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Ministry of Public Health
Republic of Uzbekistan
Centre of development of the medical education
Tashkent Medical Academy
«Application of the case-technology at the faculty therapy
studies on a theme «Systemic lupus erythematosus»
(The teaching and methodological guide for students of IV courses
of medical universities)
Tashkent 2012
1
Ministry of Public Health
Republic of Uzbekistan
Centre of development of the medical education
Tashkent Medical Academy
“Approved”
Head of the Chief Department of science
and educational institutions of MPH RUz
Professor Sh.E. Atahanov
___________________________
“____” ________________ 2012
№ of the report
«Application of the case-technology at the faculty therapy
studies on a theme «Systemic lupus erythematosus»
(The teaching and methodological guide for students of IV courses
of medical universities)
Tashkent 2012
2
Authors:
Djuraeva E.R. – department of faculty and hospital therapy of the faculty of
general medicine and internal diseases for medical prophylaxis
faculty, associate professor.
Ziyaeva F.K. – department of faculty and hospital therapy of the faculty of
general medicine and internal diseases for medical prophylaxis
faculty, assistant.
Reviewers:
Yakubov A.V. – department of clinical pharmacology of ТМА, professor, doctor
of medical science
Rahimov S.M. – department of hospital therapy and propedeutics of internal
diseases of TashPMI, professor, doctor of medical science
The teaching and methodological guide is examinationed and confirmed at the session
of ТМА CMC (report № _____ “_____” _____ 2012).
Chairman of the CMC, professor
M.Sh.Karimov
The teaching and methodological guide is confirmed on the Scientific Council of ТМА
and is recommended to publication (report № _____ “_____” _____ 2012).
The scientific secretary,
doctor of medical science, professor
Salomova F.I.
3
Theme: Systemicic lupus erythematosus
1. The study venue and equipment
Departments of rheumatology, cardiorheumatology and common therapy, department of
laboratory and instrumental diagnostics, educational rooms.
Blood, serologic analyses, clinical and biochemical analyses, immunologic examinations,
acute phase tests, X-ray examinations, ECG, FCG, EchoCS, educational and supervising tests,
thematic patients, distributing material.
- ТV-video, overhead, multimedia, charts, slides, informational computer program.
2. Duration of the lesson
Time for interpretation of the yielded theme - 270 minutes
3. The study purpose:
Teaching students of the etiology, pathogenesis, clinical symptomatology,
laboratory-instrumental diagnostics and rational therapy, preventive maintenance
of complications, follow-up care.
The training purpose – development and hardening of theoretical knowledge:
The educational purpose – formation in doctor training the interest corresponding to the world standards for a
speciality, a sense of responsibility, education of interest to the knowledge enhancement, formation of the
deontologic educational level, formation of caution in the course of practical work, lucidity and responsibility.
The development purpose – formation of self-maintained thinking and discussion at students, development of
critical thinking in students (e.g. clinical and prophylaxis).
Briefing
1.
2.
3.
4.
5.
Definition of a Systemic lupus erythematosus (SLE).
SLE etiology.
SLE pathogenesis.
SLE classification.
Clinical pattern of SLE: the subjective data, common examination, palpation, percussion and
auscultation data, the inference of the laboratory-instrumental methods of examination.
6. Differential diagnostics of SLE
7. Main principles of treatment of SLE
8. Course and the SLE prognosis.
The student should know:
- SLE etiology
- SLE pathogenesis
- SLE classification
- Methods of diagnostics of SLE
- Main principles of treatment
4
The student should be able:
- To collect the anamnesis, complaints of the patient, to perform the common examination,
palpation, percussion and auscultation
- To compound the plan of the patient examination
- To interpret the laboratory data indexes
- To interpret the data of X-ray examination
- To prove the clinical diagnosis step-by-step
- To write the prescription on drugs and explain their mechanism and side effects
4. Motivation
The present studying of a systemic lupus erythematosus has huge value, the SLE can lead to the patient lifethreatening complications.
5. Interdisciplinary and intradisciplinary communication
Interdisciplinary communication:
To integrate with following subjects:
I.
On vertical
1.
Normal anatomy
2.
Normal physiology
3.
Histology
4.
Pathologic anatomy
5.
Pathologic physiology
6.
Propedeutics of internal diseases
II.
On horizontal
1.
Radiologic diagnostics
6. The lesson content.
Theoretical part
Bunch of general diseases of a connective tissue concern:
Systemic lupus erythematosus
Systemic scleroderma
Dermatomyositis
Diffuse fasciitis
Rheumatic polymyalgia
Relapsing panniculitis
Relapsing polychondritis
Sjogren’s syndrome and disease
Mixed diseases of connective tissue
Antiphospholypid syndrome
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) - chronic polysyndromic disease of preferentially
young women and the girls, educing upon genetic caused irregularity of immune managing processes leading to
uncontrollable production of antibodies to natural cells and their components, with development of the
autoimmune and immune complex chronic inflammation.
5
Epidemiology
Annually in different regions 1face per 400-2000 affected
Disease more often educes at women (10-20:1)
50-70 recently affected per 1 million population in a year
70% fallen ill at the age of 14 - 40 years, "peak" by 14 – 25 years
The SLE etiology is not determined yet. A viral infection contamination, genetic, endocrine and
metabolic factors are supposed to educe the SLE development. In patients with SLE the lymphotoxic
antibodies and antibodies to the double-helical DNA are often found, which are being markers of a
persistent viral infection. In an endothelium of capillaries of the damaged tissues the virus-like
incorporations are being revealed.
The fact of family prevalence of the disease considerably exceeding the population testifies to
the genetic predisposition to SLE, high frequency of rheumatic diseases at relatives, cases of disease at
twins. Connection between SLE and presence of certain HLA-antigenes (DRj, DRj, Bg), deficit of С4component of the complement, genetic determined insufficiency of N-acetyltransferase enzyme
metabolizing a series of medicines is established.
The depression of immune tolerance to the natural antigens is in the basis of the disease, leading
to uncontrollable synthesis of set of autoantibodies to natural tissues of an organism, especially to the
nuclear antigens. Disturbance of immune tolerance arises due to the congenital or acquired defect as in
the system of T-lymphocytes (depression of T-supressors activity, reduction of interleukin-2
production), as well as the B-system (polyclonal activation).
Autoantibodies render direct (on erythrocytes, thrombocytes etc.) and mediated (through
formation of cell-bound immune complexes) damaging activity. At SLE the deep disturbances in the
processes cell-bound immune complexes elimination from an organism are stated.
The antibodies to native DNA and the circulating cell-bound immune complexes sedimenting
on the basal membranes of kidney glomerular capillaries, skin and other organs and tissues have their
pathogenetic value. Thus they have the damaging effect accompanied by development of typical
inflammatory response.
Prevalence of young women among patients with SLE, the frequent beginning of disease after
the delivery or abortions, disturbance of the estrogens metabolism with rise of their activity, presence
of hyperprolactinemia testifies to participation of hormonal factors in pathogenesis of the disease.
Quite often at the SLE diseased patients the symptoms specifying in a depression of adrenal function
are noted.
Catarrhal diseases, labours, abortions, pregnancy, ultraviolet radiance, intolerance of medicines,
vaccines, serums etc. can be the provoking factors in SLE development.
Pathomorphology. In the loci of the connective tissue damage the amorphous masses nuclear
substance, coloured by hematoxylin in purple-blue colour (hematoxylin bodies). The neutrophils
captured these bodies in vitro term as LE cells. Cell-bound immune complexes in a connective tissue
and vessel walls consisting of DNA, antibodies to DNA and compliment components, are coloured (as
well as fibrine) by eosine, forming a pattern of the fibrinoid necrosis.
Clinical pattern. Systemic lupus erythematosus is a disease of young women in childbearing
age. Men are ill in 10-15% of cases. Polymorphism of clinical symptoms is bound with the systemic
pathological process.
Disease more often begins with an articular syndrome, fever, dermal rashes, trophic
disturbances and astenovegetative syndrome. Within several months for no apparent reason the patient
can grow thin for 10 and more kilograms. Gradually all new organs and organism systems are
iHbolved in process, yielding the conforming clinical semiology.
6
The joints lesion occurs at 90-95 % of patients and becomes apparent by arthritis or migrating
arthralgias. All joints of arms and feet, but more often the palmar joints can be iHbolved in process.
The periarticular edema is distinctive. At a chronic clinical course the deformation of palmar fingers,
an atrophy of interosseous muscles can educe. The arthritis at SLE is well treated by corticosteroids.
Integuments at SLE clinically are impaired less often than joints. The symptom of "butterfly" erythematous rashes on face and in the field of cheeks, the nose ridge, superciliary arcs are most
typical. Dermal lesions can become apparent also by a facial diffuse erythema and open parts of a
body, elements of discoid lupus, pemphygoid rash etc.
The part of the patients have in the field of palms and fingers can have net teleangiectatic
erythema (capillarites) which also have its diagnostic value.
The lesion of serous membranes, mostly the pleura and pericardium, meets approximately at
90% of patients. Pleurites and pericardites are often dry, more rarely with a small amount of ecssudate
and its prompt iHbolution. X-Ray examination often shows traces of the carried serositespleuropericardial commissures or a pleura thickening.
At SLE the cardiovascular system is often iHbolved in pathological process. Clinically it can
proceed in the form of a myocardial dystrophy, myocarditis or endocarditis with a lesion of the valval
apparatus (endocarditis of Liebmann-Sax). Myocardium lesions are become apparent by pains in the
heart area, dyspnea, dumb heart beats, tachycardia, noises, rhythm disturbances.
The lesion of lungs proceeds as a pneumonitis (dyspnea, cough, facial cyanosis, at auscultation
fine moist rhales) or pneumosclerosis. X-Ray showings indicate intensifying and the strain of the
vascular pattern, alternating infiltrates, the fibrosis locus, preferentially in the inferior departments of
lungs are observed. The small focal dissemination in lungs at SLE demands differential diagnostics
with tubercular process.
Kidneys are impaired not less often than at every second patient with SLE. Clinically it can
become apparent by a pattern of glomerulonephritis or glomerulonephritis with nephrotic syndrome. At
the long-term treatment of patients the corticosteroid hormones can educe the secondary pyelonephritis.
Appearance of a renal pathology in a disease debut is especially prognostically unfavorable.
The pathology of a gastrointestinal tract is not often revealed. Cheilites (lesion of lips),
aphthous stomatites can be observed.
The lesion of the nervous systems is most often expressed by the astenovegetative syndrome
(weakness, malaise, rapid fatigue, adynamia, irritability, headache, sweating). Polyneurites are less
often diagnosed. Development of meningoencephalopolyradiculoneuritis is one of the prognostically
most adverse signs.
Mental disturbances - labile mood, insomnia, memory depression, epileptiform attacks are
possible to diagnose.
At many patients with SLE the lymphadenopathy becomes perceptible. Trophic disturbances
are characteristic: loss of body weight, reinforced hair fall, alopecia, sometimes full baldness, lesion of
fingernails, xeroderma.
Laboratory data. In a peripheric blood leukopenia, stab shifting, hypochromic anaemia, ESR
substantial increase. Development of hemolitic anaemia and thrombocytopenia is possible. Detection of
a great number of lupoid cells (LE-cages), rising of ANF titres and antibodies to native DNA are
typical dysproteinemia with augmentation of the gamma globulins content. At the majority of patients in a process of actuation the complement level drops. The false positive Wassermann reaction is
sometimes noted. Its development in this case is caused by production of antibodies to phospholipids,
first of all to the cardiolipin which is the basic antigen of response.
The degree of laboratory indexes changes depends on degree of activity and acuteness of lupoid
process course.
7
Diagnostics. For statement of the reliable diagnosis it is necessary to use diagnostic criterias of
the American rheumatologic association (1982):
1. Rashes on cheekbones (the “lupoid butterfly”), the fixed erythema (flat or uplifted), tending to
diffusion to the nasolabial region.
2. Diskoid rash - erythematic uplifted plaques with adjacent scales and follicular corks; atrophic scars
on the old foci.
3. Photosensitization the dermal rash as a result of a sunlight skin exposure (in anamnesis or doctor’s
examination)
4. Erosions and ulcers in oral cavity ulcerations in oral cavity or nasopharynx, routinely painless (the
doctor should register)
5. Arthritis not erosive arthritis of 2 or more peripheral joints expressed by tenderness, edema and
exudate.
6. Serosites pleuritis: pleural pains, pleural rub noise and-or presence of a pleural exudate; pericarditis:
documented by an echocardiography, or a pericardial rub noise auscultated by the doctor
7. Kidney lesion a proof proteinuria more than 0,5 g/day or cylinders (erythrocyte, canalicular,
granular, mixed) and hematuria.
8. CNS lesion: seizures – in the absence of drug intake or metabolic disturbances (uremia, ketoacidosis,
electrolytic disbalance); psychosis – in the absence of drug intake or electrolytic disturbances
9. Hematological disturbances leukopenia less than 4 * 109/l, not less than 2 times registered;
lymphopenia less than 1,5 * 109/l, not less than 2 times registered; thrombocytopenia less than 100 *
109/l, not associated with drug intake.
10. Immunologic disturbances detection of a lupoid coagulant; false positive response of the
Wassermann test during at least 6 months at proved absence of syphilis by the immobilisation reactions
of a pale treponema and the fluorescent absorption of the treponeme AB.
11. Antinuclear AB titre rising noted by a method of immunofluorescence or a similar method and lack
of drugs reception iHboking the SLE-similar syndrome.
The patient can be classified to SLE in the presence of any 4 and more criteria from 11 offered.
Diagnostic measure can be presented consistently or simultaneously, to any season of observation.
There are the following variants of SLE course (acute, subacute, chronic at first diseases and to the
further advance).
At acute course there are the sudden onset of disease, high body temperature, acute polyarthritis with
the acute joint pain, the expressed dermal changes, serious polyserosites, kidneys lesion, nerve system,
trophic disturbances, weight loss, acute augmentation of an ESR, pancytopenia, considerable quantity of LEcells in blood, high caption of ANF are characteristic. Duration of disease 1-2 years.
Subacute сourse is characterised by gradual development, articular syndrome, normal or subfebrile
body temperature, dermal changes. Activity of process during the considerable time underload, remissions
are long (before half a year). However process become gradually generalized, the plural lesion of organs and
systems are revealed.
Chronic course is expressed by mono- or some syndromic for many years. The common state remains
satisfactory for a long time. At early stages the dermal changes, articular syndrome are observed. Process
slowly progresses, and many organs and systems further are impaired.
Taking into account clinical and datas of laboratory there are three degrees of activity evolved: high
(III), moderated (II), minimal (I).
8
Degree of activity
Index
III
II
I
Body temperature
38о and more
Less 38о
The normal
Weight loss
Expressed
Moderated
-
Trophic disturbance
Expressed
Moderated
-
Skin lesion
"Butterfly" and an erythema of
lupoid type
Ecssudative erythema
Diskoid foci
Polyarthritis
Acute, subacute
Subacute
Deforming, arthralgias
Pericarditis
Exudative
Dry
Adhesive
Myocarditis
Diffuse
Focal
Cardiosclerosis,
myocardium dystrophia
Endocarditis
Lesion of many valves
Lesion (routinely
mitral) valve
Insufficiency of the mitral
valve
Pleuritis
Exudative
Dry
Adhesive
Pneumonitis
Acute (vasculitis)
Chronic (interstitial)
Pneumofibrosis
Nephritis
Nephrotic syndrome
Nephrotic or urine
syndrome
Chronic
glomerulonephritis
The nervous system
Acute
encephaloradiculonephritis
Encephalonephritis
Polyneuritis
Crises (hemolitic,
nephrotic, adrenal, etc.)
+
-
-
Haemoglobin, g/l
Less than 100
100-110
120 and more
ESR, mm/H
45 and more
30-40
16-20
Fibrinogen, g/l
6 and more
5
5
Albumines, %
30-35
40-45
48-60
α2
13-17
11-12
10-11
γ
30-40
24-25
20-23
Globulins, %
9
LE-cells
5:1000 leukocytes and more
(1-2:1000 leukocytes
Individual or absent
The antinuclear factor
(АНФ)
1:128 and above
1:64
1:32
Luminescence type
Edge
Homogeneous and
edge
Homogenous
Antibodies to nDNA
(titres)
High
Average
Low
Working classification of clinical variants of SLE course (Nasonova V. A. 1972 - 1986)
The clinic-morphological characteristic of lesions
Charact
er of
course
Phase and
degree of
activity
Acute
Subacute
Chronic
Phase:
Active
Degree of
activity:
High(III)
Moderate
(II)
Minimal(I)
Phase:
inactive
Skin
Symptom
of
“butterfly”
Ecssudative
erythema,
Dermal
purpura
Discoid
lupus.
Joints
Arthralgias
Polyarthritis
Serous
membra
nes
Polyserositis:
pleuritis/
pericarditis
Heart
Myocarditis
Endocarditis
Lungs
Kidneys
Nerve system
Pneumonitis
Pneumofibrosis
LupusNephritis
(With
nephrotic syndrome,
isolated
urine
syndrome)
Meningoencephalopolyradiculoneuritis,
polineuropaty
Treatment. Not less difficult problem, than diagnostics of this many-sided disease, is SLE
treatment. Treatment of patients is referred to the repressing the immune complex pathology and
restoration of function of the affected organs and systems.
Basics of medicamentous therapy of SLE compound GCS hormones which are terrain
clearancely shown at an establishment of the reliable diagnosis. Prednisolonum, Methylprednisolonum
(Medrolum, Urbazonum), Triamcinolonum (Polcortolonum), Dexamethasone (Dexasonum),
Betamethasone can be prescribed.
The dose of corticosteroid hormones to each patient is selected individually. It depends on
acuteness of pathological process, degree of activity, character of visceral lesions.
10
Except corticosteroid hormones to the majority of patients with SLE are prescribed
aminochinolone drugs (Delagilum, Plaquenilum, Chingaminum, Chloroquine etc.). Delagilum is taken
over in the evening after meal on 1-2 tablets (0,25-0,5 g/day), Plaquenilum - for 0,2-0,4/days are
necessary within many months or years. Aminohinoline drugs are most shown to the patients with SLE
accompanied by the skin lesion and at chronic course of the disease.
The wide spread in SLE treatment suffices have received cytostatic drugs which immediately
depress pathologic immune organism responses. Indications to application of cytostatics are: 1)
presence of progressing lupoid nephritis at patients or a lesion of the nervous system with neurolupus
type; 2) high immunologic activity of disease or presence of lupoid crisis; 3) necessity promptly to
reduce an overwhelming dose of corticosteroid hormones because of the bad shipping or expression of
side effects; 4) futility of previous therapy; 5) resistance to corticosteroid therapy.
Most often at patients with SLE Azathioprinum (Imuranum) or Cyclophosphanum
(cyclophosphamide CF) in a dose of 2-3 mg/kg a day is applied. In a medical dose the drug is
prescribed on 3-4 months, and then it is necessary to transfer to reception of maintenance doses of 50
100 mg/day within many months and even years. Azathioprinum is taken over inside, and
Cyclophosphanum – parenteral (intramuscular or intravenous). At high immunologic activity of SLE it
is possible to begin treatment with parenteral application of Cyclophosphanum for reception of more
prompt therapeutic effect, and later 2-3 weeks to transfer to the further reception of Azathioprinum.
Antimetabolites (Azathioprinum) are better for prescribing daily, and for alkising drugs
(Cyclophosphanum) is more preferable to use an alternating mean of introduction. Cyclophosphanum,
as a rule, is applied on 200 mg intravenously in-jet every other day or 400 mg 2 times a week.
Presence of nephritis at the patient with SLE of any degree of manifestation or signs of a
generalised vasculitis is the indication for incorporation in complex therapy with Heparin and
Dipiridamolum. Heparin, being direct action anticoagulant, depresses intravascular coagulation,
besides, reduces activity of complement, has anti-inflammatory effect, reduces vascular permeability.
On the background of its effects the arterial pressure drops, the diuresis is enlarged.
Heparin is prescribed with 20000-30000 MU per day. It is more preferable to introduce it
subcutaneously in the abdominal area for 5000 MU 4 times a day or under other scheme 10000 MU
intravenously droply, and the remained daily dose subcutaneously in the abdominal area - in 2-3
injections. Duration of a heparin course should compound 3-10 weeks. Heparin is introduced under
control of a blood clotting time and (or) tolerances of plasma to heparin.
Dipiridamolum (Curantylum) as disaggregant interferes with aggregation of thrombocytes due
to that efficiency of application of heparin raises. It is prescribed in a daily dose of 150-400 mg within
3-8 months.
Courses of Heparin-Curantylum schemas at patients with a lupus-nephrite 2-3 times a year are
recommended to make courses of treatment. It allows to conserve function of kidneys in a satisfactory
state for a long time.
Despite the reached successes, conducting patients with SLE remains one of the most
challenges. On a combination of efficiency and safety the drugs influencing immune inflammation GCS,
CPh, Azathioprinum, Chlorbutinum and others not always satisfy clinicians. Besides, at many patients
early administration of adequate doses of GCS and cytotoxic drugs does not allow to avoid an
irreversible damage of vitals and systemic (first of all kidneys and the central nervous system), and also
quite often associates with development of serious, potentially lethal side reactions (an intercurrent
infection contamination, a cytopenia, a hemorrhagic cystitis, osteoporotic fractures, growth of number of
malignant growths and so forth). All it spots necessity of studying of new approaches to SLE
pharmacotherapy. Perfection of action methods on immune process descends in two directions: change of
traditional regimens of their application and introduction in practice of new drugs.
11
Point of application of therapeutic procedures is action on lymphocytes, formation and immune
complex deposition and preventive maintenance, and also change of the immune answer by inducing the
antigen-specifying tolerances or interactions with the system of cytokines.
Last years especially great interest iHbokes cyclosporine A which is examined as one of the most
effective medical products with selective immune-suppressive activity. The concrete mechanisms
spotting efficiency of cyclosporine A (CsА) at SLE, up to the end are not clear. It is obvious that on
character of action the synthesis of cytokines of CsA it is rather close to GCS. It is impossible to exclude
that one of important mechanisms of activity of CsA at SLE is bound with inhibition of interpherone
synthesis. Ability of CsA to depress an expression of ligand СD40 on T-lymphocytes membrane is
interested.
Doubtless advantage of CsA in comparison with other drugs, used for SLE treatment, is smaller
frequency both immediate, and the remote side effects, first of all infectious complications and malignant
growths. Unlike other cytotoxic drugs of CsA possesses underload teratogenious ability. There is data
about depression against therapy of CsA of level of anticardiolypin new and antithrombocytal
antibodies, and also preventive activity concerning an atherosclerosis forwardness that has huge value for
patients with SLE.
Encouraging effects are received at patients with SLE of one and more selective immune-supressor
Mophetyl mycophenolate. Mophetyl mycophenolate (MMF) (Cellsept) represents synthetic
morpholyne-ethyl aether of mycophenole acids and its precursor. After reception of MMF inside hepatic
esterases completely transform it into the active bond with mycophenolic acid which is noncompetitive
inhibitor of inosinemonophosphatedehydrogenase, the enzyme limiting rate of synthesis of guanosine
nucleotide. As the functional activity of lymphocytes in a greater degree, than other promptly divided
cells, depends on synthesis purines, the drug yields more expressed the antiproliferative effect
concerning lymphocytes and displays cytostatic, instead of cytotoxic activity.
Expedient discussion of one more perspective direction of pharmacotherapy of SLE - usage of the
drugs quenching a proliferation of B-cells among which the most studied is rituximab (RM) is
represented. Advantages of appointment RM consisted in influence practically on all clinic-laboratory
parameters of SLE and prompt achievement of effect that is especially actual at development of the
critical states immediately menacing to life of patients. Probably, in the future use RM as drug of the first
line with the subsequent long-term appointment of a selective immunodepressant will appear the
optimum schema of treatment of prognostically unfavorable variants of SLE.
Prospects of treatment of patients with SLE, it is doubtless behind biological methods of action,
with use of so-called biological agents. These drugs are developed for the purpose of action on specific
immunologic processes to which concern activation of T-cells, T-B - cellular interaction, development of
antibodies with two-spiral DNA, activation of cytokines and others. In this respect major possibilities are
represented by application антииEиотипических monoclones, an intravenous immunoglobulin.
Revealing of the raised serum levels IL 10 at patients with SLE and relatives, and also their correlation
with activity of disease have formed the establishment for use monoclone antibodies to IL 10. Pre-award
effects of several examinations testify to plus influence of antibodies concerning a lesion of a skin,
nephroses, an arthritis and a serositis, refractory to GCS therapies.
Thus, use of biological agents as the majority of them does not possess generalised immunesupressive activity will be doubtless prospect of treatment of patients with SLE.
12
Now it is necessary to recognise as the most aggressive method of treatment of SLE is the
autologic transplantation of stem cells (ATSC).
Important direction of pharmacotherapy of SLE is prevention of development or treatment of an
accompanying pathology, first of all an early atherosclerosis, an osteoporosis, infectious complications
which make not less negative impact on the vital prognosis, than disease. It spots necessity of wider
introduction of up-to-date hypotensive, hypolypidemic, antiosteoporotic and hermicides. As some of
them, for example, statins, antibiotics and it is possible, bisphosphonates possess anti-inflammatory and
immune-modulating activity, their application can potentially raise efficiency of treatment of the
inflammatory rheumatic diseases.
As the SLE intensive care last years the pulse-therapy by Methylprednisolonum (Solumedrole),
is widely applied by betamethasone (Celestonum). From cytostatic drugs for pulse-therapy
Cyclophosphanum (cyclophosphamide) is used. The sense of pulse-therapy consists in introduction in an
organism of shock superhigh doses of corticosteroid hormones or cytostatics during a short time term.
These drugs in a superhigh proportioning render powerful antiinflammatory and the immunodepressive
effect, and short term of their application does not allow to educe to terrible iatrogenic complications.
Pulse-therapy by Methylprednisolonum it is shown in the presence of the active lupoid nephritis with a
nephrotic syndrome, neurolupus, prompt advance of disease, high immunologic activity of process, weak
efficiency of usual therapy.
For the purpose of intensifying of anti-inflammatory and immunodepressive effects probably
carrying out of the combined pulse-therapy. At carrying out of the combined pulse-therapy in the first
day 1000 mg methyl-prednizolona and 600-1000 mg (depending on mass of a body of the patient)
Cyclophosphanum are intravenously droply introduced. The next 2 days patients receive dropwisely only
on 1000 mg of Methylprednisolonum. From by-effects of the combined pulse-therapy it is necessary to
note a nausea, unpleasant sensations in the field of heart, a tachycardia, rarely leukopenia and a hair fall.
Combined pulse-therapy it should be prescribed under strict indications. It can be made only at patients
with a torpid and progressing lupus-nephrite, and also a generalised vasculitis.
At the most serious variants of the SLE, becoming complicated development of a lupoid crisis
(renal or multiorgan), or resistances to traditional therapy, include in treatment schemas plasmapheresis
(PPh, synchronising its carrying out with pulse-therapy CPh). Usage of PPh is referred on excision from
a blood of circulating cell-bound immune complexes (Central Electoral Committee), cryoprecipitines,
various antibodies, mediators of an inflammation, yields of metabolism etc. At PPh endogenous
phagocytosis of the Central Electoral Committee therefore expression of lesions of various organs
decreases is labilised, sensitivity of receptors of cells to action of immunodepressants raises.
Administration of the isolated extracorporal therapy for patients with SLE is essentially
circumscribed because of threat of development of a so-called syndrome of the "rebound" characterised
by rough production of autoantibodies in 12-24 h after procedure. Repressing of activity of lymphocytes
and "rebound" prevention can be reached by synchronous program application PPh/GCS and pulsetherapy of MT and CPh.
The schema of synchronous therapy consists of three sessions of PPh which is carried out in
1st, 2nd and 3rd days of treatment, in 6h after the third session PPh make pulse-therapy CPh (or CPh
and MT) which retry in 4th and 5th days of treatment.
As indications for appointment of SLE high value of clinical and laboratory indexes of
activity of SLE, disease advance, despite made conservative therapy, and the states menacing to life of
the patient serve.
13
Preventive maintenance at SLE is referred on the prevention of exacerbations of disease. Essential
value has pedantic observance of medical references on reception of medical products of pathogenetic
activity, first of all corticosteroid hormones and cytostatics (or aminochinoline drugs). Observance by
the patient of certain references on a regimen, character of work and rest is not less important. The
patient should avoid action of solar insolation, supercooling, the catarrhal diseases, the bioticly not
shown operative measures, inoculation, vaccines, serums.
The prognosis. Now the prognosis at patients with SLE was essentially refined. The survival rate of
patients with SLE in 10 years after diagnosis statement reaches 80 %, in 20 years–60 %. Nevertheless
the mortality of patients with SLE remains in 3 times above, than in population.
New pedagogic technologies applied on lesson.
CASE
Solving the problem of in-time diagnostics of SLE and a choice of rational therapy
The pedagogical summary
Subject: «Faculty therapy»
Theme: «SLE diagnostics and treatment»
The purpose of the yielded case: an excavation and dilating of knowledge of the causes of
development of SLE. Development of ability of an assessment and the analysis of a situation of
treatment patients with SLE. Skills of drawing up of diagnostic algorithm and a choice of tactics of
treatment in the conditions of a hospital.
Scheduled educational effects – by results of operation with a case students get skills:
 Assessment and the analysis of common state of patients with SLE
 Choice of the correct diagnostic algorithm of patients with SLE.
 Choice of treatment tactics in the conditions of a hospital.
For the successful solution of the yielded case the student should know:
• Measure of the SLE diagnosis.
• To perform differential diagnostics
• To number the diagnostic methods, to compound and prove the plan of examination in the
hospital conditions
• To compound and prove a treatment planning
The yielded case reflects a real situation in the hospital conditions.
Case references:
1. Internal diseases Martynova A.I., Muhina N.A., Moiseeva A.S., М, medicine, 2004
2. Internal diseases edited by Martynova A.I., Muhina N.A. – M. 2008
3. Rheumatology: the National management / by E.L.Nasonov, V.A.Nasonovoj's edition. - М,
GEOTAR-media, 2008. - 720с.
4. Rheumatology: clinical references. / by E.L.Nasonov's edition. - Moscow-005.-262s.
5. Rheumatology secrets. Sterling J.Way. Translation from English. Moscow, 1999. 768с.
6. http://.www.med-site.narod.ru/index.htm
The description, diagnostics, treatment of diseases. Pharmaceutics, anatomy.
7. http:// www.recipe.ru
Medicine: information resources, databases.
8. http:// www.vh.org
9. http:// www.meddean.luc.edu
14
The encyclopaedia of examination of the patient with set of an illustration, the short description
of diseasees, testing.
10. http://embbs.com
Case histories, training, the atlas on an electrocardiogram, etc.
11. WWW.TMA.uz.
The case performance according to typological signs
The yielded case falls into the room, subject genres. It is volumic, structured. It is a case-question.
On the didactic purposes the case is training, boosting thinking in a real situation in the hospital
conditions.
The case can be used on disciplines: therapy, infectious diseases, urgent conditions.
I CASE
« SLE diagnostics and treatment»
Introduction
Systemic lupus erythematosus - chronic polysyndromic disease of preferentially young
women and the girls, educing against genetic caused irregularity of immunoregulatory processes
leading to uncontrollable production of antibodies to natural cells and their components, with
development autoimmune and immune complex a chronic inflammation. Annually in different regions
1 per 400-2000 become ill. Disease educes at women (10-20:1) more often. Recurring 50-70 on 1
million population in a year. 70% are ill at the age of 14-40 years, "peak" on 14 – 25 years. The SLE
etiology is not positioned till now. In its development participation of a virus infection contamination,
and also genetic, endocrine and metabolic factors is supposed. Prevalence among patients with SLE of
young women, the frequent beginning of disease after the delivery or abortions, disturbance of a
metabolism of estrogens with rising of their activity, presence of hyperprolactinemia testifies to
participation of hormonal factors in a pathogenesis of disease. Catarrhal diseases, labours, abortions,
pregnancy, ultraviolet light, intolerance of medicines, vaccines, serums can be presented as provoking
factors in SLE development etc.
Complexity of in-time diagnostics of disease, variety of clinical symptoms, frequent iHbolving
from the very beginning of disease of several vitals and systems with the subsequent disturbance of
their functions prove necessity of the further studying of disease and knowledge of means of rational
therapy.
The purpose of the yielded case is development in the student – users of a case of abilities of the
analysis of a situation at curation patients with SLE. Skills of a choice of conducting tactics,
diagnostics, rendering of rational therapy in the hospital conditions.
The solution of a prospective case will allow students to reach following educational effects:
 To educe abilities of an assessment and the analysis of common state of patients with SLE
To fulfil a choice ability of the correct diagnostic algorithm of patients with SLE.
To fulfil a choice ability of treatment tactics in stationary conditions
Situation: In department of rheumatology the woman of 24 years was admitted with complaints on
temperature grow up to 39-400C, rashes of red colour on face and upper half of thorax, pain and
radiocarpal and knee joints tumescence, palpitation, edemas on the face and legs, weakness.
From the anamnesis morbi: ill for 6 months. Disease has begun in 1,5 months after the delivery.
From the anamnesis vitae:
15
• From the underwent diseases - frequent catarrhal diseases
• Menses since 13 years, sexual life since 20 years, pregnancy-1, labours-1.
• The allergy to medicinal preparations and foodstuff did not become perceptible.
• Family/social anamnesis: married, works as the nurse. Bad habits absent.
Epid. anamnesis:
• In contact to infectious patients was not,
• Blood preparations did not receive
• Injection therapy negates
Physical examination: moderately severe common state. Consciousness clear, standing active.
Integuments: on the face in the field of cheeks, malar arches, bridges and the upper half of thorax
become perceptible erythematic rashes. The face bloated, standing edemas. Joints: the tumescence of
radiocarpal and knee joints, a pain becomes perceptible at palpation and locomotions. Vesicular breath
in lungs. Cardiac sounds are dumb, tachycardia, on all points is auscultated systolic hum. A gaste soft,
painless. The liver and spleen are not enlarged. Pulse regular–110 bpm. The BP - of 130/100 mm hg.
The diurhesis is reduced.
The examinations spent in a hospital, have shown:
• Common blood analysis: Нb-80 D\л, leukocytes – 3,8, thrombocytes – 150000, a ESR - 30mm/h
• Common urine analysis: protein - of 0,132 %, erythrocytes - 20-25/1, leukocytes - 10-15/1,
cylinders - 3-4/1.
• Blood biochemical analysis: common blood protein – 58g/l, bilirubin-19 mmole/l, AlAT-0,5 and
AsAT-0,6 (within norm)
Questions and assignments
1. What additional research techniques need to be performed for diagnosis statement?
2. By your opinion, with what pathologies it is necessary to perform the differential diagnostics?
3. Enumerate the diagnostic criteria.
4. What is your diagnosis and how can you prove it?
5. Set the treatment plan.
The assignment: On the basis of the state analysis of patients with SLE it is necessary to make the
preliminary diagnosis, to spend necessary methods of diagnostics, to accept the well-founded treatment
plan.
II. Methodical indications for students
2.1 Issue: Diagnostics and treatment of patients with SLE in the stationery conditions
2.2. Subissue
1. The outward analysis
2. The analysis of the anamnesis morbi and anamnesis vitae of the patient
3. The examination analysis
4. Choice of necessary methods of diagnostics
5. The analysis of the received effects of examinations and performing of differential diagnostics
6. Choice of treatment tactics.
2.3. Algorithm of the solution
1. The outward analysis includes following examination
- Examination of skin and the visible mucous
- Face, body
16
2. The anamnesis analysis
- The underwent diseases
- The is family-social anamnesis
- Duration of disease
3. The examination analysis
- Pulse, arterial pressure.
- Auscultation of heart and lungs
- Abdominal palpation
- Examination of joints.
4. A choice of necessary methods of diagnostics
- CBA, CUA
- Biochemical analysis of blood/X of blood
Protein in daily urine
Coagulogram
Acute phase tests
Blood on LE cells and АНА
ECG
EchoCS
Chest fluoroscopy
- USI of abdominal organs
- A skin biopsy
5. To correlate the received results and to carry out differential diagnostics with:
- rheumatoid arthritis
- glomerulonephritis
- scleroderma
6. A choice of treatment tactics
- Application of traditional therapy
- Application of pulse therapy
- Application of plasmapheresis
Work stages
1. Acquaintance with
case
2. Acquaintance with
the given situation
The instruction to independent work on
the analysis and the solution of a practical situation
Sheet of the situational analysis
Recommendations and advises

Firstly make acquaintance with a case
While reading, do not try to analyze a situation at once
Read the information once again, mark the paragraphs which have seemed
important to you.
Try to characterise a situation. Mark what is important, and what is less.
17
Problem:
3. Revealing,
formulation and a
substantiation of a key
issue and subissues
Diagnostics and treatment of patients with SLE
At the situation analysis answer following questions:
1. Make definition, enumerate the causes and the mechanism of
development of SLE.
2. Enumerate the diagnostic methods of SLE using the patient
example.
3. What methods of diagnostics are necessary for diagnosis
statement?
4. Compound and prove the examination plan.
5. Formulate the clinical diagnosis and prove it.
6. What nosologies are necessary to eliminate during the differential
diagnostics?
7. Define the treatment tactics
4. Diagnostics of the
situation analysis
5. A choice and a
substantiation of
methods and problem
resolution means
Enumerate the possible means of solution of the yielded problem in the
presented situation
6. Development and
resolution of a
problem situation
State the diagnosis, choose the treatment tactics
The rating table of individual work with a case
Participants
The analysis
of a current
situation
max 1,0
Rating criteria and indexes
Detailed
Choice of
Problem
methods and development
of standards
substantiation
problem
on solution
resolution
max 0,5
realisation
max 0,5
max 0,5
Common
mark
(max 2,5) *
1.
2.
№
* 2,0 – 2,5 points – “excellent”, 1,5 – 2,0 points – “good",
1,0 – 1,5 points – “satisfactory",
Less than 1,0 points – “unsatisfactory"
18
Rating system of the group problem resolution.
1.
Each group receives two estimate points. It can donate them at once all to one candidate solution or part
it by two (1:1; 0,5:1,5; etc.), not including the own solution rating.
2. All received points on each candidate solution are summarized. The solution which has achieved the
greatest quantity of points wins. In disputable cases it is possible to take voting.
The rating table of the group problem resolution, mark
Group
1
The alternative candidates of the problem solution
2
3
№
1.
2.
№
Total
Rating of presentation of the offered solution
Group
Completeness and
clearness of
presentation
(1 – 20)
Obviousness
of the
presentation
(1 – 20)
Mass
activity of
group
participants
(1 – 20)
Originality
of presented
solutions (1
– 20)
Recption ability to
the legislative
norms
(1 – 20)
Total sum
of achieved
points (max
100)
1.
2.
№
III. THE CASE CANDIDATE SOLUTION VARIANT BY
THE TEACHER-CASEOLOGIST
1. The symptoms enumerated above in a case specify that there is a systemic disease of the connective
tissue, i.e. systemic lupus erythematosus. It is necessary to perform following iHbestigations for the
patient: Nechiporenko’s probe, Zimnitsky’s probe, protein definition in daily urine – for
acknowledgement of a systemic kidney lesion; acute phase tests, blood on LE-cells, definition of
ANA (antinuclear antibodies), the rhematoid factor – for revealing of immunologic disturbances,
blood clotting time, coagulogram – for revealing the changes in the coagulating system of blood, an
electrocardiogram, EchoCS – for revealing of a systemic heart lesion, thorax X-radiography – for
revealing of of lungs lesion and pleuritis, US of abdominal organs– for revealing of liver lesion and
ascitis.
19
2. There are not less than 40 diseases similar to SLE, especially in an disease debut. In this case
disease is necessary for differentiating with rheumatoid arthritis, acute rheumatic fever,
glomerulonephritis, systemic scleroderma, systemic vasculitis.
3. At the yielded patient following disease criterias are noted: 1) erythematic rashes, 2) joints lesion
(arthritis), 3) kidneys lesion (edemas standing, diurhesis reduction, proteinuria, microhematuria,
cylinderuria), 4) hematological disturbances (anemia, leukopenia, thrombocytopenia, ESR
acceleration). Therefore from 11 diagnostic criteria used for statement of the diagnosis 4 criterias
were noted and the diagnosis is considered reliable. The diagnosis formulation: Systemic lupus
erythematosus, subacute variant of course, activity II, with lesion of skin, joints, heart, kidneys.
4. GCS: Prednisolonum: 30mg/day, considering degree of disease activity. With the
antiinflammatory purpose – nonsteroid antiinflammatory drugs, considering presence of lupusdermatitis and arthritis - 4-aminochinoline drugs (Plaquenilum 400mg/day), anticoagulants (heparin
20000 MU/day), antiaggregants (Curantylum 150mg/day). The intensive care: plasmapheresis №2 with
the subsequent pulse therapy (Methylprednisolonum 1000 mg+ Cyclophosphanum 1000 mg)
intravenously droply №1. It is recommended to avoid solar insolation.
IV CASE – TECHNOLOGY OF TRAINING AT THE SEMINAR
4.1 Model of technology of training
Theme
Diagnostics and SLE treatment
Duration – 90 minutes
Quantity of the trained: 10 persons
The shape of educational lesson
Seminar on dilating and an excavation of
knowledge, working off of abilities of tactics of
conducting patients with SLE
1. Introduction to the educational lesson
2. Actualisation of knowledge
3. Operation with a case in minigroups
4. Presentations of effects
The seminar plan
5. Discussion, assessment and choice of the
best variant of strategy
6. The inference. An assessment of activity of
groups and students, degrees of goal
achievement of educational lesson
The purpose of educational lesson: an excavation and dilating the knowledge of the causes of
development of SLE. Development of rating ability and the situation analysis of criteria at curation
patients with SLE. Skills of composing the diagnostic algorithm and a choice of tactics of treatment in
20
the hospital conditions.
Effects of educational activity:
Tasks of the teacher:
•
•
To set and deepen the knowledge by
rating and analysis of common state of
patients with SLE
To develop a choice ability of the correct
algorithm of activities for diagnosis
statement.
• To develop skills on rendering the
rational therapy
•
Estimate and analyze a situation and
common state of patients with SLE
• Choose algorithm of activities for diagnosis
statement.
• Educe skill of self-maintained decision
making at conducting patients with SLE in
the hospital conditions.
• Develop algorithm of treatment for the
patients with SLE
Training methods
Cases-stages, discussion, practical method
Tutorials
Case, methodical indications
Form of study
Individual, face-to-face, operation in groups
Training requirements
Audience with a hardware, adapted for operation in
groups
Monitoring and assessment
Observation, blitz-poll, presentation, rating
The procedure sheet of the educational lesson based on a case.
Stage and the
operation
content
Activity
Teacher
Students
Listen
Preparational
stage
Explains appointment of a case-stages and its
influence on development of professional
knowledge. Distributes the case materials and
acquaints with a situation analysis algorithm (see
Methodical indicatings for students).
Yields the assignment of self-maintained to carry
out the analysis and bring the results in the «Sheet
of the situation analysis»
Independent study of the case
content and individually fill the
sheet of the situation analysis.
21
I stage.
Introduction to
educational
lesson
(10 mins)
II stage
basic
(60 mins)
1.1. Terms the lesson theme, plan, its purpose, tasks
and scheduled effect of educational activity.
1.2. Acquaints with the lesson regimen and criterias
of results rating (see indications for students)
2.1. Proves the statement of a problem and a
situation choice – the urgency. Makes quiz on
purpose to activate knowledge trained on a theme:
1. Comprise the SLE definition.
2. Enumerate the causes of occurrence and the
mechanism of disease development?
3. Enumerate the course variants of SLE
4. Enumerate the diagnostic criterias of SLE
5. The methods of diagnostics applied to statement
of the diagnosis
6. For which nosologies is it necessary to perform
differential diagnostics
7. Tactics of management and treatment of patients
with SLE
2.2. Divides students into bunches. Reminds the
content and case problems. Acquaints (reminds)
with operation rules in groups and discussion rules.
2.3. Yields the assignment, improves correctness of
perception of the assignment:
2.4. Co-ordinates, advises, refers educational
activity.
Estimates effects of individual operation: Sheets of
the situation analysis.
2.5. Will organise presentations following the
results of the done operation under the case
solution, discussion.
The organizer of discussion: asks questions,
replicas, reminds a theoretical stuff
2.6. An organizer - algorithm of activities in the
present state of affairs (cascade, lotus)
2.7. Reports the own candidate solution of a case
Listen
Write down the conforming
records
Answer questions, discuss, ask
defining questions.
Are divided into groups
Discuss, perform the joint
analysis of an individual
problem, spot the major aspects
of situation, the basic problems
and means of their solution,
design the solution results
Represent candidates solution of
a problem of 10-15 mins
Questions after the presentation
terminal, choose an optimum
variant
Develop uniform system,
discussion
22
III Summarizing
the lesson, the
analysis and
rating
20 mins
3.1. Extends results of educational activity, declares
results of individual and teamwork.
Listen.
Analyzes and rates the group, notes the pro and con
moments.
Can spend a self-rating and
inter-rating
3.2. Emphasises the value of a case-stage and its
influence on development of the future expert
Express the opinion
7. A quality monitoring of practical skills and theoretical knowledge.
1. Professional inquiry and examination of the patients with systemic lupus erythematosus.
The purpose:
- Reception of the information necessary for diagnostics;
- An assessment of disease probability;
- Definition of other sources of the information (relatives, other doctors, etc.);
- An establishment of confidential mutual relations with the patient;
- An assessment of the face of the patient and its attitude to disease (an intrinsic pattern of disease);
- To estimate a state of consciousness and the mental status of the patient, its standing, a habit view,
a state of iHbestments and separate fields of a body.
Indications: poll strictly for all patients who are in consciousness; examination is made to all
patient.
Equipment: well lighted boxes, physician offices, incandescent lamps.
Performance requirements: no strange persons, confidential situation.
Carried out stages (steps):
№
Action
1
2
3
4
5
6
7
8
9
1
0
Inquiry of passport data
Assembly of complaints
Assembly of the anamnesis morbi
Assembly of the anamnesis vitae
The epidemiological, allergic anamnesis
Objective examination of the patient
Will compound the examination plan
The correct statement of the diagnosis
Differential diagnostics
Compound of a treatment plan
Total
Was not
executed
0
0
0
0
0
0
0
0
0
0
0
Completely
and correctly
executed
5
15
20
15
5
5
5
5
20
5
100
23
2. Drawing up the dietary references and the treatment program.
The purpose: Treatment of disease and remission achievement
№
Action
1
2
3
4
5
6
Studying the performance of medical tables
The correctby
choice
of a dietary table
Pewzner
Assessment
of a diet
accordingoftofull
the value
diagnosis
According to the diagnosis, gravity of
According
to theappointment
diagnosis, gravity
of
disease
and a stage
of the basic
Preventive
actions
disease and
a therapy
stage appointment
of
symptomatic
Totaltherapy
Was not
executed
(0 points)
0
0
0
0
0
0
0
Completely
and correctly
executed
10
10
20
20
20
20
100
Tests
1. What laboratory indexes are the most informative at diagnostics of a Systemic lupus erythematosus:
А lymphocytosis
B. thrombocytopenia
C hemolitic anaemia
D acute augmentation of s-reactive protein
E pancytopenia, antinuclear antibodies*
2. What does not enumerate into complications of corticosteroid therapy:
А Coushing syndrome
B. hyperkaliemia*
C hypertonia
D osteoporosis
E steroid diabetes
3. What changes of the analysis of a blood are characteristic for III degree of activity of a Systemic lupus
erythematosus:
A.Hb 120 g/l ESR 20 mm/h
B.Hb 116 g/l ESR 24 mm/h
C.Hb 110 g/l ESR 38 mm/h
D.Hb 96 g/l ESR 52 mm/h*
E.Hb 96 g/l ESR 35 mm/h
4. What hematological disturbances are included into diagnostic measure of a Systemic lupus erythematosus:
А hemolitic anaemia
B. leukopenia less than 4ооо / ml
C all presented*
D thrombocytopenia less than 150 tys/ml
E lymphopenia less than 1500/ml
5. What following laboratory disturbances do not fall into the diagnostic criteria of a systemic lupus
erythematosus:
А a false positive Wassermann reaction
B. antibodies to DNA
C accelerated ESR*
D antibodies to a sm-antigen
E all specified datas of laboratory fall into to measure of SLE
24
6. Note not the characteristic dermal exhibitings of a Systemic lupus erythematosus:
А allopecia
B. Vitiligo
C discoid changes
D Lupus vulgaris*
E photodermatitis
7. At treatment of a Systemic lupus erythematosus following bunches of drugs are used:
А cytostatics antibiotics anticoagulants
B. antibiotics streptocides glucocorticoids
C GCS cytostatics antiaggregants
D glucocorticoids angioprotectors immunosuppressors
E glucocorticoids drugs 4-aminochinoline cytostatics NSAID*
8. LE-cells are:
А autoaggressive lymphocytes
B. rosette lymphocytes
C neutrophils englobing the rhematoid factor
D mature neutrophils englobing nuclear proteins of blood cells *
E broken up under the influence of the antinuclear factor
9. Clinical factors of SLE which it is necessary to specify on the work classification (Nasonov V. A) (3):
А character of course*
B. activity of patoprocess*
C the clinic-morphological performance of the affected organs and systems*
D a course phase
E quantity of the involved joints
Е the immunologic performance
10. Variants of SLE course (3):
А acute*
B. subacute*
C chronic*
D slow progressive
E fast progressive
Е lightning
11. Clinic-morphological lesions of a skin at a lupus-dermatitis (5):
А lupoid "butterfly" *
B. Vitiligo*
C Exfoliation*
D Hyperpigmentation*
E Papilloma*
Е Ichtyosis
Ж Petechial rashes
З Pustular rashes
И Bulleous rashes
12. Variants of a lesion of joints at SLE (2):
А an arthralgia without arthritis*
B. polyartritis*
C erosive arthritis
25
D mutilating arthritis
13. Shapes of heart lesions at SLE (4):
А myocarditis*
B. endocarditis with failures*
C cardiosclerosis*
D myocardial dystrophy *
E amyloidosis
F a subendocardial ischemia
G subaortal stenosis
H stenosis of the pulmonary artery valve
14. Clinic-morphological lesions of lungs at SLE (2):
А pneumonitis*
B. pneumosclerosis*
C emphysema
D bronchiectasias
15. The characteristic changes of a peripheric blood at SLE (4):
А leukopenia*
B. thrombocytopenia*
C hypochromic anemia*
D rising ESR*
E leukocytosis
F thrombocytosis
G lymphocytosis
H hyperglobulia
16. The laboratory indexes having direct diagnostic value at SLE (4):
А LE-cells*
B. ANF*
C antibodies to native DNA*
D "a rosella" phenomenon *
E. RF
F hemolitic anaemia
G thrombocytopenia
H hypofibrinogenemia
8. Measure of an assessment of monitoring
The level of student knowledge
A student on the major issues and themes for students' independent work::
Summarizes and makes decisions
creative thinking
independently analyzed
Into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Progress in %
and the score
96-100
Evaluation
5
26
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 7-10 sources and the Internet.
A student on the major issues and themes on the SIW:
creative thinking
independently analyzed
Into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 4-6 sources and the Internet.
91-95
5
A student on the major issues and themes on the SIW:
independently analyzed
Into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 3-5 sources and the Internet.
86-90
5
A student on the major issues and themes on the SIW:
Into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 3-5 sources and the Internet.
81-85
4
76-80
4
71-75
4
A student on the major issues and themes on the SIW:
Shows high activity during the interactive games
Correctly solve situational problems, but the justification for an incomplete
answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares modern visual aids or abstracts using the recent literature data of 1-2
sources.
A student on the major issues and themes on the SIW:
Correctly solve situational problems, but the justification for an incomplete
answer
Understands the subject matter
Knows, says confident
Has faithful representations or
27
A student on the major issues and themes on the CDS:
Mistakes in solving situational problems
Knows, says uncertainly
Has a faithful representation of some issues topic
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 7-10 sources and the Internet.
Prepares modern visual aids or abstracts of high quality using data from the recent
literature of 4-6 sources and the Internet.
A student on the major issues and themes on the SIW:
Understands the subject matter
Correctly solve situational problems, but can not justify a response
Knows, says confident
Has a faithful representation of some issues topic
66-70
3
61-65
3
A student on the major issues and themes on SIW:
Knows, says uncertainly
Has a partial view
55-60
3
A student on the major issues and themes on SIW:
It does not accurately represent
Does not know anything
Less then 55
2
A student on the major issues and themes on SIW:
Mistakes in solving situational problems
Knows, says uncertainly
Has a faithful representation of some issues topic
9. A chronological card of lesson.
№
Stages of practical lesson
Lesson shapes
Duration
(minutes)
270
1.
Opening address of the teacher (theme substantiation).
2.
Discussion of a theme of practical lesson, checkout of
basic knowledge of students with use of new pedagogical
technologies, a demonstration stuff (slides, audio videocassettes, X-ray patterns, an electrocardiogram,
etc.).
3.
Discussion end.
10
Poll, explanatories.
60
20
28
4.
Allocation of assignments to students for performance
of a practical part of lesson. Instructing and the
explanatory under the demands shown to practical
assignments. Self-maintained curation.
Development by means of the teacher of a practical
part of lesson.
5.
30
Case study
90
Interpreting of laboratory-instrumental methods of
examinations differential diagnostics, treatment and
preventive maintenance scheduling.
6.
Discussion of theoretical and practical knowledge of
students, their reinforcement and assessment of activity
of bunch in respect of achievement of an object in view
of lesson.
Oral poll, the test,
discussion, checkout of
effects of practical
operation.
40
7.
The inference of the teacher on the transited lesson, an
assessment of activity of each student and the
announcement of effects. Working out of assignments
for preparation for following lesson (the receiving tank
of questions).
Questions for selfmaintained operation.
20
10. Questions for control of knowledge
1. Etiology and pathogenesis of a systemic lupus erythematosus (SLE).
2. Clinical pattern of SLE.
3. Diagnostic measure of SLE.
4. SLE classification.
5. Differential diagnostics of SLE
6. SLE treatment.
11. The recommended references
The basic:
1. Internal diseases Martynova A.I., Muhina N.A., Moiseeva A.S., М, medicine, 2004
2. Internal diseases edited by Martynova A.I., Muhina N.A. – M. 2008
The additional:
1. Diagnostics of, A.N.Okorokov, M. 2005.
2. Treatment of internal diseases, A.N.Okorokov. M.2005.
3. http://.www.med-site.narod.ru/index.htm
The description, diagnostics, treatment of diseases. Pharmaceutics, anatomy.
4. http:// www.recipe.ru
Medicine: information resources, databases.
5. http:// www.vh.org
6. http:// www.meddean.luc.edu
The encyclopeedia of examination of the patient with set of an illustration, the short description of diseasees, testing.
7. http://embbs.com
Case histories, training, the atlas on an electrocardiogram, etc.
8. WWW.TMA.uz.
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