Abstract: Chronic obstructive pulmonary disease（COPD）is a highly fatal and disabling respiratory disease characterized by incompletely reversible airflow limitation. As a common comorbidity of COPD，sarcopenia is associated with the Global Initiative for Chronic Obstructive Lung Disease（GOLD）staging and is prone to acute exacerbation，and there is an association between its pathologic mechanism and osteoporosis and their mutual aggravating effects，which jointly affect the prognosis of patients. Although there are guidelines in China that suggest community-based prevention and treatment of COPD and sarcopenia-osteoporosis，there is a lack of a multimorbidity co-management system for COPD，and there are problems such as insufficient ability of general practitioners to comprehensively manage co-morbidities of COPD，referral information disconnection，and poor diagnostic and therapeutic continuity. In this paper，we report the case of a community COPD patient with sarcopenia，severe osteoporosis and lumbar vertebrae fractures，we integrated resources from“Specialized Specialty Units”in community for standardized management，with the aim of analyzing and discussing the collaborative value of the "General Practice and Specialty Integration" model in the management of COPD patients with comorbidities，aiming to explore a new model of diagnosis，treatment and management for patients with multiple chronic conditions in community under the "General Practice and Specialty Integration".

Key words: Chronic obstructive pulmonary disease, Sarcopenia-osteoporosis, Multiple chronic conditions, Specialized specialty units, General practice and specialty integration

摘要： 慢性阻塞性肺疾病（COPD）是以不可逆气流受限为特征的高致死、致残性呼吸系统疾病。肌少症作为COPD常见合并症，与慢性阻塞性肺疾病全球倡议（GOLD）分期相关且易引发急性加重，其与骨质疏松症存在病理机制关联及相互恶化效应，共同影响患者预后。当前国内虽有指南提出针对COPD和肌少-骨质疏松症的社区防治建议，但缺乏COPD共病管理体系，存在全科医生综合管理COPD共病能力不足、转诊信息断层、诊疗连续性差等问题。本文报道1例社区COPD患者合并肌少症、重度骨质疏松症及腰椎骨折的诊疗案例，通过整合社区专病特色科室资源实施规范管理，分析探讨"全-专结合"模式在COPD共病患者管理中的协同价值，旨在探索多病共存社区“全-专结合”诊治和管理的新模式。

关键词: 慢性阻塞性肺疾病, 肌少 - 骨质疏松症, 多病共存, 专病特色科室, 全 - 专结合