This case study describes a 74-year-old man, JS, who presents with shortness of breath and fever. JS has a history of COPD, heart failure, hypertension, and smoking. On examination, he is wheezing and hypoxic. Chest x-ray shows pneumonia and hyperinflation. JS is treated with oxygen, nebulized albuterol, antibiotics, and corticosteroids. Due to his severe COPD, medical comorbidities, and marked symptoms, he requires hospitalization and intensive treatment for a COPD exacerbation complicated by pneumonia.
a case study on COPD with hypertension martinshaji
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure typically does not cause symptoms.
please comment
thank u....
a case study on COPD with hypertension martinshaji
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure typically does not cause symptoms.
please comment
thank u....
COPD; a chronic, progressive airway obstruction; is directly linked with persistent inflammation and high oxidative stress. Airway obstruction is added on by plugging of airways with thick mucus. Role and efficacy of N-acetyl cysteine is reviewed with clinical cases.
Essential Drugs Dosage and Formulations (Medical Booklet Series by Dr. Aryan ...Dr. Aryan (Anish Dhakal)
This is the 22nd part of medical booklet series created by Dr. Aryan in order to familiarize doctors and medical students about the basic doses of drugs. Many students remember the mechanism of actions and other details of drug very well and regard doses as unnecessary. While you prescribe, this becomes one of the most important aspect. This study material is focused to resolve such issues.
Define and understand the types of advanced lung disease (ALD)
Discuss the impact of ALD on patients, family, and the health system
Describe the symptom burden of ALD
Appreciate factors associated with a poorer prognosis in ALD
Identify guidelines for referral to Hospice
Review the medical management of ALD
COPD; a chronic, progressive airway obstruction; is directly linked with persistent inflammation and high oxidative stress. Airway obstruction is added on by plugging of airways with thick mucus. Role and efficacy of N-acetyl cysteine is reviewed with clinical cases.
Essential Drugs Dosage and Formulations (Medical Booklet Series by Dr. Aryan ...Dr. Aryan (Anish Dhakal)
This is the 22nd part of medical booklet series created by Dr. Aryan in order to familiarize doctors and medical students about the basic doses of drugs. Many students remember the mechanism of actions and other details of drug very well and regard doses as unnecessary. While you prescribe, this becomes one of the most important aspect. This study material is focused to resolve such issues.
Define and understand the types of advanced lung disease (ALD)
Discuss the impact of ALD on patients, family, and the health system
Describe the symptom burden of ALD
Appreciate factors associated with a poorer prognosis in ALD
Identify guidelines for referral to Hospice
Review the medical management of ALD
this guideline based on recent articles by major education establishments concerned with building national guidelines. please dont be hurry to make comments about use of IV aminophylline. aminiphylline used under some extra care and when other treatment options are failing. benefits of those treatments yet remain controversial. IV aminophylline has its own risks including the possibility of toxicity.
Neurology MedicationsDo not change the format of this handout..docxgertrudebellgrove
Neurology Medications
Do not change the format of this handout.
Save your name to the document to receive credit and for easier verification.
Answer in 25 words or less if possible.
Use your own words only.
1. Define the below terms as it relates to the neurologic system.
Definition
Clonus
Extinction
Myoclonus
Spasticity
Tremor
2. What nursing interventions are appropriate for a postsurgical patient after receiving general anesthesia?
3. Describe the difference between selective serotonin reuptake inhibitors and monoamine oxidase inhibitors?
a. Give an example of each.
b. Discuss the difference in nursing interventions.
4. Describe the difference between atypical antidepressants and mood stabilizers.
a. Give an example of each.
b. Discuss the difference in nursing interventions.
5. What are the drugs of choice for epilepsy in pregnant women?
a. What is the mechanism of action for those drugs?
b. What is one contraindication?
c. What is an appropriate nursing diagnosis?
6. What nursing interventions are appropriate for an epileptic pregnant woman?
7. What nursing education should you give to the patient and their family?
8. Name a medication used to treat ADHD.
a. What is that medication’s mechanism of action?
b. What is one contraindication?
c. What is an appropriate nursing intervention?
9. How could you differentiate between addiction and pseudo-addiction in patients who are taking medications for ADHD?
10. How could you differentiate between addiction and pseudo-addiction in patients who are taking opioids?
11. Describe the parasympathetic nervous system.
12. Describe the sympathetic nervous system.
13. For each generalized seizure state the medication used for treatment and a nursing intervention. Note: some seizures can be treated using the same medication, however you should list a different medication for each.
Seizure
Medication
Nursing Intervention
Absence seizures
Status epilepticus
Tonic clonic
Partial seizures
14. Describe Parkinson’s disease.
15. What two main classes of medications are used for treatment of Parkinson’s disease? Give an example of each class.
Cardiovascular Medications
Do not change the format of this handout.
Save your name to the document to receive credit and for easier verification.
Answer in 25 words or less if possible.
Use your own words only.
1. Define the following terms in your own words.
Afterload
Preload
Cardiac output
Chronotropic
Conductivity
Irritability
Inotropic
Refractory period.
Dysrhythmia
Atherosclerosis
2. What is Angina Pectoris? (In your own words please)
Fill in the table below
What is Angina?
What causes it?
Describe the symptoms
3. Angina can be a recurring problem or a sudden, acute health concern. There are different types of angina. Fill in the table below.
Stable angina
Unstable angina
Prinzmetal’s angina
4. Nitrate medications can be administered to patients by various routes. Fill in the .
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Copd case study-numberthree
1. Case Study Number Three
• JS is a 74 year old man who presents to your family medicine office with his wife complaining of shortness
of breath and fever. They just moved to the area and had been planning to come to your office next week to
establish care as new patients.
• Due to the onset of symptoms, JS called and was given a walk-in slot today. His wife did bring records
from his last physician’s office.
Which of the following is not a risk factor for COPD?
A. Smoking history
B. Occupational exposure
C. Immunization history
D. History of severe lung infections as a child
E. Family history of lung disease
• Past Medical/Surgical History
– Heart failure following myocardial infarction at age 68 years
– COPD (on 2 L home oxygen)
– Hypertension
– Appendectomy
• Family History
– Father died of myocardial infarction at age 59 years (diabetes, hypertension, smoker)
– Mother alive (atrial fibrillation, heart failure)
– Healthy siblings
• Social History
– Married, 3 children
– 30 pack year smoking history (quit after MI)
– Worked on a farm
– No alcohol or illicit drug use
• Medications / Allergies
– Lisinopril 20 mg twice daily
– Metoprolol 50 mg twice daily
– Spironolactone 25 mg daily
– Furosemide 40 mg daily
– Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff inhaled twice daily
– Tiotropium DPI one cap inhaled daily
– Albuterol/ipratropium metered dose inhaler (MDI) or solution for nebulization every 6 hours as
needed
– Levalbuterol MDI two puffs every 4 to 6 hours as needed
– Home oxygen
• He is confused about what to use when, so you are not sure which medications he actually takes.
• No known allergies
2. Case Study Number Three
• JS Past Record Review (brought by wife)
– Echocardiogram with EF of 25%
– Spirometry with FEV1 35% predicted that does not change significantly after inhaled bronchodilator
Are these findings consistent with diagnosis of COPD?
If yes, what Stage of COPD using the GOLD criteria?
• Records Review
Unable to determine when last pneumoccal vaccine was given
– Patient and wife don’t recall “a pneumonia shot”
– Does know he got his “flu shot” last month at a grocery store
In a patient with COPD, assessment of symptoms should include the following?
A. Severity of breathlessness
B. Sputum production
C. Wheezing
D. Weight loss/anorexia
E. All of the above
• JS current symptoms include the following:
– Unable to speak in full sentences for the past several hours per wife
– Cough productive but unknown color of sputum
– Audible wheezing since last night per wife
– Mild chest tightness
– Dyspnea
• His wife has noted no change in his alertness or mental status
• When you inquire, the wife states that JS usually has a cough, worse in the morning, productive of gray
sputum, gets short of breath if he walks more then 10 feet, and has episodes of wheezing if he gets sick (e.g.
with an upper respiratory infection).
• He usually is able to help around the house with light work and fixing things.
• Physical examination
– Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral
– Unable to speak in full sentences, audible wheezing, alert and oriented
– Pertinent positives:
• General: audible wheezing, no accessory muscle use
• Nails: tar stains, clubbing
• Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation
• Heart: regular, no murmurs
3. Case Study Number Three
Which of the following is the least likely cause of patient’s symptoms?
A. COPD exacerbation
B. Recurrent aspiration
C. Heart failure
D. Pneumonia
E. Asthma exacerbation
The additional studies you are considering include which of the following?
A. Pulse oximetry
B. Spirometry
C. Alpha-1-antitrypsin level
D. None of the above
• Study results
– Pulse oximetry 86%
– Chest x-ray shows hyperinflation and right lower lobe pneumonia
– You continue his heart failure medications as per his home regimen
• No need to discontinue the cardioselective beta-blocker
• Factors that increase risk of severe COPD exacerbations
– Altered mental status
– At least three exacerbations in the previous 12 months
– Body mass index of 20 kg per m2 or less
– Marked increase in symptoms or change in vital signs
– Medical comorbidities (especially cardiac ischemia, heart failure, pneumonia, diabetes mellitus, or
renal or hepatic failure)
– Poor physical activity levels
– Poor social support
– Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted)
– Underutilization of home oxygen therapy
• Based on this information, JS has the following clinical factors that increase his risk of a severe COPD
exacerbation:
– Marked increase in symptoms and change in his vital signs including a low oxygen saturation
– a new medical co-morbidity of pneumonia
– all combined with his severe baseline COPD
4. Case Study Number Three
So will you treat JS as an outpatient or inpatient?
• Indications for hospitalization
– Risk of death from an exacerbation increases with:
• Development of respiratory acidosis
• Presence of significant comorbidities,
• Need for ventilatory support
You determine that JS needs to be hospitalized and while waiting for EMS transport to your local medical
center you instruct your nurse to place him on oxygen by nasal cannula. In addition to oxygen, you want to
provide which of the following agents via nebulizer?
A. Arformoterol
B. Albuterol
C. Formoterol
D. Budesonide
Upon arrival at the ER, respiratory therapy asks to change albuterol to levalbuterol. Which of the following
are reasons to choose levalbuterol over albuterol?
A. Improved bronchodilation
B. Less hypokalemia
C. Less tachycardia
D. None of the above
Corticosteroids should be delivered by what route in mild to moderate exacerbations of COPD?
A. Inhaled via dry powdered inhaler
B. Nebulized
C. Oral
D. Intravenous
Which of the following are indications for antibiotics in patients with acute exacerbations of COPD?
A. Dyspnea
B. Increased volume of sputum
C. Change in sputum purulence
D. All of the above
• History of Exacerbations
– Upon questioning his wife, you find out that he has had 5 exacerbations in the past year, three of
which were treated with antibiotics and oral steroids
• Amoxicillin x2 courses, doxycycline x1 course
• Most recent course 6 weeks ago
• No hospitalizations within the last 6 months
– Based on this information, and his chest x-ray findings, you initiate treatment for community
acquired pneumonia.
5. Case Study Number Three
Which antibiotic regimen is most appropriate for this hospitalization?
A. Sulfamethoxazole/trimethoprim every 12 hours
B. Amoxicillin/clavulanate every 12 hours
C. Ceftriaxone plus azithromycin every 24 hours
D. Piperacillin/tazobactam every 8 hours, levofloxacin every 24 hours and vancomycin every 12
hours
• Hospital Course
– During hospitalization, he receives the following treatment:
• Nebulized albuterol/ipratropium every 4 hours as needed
• Prednisone 60 mg daily by mouth
• 1 gm IV ceftriaxone plus 500 mg oral azithromycin daily
• Oxygen to maintain PO2 > 60 mmHg
• Preparation for discharge
– Over 3 days, JS has significantly improved and has weaned back to his home oxygen regimen.
– He is taking the albuterol/ipratropium nebulized treatments every 6 hours, and is ready to switch
back to bronchodilators via inhaler device.
– Along with antibiotics for a total of 7 days, you need to determine the dose and duration of treatment
for oral corticosteroids.
Which corticosteroid regimen would be recommended in this situation?
A. Prednisone 40 mg daily x 5 days then stop
B. Prednisone 40 mg daily x 14 days then stop
C. Prednisone 40 mg daily x 21 days then stop
D. Prednisone 40 mg daily x 10 days half the dose every 10 days for a total of 42 days
• Preparing for discharge
– In completing the medication reconciliation forms, you see that JS had a complex medication
regimen upon admission
– It is clear, during discussions with him, that he is unable to comply with this expensive, complex and
potentially unnecessary regimen.
• Medications on admission
– Lisinopril 20 mg twice daily
– Metoprolol 50 mg twice daily
– Spironolactone 25 mg daily
– Furosemide 40 mg daily
– Salmeterol/fluticasone 50/500 dry powdered inhaler (DPI) one puff inhaled twice daily
– Tiotropium DPI one cap inhaled daily
– Albuterol/ipratropium metered dose inhaler (MDI) or solution for nebulization every 6 hours as
needed
– Levalbuterol MDI two puffs every 4 to 6 hours as needed
6. Case Study Number Three
Which of the following principles of medication management should be considered when evaluating his
discharge medications?
A. Cost of medications
B. Therapeutic duplication
C. Compliance with complex regimen
D. All of the above
Discharge Medications
• Streamline regimen
– No need for levalbuterol
– Continue salmeterol/fluticasone 50/500 DPI and/or tiotropium DPI
– Short-acting bronchodilator MDI as needed
• Patient given pneumococcal vaccine prior to discharge
7. Case Study Number Three
Answers/Notes
Which of the following is not a risk factor for COPD?
Answer: C
Immunization history is not one of the risk factors for whether or not a person develops COPD although it can
be an important factor in wellness and prevention
Smoking History is the most significant risk factor for COPD is long-term cigarette smoking. Symptoms of
COPD usually appear about 10 years after initiation of smoking.
• Pipe smokers, cigar smokers and people exposed to large amounts of secondhand smoke also are at risk.
• Environmental pollution such as smog, dust, wood smoke, particulates in occupational dust and others
can cause damage to lung tissue similar to smoking.
Occupational exposure with exposure to several occupational irritants, usually in the form of dusts, be risk
factors for COPD.
Lung infections as a child
Family history mainly is a result of alpha-1-antitrypsin deficiency
• Mostly Northern European heritage
• Rare cause (2% of COPD population)
Cosio, 2009; ATS/ERS; 2003; GOLD, 2009; Dewar, 2006.
Are these findings consistent with diagnosis of COPD?
If yes, what Stage of COPD using the GOLD criteria?
YES, if done post-bronchodilator, it is consistent with Stage 3:Severe COPD
FEV1:FVC <0.70
FEV1: 30 to 49% of predicted value
Stage and severity of COPD based upon post-bronchodilator spirometry
Stage 1:Mild
FEV1:FVC <0.70
FEV1: ≥80% of predicted value
Stage 2:Moderate
FEV1:FVC <0.70
FEV1: 50 to 79% of predicted value
Stage 3:Severe
FEV1:FVC <0.70
FEV1: 30 to 49% of predicted value
Stage 4:Very severe
FEV1:FVC <0.70
FEV1: <30% of predicted value or FEV1 <50% of predicted value plus chronic respiratory failure
8. Case Study Number Three
In a patient with COPD, assessment of symptoms should include the following?
Answer: E
Assessment of symptoms:
• Severity of breathlessness, cough, sputum production, wheezing, chest tightness, weight loss/anorexia
• Change in alertness or mental status, fatigue, confusion, anxiety, dizziness, pallor or cyanosis
• COPD should be considered in any patient with a chronic cough, dyspnea or sputum production
Part of diagnosing COPD is to distinguish it from other causes. The patient’s history, in this case symptoms,
will help in considering if COPD is the etiology.
Pulmonary symptoms are the hallmark of the disease but systemic symptoms will often occur due to hypoxia.
Which of the following is the least likely cause of patient’s symptoms?
Answer B
For a patient with chronic pulmonary symptoms, a differential includes the following:
Pulmonary:
• Asthma
• Bronchogenic carcinoma
• Brochiectasis
• Tuberculosis
• Interstitial lung disease
• Pleural effusion
• Pulmonary edema
• Recurrent aspiration
• Pulmonary embolus
• Pneumonia
Non-pulmonary
• Heart Failure
But based on this patient’s history and physical examination, the most likely differential diagnoses include
COPD exacerbation, pneumonia, heart failure. No symptoms or history are present that would put recurrent
aspiration above the listed conditions. Severe persistent asthma can have many overlapping clinical features and
findings similar to COPD and should be considered in any patient with a chronic obstructive lung condition that
has acutely worsened.
9. Case Study Number Three
The additional studies you are considering include which of the following?
Answer A
Pulse oximetry is a simple office procedure and would help to determine inpatient versus outpatient treatment as
levels <88% suggest the need for supplemental O2. Arterial blood gas can also be used to obtain an accurate
oxygenation status and to get pCO2 levels which a pulse ox does not provide but they are not routinely available
in the office setting. (Strength of Recommendation: C)
Spirometry is a requirement to make the diagnosis of COPD but not practical or necessary for acute episodes.
Alpha-1 antitrypsin levels are not indicated in the acute management of COPD and would be used only in the
initial workup (Strength of Recommendation: C).
So will you treat JS as an outpatient or inpatient?
Factors that increase risk of severe COPD exacerbations
• Altered mental status
• At least three exacerbations in the previous 12 months
• Body mass index of 20 kg per m2 or less
• Marked increase in symptoms or change in vital signs
• Medical comorbidities (especially cardiac ischemia, heart failure, pneumonia, diabetes mellitus, or renal
or hepatic failure)
• Poor physical activity levels
• Poor social support
• Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted)
• Underutilization of home oxygen therapy
About 50 percent of COPD exacerbations are not reported to physicians, suggesting that many exacerbations are
mild. The risk of death from an exacerbation increases with the development of respiratory acidosis, the
presence of significant comorbidities, and the need for ventilatory support.
Patients with symptoms of respiratory distress and those at risk of distress should be admitted to the hospital to
provide access to critical care personnel and mechanical ventilation. Inpatient mortality for COPD
exacerbations is 3 to 4 percent. Patients admitted to the intensive care unit have a 43 to 46 percent risk of death
within one year after hospitalization.
Because COPD is a progressive and often fatal illness, physicians should consider discussing and documenting
the patient’s wishes concerning end-of-life care.
10. Case Study Number Three
In addition to oxygen, you want to provide which of the following agents via nebulizer?
Answer: B
Albuterol is the mainstay of treatment for acute exacerbations of COPD. It can be used alone or in combination
with ipratropium. Arformoterol and formoterol are both nebulized bronchodilators, but are long-acting beta-
agonists and should only be used for chronic maintenance therapy for COPD. Similarly, budesonide is
available for nebulization but has no role in the acute management of COPD.
Which of the following are reasons to choose levalbuterol over albuterol?
Answer: D
There are no known advantages to using levalbuterol over albuterol. It is not more effective (i.e. it does not
improve bronchodilation, FEV1, etc.) and does not lead to statistically different tachycardia or change in
potassium. Levalbuterol is also significantly more expensive than albuterol.
Corticosteroids should be delivered by what route in mild to moderate exacerbations of COPD?
Answer: C
Systemic corticosteroids have been shown to increase time to subsequent exacerbation, decrease rate of
treatment failure, shorten length of hospitalization, and improve hypoxemia when used in acute exacerbations of
COPD. However, there is no role for inhaled steroids either via dry powdered inhaler or nebulized route. Oral
steroids are as effective as intravenous steroids in patients with functional intestinal tracts who are not vomiting
and able to take medications by mouth.
High dose regimens (125 mg methylprednisolone every 6 hours) has not been shown to be more effective than
low-dose regimens (i.e., 40 – 60 mg prednisone daily) but does lead to more side effects, particularly
hyperglycemia.
Which of the following are indications for antibiotics in patients with acute exacerbations of COPD?
Answer: D
Patients should be asked about change in symptoms, change in sputum color or volume. If these are present,
antibiotics have been shown to be beneficial in the treatment of acute COPD exacerbations.
11. Case Study Number Three
Which antibiotic regimen is most appropriate for this hospitalization?
Answer: C
The patient has community acquired pneumonia, not hospital acquired pneumonia (ie. no hospitalizations in the
past 6 months). He has had multiple exacerbations of COPD and antibiotic use within the past 3 months.
Therefore, treatment should follow guidelines for community acquired pneumonia and would include
ceftriaxone plus azithromycin every 24 hours. Azithromycin can be given orally – its high bioavailability
deems IV therapy unnecessary in patients who are not vomiting and able to take oral therapy. Another option
would be levofloxacin, orally in patients able to take by mouth (high oral bioavailability also). Options A and B
are not appropriate for community acquired pneumonia. Option A should not be used for acute exacerbations of
COPD in this patient due to his recent antibiotic exposure. Option D is the treatment regimen for health-care
associated pneumonia.
Which corticosteroid regimen would be recommended in this situation?
Answer: B
The 5 day regimen for a steroid burst is appropriate for patients with asthma, but not COPD. Most patients need
14 days of treatment. For the patients with frequent steroid use or a history of relapse upon abrupt
discontinuation of steroids, a taper is necessary.
Which of the following principles of medication management should be considered when evaluating his
discharge medications?
Answer: D
The cost of the medication regimen on admission approaches $1000 per month. It also requires more than 15
“doses” daily. The patient has to make choices about how often (up to every 6 hours) and what route of
delivery (metered-dose inhaler or nebulizer) to use the albuterol/ipratropium, and when to use the levalbuterol
in addition to or instead of the albuterol/ipratropium. The patient may be confused about using the
fluticasone/salmeterol and/or tiotropium for acute relief of symptoms instead of using the short acting agents
(albuterol/ipratropium or levalbuterol). Finally, the regimen demonstrates examples of therapeutic duplication –
ipratropium and tiotropium, both anticholinergic agents; albuterol and levalbuterol, both short-acting beta-
agonists.
Because COPD is a progressive chronic illness, and none of the long-term medications have been shown to
improve FEV1 or affect mortality (with the exception of oxygen), often additional medications are added to an
already complicated regimen in an effort to improve symptoms. The family physician should review the
medication regimen to consider the above principles and maximize therapeutic outcomes.
12. Case Study Number Three
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