Bản sao của OSCE NỘI

Complications of COPD

  • SHH, TKMP, and Atelectasis

    • Complications include pressure pneumothorax and significant pleural effusion (TKMP), leading to midline shift of the mediastinum.

    • Hemodynamic instability often occurs, typically causing hypotension.

  • Pleural Disease

    • Causes of acute left chest pain include the "4 TIM":

      • Myocardial Infarction (MI)

      • Aortic Dissection

      • Acute Pericarditis

      • Cardiac Tamponade

    • Pulmonary causes include TKMP or pulmonary embolism.

    • Gastrointestinal causes such as esophageal rupture.

Treatment for Acute COPD Exacerbation

  1. Hospitalization

    • Intensive care unit (ICU) admission and level 1 monitoring.

  2. Oxygen Therapy

    • Maintain SpO2 between 88-92% using a cannula.

  3. Bronchodilators

    • Administer bronchodilators.

  4. Systemic Corticosteroids

    • For example, Methylprednisolone (Medrol) 16mg twice daily or 40mg once daily.

Special Case of Acute COPD with TKMP:

  1. Hospitalization

    • Level 1 monitoring.

  2. Oxygen Therapy

    • Administration via cannula at 3L/min to maintain SpO2 88-92%.

  3. Medications

    • Combivent (Ipratropium/Salbutamol) at dosage of 0.5mg in 2.5ml.

Non-Pharmacological Treatment for COPD

  • General Maintenance

    • Avoid dusty environments and quit smoking.

    • Vaccinations for influenza, pneumococcus, pertussis (if not vaccinated in childhood), and varicella (above 50 years), and COVID-19.

    • Physical therapy and exercise.

Specific Treatment for Uncontrolled Asthma With Future Risks

  • Monitor adherence to treatment.

  • Educate the patient on correct usage of inhalers.

  • Escalate treatment if the patient adheres but still remains uncontrolled. For example:

    • Use of Albuterol and Fluticasone combination.

Light's Criteria for Pleural Effusion Analysis

Light's Criteria Evaluation

  • Protein ratio of pleural fluid to serum protein: 48.4/60 > 0.5 (2 points)

  • LDH ratio of pleural fluid to serum: 1950/203 > 0.6 (1 point)

  • Pleural LDH > 2.5 times upper limit of normal for serum. Each point confirmed leads to exudative pleural effusion diagnosis.

Treatment of Exudative Pleural Effusion

  1. Hospitalization

    • General ward, level 3 care.

  2. Oxygen Supplementation

    • Cannula at 2L/min ensuring SpO2 ≥ 95% (in this case of no SHH).

  3. Antibiotic Therapy

    • Minimum 5 days of Levofloxacin at 750mg once daily.

Diagnostic Imaging for Pleural Effusion

  • Technique

    • AP film taken with full inspiration, adequate exposure.

    • Ensure soft tissue is not compromised, no subdiaphragmatic free air under ribs.

    • Assess ribs for fractures or cracks; look for homogeneous opacity of left lung pushing the mediastinum right.

Characteristics of Pleural Exudate

  • Dark red effusion with blood clots indicates vascular involvement.

  • Pleural fluid analysis such as protein, LDH, and ratios indicating exudate versus transudate.

Evaluation of Asthma Control

  1. Symptoms Frequency

    • Daytime asthma symptoms more than 2 times a week?

  2. Nocturnal Symptoms

    • Awakenings at night due to asthma?

  3. Reliever Use

    • Use of rescue inhalers more than 2 times a week?

  4. Activities Limitations

    • Any activity limitations due to asthma symptoms?

Differential Diagnosis of COPD

  • List possible future risk factors for asthma in patients:

    • Uncontrolled asthma

    • Obesity

    • Gastroesophageal reflux disease (GERD)

    • Smoking

    • Food allergies

Specific In-hospital Treatment Orders

  • Antibiotics: Administer with signs of infection (fever, purulent sputum, imaging abnormalities).

  • Oxygen: Maintain SpO2 between 93%-95%.

  • Sedation: Avoid in acute asthma attacks as it suppresses respiratory drive.

Clinical Laboratory Orders for Pneumonia Diagnosis

  1. Blood gas analysis

  2. Chest X-ray

  3. Serum Urea levels

  4. Complete Blood Count (CBC) with differential.

Severity Classification of Pneumonia (by ATS/IDSA 2007)

  • Classifications, especially in sepsis, might need vascular support and respiratory failure interventions.

Initial Management of COPD Exacerbation

Management Pathway for COPD and Pneumonia

  • Follow the CURB-65 protocol for pneumonia severity.

  • Management based on patient presentation and clinical guidelines.

Conclusion

  • Continuous monitoring and reassessment for both COPD and asthma patients are crucial for effective treatment and management.