, and expected outcomes of training
the
training activities.
session
1.2. Introduces the mode of operation for
(10 min)
employment and evaluation criteria (see
guidance for students).
1.3. Explains the purpose of the case study
and its impact on the development of
professional knowledge.
1.4. Distributes materials case and introduces
the algorithm for analysis of the situation (see
guidance for students).
1.5. Gives the task independently analyze and
record the results in the "List of analysis of
the situation."
phase II
2.1. Conducting a poll in order to enhance
primary
students' knowledge on the topic:
60 min.
students
listen
record
Independently study the
contents
of
the
individual case and fill
the sheet of the situation.
Answer questions.
at the heart attack of breathlessness in
asthma?
asthma?
final diagnosis?
attacks?
2.2. Divides students into groups.
Reminds Group norms and rules of debate.
2.3. Gives the task:
Divided into groups.
individual work with a case (situation analysis
sheets) in small groups;
Perform
task.
activities to address suffocation;
entation.
2.4. Coordinates, advises, directs the learning
activities.
Monitors and evaluates the results of
individual work: sheets of the situation.
2.5. Of the presentation on the results of the
work done to address the case study,
discussion and vzaimootsenki.
2.6. Comments, notes about the selected event
in the analysis for the treatment of asthma.
2.7. Tells own solution.
the
learning
17
Groups are involved in
the presentation of the
results. Participate in
discussions,
ask
questions, evaluate.
10 min
2.8. Organizes a student's skills
Palpation,
percussion,
auscultation,
conduct
and interpretation of data
pikfluometrii
IIIetap-A
Final 3.1. Sums up the lesson, summarizing the listen
Assessment
results of training activities, announces
10 min.
evaluation of individual and collaborative
work.
3.2. Stresses the importance of the case study Opine
and its impact on the future specialist.
3.3 gives homework.
record
Example address patient
presented in the case studies
Situation.
An appointment with a GP, accompanied by relatives turned 32 years old patient with
complaints of asthma is difficult to breath when entering the cold air, rising from the bed and
nervous tension, cough with difficult scanty sputum, weakness.
From history-sick for 20 years, as a child hives and shortness of breath when going out of town.
Exacerbation of the disease is often in the spring and early summer. Suppresses seizures inhaled
salbutamol, aminophylline injection, is in "D" account. In the last 3 months of frequent attacks,
18
1-2 times a week at night worried. Works as a shop in the grocery store. Smoked 6 years, in
the last 5 years does not smoke.
An objective examination: moderate condition, the position of orthopnea, cyanosis of the lips,
hands, breathing with minor muscle and extended expiration. Over light percussion lung sounds
of the boxed color. Auscultation: a weakened vesicular breathing, scattered dry wheezing. Heart
sounds are muffled, accent II tone of the pulmonary artery. Pulse 88 in 1 min. Blood pressure
120/70 mm Hg. PT. Abdomen soft and painless. Regular chair. The liver was not enlarged.
Diuresis b / o. Symptom effleurage negative on both sides.
KLA.
17% monocytes, 7%, ESR 16 mm / h
OAM. 0.033% 0 protein, leukocytes 1-2/1, 0-1/1 epitope, erythema 0-1/1.
LHC. Sugar 5.3 mmol / L, total cholesterol 5.5 mmol / L, ALT 0.3 mmol / L, AST, 0.2 mmol / L,
bilirubin 13.1 mmol / L, creatinine 0.05 mmol / L, urea 7.2 mmol / l.
Coagulation. PTI 85%. Fibrinogen 300 mg%.
ECG revealed sinus rhythm, correct. HR 88 v1min. EOS denied the right, P-pylmonalae.
Incomplete right bundle branch block.
X-ray - hilar compacted lung fields promoted luchepronitsaemosti,
Date:
I
complaints:
II
III
IV
Anamnesis
morbi:
Anamnesis
vitae:
Risk factors:
V
Problems
VI
General
examination:
VII
The patient is 32 years old, the seller, the floor - M Index smoker - 60
-72. t0C = 36,5, Pulse 88 minutes. A / D 120/70 mm. Hg. Art.
for asthma attacks with difficult breathing out when leaving the cold
air, rising from the bed and nervous tension, cough with difficult
scanty sputum, weakness.
He considers himself a patient for 20 years, dyspnea, and rash
bothered when going out of town, asthma attacks in the past 10 years.
Exacerbation of the disease is often in the spring and early summer.
Suppresses seizures inhaled salbutamol, aminophylline injection, is in
"D" account. In the last 3 months of frequent seizures, is in the
dispensary.
Growing and developing in satisfactory conditions, smoked for many
years, dropped out, was sick with hepatitis, hereditary, allergic and
epidemic anamnesis denies.
Managed: smoking, exposure to allergens, hypothermia
Unmanaged: gender, age and heredity.
Key: asthma, cough with difficult expectoration, wheezing with
difficulty exhaling.
Related: weakness, insomnia.
The general condition: the state of moderate severity, location
orthopnea, cyanosis of the lips, hands, breathing with minor muscle
and extended expiration.
Respiratory system: over light percussion lung sounds of the boxed
color. Auscultation: a weakened vesicular breathing, scattered dry
wheezing. CCC: border of the relative dullness of the heart were
normal. Heart sounds are muffled, accent II tone of the pulmonary
artery. Pulse 88 in 1 min. Blood pressure 120/70 mm Hg.
Digestive organs: Abdomen soft and painless. Regular chair. The liver
19
VIII
Preliminary
diagnosis:
Survey plan
by:
IX
Research
category 3.1:
X
XI
Interpretatio
n of clinical laboratory
and
instrumental
experimental
analysis:
The
differential
diagnosis:
XII
was not enlarged.
Urine: Urine output b / o. Symptom effleurage negative on both sides.
No edema.
Main: Asthma III level, persistent current.
Complication: NAM II degree.
Category 2.
Category 3.1:
- Professional questioning and inspection
- KLA, OAM
- pikfluometriya
ECG
-total sputum
Category 3.2:
- Bacteriological sputum culture with antibiotic susceptibility
- X-ray methods
KLA
Pikfluometriya
ECG
Self-stepping
KLA: eosinophilia - 8%, ESR-slightly increased to 15 mm / h
OAM and biochemical blood tests - normal.
The general analysis of sputum: dominated eosinophils, CharcotLeyden crystals, spiral Kurshmana.
Chest X-ray: gipervozdushnost lung tissue.
Pikfluometriya-MPV reduction (PIC) and FEV1 on spirometry data
below 80% of normal for the patient's values.
ECG showed sinus tachycardia, heart rate 92 in 1min., P-rulmonalae,
right bundle branch block
Asthma, family history, history of allergic reactions, asthma attacks,
no attacks - almost healthy, seasonal exacerbations, the reversibility of
bronchial obstruction, UAC - eosinophilia in sputum eosinophils
predominate, are the spiral Kurshmana, Charcot-Leyden crystals.
COPD - risk factors - smoking and prolonged exposure to adverse
environmental factors (including professional), alcohol abuse,
frequent viral infections, the predominant age over 40 years, the
absence of attacks of breathlessness, in times of acute outbreaks of
SARS and hypothermia, mucous and phlegm often - purulent ,
increased body temperature, sputum neutrophil-dominated, FVDvalues of FEV1 and PIC reduced minimum speaker after use
bronchodilator.
Pulmonary tuberculosis: the study of sputum revealed mycobacteria
from the history prolonged contact with smear, infiltrative pulmonary
tuberculosis is more often localized in the S1, S2, S6 segments of the
lung.
Lung cancer: for a long time without symptoms, asthma and shortness
of breath worrying compression of the bronchi, may hemoptysis,
weight loss, depression, anemia, changes in the diagnostic X-ray and
CT scan, sputum - atypical cells, red blood cells.
20
XIII
XIV
Clinical
diagnosis:
Determined
the form in
which the
prevention of
the patient
needs:
Drug-free
treatment
Main: Asthma III stage, medium-severe persistent current.
Complication: NAM II degree.
Category 2.
Secondary prevention and b: to identify and make an accurate
diagnosis in the early stages of the disease, non-drug treatment for the
disease and drug therapy of proven efficacy.
Tertiary b-diagnosis complications, treatment.
1. bed rest
2. Health food - easily digestible, enriched with vitamins and proteins
food
3.Lechebnaya breathing exercises
4. Prohibited from smoking and alcohol.
5. Positional drainage, chest compressions
6. oxygen therapy
Medication: 1.Bronholitiki - B2 - agonists - inhalation
-salbutamol (Ventolin) for 1-2 breaths - 3 times a day
- M anticholinergics - atrovent inhalation, 1 inhalation 2 times a day
- Theophylline (teopek, teodur and TE) 200 mg - 1-2 times a day
2. Anti-inflammatory treatment:
- GCS - prednisone 60 mg -90 fiz.rastvore / drip, beklametazon
inhaled
- Antihistamines (suprastin, ketotifen)
3. Mucolytics - Ambrobene in tablets of 30 mg 3-4 times a day,
XVI
sodium bicarbonate 4% -200 ml / drip
4. Drugs to reduce pulmonary hypertension - calcium channel
blockers (verapamil)
Convinced of the need for patient hospitalization in a specialized
XVII
Spent the
feedback to pulmonary department at discharge - a visit to a GP, setting the date
set a date and of re-examination and investigation. Convinced of the patient's
understanding of the recommendations.
time of
follow-up visit
the patient in
the joint
venture or
SVP to
monitor the
effectiveness
of treatment:
XVIII Took patient Group clinical supervision D3s
registration,
predetermined
by the teamsulfur
dispensary
observation
XV
21
XIX
All types of
prevention:
XX
Stages of
clinical
examination:
Primary prevention - prevention of the disease: a) to promote a
healthy lifestyle
B) early detection of risk factors and the removal of controlled risk
factors, exposure to allergens, polyutantami, occupational hazards,
improving ekologiiP
.
Secondary prevention: a) the identification of the disease in the early
stages (preventive checkups, screenings)
B) timely drug and non-drug treatment of identified diseases with the
use of drugs with proven efficacy.
Tertiary prevention: a) timely observation of patients, prevention of
acute and chronic complications, monitoring, laboratory and
instrumental studies, the use of drugs with evidence, correction of risk
factors, and dynamic monitoring;
B) continuing treatment measures and qualitative rehabilitation of
existing complications
Stages of clinical examination after the final diagnosis:
1st - determine nosological form of the disease and clinical
examination of the group-III-D
2nd - definition of multiplicity of observations (medical
examinations) for the first year and 1 time in a month, then 1 every
3mesyatsa.
3rd - justification consultation specialists when indicated, pulmonary,
tuberculosis, allergist, 1 time a year.
4th - justification multiplicity planned laboratory and other
examinations for the year - the KLA and sputum, ECG one every six
months, chest X-1 once a year.
5th - drawing algorithm therapeutic and recreational activities as a
general practitioner for a year - in-patient treatment in a specialized
pulmonary department 2 times a year, a spa treatment one time per
year. LFC-regular classes.
6th - On the basis of clinical examination of the performance criteria
specific patient move from one patient to another dispensary group
when necessary.