Download Case AORTIC HEART DISEASE

MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
Tashkent Medical Academy
DEPARTMENT OF HOSPITAL AND FACULTY TREATMENT AND INTERNAL
MEDICINE
CASE - TECHNOLOGY
A teaching manual for the practical training of students IY course of medical faculty
SUBJECT: AORTIC HEART DISEASE
Teaching abstract
The course of study, "Teaching therapy"
Topic: "Diagnosis and treatment of aortic defect"
The purpose of this case study: the deepening and widening the knowledge of the causes of aortic defect.
The development of the c sobnosti situation assessment and analysis criteria for the supervision of patients
with mitral heart disease. Skills with the representation of the diagnostic algorithm and the choice of
treatment strategy in a hospital.
Expected learning outcomes - the results of a case: students acquire skills:
lysis of the general condition of patients with mitral heart disease
For the successful solution of this case study the student should know
Criteria for the diagnosis of aortic defect.
•
•
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Make a differential diagnosis
List the methods of diagnosis, develop and justify a plan to survey the conditions and hospital ies
Create and validate a treatment plan
This case reflects the real situation in the hospital
Sources of information case study
Medical history
Internal Medicine, ed. Martynov AI Mukhin NA, Moses, AS, AM, Medicine, 2004
Internal Medicine, ed. Martynov AI Mukhin NA - M. 2008
Diagnosis of diseases of internal organs, AN Hams. M oskva 2005.
Treatment of diseases of internal organs, AN Hams. M oskva 2005.
Characteristics of case study according to the typological features
This case is classified as a desk, a plot. It is volume, n structuring HYDRATED. This case-issue.
For didactic purposes Case Training, stimulating thinking in real situ a tion in the hospital.
Case can be used for the following disciplines: Therapy, Cardiology
I CASE
"Diagnosis and treatment of aortic defect"
Introduction
Aortic valve insufficiency
This is an incomplete closing of the leaflets during ventricular systole, accompanied by regurgitation of
blood from the left ventricle in LP. Isolated aortic valve is about 5-10% of the total number of heart
defects. Mitral regurgitation slightly more common in men.
The clinical picture of Complaints - In the compensation stage patients can withstand considerable physical
activity, not showing any complaints. By reducing the contractility of the left ventricle and the development
of pulmonary hypertension patients complain of shortness of breath on exertion and palpitation. With an
increase in stagnation occur at rest and dyspnea attacks of cardiac asthma. By reducing the contractile
function of the pancreas, pain in right hypochondrium region, as well as swelling in the legs. Appearance of
patients - With increasing stagnation in the pulmonary circulation mark acrocyanosis, with examination of
the chest wall is sometimes reveal the heart bump, palpation and visually determine the cardiac impulse,
shifted to the left and down (a sign of left ventricular hypertrophy); well visible pulsation of the carotid
arteries. Inspection and palpation of the heart - I Most patients with mitral insufficiency prevails
eccentric hypertrophy (hypertrophy + dilation) of the left heart, which is characteristic for volume overload.
The apical impulse in the connection with This is reinforced, poured and shifts to the left, outside from
the left mid-clavicular line. Percussion-The most characteristic displacement of the left border of the
relative dullness of the heart left ventricular dilatation due.
Cardiophony The changes I tint. For organic aortic valve insufficiency is characterized by weakening of the
tone I at the top, or even its disappearance due to the lack of tightness of the LV during the isovolumic
phase of ventricular contraction (no period of closed valves). However, when a small valve defect and
preserved LV systolic function expressed by the weakening tone I can not be for a long time, it retains its
volume. Changes II tone. In Many patients with a small defect in the aortic valve II tone is not changed.
Accent II tone on the pulmonary artery is detected only in later stages of the disease in the event of failure
and left ventricular the development of pulmonary hypertension. Pathological III can sometimes hear the
tone in aortic valve insufficiency. It is caused by left ventricular volume overload. III the tone is better
defined on the exhale. Its absence does not exclude the aortic valve, indicating only a small manifestation of
evil. Systolic murmur at the apex - the most important auscultatory sign of aortic valve insufficiency. It
occurs in result of turbulent blood flow from the LV in the LP during the period of exile. The absence of
systolic murmur is almost completely eliminates organic mitral insufficiency.
Electrocardiography Electrocardiographic study in patients with mitral insufficiency can reveal signs of
myocardial hypertrophy LP and LV, and and various cardiac arrhythmias, and conductivity. Recall that
the ECG changes characteristic of the compensatory hypertrophy of the LP include:
-mitrale);
n amplitude and duration of the second negative phase of P wave in abduction V 1 (V 2
less);
ECG signs of left ventricular hypertrophy, include:
in the amplitude of R wave in the left chest leads (V 5, V 6) and S-wave amplitude - In
right precordial leads (V 1, V 2). At the same RV 4 <= RV 5 or RV 4 < RV 6; RV 5, 6> 25 mm or a RV 5,6 + SV
1,2 > = 35 mm (ECG persons older than 40 years) and > = 45 mm (ECG young people);
R I + S III > 25 mm;
-T segment in the leads V 5, V 6, I, aVL, and below the isoelectric line formation
of negative or biphasic (- +) T wave in leads I, aVL, V 5, and V 6, increasing the duration of the QRS interval
in the internal deviation the left chest leads (V 5, V 6) more than 0.05 s.
Echocardiography direct echocardiographic signs of mitral insufficiency when using single-and twodimensional echocardiography does not exist. The only reliable sign of organic mitral regurgitation separation, aortic valve during ventricular systole - Detected very rarely. To Indirect echocardiographic
signs of mitral insufficiency reflecting the characteristic of this defect hemodynamic changes include:
increasing the size of the LP, hyperkinesia back of the LP, the general increase in stroke volume (by the
method of Simpson); myocardial hypertrophy and LV cavity dilatation. A trans opplerogramma aortic blood
flow, register - regurgitation of blood from the left ventricle in the LP.
Treatment
Mitral regurgitation is mild does not require special treatment.
When mitral regurgitation of moderate or severe shown careful assignment of ACE inhibitors. Reduction of
they help value afterload understandably easy release of blood aorta, and amount of regurgitation in LP
decreases regularly.
If you have any left ventricular failure demonstrates the use of diuretics (saluretikov and loop diuretics)
and drugs that reduce blood flow to the heart, such as nitrates. It is also the use of cardiac glycosides, if
there is a decrease in LV systolic function. It should be remembered that when mitral regurgitation is a
normal ejection fraction more than 65%. right heart failure requires use of diuretic drugs and aldosterone
antagonist (Aldactone, veroshpiron). If there is a permanent form of atrial fibrillation used cardiac
glycosides (digoxin) and β-blockers, converting tachisystolic form of atrial fibrillation in the normosystolic.
In later stages of the disease requires the appointment of anticoagulants to prevent thromboembolic
complications.
Surgical treatment is valve replacement with the corresponding Fr ezom (prosthesis). If there is no
calcification of the aortic valve and doors retain sufficient mobility, it is possible reconstruction surgery
(plastic) valve.
Indications for surgical treatment are:
A. Severe mitral regurgitation (III-IV degree) with regurgitant volume 30-50% greater, even in the presence
of a moderately pronounced clinical manifestations of the disease.
2. Moderate and severe mitral insufficiency II-IV degree with evidence of left ventricular systolic
dysfunction (dyspnea in the alone, decreased performance, FW less than 60%, the index of MLC more
than 100-120 ml / m 2).
The purpose of this case study is the development of the student - User case study and anal abilities of the
situation in the supervision of patients with mitral defect. Skills choosing tactics, diagnostician, and ki,
provide a rational therapy in the hospital.
The solution proposed case study will allow students to achieve the following training pe results:
the selection of the diagnostic algorithm of patients with mitral defect
-making in this situation
hoice of treatment in hospital
Situation: Patient 25 years old, recently noted palpitations, shortness of breath, swelling of the legs.
From the history: for many years suffered from rheumatism, mitral defect.
From the history of life: from an illness - chronic tonsillitis
•
Allergies were noted.
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Family / social services. history: married, homemaker
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Menstruation at 10 years, sexual activity at age 20, -1 pregnancy, childbirth-1.
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Heredity: the grandmother suffered from rheumatism
Epid.anamnesis
In contact with infectious patients were not,
Blood products has not received
On-no: cyanosis of the lips, pastry on the legs, the lungs in the lower single finely wheezing. At the apex
of the heart I relaxed tone, systolic murmur over the pulmonary artery tone accent II. The liver is one, see
Surveys conducted in the hospital, showed
KLA: HB-100 g \ l, white blood cells - 8.8, ESR-30mm / h
Biochemistry of blood: total blood protein - 68g / L, bilirubin -16 mmole / L, ALT-0, 5 and ACT-0, 2 (normal),
2 + CRP, ASO 425
Questions and tasks
What additional methods should be performed for diagnosis?
In your, opinion, with any abnormalities need to make a differential diagnosis?
What is your diagnosis and justify it?
Make a plan of treatment.
II. Guidelines for students
2.1 Problems: Diagnosis and treatment of patients with mitral heart disease in a hospital
2.2. Subproblems
A.
Analysis of the appearance of
Two.
Analysis of the history of the disease and the patient's life history
Three.
Analysis of the survey
4.
Select the required diagnostic
Five.
Analysis of the results of research and implementation of the differential dia grams nostiki
6.
The choice of treatment.
2.3. An algorithm for solving
A.
Analysis of the appearance includes the following research
- Examination of the skin and visible mucous
- A person's body
Two. The analysis of anamnesis
- Past illnesses
- Family and social history
- The duration of the disease
- Heredity
- Bad habits
Three. Analysis of the survey
- Ps, blood pressure, thermometry
- Auscultation of heart and lung
- Palpation of the abdomen
4. Select the required diagnostic
- KLA, OAM
- Acute-phase samples (CRP, ASO, haptoglobin)
- B / c levels (ALT, AST, total protein)
- Coagulogram
- ECG
EchoKS
Chest x-ray of the esophagus with contrast
Five. Correlate the results and make a differential diagnosis with
- Stenosis of the aortic opening
- Aortic defects
- Congenital
6. The choice of treatment
- The use of antibiotic therapy
- The use of anti-inflammatory therapy
- Treatment of heart failure
- The use of surgical treatment
Instructions to work independently on
analyzing and solving practical situation
Leaf analysis of the situation
Stages of work
Recommendations and advice
A. Familiarization with case
First, familiarize yourself with case reading · Do not try to immediately analyze the situation
Two. Introduction to the given situation
Again, read the information, select the paragraphs that seemed important to you. Try to describe the
situation. Determine that it is important and what is secondary.
Three. Identification, formulation and justification of the key problems and subproblems
Problem: Diagnosis and treatment of patients with mitral heart disease
4. Diagnostic analysis of the situation
When analyzing the situation, answer the following questions: 1.On your, opinion, with which abnormalities
should make a differential diagnosis? Two. What is your diagnosis and justify it? Three. Do you need
hospitalization, if so, what branch? 4. The tactics of treatment in this situation.
Five. Selection and justification of the ways and means to address
List all the possible ways of solving this problem in this situation
6. Development and resolution of the problem situation
Place the diagnosis, then treatment strategy
III. OPTION ACTION CASE
CASE IV - TECHNOLOGY TRAINING WORKSHOP
4.1 The model of technology training
Topic
Aortic heart disease
Number of hours - 6:00
Number of students: 10
The form of training session
Seminar on the expansion and deepening of knowledge, development of skills tactics mitral heart disease
patients
Plan Workshop
A. Introduction to the training session 2. Updating of knowledge 3. Working with the briefcase in a mini Group 4. Presentation of the results 5. Discussion, evaluation and selection of the best options strategies 6.
Conclusion. Evaluation of groups and students, the degree of achievement of educational activities
The purpose of training session: deepening and broadening knowledge of the causes of aortic defect.
Developing the ability to assess and analyze the situation in the supervision of patients with mitral defect.
Skills and skills of the diagnostic algorithm and the choice of treatment strategy in a hospital.
Tasks teacher: • consolidate and deepen the knowledge on assessment and analysis of the general
condition of patients with MI • develop the ability to select the correct action of the algorithm for diagnosis.
• Develop the skills to provide a rational therapy
The results of training activities: • assess and analyze the situation and the general condition of patients
with mitral defect • select algorithm of actions for the diagnosis. • develop skills of independent decisionmaking in the management of patients with mitral defect in a hospital environment • develop an algorithm
of treatment of patients with mitral defect
Methods of teaching
Case studies, discussion, practical method
Learning Tools
Case, guidance
Study
Individual, front, group work
Conditions of Learning
Audience with the technical equipment adapted for group work
Monitoring and evaluation
Seeing a blitz poll, presentation, evaluation
A technological card of the educational employment based on a case.
Stage and the work maintenance
Activity
The teacher
Students
Preparatory stage
Explains appointment a case - stages and its influence on development of a professional knowledge.
Distributes materials of a case and acquaints with a situation analysis algorithm (Methodical instructions for
students see). Gives the task independently to carry out the analysis and to bring results in «Sheet of the
analysis of a situation
Listen Independently study the maintenance of a case and individually fill sheet of the analysis of a
situation.
I stage. Introduction in educational employment (10-15 mines)
1.1. Name an employment theme, the plan, its purpose, problems and planned result of educational
activity. 1.2. Acquaints with an operating mode on employment and criteria of an estimation of results
(instructions for students see)
Listen Conduct corresponding records
II stage the basic 60 mines
2.1. Proves statement of a problem and a situation choice - an urgency. Spends a blitz-interrogation on
purpose to make active knowledge trained on a theme (the appendix №1): • make definition defect. • list
the reasons of occurrence and the mechanism of development of disease? • list clinical stages of
insufficiency the valve 2.2. Divides students into groups. Reminds the maintenance and case problems.
Acquaints (reminds) with work rules in group and discussion rules. 2.3. Gives the task, specifies correctness
of perception of the task (the appendix №2): • With what it is necessary to carry out differential diagnostics
• the Methods of diagnostics applied to statement of the diagnosis • Tactics of conducting and treatment
sick by defect • 2.4. Co-ordinates, advises, directs educational activity. Estimates results of individual work:
Sheets of the analysis of a situation. 2.5. Will organise presentations following the results of the done work
under the case decision, discussion. The organizer of discussion: sets questions, remarks, reminds a
theoretical material 2.6. An organizer - algorithm of actions in the given situation (the cascade, a lotus) 2.7.
Informs the variant of the decision of a case
Answer questions, discuss, set specified questions. Share on groups Discuss, carry out the joint analysis of
an individual problem, define the major aspects of a situation, the basic problems and ways of their
decision, make out results of the decision Represent variants of the decision of a problem of 10-15 mines
Questions after the presentation termination, choose an optimum variant Develop uniform system,
discussion
III Summarizing of employment, the analysis and estimation of 20 mines
3.1. Generalises results of educational activity, declares estimations individual from teamwork. Analyzes and
estimates group, marks the positive and negative moments. 3.2. Underlines value a case - stages and its
influence on development of the future expert
Listen. Can spend a self-estimation and express the opinion.