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Guidelines for Third-year Students of the Medical Department




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Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines For third-year students of the medical department
Guidelines For third-year students of the medical department
Guidelines for Third-year Students of the Medical Department
Guidelines For third-year students of the medical department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department
Guidelines for Third-year Students of the Medical Department

UKRAINIAN MINISTRY OF PUBLIC HEALTH

Vinnytsya National Medical University n.a. M.I. Pyrogov


«APPROVED»

At the methodological meeting of the internal medicine propedeutics department

Chief of the department

____________ prof. Mostovoy Y.M.

«______»_______________ 20 ___ y.


Guidelines

for Third-year Students of the Medical Department



Subgect

Propedeutics of the internal medicine

Modul №

1

Enclosure module №

2

Topic

Clinical presentation of chronic obstructive pulmonary diseases, bronchial asthma

Course

3

Faculty

Medical № 1


Methodical recommendations are made in accordance with educationally-qualifying descriptions and educationally-professional programs of preparation of the specialists ratified by Order MES of Ukraine from 16.05 2003 years № 239 and experimentally - curriculum, that is developed on principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH of Ukraine from 31.01.2005 year № 52.


Vinnytsya- 2012


    1. Importance of the topic

Bronchial asthma and chronic obstructive pulmonary disease (COPD) are widely spread internal diseases. They produce serious problems with health. Prevalence of COPD a-is increasing from year to year and now it is one from frequent cause of death in the world. Ability to recognizing COPD and bronchial asthma is very important for every doctor or student, because sometimes these diseases appear with emergency life-threatened condition that should be resolved immediately.


2. Concrete aims:

  • Study main symptoms and signs of the bronchial asthma

  • Learn main instrumental methods that can help to establish bronchial asthma

  • Learn classification of bronchial asthma

  • Study main symptoms and signs of COPD

  • Learn instrumental and functional exanimation patients with COPD

3. Basic training level


Previous subject

Obtained skill

Normal anatomy

Anatomy of the airways and lungs, their blood supply and innervations

Normal physiology

Mechanics of breathing, gas exchange in the lung and tissues of system organs

Histology

Ontogenesis of the respiratory tract, histological structure of the respiratory tract and alveoli

Propedeutics to internal medicine

Subjective, objective and instrumental examinations of the respiratory patients

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training


Term

Term

Bronchial obstruction

Hyperinflation

Reversibility of obstruction

Respiratory failure

Emphysema

Asthma attack


4.2. Theoretical questions:

  1. Definition of bronchial asthma

  2. Causes of bronchial asthma and its classification

  3. Symptoms of bronchial asthma

  4. Signs of bronchial asthma

  5. Instrumental and laboratory methods of examination of patients with bronchial asthma

  6. Definition of COPD

  7. Symptoms and signs of COPD

  8. Data of additional methods of examination of patients with COPD.

  9. . Classification of COPD.

4.3. Practical task that should be performed during practical training

  1. Revealing and assessment of symptoms and signs of bronchial asthma

  2. Revealing and assessment of symptoms and signs of COPD

  3. Revealing and assessment of functional data at patients with bronchial asthma and COPD

Topic content

Bronchial asthma is a chronic inflammatory disease of the airways resulting in airflow obstruction secondary to airway edema, increased mucus production, bronchospasm and infiltration of the airway with leukocytes (eosinophils, lymphocytes and neutrophiles). It is usually reversible either spontaneously or with treatment. May be allergic and non-allergic and genetic burden.

Clinical presentation:

Episodic dyspnea

Wheezing

Cough dry and nocturnal or morning or episodic as asthma attack equivalent

Episodic chest tightness

Signs of reversible bronchial obstructive syndrome

Visual examination:

The patient sits upright and leans on the edge of the table or chair with hands. This position mobilizes accessory respiratory muscles, does exhalation active and facilitates breathing. There is cyanosis, tachypnea and lengthened exhalation. Auxiliary muscles take part in breathing. If patient is sick during 5 or more year his chest has barrel shape.

Palpation of the chest

Vocal fremitus is diminished. Potenzher symptom is negative and pleural points are painless. Chest has increased resistance.

Percussion of the chest

Comparative percussion: There is resonant percussion sound over chest. Because account of air in lung increases due to dysfunction of breathing.

Topographic percussion: The lower borders of the lungs descend down and apexes of lungs lift up. There is dimension of lower lung border excursion.

Auscultation of the lung

There is diminished rough vesicular breathing with prolonged exhalation, polyphonic wheezes due to narrowing of airways of differing caliber.

Investigations:

Lung function tests: pre- and post-bronchodilator test – FEV1 is increased by> 12% and > 200 ml.

Peak expiratory flow rate: difference of > 20% between morning and afternoon PEF may suggest asthma

Bronchoprovocation test: test for airway hyperreactivity. Test positive if FEV1 drop to 20%.

Classification of bronchial asthma:

I step – Intermittent symptoms rare than 1 a week and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)

II step – mild persistent - symptoms rare than 1 a day and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)

III step – moderate persistent – daily symptoms and night symptoms one a week (PEF, FEV1 80-60%)

IV step – severe persistent – continua day symptoms and frequent night symptoms

(PEF, FEV1<60%)

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

Risk factors: smoking, occupational dust and chemicals, air pollution and chronic recurrent respiratory infections, hereditary α-1 antitrypsin deficiency.

Symptoms of COPD:

Cough is productive, slowly progressive dyspnoe with difficulty during expiration, wheeze, decreased exercise tolerance.

Significant airflow obstruction may be present before the patient is aware of it.

Signs of bronchial obstruction:

Visual examination:

The patient sits upright and leans on the edge of the table or chair with hands. This position mobilizes accessory respiratory muscles, does exhalation active and facilitates breathing. There is cyanosis, tachypnea and lengthened exhalation. Auxiliary muscles take part in breathing. The chest has barrel shape.

Palpation of the chest

Vocal fremitus is diminished. Potenzher symptom is negative and pleural points are painless. Chest has increased resistance.

Percussion of the chest

Comparative percussion: There is resonant percussion sound over chest. Topographic percussion: The lower borders of the lungs descend down and apexes of lungs lift up. There is dimension of lower lung border excursion.

Auscultation of the lung

There is quiet breath sounds with prolonged exhalation, wheezes, quiet heart sounds (due to overlying hyperinflated lung)

Signs of Cor pulmonale and CO2 retention (ankle oedema, raised jugular vein pulse, warm peripheries, plethoric conjunctivae, bounding pulse, polycythaemia. Flapping tremor if CO2 acutely raised).

Investigations:

  1. Lung function tests: obstructive spirometry and flow-volume loops, reduced FEV1 to<80% predicted, FEV1/FVC< 70%, reversibility less than 12%, raised total lung volume, FRC and residual volume because of emphysema, air trapping and loss of elastic recoil.

  2. Chest X-ray shows data of emphysema.

  3. Sputum examination is significant if patient has exacerbation (microscopy and culture)

  4. Pulse oximetry and arterial blood gas analysis - Pa O2 decreased, Sa O2 <95%.

Classification of COPD by severity (GOLD):

Stage 0, at risk: Lung function still normal; chronic symptoms (chronic cough and sputum production).

Stage I, Mild COPD: Mild airways limitation (FEV1/FVC<70%, but FEV1≥80% predicted) and usually, but not always, chronic cough and sputum production.

Stage II, Moderate COPD: Worsening airways limitation (FEV1/FVC<70%, 50%≤FEV1<80% predicted) and usually progression of symptoms, with shortness of breath typically developing on exertion.

Stage III, Severe COPD: Further worsening of airflow limitation (FEV1/FVC<70%, 30%≤FEV1<50% predicted) progression of symptoms with shortness of breath and exacerbations which have impact on patient’s quality of life.

Stage IV, Very severe COPD: severe airflow limitation (FEV1/FVC<70%, FEV1<30% predicted) or FEV1<50% plus chronic respiratory failure. Quality of life is very appreciably impaired and exacerbations may be life-threatening.

7. Reference source


  • Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000 – P.79-82, 206-210.


Lecturer Demchuk H.V.

Test for self-control

1. Bronchial asthma is a…

  1. Acute inflammatory disease;

  2. Acute infective disease;

  3. Chonic infective disease;

  4. Chonic iinflammatory disease;

  5. northing from above.

2. Chronic obstructive pulmonary disease is a…

  1. chronic inflammatory of trachea and large bronchus

  2. chronic inflammatory of large and medium bronchus

  3. chronic inflammatory of medium, small bronchus with involving lung parenchyma and vessels

  4. All from above

  5. Northing from above

3. Which symptoms characterize bronchial asthma?

  1. Mixed dyspnea, cough with purulent sputum

  2. Episodic dry cough, tightness of the chest, wheezing

  3. Chest pain with radiation to jaw, inspiratory dyspnea

  4. Permanent expiratory dyspnea, cough

  5. Episodic hemoptysis and dyspnea due to physical effort

4. Which symptoms characterize COPD?

  1. Mixed dyspnea, dry cough, chest pain

  2. Episodic dry cough, tightness of the chest, wheezing

  3. Chest pain with radiation to jaw, inspiratory dyspnea

  4. Permanent expiratory dyspnea, cough, sputum production

  5. Episodic hemoptysis and dyspnea due to physical effort

5. What symptom doesn’t characterize bronchial asthma?

    1. Wheezing

    2. cough

    3. tightness in the chest

    4. dyspnea

    5. purulent sputum

6. What symptom doesn’t characterize COPD?

  1. Wheezing

  2. cough

  3. chest pain

  4. dyspnea

  5. purulent sputum

7. What change of vocal fremitus can be at the patient with COPD?

  1. Amplifying

  2. Decreasing

  3. Absence

  4. Not changed

  5. Change depends on clinical situation

8. What change of vocal fremitus can be at the patient with bronchial asthma?

  1. Amplifying

  2. Decreasing

  3. Absence

  4. Not changed

  5. Change depends on clinical situation

9. If patient has asthma symptoms 1-2 times in a week, 1 night awaking in a mouth, he has…

  1. Intermitend asthma;

  2. Mild persistent asthma;

  3. Moderate persistent asthma;

  4. Severe persistent asthma;

  5. depends on clinical situation

10. If patient has asthma symptoms 1-2 times in a day, 1 night awaking in a week, he has…

  1. Intermitend asthma;

  2. Mild persistent asthma;

  3. Moderate persistent asthma;

  4. Severe persistent asthma;

  5. depends on clinical situation

11. If patient has asthma symptoms 1-2 times in a year, night awaking is absent, he has…

  1. Intermitend asthma;

  2. Mild persistent asthma;

  3. Moderate persistent asthma;

  4. Severe persistent asthma;

  5. depends on clinical situation

12. If patient has asthma symptoms 8-10 times in a day, every night awaking, he has…

  1. Intermitend asthma;

  2. Mild persistent asthma;

  3. Moderate persistent asthma;

  4. Severe persistent asthma;

  5. depends on clinical situation

13. How percussion sound is changed at the patient with COPD?

  1. unchanged

  2. dull

  3. small box sound

  4. tympanic

  5. depend on clinical situation

14. How mobility of the lung border is changed at the patient with COPD?

  1. unchanged

  2. limited

  3. increased

  4. became immovable

  5. depend on clinical situation

15. How percussion sound is changed at the patient with mild asthma?

  1. unchanged

  2. dull

  3. small box sound

  4. tympanic

  5. depend on clinical situation

16. What are auscultation findings at the patient with asthma attack?

    1. Vesicular rough breathing with prorogated expiration, wheezing

    2. Diminished vesicular breathing,

    3. Diminished vesicular breathing and moist rales

    4. Diminished vesicular breathing and crepitation

    5. Vesicular breathing and pleural friction rub

17. What are auscultation findings at the patient with COPD?

  1. Vesicular rough breathing

  2. Diminished vesicular breathing with prolongated expiration, wheezing

  3. Diminished vesicular breathing and moist rales

  4. Diminished vesicular breathing and crepitation

  5. Vesicular breathing and pleural friction rub

18. How is FEV1 increased after bronchial spasmolytic if patient has reversible obstruction?

  1. >12% from initial

  2. >20% from initial

  3. >25% from initial

  4. > 30% from initial

  5. > 10% from initial

19. If patient has permanent expiratory dyspnea during physical effort, FEV1 is 52% from predicted and FEV1/FVC 55% he has…

  1. Mild COPD

  2. Moderate COPD

  3. Severe COPD

  4. Very severe COPD

  5. Depend on clinical situation

20. If patient has permanent expiratory dyspnea in a rest, FEV1 is 22% from predicted and FEV1/FVC 45% he has…

  1. Mild COPD

  2. Moderate COPD

  3. Severe COPD

  4. Very severe COPD

  5. Depend on clinical situation



Control questions:

  1. What is a bronchial asthma?

  2. What are causes of bronchial asthma?

  3. What stage of bronchial asthma do you know?

  4. What are the main symptoms of bronchial asthma?

  5. What are signs of bronchial asthma?

  6. Which instrumental and laboratory investigations are used for establishing bronchial asthma?

  7. What is COPD?

  8. What are risk factors of COPD?

  9. What are the main symptoms and signs of COPD?

  10. What are findings of instrumental investigations of patients with COPD?

  11. What stage of COPD do you know?

4.3. Practical task that should be performed during practical training

  1. Revealing and assessment of symptoms and signs of bronchial asthma

  2. Revealing and assessment of symptoms and signs of COPD

  3. Revealing and assessment of functional data at patients with bronchial asthma and COPD

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