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    Asthma discussion

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    Dr:Sonia
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    الاقامة : الخرطوم- السودان
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    تاريخ التسجيل : 27/10/2008

    ممتاز Asthma discussion

    مُساهمة من طرف Dr:Sonia في الأربعاء 25 فبراير 2009, 7:42 pm




    الموضوع دا عبارة عن حالة ومعها عدة اسئلة ياريت تشاركونا بالحلول



    A 26-year-old white female was brought to the Emergency Room by her husdand because of shortness of breath and wheezing. She claims to have "asthma" which has been worse for the past two months. Recently, she complains of more frequent and severe attacks in addition to a persistent cough which has been especially troublesome at night. She has started to intermittently produce increasing amounts of thick yellow sputum and complains of frontal headaches, especially in the morning, for the past two weeks. She complains of chest tightness but denies fever. She has been using Primatene Mist every 1 to 2 hours for the past 24 hours with decreasing efficacy.

    The ER physician notes that the patient is in moderately severe respiratory distress and is unable to lay flat. Vitals: BP 150/90 (pulsus paradox = 20), HR = 120, RR = 24, T = 37.0. Accessory muscle use was noted as well as diffuse inspiratory and expiratory wheezing. The rest of the exam was normal.

    A pulse oximeter revealed an oxygen saturation of 91% on room air. Peak Flow was 100 liters/min.

    Before obtaining more history, the ER physician orders the following:

    * Oxygen - 4LPM by nasal cannula
    * Albuterol nebulization treatment - 0.5cc in 2.5cc saline




    [size=24]Questions for Discussion:

    1. List the conditions in which one may hear diffuse wheezing, focal wheezing, and stridor.

    2. How is pulsus paradox measured? What is the "normal" value for pulsus paradox? What is the significance of a pulsus paradox of 20 mmHg?

    3. What is a normal peak flow?

    4. Name the accessory muscles and describe the significance of intercostal retractions.

    5. What is a nebulizer? What is metered-dose inhaler (MDI)? Describe how to properly use a MDI. Is there data suggesting that either nebulizers or MDI's are more effective than the other?

    The patient improves, the peak flow increases to 160, and additional history is obtained:

    Her asthma began at the age of seven, resulting in frequent school absences, especially in the spring. At age 17 she had to quit her job in a bakery because the flour dust worsened her asthma. She also reports seasonal rhinitis, most noticeable in the summer months, until the first frost. She has never been able to cut the grass because it brings on an attack of asthma. Nonetheless, she has always been active, participating in sports in high school, and remaining completely asymptomatic for long periods of time. Recently, however, she has noted severe coughing spells, sometimes associated with frank wheezing, after completing her morning jog, especially during the winter months since moving to Chicago. She has a dog and cat at home. Her father and nephew both have asthma. Her mother and grandmother have hay fever. She denies aspirin sensitivity, nasal polyps, or eczema. She also denies symptoms of GERD.

    6. What is the definition of asthma? Does this patient have asthma?

    7. Describe the airway abnormalities found pathologically during an acute attack of asthma.
    8. What are the common precipitants responsible for inducing an attack of asthma?

    9. Describe the clinical features of:
    * Cough-Variant Asthma
    * Exercise-Induced Asthma (EIA)
    * GERD-Associated Asthma
    * Cardiac Asthma
    * Sampter's Triad
    * Allergic Broncho-Pulmonary Aspergillosis (ABPA)

    10. As they relate to asthma, what is the significance of:
    * family history
    * associated allergic conditions
    * chronic sinus congestion / post-nasal drip


    Unfortunately, her shortness of breath worsens again, although both the wheezing and pulsus paradox have decreased. Peak Flow is measured to be 60 lpm. The ER physician orders:

    * Repeat albuterol nebulization treatment
    * 125 mg methylprednisolone IV
    * Chest X-ray
    * Arterial Blood Gas
    * CBC

    11. Why, if the patient's shortness of breath has worsened, have the wheezing and pulsus paradox improved?

    12. The chest x-ray failed to show evidence of pneumonia or pneumothorax. What findings on chest x-ray would be expected during an exacerbation of asthma?

    13. ABG (on room air) reveals: pH = 7.38, pCO 2 = 41, pO 2 = 70.

    * What is the acid-base status of this ABG?
    * What are the classic patterns of pCO 2 /pH changes during mild, moderate, and severe attacks of asthma?

    * How is the A-a gradient calculated? Is the patient's A-a gradient normal?

    * What is the mechanism of hypoxia in asthma?


    14. CBC reveals a hemoglobin of 14.2 and a WBC of 6.8 with 65 polys, 5 bands, 20 lymphs, and 10 eos. What is the possible significance of peripheral eosinophilia?

    The patient was admitted to the hospital, started on a broad-spectrum antibiotic, and continued on albuterol nebulizers and corticosteroids. She improved within 48 hours and was switched to oral medications and discharged.

    15. What was the significance of this patient's yellow sputum?

    16. What antibiotics would be appropriate in this situation?

    17. Discuss the overall long-term management of asthma with reference to:

    * “Controller” vs “Reliever” medications
    * Daily Home Monitoring of Asthma Severity

    18. Using the algorithm advocated by NIH Expert Panel in the 1997 NHLBI'a Guidelines for the Diagnosis and Management of Asthma (which is nicely summarized at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm ), what would be the most appropriate medical therapy recommended for the following patients:

    * A patient with very infrequent, non-life-threatening exacerbations, which have always responded well to inhaled B-agonists?

    * A patient with exacerbations which occur once or twice a week?

    * What options exist for a patient such as that described in “b” above who fails to respond adequately to your initial recommended therapy?


    19. What are the major potential side effects of long-term inhaled corticosteroid use? How might the oral-pharyngeal side effects be minimized?



      الوقت/التاريخ الآن هو الأربعاء 17 أكتوبر 2018, 3:34 pm