1. Step 6
1.1. Review session 1
1.1.1. Summary of step 5
1.1.1.1. smoking
1.1.1.1.1. related to respiratory disease
1.1.1.1.2. 15 % of smokers developed COPD
1.1.1.1.3. smoking is declining in UK
1.1.1.1.4. smoking damge is slow
1.1.1.1.5. cause paralyze of the cillia
1.1.1.1.6. 1 out of two persistent smoker s developed any chronic respiratory diseases
1.1.1.1.7. cause acute respiratory diseases
1.1.1.1.8. cause chronic respiratory diseases
1.1.1.1.9. poor control of asthma
1.1.1.1.10. 4000 harmful component 48 f them are cancerous
1.1.1.1.11. contains polycyclic aramotic hudrocarbons
1.1.1.1.12. related to coronary heart disease
1.1.1.1.13. nicotine attract the neotrophills and macrophages which release the elastase
1.1.1.1.14. cause mucus secretion
1.1.1.1.15. mechanism
1.1.1.2. sputum analyzing
1.1.1.2.1. IS PRODUCTION OF MATERIALS FROM THE UPPER RESPIRATORY TRACT
1.1.1.2.2. amount , color, blood, duration ,((full history))
1.1.1.2.3. 4 types
1.1.1.2.4. green means nuetrophills dead
1.1.1.2.5. yellow means active infection
1.1.1.3. shortness of breath
1.1.1.3.1. definition
1.1.1.3.2. causes
1.1.1.3.3. classification MRC
1.1.1.3.4. clinical indication
1.1.1.4. Chronic Obstructive Pulmonary Disease
1.1.1.4.1. chronic bronchitis and emphysema
1.1.1.4.2. causes
1.1.1.4.3. symptoms
1.1.1.4.4. goblet cells hyperatrophy
1.1.1.4.5. developes pulmonary hypertension
1.1.1.4.6. to diagnose we need spirometry
1.1.1.4.7. emphysema pink buffers
1.1.1.4.8. chronic bronchitis
1.1.1.4.9. physical exmination rapid respiratory rate and the use of accsary muscles, hepatomegaly , wheezing
1.1.1.4.10. excacerbations will increase the dyspnea and other symbtoms caused by infections
1.1.1.5. hypertension and its effect on the respiratoy system
1.1.1.5.1. pulmonary hypertension failure of hypoxic kidneys to excertion of sapdium and water which developed the swollen ankle
1.1.1.5.2. more prone to developed pulmonary embolism
1.2. Report new knowledge
1.3. 40 minutes
2. Step 8
2.1. Diagnostic decision
2.1.1. acute exacerbation of COPD with acute respiratory failure
2.2. Mechanism
2.2.1. chronic COPD and acute infections beacause of the smoking
2.3. Presentation
2.3.1. respiratory failure
2.3.2. dyspnea
2.3.3. wheezing
2.3.4. productive cough
2.3.5. swollen ankle
2.4. Supporting data
2.4.1. tests results
2.4.1.1. CXR
2.4.1.2. spirometry
2.4.1.2.1. 0.95/1.85
2.4.1.2.2. predictive value 2.2/2.7
2.4.1.3. oxygen
2.4.1.3.1. 86%
2.4.1.4. PH
2.4.1.4.1. 7.25
2.4.1.5. PaCO2 60,mmHg
2.4.1.6. PaO2 90
2.4.1.6.1. normal more than 75
2.4.1.7. Hco3 29 mEq / liter
2.4.1.7.1. normal 24-26
2.4.1.8. Sa O2 99%
2.4.1.8.1. normal above 95
2.4.1.9. ECG
2.4.1.9.1. sinus tachycardia and no other problems
2.4.1.10. CBC
2.4.1.10.1. NORMAL
2.4.1.11. ELECTROLYTS
2.4.1.11.1. NORMAL
2.4.1.12. ESR
2.4.1.12.1. slightly elevated
2.4.1.13. sputum examination
2.4.1.13.1. muco purulunt
2.4.1.13.2. moderate moraxella catarrhalis
2.4.2. physical examination
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. started two weeks ago dry cough, rhinitis
3.1.1.1.1. productive cough before one weeks
3.1.1.1.2. half a cop
3.1.1.1.3. yellow sputum
3.1.1.2. wheezing at night
3.1.1.3. cant go out home
3.1.1.4. off to work
3.1.1.5. worsen breathlessness
3.1.1.5.1. in the last 24.48
3.1.1.5.2. not releaf by the drug
3.1.1.6. swollen ankle unable to walk
3.1.1.7. called ambulance
3.1.1.8. smokers cough
3.1.1.8.1. small amount of mucus
3.1.1.9. developed winter bronchitis
3.1.2. Previous medical / surgical history
3.1.2.1. didnt take the influnza vaccine
3.1.2.2. havent dignosed with asthma
3.1.2.3. hypertensive
3.1.2.4. no heart disease
3.1.2.5. no cholestrol measure
3.1.2.6. early menapause 42
3.1.3. Drug history / allergy
3.1.3.1. inalapril
3.1.3.1.1. twice a day
3.1.3.2. aspirin 100 mg
3.1.3.3. salbtmol
3.1.3.3.1. 4 times a day
3.1.3.3.2. for long times
3.1.3.3.3. when needed
3.1.4. Family history
3.1.5. Social / occupational history
3.1.5.1. born in australia
3.1.5.2. smokers 10 ciggarate per day started at 11
3.1.5.2.1. 25.5 packyeras
3.1.5.3. when not working she works in her garden and caree of her grandchildren
3.1.5.4. worked at clothing manufacture
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. 37.1 tempruter
3.1.7.2. BB 170/90
3.1.7.3. pulse 124
3.1.7.4. 20.8 BMI
3.1.7.5. 56 KG
3.1.7.6. 164 m
3.1.7.7. RR 30
3.1.7.8. using accesary muscles
3.1.7.9. audiable wheezing
3.1.7.10. oxygen mask
3.1.7.10.1. 6L per minute
3.1.7.11. astrecsis
3.1.7.12. redused chest expansion bi lateraly
3.1.7.13. resonant percusion
3.1.7.14. reduced lung sound in tensty through both lung feild but the character is normal
3.1.7.15. polyphonic sound
3.1.7.16. crackles both basis of lung no change with coughing
3.1.7.17. heat sound dull soft systolic flow murmers at LSE
3.1.7.18. mild bitting oedema bi laterally
3.1.7.19. the rest physical examination unremarkble
3.1.8. tests results
3.1.8.1. CXR
3.1.8.2. spirometry
3.1.8.2.1. 0.95/1.85
3.1.8.2.2. predictive value 2.2/2.7
3.1.8.3. oxygen
3.1.8.3.1. 86%
3.1.8.4. PH
3.1.8.4.1. 7.25
3.1.8.5. PaCO2 60,mmHg
3.1.8.6. PaO2 90
3.1.8.6.1. normal more than 75
3.1.8.7. Hco3 29 mEq / liter
3.1.8.7.1. normal 24-26
3.1.8.8. Sa O2 99%
3.1.8.8.1. normal above 95
3.1.8.9. ECG
3.1.8.9.1. sinus tachycardia and no other problems
3.1.8.10. CBC
3.1.8.10.1. NORMAL
3.1.8.11. ELECTROLYTS
3.1.8.11.1. NORMAL
3.1.8.12. ESR
3.1.8.12.1. slightly elevated
3.1.8.13. sputum examination
3.1.8.13.1. muco purulunt
3.1.8.13.2. moderate moraxella catarrhalis
3.2. 40 minutes
4. objectives for next session
4.1. manegment
4.2. prevention
4.3. types respiratory failure
4.4. moraxella catarrhalis
4.4.1. why patient is not fibril, and CBC is normal?