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ODESSA NATIONAL MEDICAL UNIVERSITY
FAMILY MEDICINE AND GENERAL PRACTICE DEPARTMENT
Subject Title: “General Practice - Family Medicine”
Independent Study Guidelines for practical sessions for 6th year Medical Faculty
students
MODULE 1: «ORGANIZATIONAL ASPECTS OF PRIMARY HEALTHCARE IN
UKRAINE, ITS PRIORITY ROLE IN THE DEVELOPMENT AND REFORM OF
HEALTHCARE. FEATURES OF OUTPATIENT CARE»
CONTEXT MODULE 5: “Emergency Medical Aid in an Outpatient Setting”
LESSON 11: «FIRST AID FOR THE PAIN SYNDROME IN FAMILY PRACTICE»
Year: 6 th
Faculty: Medical
Approved
By the department methodical board
“____”_____________20__
Protocol № ______
Department Head
___________Velichko V.I., M.D., PhD.
Odessa
«FIRST AID FOR THE PAIN SYNDROME IN FAMILY PRACTICE »
I.
Relevance of the topic (current applicationes): Pain affects quality of life,
and sometimes represents an immediate danger to life of the patient, then immediate action from the
doctor determine the fate of the patient. With various pain syndromes found a doctor in any
specialty almost daily. It is therefore necessary knowledge of the topic by general practitioners.
Every doctor should be able to recognize the pain syndrome and identify its cause, to be able to
assess the expression of pain and the severity of the patient's condition; own methods of providing
emergency care and anesthesia for pain.
II.
Educational objectives (goals and objecties):
Know:
- Etiologic factors and classification of pain
- Clinical diagnostic features of the pain syndrome of various etiology and localization
- Methods for emergency care and anesthesia for pain syndrome, including the painful shock.
Be able to:
- Be able to assess the degree of manifestation of pain and severity of the patient,
- Identify the cause of pain,
- Make intramuscular, intravenous, subcutaneous injection, infusions injection,
- Tourniquet to stop bleeding,
- Conduct activities intensive care (mechanical ventilation, indirect heart massage),
- Provide immediate assistance for pain syndrome, including pain in shock.
Master the skills:
- Diagnosis of pain, recognition of the causes of pain,
-Determining
the
degree
of
manifestation
of
pain
and
severity
of
the
patient,
- Appointment of an adequate therapy for pain syndromes of different etiologies, necessary
manipulation,
- Prescription for medications for relief of pain.
III.
№
1.
Interdisciplinary integration.
Subjects
(Disciplines)
Provisioning:
- Anatomy;
The anatomical structure of
the cardiovascular and
nervous systems.
- Histology and Embryology;
- Normal physiology
2.
Security:
- Morbid anatomy
Be able to
Determine the location of
lesions of nerve fibers or blood
vessels.
Histological structure of all
elements of the human
nervous system.
Writing feature
micropreparations derived
from elements of the nervous
system.
Physiological characteristics Conduct clinical and
of the human nervous
laboratory-instrumental study
system.
of the normal nervous system.
Pathological characteristics of the
pain syndrome.
Determine the location of lesions of
the nerve fiber or receptacle.
- Physiopathology
Pathophysiological basis of pain.
Conduct clinical and laboratoryinstrumental examination of the
nervous system disease.
- Pharmacology
Select an anesthetic drug and its
Pharmacokinetics,
pharmacodynamics, and dosage of dosage to eliminate the pain.
pain medication.
- Propedeutics internal medicine
3.
Know
(possess knowlge of)
Interdisciplinary integration
(between the topics of this discipline)
Conduct clinical and laboratoryMethods for objective and
instrumental study of patients with
laboratory studies
pain syndrome.
patient
The relationship between the
Perform clinical and
circulatory system and other
laboratory-instrumental
systems of human organism and its
examination of all organ
changes in patients with pain
systems of the body in patients
syndrome.
with pain syndrome.
The content of the theme sessions (Topic Contents):
Worldwide, the pain is one of the most frequent reason for seeking medical help.
Pain is the most frequent symptom of the disease, psycho-physiological reaction, occurred when a
strong stimulation
of
sensory nerve
endings
embedded
in
the
organs
and
tissues
Classification of pain:
1) On the localization:
a) somatic pain
- Surface (in case of damage to the skin),
- Deep (with damage of the musculoskeletal system)
b) abdominal pain (if damaged internal organs)
c) neurogenic pain (nerve damage, spinal cord conduction pathways, or thalamus)
d) psychogenic pain.
2) At the time characteristics:
a) acute pain (new, recent pain, are inextricably linked with injury)
b) chronic pain (often acquires the status of separate diseases, continues a long period of time
even after the removal of the cause that caused severe pain.
Comparative characteristics of somatic and neuropathic pain
Somatic pain
Pain stimulus is evident.
The pain is usually well localized, visceral pain
may radiate.
Reminiscent of other somatic pain, previous.
Diminished by anti-inflammatory and narcotic
drugs. Acute somatic pain usually responds
well to treatment of non-opioid analgesics.
Opioid analgesics required to address the very
pronounced pain.
Neuropathic pain
No obvious pain stimulus.
Often poorly localized.
Unusual, unlike somatic pain.
Partly facilitated by drugs. Sensory symptoms
of neuropathic pain can be described by the
following terms: neuralgia, hyper- and
dysaesthesia, alodiniya, causalgia. Poorly
cured, using anticonvulsants, and chemical
(sympatholytic) and surgical simpatectomia,
tricyclic antidepressants.
The pain is most common in general practitioners‘ work:
• headache (migraine, chronic paroxysmal hemycrania and muscle tension headaches, secondary or
symptomatic - a consequence of the transferred traumatic brain injury, cerebrovascular pathology,
tumors, etc.)
• pain associated with inflammation of the elements of musculoskeletal (joint pain, discogenic
radiculitis, myofascial pain myalgia)
• abdominal pain
• pain in trauma (bruises, sprains)
• pain in lesions of the skin (abrasions, burns)
• dental pain and pain after dental procedures
• pain in angina pectoris
• menstrual pain
• pain in cancer patients.
Treatment of pain depends on the clarification of its reasons for launching and reinforcing factors.
The best way of coping with acute pain is addressing its causes. In order to eliminate pain using
such drugs as inhibitors of cyclooxygenase (COX), opioids, antidepressants, antipsychotics,
corticosteroids, anticonvulsants, local anesthetics.
Other methods of treatment of pain: psychotherapy, physiotherapy (heat, cold), immobilization.
The sequence of actions in appointing anesthetics:
1 First of all, a thorough medical history and careful examination of the patient with the explanation
of the effectiveness and duration of previously taken medications, presence of concomitant diseases
and drug complications. Necessary to identify the leading peripheral components of pain (tendonmuscular, neurogenic, others), to ascertain the presence of psychosocial and emotional stress
predictors of chronic pain syndrome. Analysis of the data allows you to select the primary, specific
to this patient, drug group (NSAID-nonsteroidal anti-inflammatory drugs, inhibitors reuptake of
monoamines) and create a treatment regimen.
2 Secondly, should adhere to the principle of consistency in the appointment of analgesics, which
means the following:
• Have in place a few medicines, maintaining analgesia
• Use an adequate period of time to assess the effectiveness of the drug,
• Use combinations of drugs
• If possible, to limit their side-effects.
3 Thirdly, it is necessary to use drugs only as a component of an integrated treatment of pain, i.e.
combine them with physical therapy, behavioral therapy, blockades and possibly neurosurgical
techniques.
The means for pre-hospital treatment of acute pain based on the following principles:
-Ability to obtain a clear clinical effect after a single application in most patients;
-Fast-attack effect;
-Controllability and reversibility of the effect;
-Ability to parenteral or sublingual administration, or, if necessary, the local effect without the
development of resorptive action;
- Minimum probability of adverse action or adverse interactions with other drugs prescribed
simultaneously, and accepted by patients themselves or by medical prescription.
Thus, to select the optimum for use in the prehospital phase of anesthetic necessary to know the
basic pharmacological parameters of the drug, because of pain, the main mechanism of action (level
of impact from the standpoint of a multifactor model of pain), the speed of effect, the possibility of
different routes of administration, the main path of metabolism and options unwanted
pharmacological interactions, a list of possible side effects.
Cyclooxygenase inhibitors. For oral use of COX inhibitors, such as salicylates, acetaminophen,
nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors (coxibs group). By
inhibiting COX these drugs inhibit the synthesis of prostaglandins, causing analgesic, antipyretic
and anti-inflammatory effects. COX inhibitors very effectively eliminate some types of pain,
especially after orthopedic and gynecological procedures, pointing to the important role of
prostaglandins in their genesis, as well as having an important impact on the peripheral and central
nervous system. All medications are metabolised in the liver and kidneys are derived, so in diseases
of the liver and kidneys of the dose should be reduced.
The most common such side effects of aspirin and NSAIDs as indigestion, heartburn, nausea and
indigestion. Some patients have ulcers of the gastric mucosa, which is caused by inhibition of
prostaglandin-depended mechanism of secretion of gastric mucus and bicarbonate. Other side
effects: dizziness, headache and drowsiness. With the exception of paracetamol, all COX inhibitors
disrupt platelet aggregation. Aspirin and NSAIDs may provoke bronchospasm, if patient has polyps
in the nose combined with rhinitis and asthma. Aspirin is not recommended to be used in children
under the age of 12 years, as it promotes the development of Reye syndrome. Finally, NSAIDs can
trigger the development of acute renal failure and renal papillary necrosis, especially with
concomitant renal dysfunction.
Cyclooxygenase plays a key role in the synthesis of prostaglandins. We studied the two isoforms of
the enzyme - COX-1 and COX-2. The main enzyme (COX-1) is produced in virtually all tissues,
whereas the production of COX-2 is virtually impossible without the induction of inflammatory
stimules. It is believed that COX-2, basically, is responsible for the synthesis of neurotransmitters
prostanovyh pain, inflammation and fever. It is also believed that COX-2 participates in the process
of ovulation, implantation, closure of the ductus arteriosus, as well as in the functions of the central
nervous system, particularly in the development of fever, pain sensitivity and cognitive function.
Specific inhibitors of COX-2 did not affect COX-1, and only provide anti-inflammatory and
analgesic effects. The effect of these drugs is not only focused, but also quite powerful. The main
advantage is their lack of inherent non-selective NSAID side effects as the influence on blood
coagulation and gastrointestinal tract. Low risk of complications leading to a decrease in the cost of
their prevention, treatment and other hospital costs associated with re-hospitalization, intensive
care, infusion of blood and other factors. Specific inhibitors of COX-2 may act on the central ( can
easily penetrate the blood-brain barrier) and the peripheral nervous system. Finally, the induction of
COX-2 under the influence of the stimulus, probably kept until the disappearance of peripheral
inflammation. Therefore, selective inhibition of COX-2 plays an integral role in the treatment of
pain.
Opioids (morphine 1%, omnopon 1%, promedol 2%, fentanyl 0.005%). For a moderate
postoperative pain is shown inside the appointment of opioids (as required, or at regular intervals).
Often opioids combined with inhibitors of COX, tighten analgesic effect and reduces the severity of
side effects. All opioids are biotransformation and conjugation in the liver and then eliminated by
the kidneys.
Disadvantages of opiate analgesia:
• respiratory depression, significantly for the patients with spontaneous breathing or receiving
assisted ventilation;
• hypotension usually develops on the background of hypovolemia;
• stagnation in the stomach, which patients in critical condition exacerbated when taking opiates;
• a high enough narcogenic potential;
• lack of vegetonormalizing effect in pain syndromes.
Antidepressants. The doses of these drugs used for analgesia, lower than the dose causing the
antidepressant effect. Both of these effects are due to block of presynaptic serotonin, norepinephrine
or both neurotransmitters. Drugs that effectively block the reuptake of serotonin, have the most
pronounced analgesic activity. Antidepressants are shown mostly in neuropath pain, such as
postherpetic neuralgia and diabetic neuropathy. They potentiate the action of opioids and normalize
sleep. Antidepressants differ in their side-effects caused by the following mechanisms: block of M-
cholinergic receptors causes dry mouth (xerostomia), accommodation disturbances, urine retention
and constipation, the blockade of receptors (N1 and N2) - a sedative effect and increase the pH in
the stomach, the blockade of α-adrenoreceptor manifested orthostatic hypotension, and hinidin-like
effect (especially amitriptyline).
Neuroleptics. Some doctors believe that neuroleptics can eliminate neuropathic refractory pain,
especially effective when they expressed excitement and psychosis. The most frequently used
haloperidol and chlorpromazine. The mechanism of action is the blockade of dopaminergic
receptors in the mesolimbic area. Unfortunately, the blockade of dopaminergic receptors
nigrostriatal system is the cause of extrapyramidal disorders manifested masklike face, a symptom
of "gear" and bradykinesia. By slowly developing side effects include akathisia (motor restlessness)
and tardive dyskinesia. Like antidepressants, neuroleptics, most have antihistaminic, anticholinergic
(M-cholinergic receptor blockade) and antiadrenergic (α-adrenoceptor blockade) actions.
Anticonvulsants. These funds are shown in neuropathic pain, especially in trigeminal neuralgia, as
capable of suppressing spontaneous neuronal impulses, which plays a major role in the genesis of
neuropathic disorders. The most frequently used phenytoin, carbamazepine, valproic acid and
clonazepam.
Corticosteroids. These drugs are widely used in the treatment of pain, because they are
inflammatory and possibly analgesic effects. Route of administration - local, orally or parenterally
(intravenous, subcutaneous, intrabursalno, intra-articular, epidural). Preparations are distinguished
from the power main effect of relative glucocorticoid and mineralocorticoid activity, as well as the
duration of action. Increasing the dose and the extension of treatment increase the severity of side
effects. Excessive glucocorticoid activity manifested hypertension, hyperglycemia, increased
susceptibility to infections, ulcers, osteoporosis, aseptic necrosis of the femoral head, proximal
myopathy, cataracts, and rarely - psychosis. The patient may become characteristic of Cushing's
syndrome appearance. Excessive mineralocorticoid activity results in reduced sodium,
hypokaliemia, as well as provoke the development of heart failure.
Systemic application of local anesthetics. In patients with neuropathic pain, local anesthetic is
sometimes injected to induce sedation and central analgesia. The analgesic effect often exceeds the
time pharmacokinetic profile of a local anesthetic and interrupts the pain cycle. The most common
lidocaine, procaine and chlorprocaine.
In general practice rather frequent causes of acute pain syndrome first emerged is back pain, renal
colic, oncogenic pain, pain in acute coronary syndrome.
Back pain – dorsalgia- has developed as a result of degenerative, inflammatory and functional
changes in the tissues of the vertebral-motor segments and related structures: the facet joints of the
vertebrae, intervertebral disc, fascia, muscles, tendons and ligaments. The most frequently develops
as a result of the defeat of the lower cervical vertebrae followed by the defeat of radial nerve or
lumbosacral spine with the development of pain syndrome in his lower back. The primary cause of
primary back pain is spondylarthritis, which is characterized by bilateral, paravertebral pain arthralgia, increasing during prolonged standing and unbending, decreasing during walking and in
sitting position. In uncomplicated cases, the defeat of the lumbosacral spine leads to the
development of well defined symptom complex, which enables diagnosis of spondylarthritis already
on pre-hospital stage. It spondyloarthrosis is the most common cause of benign back pain in the
elderly. Myofascial syndrome as a primary cause of back pain are diagnosed with chronic local or
regional, limiting movement, muscle pain, in the presence of trigger points, local muscle tension,
lack of motor and sensory disorders. Neuropathic pain occurs as a result of prior or collateral
damage to the central nervous system. It may develop and persist in the absence of explicit
peripheral pain stimulus, often poorly localized and accompanied by various disturbances of the
surface sensitivity. Compared with nociceptive, neuropathic pain is much less susceptible to the
action of opioid analgesics.
Differential diagnosis of back pain:
-Communicable diseases (tuberculosis or nonspecific spondylitis).
-Inflammatory diseases (spondyloarthropathies, polymyalgia rheumatica);
-Metabolic diseases (osteoporosis, hyperparathyroidism, Paget's disease).
-Neoplastic diseases (primary and metastatic spinal tumors, multiple myeloma);
-Somatic diseases (aortic aneurysm, or thrombosis, diseases of the pancreas, urogenital system,
gastrointestinal tract, retroperitoneal pathology, gynecological diseases).
In renal colic, acute pain is the result of an acute violation of urine outflow, which leads to the
development of hypertension in the kidney reflex spasm of the arterial vessels of the kidney, venous
stasis and edema of the parenchyma, hypoxia and the overdistension of the fibrous capsule. The
cause of acute pain in patients with urolithiasis, often becomes ureterolitiaz. Occlusion of the ureter
may develop as in strictures, kinking and torsion ureter, with obstruction of its lumen of blood clots,
mucus or pus, caseous mass in tuberculosis kidneys rejected by necrotic papillae. Renal colic occurs
with intense colic-like periodic pain, accompanied by nausea and vomiting. The pain often
irradiates the course of the ureter in the groin and genitals, accompanied by abdominal distension
and anxiety of patients. The patients are trying to find a comfortable position, but can not find it.
The specific for renal colic behavior distinguishes renal colic from acute surgical diseases of
abdominal organs. Typically, renal colic revealed hematuria and dysuria. In patients with renal colic
for pain is advisable to apply metamizole as monotherapy or in combination with spasmolytic
drugs. Effective pain relief in renal colic does not provide for appointment of morphine and other
opioids, can distort the clinical manifestations of "acute abdomen".
Oncogenic pain
Besides the development of sustainable pain in lesions of the spine and other parts of the locomotor
apparatus in patients with cancer develop persistent pain caused by destruction of nerve trunks,
internal organs and synovial membranes. Nevertheless, the intensity of pain in cancer patients is not
directly dependent on the type and extent of lesions and in most cases - the result of summation of
nociceptive and neuropathic pain. The vast majority of patients actually oncologic pain develops in
the later stages of the disease and is essentially a persistent pain. In addition, those who receive
specific treatment, persistent pain can result from cancer therapy, with the accession of infection or
late metastasis. Prehospital phase in patients with cancer is associated with a number of challenges:
a practical and effective pain relief, which under the law should be free, is unaffordable for most
cancer patients, they are not receiving narcotic analgesics. On the other hand, cancer patients
undergoing outpatient treatment, require constant monitoring and if necessary - correction therapy,
prevention and elimination of undesirable effects of analgesics.
According to WHO recommendations, the choice of means for analgesia based on the expression of
oncogenic pain. WHO proposes "steps" scheme pain of cancer patients, according to which the
strength of analgesia increased gradually, from 1 st to 4 th level, allowing a satisfactory analgesia in
90% of patients:
Level 1: Non-opioid drugs;
Level 2: Non-opioid drugs + weak opioids.
Level 3: Non-opioid drugs + strong opioids.
Level 4: invasive methods of pain relief - spinal analgesia, the use of hypodermic applicators etc.
At any stage of treatment efficacy of analgesia in cancer patients can be enhanced using adjuvant.
These assets include not only drugs, potentiating effect of analgesics (psychotropic, hypnotics, etc.),
but also a means to correct the side effects (corticosteroids, antibiotics, antacid, and overlying, etc.).
Acute coronary syndrome
1. Sublingual nitroglycerin (again by 0.5 mg tablets or 0,4 mg per spray).
The positive effect of nitroglycerin is associated both with the vasodilating effect of the drug on the
coronary vessels, as well as with positive hemodynamic and antiplatelet effects. Nitroglycerin is
able to influence and extending to the atherosclerotic changes, and intact coronary arteries, which
improves circulation ischemic areas. According to the recommendations of the ACC (American
College of Cardiology) / AHA (American Heart Association) (2002) for the treatment of patients
with ACS (acute coronary syndrome), nitroglycerin is advisable to apply to patients with systolic
blood pressure (SBP) is not below 90 mm Hg. and in the absence of bradycardia (heart rate less
than 50 beats per minute) under the following circumstances: during the first 24-48 hours after
myocardial infarction (MI) in patients with heart failure, extensive anterior infarction, transient
myocardial ischemia and high blood pressure, after the first 48 hours in patients with recurrent
angina attacks and / or stagnation in the lungs.
Instead of nitroglycerin can use isosorbide dinitrate. The drug injected intravenously under the
control of blood pressure in the initial dose of 1-4 drops per minute. With good endurance rate of
the drug increase by 2-3 drops every 5-15 minutes.
2. Introduction of narcotic analgesics on the pre-hospital stage: the drug of choice is morphine intravenous slowly 1 ml of 1% solution to 20 ml of saline.
3. Introduction of narcotic analgesics in hospital: fentanyl 2 ml 0.005% solution + droperidol 1-4ml
0.25% solution intravenous or intramuscular or talomonal 1- 2 ml in 20 ml of saline.
4.Simptomatic therapy (antishock, aimed at stabilizing the hemodynamics and gas exchange,
limiting areas of necrosis).
ІV. Content control
The list of questions for the survey:
1. The anatomical structure of the nervous system. Physiological characteristics of the
human nervous system.
2. Clinical and laboratory-instrumental study of the nervous system in health and disease.
3. The phenomenon of pain. Etiological factors and classification of pain.
4. Requirements for prescriptions for medications used for relief of pain.
5. Drugs used for treatment of emergency conditions, pain syndrome.
6. Side effects pain medication, restrictions on their use.
Scheme 1. Emergency care for pain syndrome in renal colic
Complaints
-Pain
(Nature, irradiation)
-Temperature
-Nausea, vomiting
-Disuric disorders
Objective data
-Temperature
-Excited behavior
History
Elapsed disease (Time
of onset of the disease)
-For the first time or not
- How to stop attacks
- Radiating to the external
genitalia
-Disuric disorders
-Pasternatskiy symptom
-Type of urine
The amount of medical assistance
- Heat procedures
- Antispasmodic therapy (no-shpa, atropine,
platifilin, renalgan, baralgin)
- Painkillers (analgine), with failure-narcotic
analgesics
- Nitrous oxide
attack
Cupping, relief
Observation of the clinic
Not docked,
admission to the
urology department
Recall doctor
-Macrohematuria
- Hyperthermia
Scheme 2. Emergency care for pain syndrome in migraine
Migraine without aura
Anamnestico research
- Location, character, intensity of headache (unilateral,
throbbing, increasing during loading)
- The presence of at least one of these syndromes as nausea,
vomiting, light- and sound fear
- Duration of attack from 4 to 72 hours
- At least 5 attacks in history
- Duration of symptoms of aura not more 60 min
- Complete the opposite effect aura symptoms
Migraine with aura
-Ophthalmic
-Oftalmoplegic
-Afatic
ECG
BP
pulse
Tº body
The assistance
-The reflex-action (pull his head with a towel, darken the room, take a bath, hot
tea)
- Sedative, antispasmodic, analgesic, kombispazm, antimigren
V. Materials for self control:
The list of questions for the survey:
• What is pain? The phenomenon of pain and its etiological factors.
• Definition of "pain syndrome".
• Pathogenesis and classification of pain.
• Clinical characteristics and emergency care for different types of pain:
- acute back pain
- acute coronary syndrome
- acute abdomen
- renal colic
- oncology
• Pharmacotherapy of pain:
- NSAIDs, indications for use, their side effect
- Opioids, disadvantages of opiate analgesia
- Antidepressants, antipsychotics, corticosteroids, anticonvulsants, local anesthetics
• Other methods of treatment of pain (physiotherapy, psychotherapy).
Case problem
1) In patients 40 years complain of pain in the left hypochondrium zoster character with irradiation
in the back, increasing after taking the fat, fried foods, especially in the evening. Pain not relieved
after taking antacids, attachment of heat, somewhat reduced after attachment of cold, in the
situation in the stomach and Bozeman. The pain is accompanied by repeated vomiting without
relief, bloating, diarrhea. Sick for three years. OBJECTIVE: tongue moist, coated with white layers.
The abdomen is moderately distended, palpation painful at Mayo-Robson. Liver from the costal
arch. Spleen not palpable. What kind of disease to think? What measures are needed to relieve pain?
Answer: Chronic pancreatitis, acute stage.
Pressing the cold, starvation→ diet 5P, M-cholineblocker (atropine, platifilin,
gastrotsepin, buscopan). Miotropic spasmodicals (papaverine, no-shpa). Non-narcotic analgesics,
H2-blockers (famotidine, ranitidine, nizatidin, roksatidin), proton pump inhibitors (omeprazole,
lansoprazole, pantoprazole), somatostatin (stalamin). Enzyme supplementation therapy: pancreatin
(creon, pantsitrat, likreaz). Liquidation duodenostasis, diskinetic violations biliary, pancreatic ducts:
domperidone (motilium), prepulsid, tsizaprid (koordinaks).
2) The patient received urgent to the hospital complaining of intense headaches. BP 240/120
mmHg. The last two weeks meant he did not take antihypertensive drugs. Urinalysis revealed no
changes. On the ECG - left ventricular hypertrophy, sinus tachycardia, heart rate 98 'per minute. At
the fundus: papilledema. Diagnosis. What is the emergency treatment in this case is necessary and
will help get rid of pain?
A: Hypertensive heart disease. Hypertensive crisis.
Diuretics, β-blockers, nifedipine.
3) Patient K, aged 32, complained of pain in the epigastrium, which occurred after 15-20 min after
eating, vomiting, food brought relief. Epigastric pain bothered before. It is known that his father
was ill patient with gastritis. What is the pathogenetic event to address the pain? Your continued
therapeutic approach?
Answer: Carrying FEGDS, biopsy, breath test with 13C-labeled urea.
Treatment in case of detection peptic ulcers, H.pylori (+): Omeprazole 20 mg twice daily
+ claritoromicin 500 mg twice daily + amoxicilin 1000 mg twice a day- treatment for 7 days. In the
future, continue to receive omeprazole 20 mg twice a day - 4 weeks. Upon completion of treatmentFEGDS and biopsy of the scar on the end of treatment + breath test with 13C-labeled urea at 4
weeks after treatment + FEGDS with biopsy every 6 months.
Tests
1) The girl, 14 years, complained of periodic attacks of headaches in the occipital region, nausea
and vomiting, after which there comes relief, irritability. Her mother is sick with essential
hypertension. OBJECTIVE: Skin pale, moist, hyperhidrosis limbs, heart rate - 86 bpm. for 1 min,
heart tones sonorous, rhythmic, BP - 145/80 mm Hg., BH - 22 for 1 min, vesicular breath. The
abdomen was soft, not painful. What kind of survey you set in the first place to verify the
diagnosis?
A. Ocular fundus, the exclusion of renal pathology
B. Monitoring of BP, the exclusion of renal pathology
C. Monitoring of blood pressure, fundus of the eye, blood lipids
D. Ocular fundus, cholesterol, blood lipids
E. ECG, ocular fundus, cholesterol, blood lipids.
2) The girl, 3 years, with meningococsemia appeared severe headache, generalized convulsions,
respiratory arrhythmia, hemodynamic, bilateral pathological reflexes. The temperature - 38,6 ° C.
OBJECTIVE: positive symptoms Kernig, Brudzinskiy, stiff neck. Ocular fundus: swelling of the
optic nerve papilla. Spinal puncture: protein - 3,3 g / l, cells - 0,7 *109g/l. In the blood: Hb - 100 g /
l, erythrocytes - 2,8 T / l, Tr. - 150 thousand, metabolic acidosis. What a complication develop?
A Insult
B Accelerated hypertension
C Subarachnoid hemorrhage
D Swelling of the brain
E Syndrome Waterhouse-Frideriksen.
3) 11-year old girl complained of a throbbing pain in the right half of the head, which is
accompanied by vomiting. Before the storm there are bright spots, and "flies" before the eyes. The
examination revealed no focal symptoms. What is the question should ask a doctor to girl’s
parents?
A Do not suffer like the grandfather sick headaches?
B Is there a house dog?
C Not the patient's mother suffers from such headaches?
D There was no head injury during the last year?
E There was no poisoning in recent times?
4) The patient was 38, complaining of a headache as the attack, which suffers from the age of 9.
Frequent headaches are in the mother. The attacks begin with a feeling of heaviness in the left
fronto-temporal region, around the orbit, which vary pulsating pain. Face swells, there is pallor.
There is vomiting, then the pain stops flashing, but remains a burden to the whole head. The attacks
provoked by physical exertion, the onset of menstruation. OBJECTIVE: no focal neurological
pathologies. Persistent red dermographism, cooling the extremities, blood pressure 105/70 mm Hg.,
pulse 60 beats / min, EEG, REG normal. At the fundus is no pathology. What is the most likely
syndrome in a patient?
A Liquor-hypertensive syndrome
B Hypertensive crisis
C Migraine
D Hypotonic crisis
E Epilepsy.
5) The patient contacted a doctor in the absence of pregnancy. The examination found inflammatory
disease of the uterine appendages. The patient said that perhaps she would have no children. Since
then, concerns dull constant headache, covering the entire head. The patient can not indicate the
precise localization of pain, carried away by his illness. For 10 years treated by a gynecologist. He
took cardiovascular and analgesic medications without effect. Aggravating factors of headache
could not specify. Does not work, social circle is limited. Neurological examination revealed no
focal lesions. What is the most likely type of headache?
A Psychological pain
B Vascular cephalgias
C Headache muscular tension
D Epilepsy
E Migraine without aura.
6) The patient aged 42 complained of heaviness in the head, diffuse headache, more in the occipital
region. The pain is worse in the morning after awakening, "as soon as he opened his eyes." The
intensity of pain decreases after the transition to a vertical position. The patient notes that sleep
easier at high pillow. Objectively : his face was pale, cyanosed circles under the eyes, the fundus varicose veins. Changes in the REG confirm venous discirculation. Which state is most likely the
patient?
A Hypertensive crisis
B Migraine
C Venous cephalgias
D Liquor-hypertensive syndrome
E Cervicalgia.
7) Female patient, 37 years complained of a feeling of compression, tenderness of the scalp.
Headache-sided, more in the occipital or parietal area, pain when combing the hair, "often freezes
the scalp, feeling close to his head headdress. The pain is triggered by emotional and mental load at
work, when a long time is in a sitting position. First, the headache appeared only during the day,
later joined by night pain. There was increased sensitivity to sounds, bright light. OBJECTIVE:
found painful compression and trigger zone palpation trapezoidal and neck muscles. At the
roentgenograms of the cervical spine - manifestations of osteochondrosis. What kind of headache is
most likely the patient?
A Cerebrospinal fluid-dynamic pain
B Vascular pain
C The pain of muscle tension
D Psychological pain
E Epilepsy.
8) The patient was 55 years complained of attacks of (1 min) unilateral sharp shooting pain in the
left half of the face more in the mouth and nose, salivation, facial flushing, swelling of soft tissues
in this area. The patient describes the state as the passage of electric current. Seizures provoked by
chewing, brushing teeth, wash in cold water, spicy food intake. During the attack, the patient can
not move. In the interictal period, no complaints. Sick of about 3 years. OBJECTIVE: pain on
palpation of exit points 2nd branch of the trigeminal nerve, the presence of the trigger zone, dry
skin, mild hypotrophy of facial muscles, especially on the left. What disease is most likely?
A Hypertensive crisis
B Migraine
C Prosoponeuralgia (trigeminal neuralgia)
D Insult
E Inflammation of the facial nerve.
9) From the medical point of the regiment from the place of summer field training exercises gunfire
brought the crew with the same type of complaints and clinical features: severe constricting
headache in the temples, nausea, dizziness, one of them with the suppression of vomiting,
disorientation. The man's face a few pasty, injected sclera. Blood pressure increased, tachycardia.
One - respiratory failure. The most likely pathology in the military?
A Poison powder gases
B Overheating
C Mine blast trauma, concussion.
D Acute gastro-intestinal disease
E Surrogate alcohol poisoning.
10) At the reception office Central District Hospital from the accident scene, where the truck was
destroyed in a liquid, delivered injured. He complained of weakness, headache. Shortness of breath
at the slightest exertion, pain in the eyes, tearing, compression of the chest, a dry cough. After
breathing through a damp cloth and exit from the place of the accident condition slightly improved,
but after an hour it became worse. Seen excited, anxious, the skin moist, cyanotic, hyperemic
conjunctivitis. Pupils up to 6 mm react to light, pulse 62 / min. rhythmic heart sounds relaxed. BP
100/85, respiration rate 28/min, breathing hard, relaxed, wheezing. Formulate a diagnosis.
A Defeat dihloretan
B Defeat chlorine (phosgene?). Toxic pulmonary edema..
C Defeat phosphorus toxic compounds, bronhoreya.
D Defeat sulfuric acid, pulmonary edema.
VI.
Literature:
Main
1. Bosek V., Migner R. Year book of pain.-1995.-P.144-147.
2. MacPherson R.D. New directions in pain management// Drugs of Today.-2002.-3 (2). - P.135145.
3. McGormac K. Are COX-2 selective Ingibitors effectie analgesics? // Pain reviews. - 2001.-Vol.8,
№ 1. - P. 13-26.
4. McQuay H.J., Moore R.A. An evidence-based resource for pain relief. - Oxford Uniersity Press.
1998. -P.264.
5. Cousins M. Acute and postoperative pain// textbook of Pain.-3-rd/ Wall P., Melzak R.Philadelphia: Churchill- Livingstone.- P.357-385.
6. Study Guidelines for 6th year Medical Faculty students.-2010.-Odessa, ODMU.
Additional literature
1. Bille B. Migraine in schoolchildren // Acta Pedaiatr. Scand. Suppl., 51 (1962) 1-151.
2. Dalsgaard-Nielsen T., Holm H.E. Clinical and statistical investigations of the epidemiology of
migraine // Dan. Med. Bull. 17 (1970) 138-148.
3. McGrath P.J., Unruh A.M. Pain in Children and Adolescents // Elsevier, Amsterdam, 1997.
4. Merskey H. Classification of chronic pain: descriptions
of chronic pain syndromes and
definitions of pain terms //Pain, Suppl., 3 (1996) 51-58.
5. Waters W.E.Community studies of the prevalence of headache // Headache 9 (1990) 178-186.
6. Wildholm O.Dysmenorrhea durin adolescene //Acta Obstet. Gynecol. Scand.,87 (1999) 61-66.
Methodological guidelines prepared
Discussed and approved by the department methodical board
Protocol № __ “____”_____________2010
Department Head ___________Popik G.S., M.D., Prof.
Study guidelines prepared by_________________________________________________________
Discussed and approved in Department meeting № __ of_______________201_.
Department Head
V.I. Velichko, MD, PhD____________________