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The Ministry of Health of the Republic of Uzbekistan
Tashkent Medical Academy
The department of internal diseases № 3 of medical and pedagogical faculty
"APPROVED"
Vice Rector for Academic Affairs, TMA,
Professor Teshaev O.R.
«_____» ______________2016 year
Discipline: INTERNAL DISEASES
6 course
TECHNOLOGY OF TRAINING
Cycle: Gastroenterology
Syndromes:
"Dysphagia"
"The pain in the abdomen"
"Hepatomegaly"
"Jaundice"
Topics 1-5
_____________________________________________________________________
(Teaching guidelines for teachers and medical students)
Tashkent-2016
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND TRAINING SKILLS FOR STUDENTS ON
THE BASIS OF SOLVING THE PROBLEM OF PATIENTS
WITH DYSPHAGIA
Objective: To teach students to solve the problems of patients with dysphagia, as well as the principles of
their management in primary health care as part of the qualifying characteristics of GPs
Main learning tasks:
• To teach students solving the problem connected with dysphagia.
• To train students timely diagnosing the problems connected with dysphagia.
• To teach students to differentiate the disease, accompanied with dysphagia.
• Improve the knowledge, skills and practical skills in solving problems of patients with dysphagia (gathering
information, identifying problems and physical examination, as well as the ability to reasonably prescribe
laboratory and instrumental methods of research);
• To teach students reasonably choosing the tactics;
• To teach students to exercise reasonable medical and preventive measures and monitoring in RPP and FP.
While investigating the problem of patients the key moments of assessing the students must be:
• Ability to identify the underlying problem, which is reflected in the quality of patients' life.
• Ability to ask support questions of rational history.
• Ability to identify risk factors.
• Ability to name a disease or condition that may be causing the problem.
• Ability to conduct reasonable physical examination.
• Ability to use sound laboratory and laboratory studies in a RPP or FP.
• Ability to identify the need for additional research outside of RPP or FP.
• Ability to establish the root cause (diagnosis) of the problem based on the information received.
• Ability to determine the tactics on the basis of qualifying characteristics of RPP and FP.
• Ability to provide non-pharmacological advice.
• Ability to identify drug treatment based on evidence-based medicine
• Ability to identify preventive measures at the level of primary health care.
• Ability to identify the principles of clinical examination and rehabilitation of patients in RPP or FP.
What the student needs to know while solving the problem of patients with dysphagia:
№ The list of knowledge
The basic level
The student should know at least 10 of the
1
The list of diseases which occur with dysphagia
most common diseases
A list of the most dangerous diseases that present
The student should know at least 5 diseases
2
with dysphagia
The list of conditions that require
According to the qualifying characteristics of
3
management in RPP and FP (1 category)
of RPP and FP
The list of conditions that require
According to the qualifying characteristics
4
specialist's consultation or hospitalization (category 2)
of GP
According to the qualifying characteristics
5
A list of studies required in RPP and FP (3.1category)
of GP
The list of studies required outside RPP and FP (3-2
According to the qualifying characteristics
6
category)
of GP
The student must know the characteristics
Key points (criteria) of diagnosing diseases occurred
7
and manifestations of each disease, and the
with abdominal pain
criteria for their diagnosis.
The student should know:-What is
dysphagia?
-What is odenofagiya?
8
Difficulties while swallowing
-What is the sensation of a lump in the
thе roat?
9
Scale for the assessment of the patient's dysphagia
10
Localization of problems in swallowing
The student must know the degree of breakes
in swallowing on the scale from 0 to 4.
The student must know the oropharyngeal
11
Symptoms of internal organ's disfunctions
12
Performance indicators of the laboratory instrumental
studies
13
Therapeutic tactics
14
The principles of primary, secondary and tertiary
prevention
15
The principles of clinical examination
and rehabilitation
of disorders that occur with dysphagia in RPP or FP
(category 4)
and esophageal dysphagia.
The student should know the signs of heart,
lung, liver, spleen, stomach, 12 pc., Intestines
and kidneys' s disfunctions
The student should know:
-Normal values, as well as their changes in
pathology.
The student must know the techniques and
principles of treatment (including non-drug).
The student should know the basic activities
required for the primary, secondary and
tertiary prevention
The student must list the main activities
for clinical examination and rehabilitation
What the student should be able to do while solving the problems of patients with dysphagia:
№
The list of skills
The basic level
The student should be able to ask concise questions
that really helps to set the probable diagnosis.
The student should be able to identify specifically
and assess the patient's complaints.
The student must be able to analyze medical history:
1
Ask the patient and his relatives
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze the history of
life: the identification of risk factors, the health of
parents and close relatives.
The student must be able to identify the managed
and unmanaged risk factors both based on
2
Identify risk factors
questioning the patient and on the basis of an
objective approach
The student must be able to identify signs:
3
Calculate the index of weight /body
-Underweight
-Increased weight.
The student must be able to detect the presence of
4
Perform visual inspection of the skin
pallor, cyanosis, presence of rash, induration,
erythema, age, etc.
The student must be able to assess the condition of
the oral cavity.
The student must be able to assess the condition of
the throat.
The student should be able to note the presence of
To conduct a full examination of the head
tumors, adenopathy
5
and neck
The student must be able to assess the condition of
the cervical spine.
The student must be able to detect: mask-like face,
the presence symptom"purse-string suture."
The student should be able to inspect and palpate the
thyroid gland.
The student must be able to assess the following:
•Sensitive and motor function of the cranial nerves
6
Conduct neurological examination
involved in swallowing
• V3 mandibular branch of the trigeminal nervemotor innervation of the mouth floor
7
To conduct palpation, percussion and
auscultation of the respiratory system.
8
To conduct palpation,
percussion and auscultation of the
cardiovascular system.
9
Conduct a superficial abdominal palpation
10
Conduct a deep abdominal palpation
11
Interpret the clinical and biochemical
analyzes
12
Radiological and endoscopic examination
of the esophagus.
13
Differentiate between diseases
accompanied with dysphagia
14
Post a non-drug advice
15
Use medicine rationally while treating the
diseases accompanied with dysphagia
16
Conduct monitoring and surveillance of
patients
• VII taste, motor innervation of the mouth floor
• IX movement - the upper part of the pharynx, the
sensitivity - the back of the tongue
• X motion-reduction of larynx, esophagus
• XII tongue movement
The student must be able to assess:
-A tour of the chest
-Voice trembling
- Change in pulmonary sound and interpretation
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify signs:
-Hypertrophy of the heart
The student must be able to assess:
-Heart sounds;
- If the heart murmur, be able to identify their
epicenter, and relevance to the phase of cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional heart murmur
from organic ones.
-Noisepericardial friction
The student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To carry out the test Shetkin-Blumberg
The student should be able to:
- To evaluate all available structures in the abdomen
The student must be able to identify signs:
-Increase or decrease of a sign in performance from
the norm.
The student must be able to interpret the results.
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination, laboratory and instrumental
investigations)
The student should be able to:
-Teach patient a self-monitoring
-Advise a diet
-Advise a healthy life style
The student should be able to choose drugs with
proved efficacy.
When selecting a drug student should be able to
evaluate:
- Efficiency
- Safety
- Eligibility
- Profitability.
The student must be able to carry out monitoring and
control status in RPP and FP.
Practical lesson 1
Topic 1: «Dysphagia. Differential diagnosis of esophagitis, reflux esophagitis, dysphagia in
scleroderma and tumors of the esophagus. Tactics of GPs. The principles of treatment, follow-up,
control and rehabilitation in RPP or FP. The principles of prevention. The principles of teaching the
theme.»
Training technology.
Study time: 6 hours
1. Department's training office.
2. Teaching aids, handouts, a collection of case studies and tests
The structure of the training session
3. Hospital wards.
4. TV, video equipment, multimedia
The purpose of the training session:
Teaching GP diagnosis and differential diagnosis, finding the best option of treatment strategy for
dysphagia caused by various diseases, as well as the principles of management of patient sinprimary care,
provided according to the requirements of the"Qualification characteristics of the general practitioner."
Pedagogical objectives:
Learning outcomes:
1.Consider diagnosis of dysphagia.
The student should know:
2. Demonstrate patients with
1.The mechanism and causes of dysphagia.
dysphagia.
2. Clinical manifestations of dysphagia.
3. Discuss the results of clinical,
3. Diagnosis of dysphagia.
laboratory and instrumental studies
4. Differential diagnosis of dysphagia.
with dysphagia.
2. Tactics of GPs.
4. Discuss the differential diagnosis of
3. The principles of treatment (medical and non-medical) in
dysphagia.
these diseases.
5. Discuss the tactics in the qualifying
4. Principles of follow-up and monitoring of patients in RPP or
characteristics of GPs
FP.
6. Discuss the principles of treatment
5. The principles of primary, secondary and tertiary prevention
(medical and non-medical).
of these diseases.
7. Discuss the principles of
The student should be able to:
management, supervision and
1.Analyze the data and history of complaints for the diagnosis
monitoring of patients in RPP or FP.
of dysphagia.
8. Discuss the principles of primary,
2. Diagnose, differentiate different types of dysphagia by
secondary and tertiary prevention of
clinical and laboratory-instrumental investigations.
these diseases.
3. Choose drugs with proved efficacy
4. Advise the non-drug therapies.
5. Monitor in RPP or FP.
The method of "The handle on the middle of the table"; graphic
Training methods
organizer-fishbone.
Forms of organization of training
Individual work, team work, collective work
activities
Training manuals, training materials, ECG patients, slides,
Tools for training
video and audio recordings, medical history
Methods and feedback means
Quiz, test, presentation of the results of the training task, filling
medical history,performance of practical skill named
"professional debriefing"
Technology chart of training classes
"Dysphagia. Differential diagnosis of esophagitis, reflux esophagitis, dysphagiain scleroderma and
tumors of the esophagus.Tactics of GPs.The principles of treatment, follow-up, control and
rehabilitation in RPP or FP.The principles of prevention. The principles of teaching the theme.”
№
Stages of the practical training
The form of training Duration of
Place
classes
225
1
Introductory part ( theme explanation)
10
2
3
4
The discussion of the practical lessons with the
use of new educational technologies (method of
"three-step interview"), as well as demonstration
material(sets of medical charts, tables, posters, xray), define the initial level.
Conclusion discussion
Definition of tasks to perform the practical partprofessional questioning. Explanation of the
provision sand recommendations for the job by
filling in the history of the disease.
5
Mastering the practical part of the training under
the guidance of a teacher.
6
Interpretation of the survey data of patients,
complaints, inspection, palpation, percussion,
auscultation of patients, as well as research
general blood test, urines
and biochemical analysis and diagnosis
Discussion of theoretical and practical knowledge
of the students, securing the material to determine
the level of assimilation of knowledge
assessment.
The survey, discussion
40
Classroom
Discussion
10
20
Inspection of the wards
Prof.questioning. A
conversation with patients
and filling medical
history, situational
problems.
20
Inspection of the wards
7
8
Defining output on practical sessions on a 100point rating system and announcing evaluations.
Homework to the next training session (a
collection of questions).
25
Medical history,
laboratory data, situational
problems
Oral questioning, tests,
discussion, identification
of practical skills
Classroom
Information, questions for
homework.
Classroom
75
25
2. Motivation
Patients with complaints on dysphagia seek medical help. In this situation, the force of a general
practitioner (GP) is directed to the diagnosis of the complaints, caused by various diseases, to provide
medical care in the FPP, or direct to specialized hospitals. These circumstanceses are the basis for the
inclusion of this subject in the training of GPs.
3. Inter and intra disciplinary communication.
The teaching of this subjects is tcrbased on the knowledge of students of basic anatomy, histology and
cytology with embryology, biology, normal physiology, biochemistry. Pathological Anatomy, Pathological
Physiology, Topographic anatomy and operative surgery, internal medicine ,Propedeutics,
Tuberculosis,Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy,
Hospital Therapy, Orthopedics.
4. Contents of exercises:
4.1.Teoretical part
While analysing the theme focus on the following points.
The main symptom of functional and organic diseases of the esophagus is dysphagia, which develops as a
result of violations of one of three phases of swallowing - oral, which is a free act, pharyngeal, depending on
the swallowing reflex involving the muscles of the pharynx, larynx, esophageal (low), ie related to cross the
esophagus in its middle and lower thirds.
By their nature, dysphagia can have a functional and organic origin. The functional dysphagia include:
psychogenic, hysterical, dysphagia with stem stroke, in botulism and cardiospasm. The basis of the
functional forms of swallowing disorders is dyskinesia of the esophagus.
Dyskinesia of the esophagus - the functional disorder, manifested a violation of its motility. There are
primary esophageal spasm, which is a consequence of the regulation of cortical disorders of the esophagus,
and esophageal spasm secondary - emerging diseases such as esophagitis, peptic ulcer, etc. or in cases
involving the general convulsions. Clinical evidence of dysphagia and esophageal spasm are chest pain, in
some cases resembling coronary. Dysphagia is intermittent, sometimes a paradoxical form: occurs when
fluid intake and not if swallowed thick and pasty food. The diagnosis is confirmed by X-ray examination of
the esophagus, detecting various strains spastic esophagus if swallowed barium suspension: in the form of a
corkscrew, rosaries, false diverticula, etc. Treatment involves administering a sedative, antispasmodic and
anticholinergic agents. In secondary esophagospasm the treatment of the underlying disease is needed.
Psychogenic, hysterical dysphagia observed in the neuroses, is more common in women aged 20-40 years.
Dysphagia may be a manifestation of anxiety neurosis (anxiety syndrome). The objective manifestations of
the disease, along with dysphagia include increased tone of skeletal muscles, psychogenic headache, tremor,
muscle twitching, tremors, anxiety, fatigue.
Dysphagia can be observed in stem stroke, which, along with paresis of limbs, often observed swallowing
disturbances, cerebellar symptoms (severe dizziness), nystagmus, hypotonia or atonia, chanted or dizartrich
speech. All of these symptoms are manifestations of the syndrome of the lateral medulla oblongata at the
stem stroke.
In botulism, dysphagia occurs in connection with the use of poor-quality canned products. Therefore,
constant vigilance of the physician in infectious hue appears on the background of choking, the presence of
paresis and other symptoms of the disease, in which the prognosis depends on prompt diagnosis.
When cardiospasm (synonyms: achalasia cardia, hiatospazm, megaezofagus, idiopathic enlargement of the
esophagus) of swallow is the leading symptom of the clinical course of the disease. The disease equally
affects both men and women, most often occurs between the ages of 20 and 40. The main symptoms are
dysphagia, regurgitation, and chest pain. Dysphagia first episodic, in severe cases, it is observed at every
meal and is especially apparent if swallowed dry or poorly chewed food. Chest pain is manifested in the form
of painful crises, occurring more frequently at night. Achalasia of the esophagus when there is a lot of spit up
stuck in the esophagus of the masses (saliva, mucus, food residues) that occurs when the torso, the overflow
of the esophagus. Regurgitation is possible at night (a symptom of "wet pillows"). Complications of the
disease include: recurrent pneumonia and chronic bronchitis, due to aspiration regurgitate the masses, as well
as chronic esophagitis, esophageal diverticula. The diagnosis is confirmed by radiographic and endoscopic
studies of the esophagus.
We must dwell on hiatal hernia, not infrequently accompanied by esophagitis. Distinguish the
gastroesophageal axial hernia (sliding) and paraezofagal type. The appearance Barrett's esophagus - a
congenital or acquired pathology with shortening of the esophagus can cause. The diagnosis is confirmed by
radiographic studies of the esophagus, in both the vertical and horizontal position of the patient. Generally, a
conservative symptomatic treatment of reflux esophagitis. In the absence of an effect or accession
complications surgical treatment of hiatalhernia.
Oesophagitis - inflammation of the esophagus. Esophagitis distinguish acute, subacute and chronic. Acute
esophagitis occur due to irritation of the mucous membrane of the esophagus hot food and liquid chemicals
can be observed in acute infectious diseases (scarlet fever, diphtheria, sepsis, etc.). The most frequent cause
of subacute and chronic reflux esophagitis is an active gastric and intestinal juice into the esophagus due to
cardiac failure esophageal sphincter - the so-called reflux esophagitis, which is usually observed in the axial
hiatal hernia. For reflux esophagitis are the main symptom of heartburn and regurgitation, worse torso in a
horizontal position. The most reliable method of diagnosis is esophagoscopy, which allows you to identify
esophagitis and to determineits extent and character.
Tumors of the esophagus. Benign tumors of the esophagus are rare. Of the malignant tumors of the
esophagus is most common cancer, which affects mostly men (women get 3 times less) over the age of 40
years. The main symptom - dysphagia is most often the first manifestation of the disease. Sometimes the
appearance of dysphagia preceded by chest pain when swallowing (especially solid food), pain during the
passage of food to the level of destruction, "scratching" in the chest, feeling of a foreign body in the
esophagus. Intermittent nature of dysphagia does not exclude the diagnosis of cancer. With further growth of
tumors appear dull pain in the chest, back, chest pain, simulating angina, cough, hoarseness, shortness of
breath, and general symptoms of cancer illness - fatigue, malaise, loss of appetite, etc. Diagnosis is based on
these clinical symptoms, X-ray data and esophagoscopy with biopsy. In cancer of the esophagus is
recommended surgical and combined treatment. During unresectable tumors radiation therapy and palliative
is needed.
The defeat of the esophagus in systemic sclerosis is accompanied by a number of patients against the passage
of food through the esophagus and pain, the need to wash down the dry food with water. When X-ray
observed dysmotility of the distal esophagus and cardia insufficiency, regurgitation of food into the
esophagus, particularly in the patient lying down, reflux esophagitis. Especially dangerous is the
development of chronic esophagitis, which can lead to a narrowing of the lower esophagus and severe
dysphagia, esophageal radiographic changes are also observed in those patients who are not clinically
observed no clinical signs of lesions of the esophagus.
Half of the patients with dermatomyositis digestive organs are involved in the pathological process.
Violation of swallowing in patients with dermatomyositis associated with hypotension upper third of the
esophagus. This is associated with damage to the muscles of the esophagus. In the following may develop
mucosal lesions of the mouth and esophagus to produce necrosis, edema and hemorrhages.
Stricture and stenosis of the esophagus, and is accompanied by symptoms of dysphagia. Dysphagia symptom
severity depends on the degree of stenosis of uncertain discomfort behind the breastbone to the complete
inability to take food and water. In patients with high stenosis of the esophagus when you try to eat, the
water and the food hits the esophagus and into the airway, causing laryngospasm, agonizing bouts of
coughing and breathlessness. When long-existing narrowing of the distal esophagus often develops his
suprastenotic extension. The diagnosis of esophageal stenosis, confirmed by X-rays and esophagoscopy.
The main method of treatment of beginn esophageal stenosis is its probing. In cases where the lack of
success of bougienage resorting to surgery. In cases of severe malnutrition and contraindications for surgical
intervention is recommended overlaying gastrostomy.
The causes of dysphagia can be diverticulum of the esophagus. With larger diverticulum it can accumulate a
significant amount of food, whereby the pouch compresses the esophagus and makes it difficult to pass
through it first solid food, and then the liquid. Some time after the meal can be spontaneous regurgitation of
undigested food and mucous fluid from the sac diverticulum. Diagnosis of esophageal diverticula is possible
only if the contrast X-ray examination and esophagoscopy. The exception is faringoezofagalnye (neck)
diverticula, which sometimes can be detected during the inspection and palpation of the neck. In the absence
of indications for surgery treatment should be aimed at preventing delays in the diverticula of food masses.
Dysphagia sideropenic - observed with a deficiency of iron in the body, usually associated with gastric Akhil
and iron deficiency anemia. Manifested dysphagia, over time becoming permanent and is accompanied by
unpleasant sensations in the course of the esophagus. At survey trophic changes in the skin, hair, nails, pale
skin and mucous membranes, atrophic glossitis, sore throat and other symptoms of anemia. Determined by
endoscopy esophagitis, and atrophic gastritis.In a number of cases in the initial segment of the esophagus
revealed thin connective tissue membrane.When X-ray changes are usually not detected. Treatment:
prescribers iron, in addition-Bvitamins
Dysphagia may occur with compression of the esophagus or displacement due to hyperplasia of the thyroid
gland, tumors or mediastinal abscesses, pericarditis, aortic aneurysm, and pleural effusion. Violation of
swallowing can be observed in the presence of foreign bodies in the esophagus.
Checking the initial level of readiness of students, using the 'pen in the middle of the table. "
Maximal score 2019
excellent
100%-86%
18-17points
16-15points
14-13points
12points
good
85%-73%
satisfactory
70-56%
not satisfactory
53%-46%
bad
43% or less
The purpose of the method: simultaneous involvement in the process of discussing topics of all students
with an objective assessment of their knowledge.
Action: The proposed mission to the whole group, each student writes down on a piece of your answer and
sends it to a neighbor, and my pen moves to the middle of the table, not to supplement its answer further
information heard. Advantage of the method is. That is controlled by employment in the educational process
of all members of the group with simultaneous evaluation of knowledge. The disadvantage of the method is
that the student can see the corresponding previous answers.
Example: List the causes of dysphagia.
Each student must write one of the following responses:
Functional and organic, psychogenic, hysterical, after stem stroke in botulism, cardiospasm, hiatal hernia,
Barrett's esophagus, tumors of the esophagus, esophagitis, esophageal stricture, esophageal diverticulum.
The teacher monitors the work of the group and the involvement of everyone, read and summarize the results
of the answers. Students record the final answer in their workbooks.The evaluation criteria
4.2. The analytical part
4.1. Situation tasks:
1. Sick 19 years appealed to the GP complaining of pain after eating, especially solid, chest pain lasting
10-15 minutes, sometimes up to several hours after taking the pass erinita, difficulty swallowing and
passage of the bolus in the projection of the xiphoid process, palpitations , after growing unrest
regurgitation (spitting up food eaten), often at night (according to the patient's pillow in the morning get
wet), excessive salivation. Objective: The general condition is satisfactory. Skin is pale, dry. Low
power.In the lungs, vesicular breathing. Cardiac clear, rhythmic. Pulse 92 beats per 1 minute. BP 100/70
mm Hg Marked elongation of auscultatory time swallowing, auscultation over the xiphoid process is
determined by the deaf, a gurgling sound, appearing in 1.5-2 minutes after a sip of water. Tongue is
moist. The abdomen was soft and painless. Faeces and urine is free. Complete blood count, ECG was
normal.
1. Name at least three diseases in which the above-mentioned symptoms can be observed;
2.Specify your most likely a preliminary diagnosis;
3. More research is needed to confirm your diagnosis;
4. Specify the method of research, which is crucial in making a diagnosis;
5. Tactics GPs and treatment guidelines;
Example answer:
1.Ahalaziya, cardiospasm, esophagitis, coronary pain, mediastinal tumors.
2. Cardiospasm (achalasia cardia)
3.Rentgenoskopiya, rentgenografiya with barium,
4. EGFDS with esophageal biopsy
5.Gastroenterologists consultation, if necessary, hospitalization dep. of gastroenterology.
6. Treatment: spasmolitiks-noshpa, platifillina g-t.
_____________________________________________________________________________
2. Sick 52 years at a reception at the GP complaining of chest pain, epigastric (especially after coughing
and physical effort), heartburn (especially torso and in the supine position), burping air and eaten food,
occasionally persistent hiccups, quick sense of saturation, sometimes vomiting with blood, on the night
regurgitation of food (a symptom of "wet pillows"). Objectively: the patient's general condition is
relatively satisfactory. Skin is pale. On the part of the lungs, heart and other internal organs were normal.
Jabs: hypochromic anemia. ECG is normal.
1. Name at least 3 diseases, which are characterized by the above symptoms;
2. Your preliminary diagnosis;
3. Additional research is needed to confirm the diagnosis;
4. The method of investigation, which is crucial in making a diagnosis;
5. Treatment;
6. Tactics of GPs.
_______________________________________________________________________________
3. A patient 22 years old, student, turned to the GP complaining of a burning sensation behind the
breastbone and around the xiphoid process, soreness or burning sensation when passing food through the
esophagus, impaired swallowing, regurgitation of food sometimes, sour or bitter liquid, worse torso in a
horizontal position .
With rentgenscopy esophagus detected from the flowing contrast agent stomach into the esophagus.
Complete blood and urine tests, as well as an electrocardiogram, were normal.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
________________________________________________________________________________
4. Patient 34 years old at the reception of the GP complaining of a violation of swallowing, burning
sensation behind the breastbone, cold hands, especially in the cold, pain in the joints of the hands,
shortness of breath, slight cough, difficulty opening the mouth, general weakness. Objective: The general
condition of moderate severity. Consciousness is clear. Position is activated. Skin is thick, shiny, on the
forearms and hands are not taken into the fold. In the light scattered dry rales. Heart sounds are muffled,
rhythmic. Pulse 104 beats per 1 minute. BP 120/80 mm Hg The abdomen was soft, slightly painful in the
epigastric region. The liver and spleen were not enlarged. A of bl.C: Hb - 92 g / l, leukocytes - 3.6 x 10 /
l, 28-ESR mm / hour.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
_________________________________________________________________________
5. A patient 67 years old, at a reception at the GP complaining of pain and a feeling of pressure in the
chest, sometimes in the night, impaired swallowing, belching air, food regurgitation, vomiting, drooling,
loss of appetite, hoarseness. Objectively: the patient malnutrition. Consciousness is clear. Skin is ashy
gray. Palpable enlarged cervical lymph nodes. In the lungs, vesicular breathing heart sounds are muffled,
rhythmic. Rhythmic pulse is 100 beats per 1 minute . BP 150/70 mmHg Tongue coated with white
bloom. The abdomen was soft and painless. The liver and spleen were not palpable. The chair is prone to
constipation. Urination is free.
Jabs: revealed anemia, ESR-36 mm / hour.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
________________________________________________________________________
6. Patient 25 years old at the reception of the GP complaining of retrosternal pain associated with
swallowing, a delay in the esophagus dry and poorly chewed food, belching, regurgitation of food at
torso. Dysphagia is intermittent, sometimes occurs on a liquid diet and disappears if swallowed solid
food. Objectively: the pathological changes of the internal organs were found.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
_________________________________________________________________________
7. A patient 37 years appealed to the GP complaining of chest pain in the epigastric region, emerging and
evolving with food or immediately after, sometimes in the supine position, lasting from several minutes to
several hours. Concerned about dysphagia, heartburn, belching with acidic stomach contents, worse torso
and in the supine position. At times there is vomiting with blood streaks. On radiographs of the lower
third of the esophagus revealed a symptom of "niche". From other internal organs revealed no pathology.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
__________________________________________________________________________
8. Patient 84 years old at the reception of the GP complaining of pain and a feeling of pressure in the
chest, sometimes in the night, impaired swallowing, belching air, food regurgitation, vomiting, drooling,
loss of appetite, aversion to meat. Objectively: the patient malnutrition. Consciousness is clear. Skin is
ashy gray. Palpable enlarged cervical lymph nodes. In the lungs, vesicular breathing heart sounds are
muffled, rhythmic. Rhythmic pulse is 100 beats per 1 minute. BP 130/70 mmHg Tongue coated with
white bloom. The abdomen was soft and painless. The liver is enlarged dense, hilly. The spleen is not
palpable. The chair is prone to constipation. Urination is free.
Jabs: revealed anemia, ESR-56 mm / hour.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
___________________________________________________________________________
9. Patient R., 36, a longshoreman, he turned to see a GP with complaints of frequent heartburn, about
which constantly takes teaspoon soda. In recent days there pain in the xiphoid process, especially after the
heavy lifting at work and tilted forward. In the history of gastrointestinal disease denies. Objectively: the
patient moderate power, the skin and mucous normal color, clean. Cor-high tones sonorities, rhythmic.
Pulse 70 beats in 1 min. Blood pressure 120/70 mm Hg. In the lungs vesicular breathing is auscultated.
The abdomen was soft, with no pain. The liver and spleen were not enlarged. Faeces and urine are
regular.Society. An. Blood: Hb-130 g / L, white blood cells, 7.2 × 10 9 monocytes. - 5, lymphocyte. - 27
ESR 10 mm / hr.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
____________________________________________________________________________________
10. A patient 40 years appealed to the GP complaining of chest pain in the epigastric region, emerging
and evolving with food or immediately after, sometimes in the supine position, lasting from several
minutes to several hours. Concerned about dysphagia, heartburn, belching, regurgitation of stomach
contents, worse torso and in the supine position. List at least four diseases with which is necessary to
conduct a differential diagnosis;
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
The evaluation criteria
Maximal score20-19
excellent
18-17points
good
16-15points
14-13points
satisfactory
not satisfactory
12points
bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
Tests.
1. Primary achalasia (cardiospasm) of the esophagus is more common:
a) in the elderly
b) children
c) in young and middle-aged
r) in newborns
d) teenagers
2. An early symptom of cancer of the esophagus is:
a) dysphagia
b) constant chest pain
c) melena
d) hoarseness
e) weight loss
3. Factors contributing to the development of reflux esophagitis does not apply:
a) hiatal hernia
b) obesity
c) pregnancy
d) alcohol, smoking
d) receiving cerucalum
4. Drug normalizing gastric motility and used for the treatment of reflux esophagitis is:
a) metacin
b) atropine
a) cimetidine
g) cerukal
d) ranitidine
5. Male 50 years old, height 180 cm, weight 70 kg. complains of a painful burning sensation behind the
breastbone, which is increasing at a slope, in a horizontal position, after eating, radiating to the neck, back,
subside after taking the soda burp eaten food. It is most likely that the patient:
a) reflux esophagitis
b) stable angina
c) the output of the gastric cancer
g) unstable angina
e) a stomach ulcer
6. Female 46 years old are over weight complain of pain in the heart, epigastric pain arising in the
performance of work related to the slopes, alone at night, periodically occurring heartburn.
On examination: ECG at rest and during exercise - no pathology. It is most likely that the patient:
a) angina
b) peptic ulcer
c) osteochondrosis with radicular syndrome
g) hiatal hernia
d) painless form of coronary artery disease
7. A patient 52 years for 5-6 years old notes chest pain after eating, when tilted in the horizontal position,
which nitroglycerin not cropped, reduced in the transition to a vertical position. The ECG changes during
pain have been identified.
1. The likely diagnosis:
a) angina
b) vegetative-vascular dystonia
c) hiatal hernia
g) Tietze's syndrome
e) intercostal neuralgia
8. The tactics of GPs:
a) surgical consultation
b) consultation of a cardiologist
c) consulting gastroenterologist
g) treatment and supervision in a family health center (rural medical station)
d) in-patient treatment
9. For the drug ranitidine right characterization is:
a) H2 gistaminretseptors-blocker
b) the total anticholinergic action
c) topical anticholinergic
d) an antacid
e) miotonik
10. For drug almagel right characterization is:
a) H2-gistaminretseptors blocker
b) the total anticholinergic action
c) topical anticholinergic
d) an antacid
e) miotonik
The evaluation criteria
Maximal score20-19
excellent
18-17points
good
16-15points
14-13points
satisfactory
not satisfactory
12points
bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
4.2.2. Graphic organizer"fishbone".
The purpose of the scheme "fishbone" to describe the wholerange offield problem sand try tosolve it,
develops and activates the system, creative, analytical thinking.
Progress chart: students get acquainted with the rules ofcon struction of the scheme. Individuallyorin pairsto
write down the top bonewording of sub-problem sandon the bottom- the factsprove that these problems exist.
Together in a minigroup, compare and complementy our scheme.
Next, conduct a presentation of the results. Presentation of the completed scheme in order to demonstrate the
relationship of subproblems. Their complex character.
Diagnostic of dysphagia
wornclinic
Latent with in
similar symptoms
simulation
Lack of Lab
patient has not
time to come
economic
The doctor
illiterate
The doctor in
considerate
Lack of equipment
The doctor careless
The doctor
nonprogressive
diagnostic of
dysphagia
Nurse negligence
Nurse illiterate
???????????
nursenon-executive
The evaluation criteria
Maximal score
18-17points
20-19
excellent
well
100%-86%
85%-73%
16-15points
14-13points
12points
good
satisfactorily
nonsatisfactorily
70-56%
53%-46%
43% or less
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1.Perform a visual inspection of patients with diseases with dysphagia.
2. Interpretation of the analyzes, the data of laboratory and instrumental studies (clinical and biochemical
analyzes of blood, urine, feces, vomit, gastrointestinal radiographic studies of the esophagus in particular,
EFGDS)
3. Prescription of drugs depending on the etiology of diseases that are accompanied by dysphagia.
The evaluation criteria
satisfactorily
nonsatisfactorily
excellent
well
good
№ evaluation
4
Assimilationin%
The practical part
100%-86%
15-12,9
point
85%-71%
12,75-10,6
point
70-55%
10,5-8,25
point
54%-37%
8,1-5,5- point
5. TYPES OF ASSESSMENT OF KNOWLEDGE, SKILLS AND ABILITIES
•Verbally
•In writing
•The decision of situational problems
• Demonstration of practical skills mastered
36% or less
5,4 point
Criteria for assessment the knowledge, skills and practical skills of students.
satisfactory
excellent
good
№ Assessment
Assimilation in %
1
2
3
4
100%86%
The theoretical
20-17,2
part
point
Case studies
50-43
point
Test
15-12,9
point
The practical part
15-12,9
point
85%-71%
17-14,2 point
42,5- 35,5point
12,7-10,6 point
12,75-10,6point
70-55%
14-11 point
35- 27,5
point
10,5-8,25
point
10,5-8,25
point
not
satisfactory
bad
54%-37%
36% or less
10,8-7,4
point
27-18,5
point
8,1-5,5
point
8,1-5,5point
7,2 point
18 point
5,4 point
5,4point
6.The evaluation criteria of the current control
levels of
Rating
Characteristics of the student
estimates
points
Point of presence on the practical session. Complete lack of
knowledge and ability to performa skill- the studentis not ready
20
for practical employment.
The student answer sunsatis factory.
Students do not know the fundamentals of knowledge and skills,
at least one of the following:
• Do not know the definition of the term "dysphagia"
• Do not know the definition of the terms "esophagitis" and
"reflux esophagitis"
• Do not know the causes, the etiology of dysphagia
•Can not list the main diagnostic methods for various diseases of
esophagitis
• Do not know the group of drugs for the treatment of esophagitis,
reflux esophagitis, dysphagia in scleroderma and esophageal
Not
tumors
20 - 54,9
satisfactory
•Notable to assemblea rational history of supervision of patients
during esophagitis, reflux esophagitis, dysphagia in scleroderma
and esophageal tumors
• During supervision is not able to objectively assess the condition
of patients wit esophagitis, reflux esophagitis, dysphagia in
scleroderma and esophageal tumors
•Notable to make rational plan of investigationin patients with
esophagitis, reflux esophagitis, dysphagia in scleroderma and
esophageal tumors
•Not able to make a differential diagnosis of patients with
dysphagia
Providing basic knowledge and skills
55-60,9
satisfactory
55-70,9%
61-65,9
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and skills
(see below), but when replying or performing skills makes serious
mistakes.
Moderately satisfactory answer.
The student thas basic knowledge and skills (see below), but
when replying or performing skills makes mistakes(subject to
someerror)
Satisfactory answer quality.
66-70,9
The student is wholly owned by the basic levels of knowledge
and skills:
• Know the definition of the term "dysphagia"
• Know the definition of the terms "esophagitis" and "reflux
esophagitis"
• Know the causes, the etiology of dysphagia
• Can list the main diagnostic methods for various diseases
esophagitis
• Knows the group of drugs for the treatment of esophagitis,
reflux esophagitis, dysphagia in scleroderma and esophageal
tumors
• Able to build a rational history of supervision of patients during
esophagitis, reflux esophagitis, dysphagia in scleroderma and
esophageal tumors
• During supervision able to objectively assess the condition of
patients with esophagitis, reflux esophagitis, dysphagia in
scleroderma and esophageal tumors
• Able to be rational plan of investigation in patients with
esophagitis, reflux esophagitis, dysphagia in scleroderma and
esophageal tumors
• Able to make a differential diagnosis of patients with dysphagia
• Can interpret the results of laboratory and imaging studies - may
indicate the presence of leukocytosis, elevated erythrocyte
sedimentation rate, can be interpreted EGDFS conclusion,
gastrointestinal tract rentgengraphy with barium
• Able to correctly fill in the patient diary.
Advanced level of knowledge
good
71-85,9%
71-75,9
76-80
81-85,9
The studentis wholly owned by the basic levels of knowledge and
skills (listed under "66-70,9") + has the following knowledge and
skills:
•Knows theetiology of dysphagia
•Know the classification of dysphagia
•Knows the mechanism of action of drugs used for the treatment
of dysphagia
•Rationally find drugs to the patient, depending on the cause of
dysphagia.
The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "71-75,9",
and also owns the following knowledge and skills:
• Knows the pathogenesis of dysphagia
• Knows the principles of primary, secondary and tertiary
prevention of dysphagia with esophagitis, reflux esophagitis,
dysphagia in scleroderma and esophageal tumors
The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "71-75,9"
and "76-80", and also owns the following knowledge and skills:
• Can tell the basic principles of management, supervision and
monitoring of patients with esophagitis, reflux esophagitis,
dysphagia in scleroderma and esophageal tumors in a RPP or FP.
• Is able to advise you on the boards of non-drug and drug-using
skills of IPC.
• Knows the principles of clinical examination and rehabilitation of
patients with dysphagia in a RPP or FP.
86-90
91-95
excellent
The student is wholly owned by the basic levels of knowledge and
skills (see above) the knowledge referred to in paragraph "81-85,9",
and also owns the following knowledge and skills:
• Knows the principles of treatment of esophagitis, reflux
esophagitis, dysphagia in scleroderma and esophageal tumors
• Knows the indications and contraindications of drugs used in
dysphagia
• Is able to provide reliable information about dysphagia based
Internet data
The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "86-90",
and also owns the following knowledge and skills:
• Know the classification of tumors of the esophagus by TNM?
May explain the mechanism of dysphagia in scleroderma
86-100%
96-100
The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "91-95",
and also owns the following knowledge and skills:
• to provide scientific data on the basis of additional literature
(articles and Internet)
• Know the indications and contraindications for surgical treatment
of dysphagia in tumors of the esophagus, the types of surgery
• Can be in inglish ask complaints, gather medical history and talk
briefly about the disease to the patient with dysphagia
• Has a pedagogical skill - good topic to teach the audience lucidly
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle
of "security" for the patient.
7. Test questions.
1. The etiology of dysphagia.
2. Clinic of dysphagia.
3. Diagnosis of dysphagia.
4. Differential diagnosis of dysphagia.
5. Appointment of outpatient treatment of dysphagia.
6. Clinical supervision of patients with dysphagia.
8. References
Main Readings
1. Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2. Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1. Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2. Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3. Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4. Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5. Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6. Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7. Диагностика болезней внутренних органов. Окороков А.Н..2005.
8. Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru
9. Chronological content classes
Time
Activity
Content
Materials
8.30–
9.30
Morning
conference
The report of the doctor on duty and
duty subordinators on duty.
Medical history,
ECG, overhead
projector.
9.1510.00
Clinical audit to
prescribe
patients.
Theoretical
analysis of the
topic
A detailed report on the students'
prescription patients.
10.45 11.05.
Study of
practical skills.
11.0511.45
Curation of
patients
in the
department
Student under the supervision of a
teacher must complete at least two
practical skill.
Each student is supervised by a
particular patient wards.
11.4512.15
12.2013.20
Break
10.0510.45
Analysis of
case-patients
Checking the initial level of
preparedness of students, using a
"handle on the middle of the table." The
solution case studies on the subject with
the analytical abilities of students.
At the choice of the teacher conducted a
full examination of the patient on the
theme of employment or patients
preparing for discharge, data analysis,
laboratory and instrumental studies, the
rationale for the preliminary and final
clinical diagnoses. Determined by the
treatment plan with the doses of drugs.
Duration of
training
1 hour
45 minutes
Folder with
situational
problems,
educational
boards, tables,
corresponding to
a subject class.
The patient or
volunteer.
40 minutes
20 minutes
The patient,
40 minutes
stethoscope,
sphygmomanomet
er, medical
history (with data
of clinical and
laboratory
findings).
30 minutes
The patient,
stethoscope,
sphygmomanome
ter, medical
history (data of
clinical and
laboratory
findings).
1 hour
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND SKILLS TRAINING FOR STUDENTS
ON THE BASIS OF SOLVING THE PROBLEM OF PATIENTS
WITH ABDOMINAL PAIN
Objective: To teach students by sindrom addressing patients with abdominal pain, as well as the
principles of their management in primary health care as part of the qualifying characteristics of GPs
The main learning objectives:
• To teach students problem solving associated with abdominal pain.
• To train students in a timely diagnosis of the problems associated with abdominal pain.
• To teach students to differentiate the disease, accompanied with abdominal pain.
• Improve the knowledge, skills and practical skills in solving problems of patients with abdominal pain
(gathering information, identifying problems and physical examination, as well as the ability to reasonably
prescribe laboratory and instrumental methods of research);
• To teach students to reasonably choose the tactics;
• To teach students to exercise reasonable medical and preventive measures and monitoring in RPP and
FP.
While investigating the problem of patients the key moments of assessing students must be:
• Ability to identify the underlying problem, which is reflected in the quality of life of patients.
• Ability to ask support questions rational history.
• Ability to identify risk factors.
• Ability to transfer a disease or condition that may be causing the problem.
• Ability to conduct reasonable physical examination.
• Ability to use sound laboratory and laboratory studies in a RPP or FP.
• Ability to identify the need for additional research outside of RPP or FP.
• Based on the information received ability to establish the root cause (diagnosis) of the problem.
• Ability to determine the tactics on the basis of qualifying characteristics of GPs.
• Ability to provide non-pharmacological advice.
• Ability to identify drug treatment based on evidence-based medicine
• Ability to identify preventive measures at the level of primary health care.
• Ability to define the principles of clinical examination and rehabilitation of patients in a RPP or FP.
What the student needs to know to solve the problems of patients with abdominal pain:
№
The list of knowledge
1
The list of diseases which occur with abdominal pain
2
3
4
A list of the most dangerous diseases that present with
abdominal pain
The list of conditions that require management in RPP or FP
(1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
5
A list of studies requiring in RPP or FP (3.1 category)
6
The list of research areas requiring outside RPP or FP (3-2
category)
7
Key points (criteria) diagnosis of diseases occurring with
abdominal pain
8
The nature and location of pain
9
Signs of acute abdomen
10
Symptoms of internal organ
11
Indicators of results of laboratory and instrumental
investigations
12
Therapeutic tactics
13
The principles of primary, secondary and tertiary prevention
14
The principles of clinical examination and rehabilitation of
disorders that occur with abdominal pain in RPP or FP
(category 4)
The basic level
The student should know at least 10
of the most common diseases
The student should know at least 5
diseases
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
The student must know the
characteristics and manifestations
of each disease, as well as criteria
for diagnosis.
The student must know the
characteristic location of the pain
in diseases of the abdominal cavity
The student must list the symptoms.
The student should know the signs of
heart, lung, liver, spleen, stomach,
12 pc., Intestines and kidneys
The student should know:
- Normal values, as well as their
changes in pathology.
The student must know the
techniques and principles of
treatment (including non-drug)
The student should know the basic
activities required for the primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination
and rehabilitation
What the student should be able to solve the problems of patients with abdominal pain:
№
The list of skills
The basic level
• The student must be able to ask questions of management
concise questions that really helps to set the probable
diagnosis.
• The student must be able to specifically identify and
assess the patient's complaints.
1
Ask the patient and his relatives
• The student must be able to analyze medical history: the
beginning of the disease, the first symptoms, the causal
relationship and the dynamics of their development.
• The student must be able to analyze the history of life: the
identification of risk factors, the health of the parents and
close relatives.
The student must be able to identify unmanaged and
2
Identify risk factors
uncontrolled risk factors such as on questioning the patient,
so on the basis of an objective approach
The student must be able to identify signs:
3
Calculate the index of weight / body
- Underweight
- Increased weight.
The student must be able to identify:
- liver palms,
4
General inspection
-gynecomastia
- cachexia.
The student must be able to detect the presence of:
pale- Ikterics,
5
Perform visual inspection of the skin
-presence of lesions
- seals
- teleangiectasia.
6
Inspection of the mouth
The student should be able to appreciate the language.
The student must be able to assess:
- A tour of the chest
To conduct palpation, percussion and
- Voice trembling
7
auscultation of the respiratory
- Change in pulmonary sound and interpretation
system.
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify signs:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
To conduct palpation, percussion and
- If the heart murmur, be able to identify their epicenter, and
8
auscultation of the cardiovascular
relevant to the phase of cardiac (systolic or diastolic
system.
murmur);
- To be able to differentiate functional from organic heart
murmur.
- Noise pericardial friction
The student must be able to detect the presence of:
-ascites
-flatulence
9
General inspection abdomen
-spider veins
- venous collaterals
- injuries and bruises
The student should be able to:
Conduct a superficial abdominal
- To identify sensitive points
10
palpation
- To evaluate the presence of tension in the muscles of the
abdominal wall
11
Conduct a deep abdominal palpation
12
Conduct percussion liver
13
To conduct palpation of the liver and
gall bladder
14
Conduct percussion and palpation of
the kidneys.
15
Conduct a survey of anorectal
16
17
Conduct a gynecological
examination
Interpret clinical, instrumental and
biochemical analyzes
18
Remove the ECG and decrypt it
19
Differentiate diseases accompanied
with abdominal pain
20
Post a non-drug advice
21
Rational use of medicines in the
treatment of diseases that occur with
pain in the abdomen.
22
Conduct monitoring and surveillance
of patients
- To identify the presence of enlarged organs or tumor
formation.
- To test Shchetkin-Blumberg
The student should be able to:
- To evaluate all available structures in the abdomen
The student should be able to:
- determine the limits of the liver Kurlov
The student should be able to:
- To evaluate the properties of the liver and gall bladder.
The student should be able to:
- Test for tapping the lumbar region
- Palpation evaluate the performance of the kidneys
The student should be able to anorectal examination, taking
into account the principle of step.
The student should be able to gynecological examination,
taking into account the principle of step by step.
The student must be able to identify signs:
- Increase or decrease in performance from the norm.
The student should be able to record the ECG with the
incremental principle.
The student must be able to decipher the results of the ECG
The student must be able to differentiate the disease on the
basis of the distinctive features (history, physical
examination, laboratory and instrumental investigations)
The student should be able to:
- Educate patients on self-monitoring
- Advise on diet
- Advise on healthy lifestyles
1. The student should be able to choose drugs with proven
efficacy.
2. When selecting a drug student should be able to
evaluate:
3. Efficiency
4. Safety
5. Eligibility
6. Profitability
The student must be able to carry out monitoring and
control status in RPP or FP
Practical lesson 2
Theme: "The pain in the stomach. Differential diagnosis of gastritis and peptic ulcer disease
(gastric and 12 duodenal ulcer). Tactics of GP. Indications for referral to a specialist or hospital in the
profile department. The principles of treatment, follow-up, control and rehabilitation RPP or FP. The
principles of prevention. The principles of teaching subjects. "
Training Technology
Study time: 6 hours
1. Training room.
2. Hospital wards
3. Tutorials, phantoms, models, handouts, a collection
The structure of the training session
of case studies and tests
4. TV, video equipment, multimedia
The purpose of the training session: Getting GPs differential diagnosis and selection of the optimal
treatment strategy options in chronic gastritis and peptic ulcer and 12 duodenal ulcer, as well as the
principles of management of patients in primary care, provided the requirements of the
"Qualification characteristics of the general practitioner."
Pedagogical objectives:
1. Consider the issues of diagnosis of chronic
gastritis and peptic ulcer and 12 duodenal ulcer
2. Demonstrate patients with chronic gastritis
and peptic ulcer and 12 duodenal ulcer
3. Discuss the results of clinical, laboratory
and instrumental studies in chronic
gastritis,peptic ulcer and 12 duodenal ulcer
Learning outcomes:
GP should be aware of:
1. The mechanism and cause of chronic gastritis, peptic
ulcer and 12 duodenal ulcer
2. Clinical manifestations of chronic gastritis,peptic ulcer
and 12 duodenal ulcer
3. Diagnosis of chronic gastritis, peptic ulcer and 12
duodenal ulcer
4. Differential diagnosis of chronic gastritis,
peptic ulcer and 12 duodenal ulcer.
4. Differential diagnosis of gastritis, peptic ulcer and 12
duodenal ulcer
5. Discuss the tactics in the qualifying
characteristics of GPs
5. Medicinal products used in the treatment of chronic
gastritis , peptic ulcer and 12 duodenal ulcer, their
pharmacodynamics and dosage.
6. Discuss the principles of treatment
(medication and non-medication).
7. Discuss the principles of management,
supervision and monitoring of patients in a
hovercraft or a joint venture.
8. Discuss the principles of primary,
secondary and tertiary prevention in these
diseases.
6. 3-and 4-component treatment of peptic ulcer
7. Principles of supervision and monitoring of patients in a
hovercraft or a joint venture.
8. The principles of primary, secondary and tertiary
prevention
GPs should be able to:
1. Analyze the data and history of complaints in the
diagnosis of chronic gastritis and peptic ulcer and 12
duodenal ulcer
2. Diagnose, differentiated by clinical and laboratory
research tool chronic gastritis,peptic ulcer and 12
duodenal ulcer.
3. Choose the right medications for chronic gastritis, peptic
ulcer and 12 duodenal ulcer.
4. Tactics of GPs.
5. The principles of treatment (medication and nonmedication) in these diseases.
6. Principles of follow-up and monitoring of patients in a
hovercraft or a joint venture.
Training methods
Forms of organization of learning activities
Learning tools
Methods and feedback means
7. The principles of primary, secondary and tertiary
prevention in these diseases.
the method of "snowballs", demonstration, entertainment
experience, discussion, conversation, decision tests and
case studies
Individual work, group work, team, classroom,
extracurricular.
Hand-learning materials viziualnye materials, videos,
models, graphic organizers, history, tables, benches.
Quiz, test, presentation of the results of the learning task,
filling medical records implementation of practical skill
"professional debriefing"
Technology chart of classes
“Differential diagnosis of gastritis, duodenits and peptic ulcer disease. Tactics of GPs. Prevention
and treatment of gastroduodenal diseases with impaired secretion in primary care differential
diagnosis of diarrhea of infectious and noninfectious etiologies. Hypovitaminosis. The tactics of the
general practitioner. Indications for referral to a specialist or hospital in the profile department. The
principles of treatment, follow-up, control and rehabilitation in RPP or FP. The principles of
prevention. The principles of teaching topics”
№ Stages of the training session
Form of the classes
Duration
n of classes
Place
225
1
Introductory part ( theme explanation)
10
2
The discussion on the practical lessons with the use of new The survey, discussion
educational technologies (method of "snowballs"), as well
as demonstration material (history, charts, posters, x-ray), Training Room
define the initial level.
Conclusion discussion
Definition of tasks to perform the practical part Discussion
professional questioning. Explanation of the provisions
and recommendations for the job by filling in the history
of the disease.
40
5
Mastering the practical part of the training under the
guidance of a teacher.
20
6
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research urin analisis and biochemical analysis
and diagnosis
7
Discussion of theoretical and practical knowledge of the
students, securing the material to determine the level of
assimilation of knowledge assessment.
Oral questioning, tests,
75
discussion, identification of
practical skills
Classroom
8
Defining output on practical sessions on a 100-point rating
system and ad evaluations. Homework next practice
session (a collection of questions).
Information, questions for
homework.
Classroom
3
4
Prof. questioning. A
conversation with patients
and filling medical history,
situational problems.
Thematic inspection of
patients in the wards
Medical history,
laboratory data,
situational problems
10
20
25
25
2. Motivation
Patients complaining of belching, heartburn, nausea, vomiting, epigastric pain often encountered in
practice, primary care physicians. In this situation, the force of a general practitioner (GP) is directed to the
diagnosis of diseases for medical care in a RPP, or referral to specialized hospitals. These and other
conditions are the basis for the inclusion of this subject in the training of GPs.
3. Inter and intradisciplinary communication
The teaching of this subject is based on the knowledge of the students basics of anatomy, physiology,
pathophysiology, pathology, microbiology, biochemistry, therapeutics, propaedeutics childhood diseases,
clinical pharmacology. The results obtained in the course of training knowledge will be used during the
passage of the GP - pediatrics and other clinical disciplines.
4. The content of classes
4.1. The theoretical part
Dyspepsia - a general term for symptoms caused by digestive problems, who are treated gastroenterology
patients to medical practitioners and clinics of hospitals.
Dyspepsia includes the following symptoms: nausea, heartburn, regurgitation, epigastric discomfort, and
in the lower parts of the chest, feeling of fullness or heaviness in the epigastrium, flatulence. At the heart of
gastric dyspepsia is a violation of its secretion and motor function.
Dyspeptic syndrome accompanies almost all diseases of the digestive system, the main of which are as
follows: non-ulcer dyspepsia, overeating, smoking, gastro, etc.; reflux esophagitis, hiatal hernia, esophageal
dysmotility, peptic ulcer and 12 duodenal ulcer, cancer of the esophagus , stomach, pancreas, liver disease,
biliary tract and pancreas, inflammatory disease of the gastrointestinal tract: gastritis, giardiasis, Crohn's
disease, irritable bowel syndrome, variants of coronary heart disease, alcohol consumption, and adverse drug
effects and toxicity.
During prolonged and severe indigestion to establish the cause perform the following laboratory and
instrumental investigations: blood, fecal occult blood test, analysis of gastric juice, if necessary with the
histamine test, stress ECG - sample, abdominal ultrasound, x-ray gastrointestinal tract and gall bladder
mucosal biopsy with EFGDS, retrograde holetsistopankreatografy, esophageal manometer, tumor markers,
carcinoembryonic antigen embriogenalny for suspected cancer of the colon, A-fetoprotein - for suspected
cancer of the liver.
It must be emphasized that the leading role in the diagnosis of various forms of dyspepsia is a correct
assessment of anamnestic data and posistemny patient survey.
Heartburn and belching air, acid are the most common painful gastrointestinal symptoms in patients. We
must always remember that they are not necessarily a manifestation of hyperacid condition and can be
observed even in cancer patients with deep Akhil (lactic acid, bile, pancreatic juice). Epigastric discomfort
may accompany diseases of the chest, retroperitoneum, spine, and in these cases timely ECG and
radiographic examination to avoid rough diagnostic errors.
USING " snowball "
Objective: The involvement in the educational process of all students while controlling their knowledge
of the topic under discussion.
Group 2-3 is divided into smaller sub-groups which discuss the same problem or situation to set the
highest number of correct answers. Each correct answer is recorded on the score of this group in the form
of snowballs. Group receiving the highest number of points, give higher ratings.
1. Determination of chronic gastritis.
2. Diagnosis of chronic gastritis.
3. Eradication H.pylorici.
Answers:
1. Chronic gastritis - a chronic inflammation of the gastric mucosa in violation of the physiological
regeneration and progressive atrophy of the specialized glandular epithelium with the development of
intestinal metaplasia, dysplasia and later, and a violation of motor and secretory functions.
2. EFGDS + biopsy, fractional study of gastric juice, revealing H.pylorici (cytological and histological
study, the degree of contamination of the mucous membranes, immunological).
3. First-line therapy in 7 days: omeprazole 20 mg 2 times / day + clarithromycin 500 mg 2 times / day. +
Amoxicillin 1000 mg 2 times / day
+ Metronidazole 500 mg 2 times / day, second-line therapy 10 days of omeprazole 20 mg 2 times / day +
bismuth subcitrate 120 mg 4 times / day + tetracycline 500 mg 4 times / day. + Metronidazole 500 mg 2
times / day
№
Rating
Assimilation in%
Excellent
100%-86%
1
The theoretical part
20-17,2
point
Good
85%-71%
17-14,2
point
Satisfactory
70-55%
Not satisfactory
54%-37%
14-11 point
10,8-7,4
point
Bad
36% and
less
7,2 point
4.2 The analytical part
4.2.1. Case studies:
1. Male 20 years old at the reception GP notes epigastric pain, heartburn, nausea. The pain was after 20
minutes. after ingestion. From history revealed that the patient eats regularly, and enjoys rough and fried
food. General state of moderate severity. On the part of the heart and lungs normal. Tongue coated white
coating, wet, says teeth marks. The abdomen is involved in the act of breathing. When palpation diffuse
epigastric tenderness. The chair is prone to constipation.
1. List at least four diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to confirm the diagnosis;
4. Tactics GPs. Treatment.
Answers:
№
Answers
Point
1
a) irritable stomach, b) type B chronic gastritis with increased secretion, c) chronic gastritis
type B with preserved secretion, d) a stomach ulcer.
15
2
chronic gastritis type B with an increased secretion.
25
3
EFGDS + biopsy, fractional study of gastric juice, revealing H.pylorici (cytological and
histological study, the degree of contamination of the mucous membranes, immunological).
20
4
Eradication H.pylorici, anti-secretory drugs (ranitidine or omeprazole or gastrotsepin),
20
antacids (Maalox), preparations protecting coolant (denol or sucralfate), correction of the
impaired microcirculation
________________________________________________________________________________
2. A patient 26 years old at the reception of the GP notes heaviness in the epigastric region, nausea,
salivation, increasing the temperature to 38 ˚ C. From the history 2 days ago, he tried not benign food.
Subsequently he observed vomiting and diarrhea. The general condition of the patient a heavy, moist skin,
pale. Of the heart - tachycardia, heart rate 100 beats / min., rhythmic. In the lungs vesicular breathing. On
palpation of the abdomen is soft, there is a slight pain in the epigastric region. Urine output is reduced.
1 .Name at least 3 diseases that manifest the above symptoms;
2. Your preliminary diagnosis;
3. Additional studies to confirm the diagnosis;
4. Specify the method of research, which is crucial in the diagnosis;
5. Tactics of GPs and principles of treatment (non-pharmacological and pharmacological).
____________________________________________________________________________________
3. A patient 48 years old at the reception of the GP complaining of heaviness, distension, dull epigastric
pain, nausea, anorexia, bad taste in mouth, belching rotten, rumbling, bloating, diarrhea, hair loss.
Objectively: the patient's general condition of moderate severity. Skin pale, dry, marked trophic nail changes.
In the lungs there is a vesicular breathing. Heart sounds. Pulse 96 beats per 1 minute. BP 110/70 mmHg
Tongue moist, coated with white bloom. The abdomen was soft, painful in the epigastric region. The liver
and spleen were not enlarged. Faeces occasionally diarrhea. Urination is free and painless.
Fluoroscopy tract: the relief of the mucous membrane is flattened, the tone and peristalsis weakened,
gastric emptying accelerated. The study of gastric secretion: total acidity – 18.
1. Name at least 6 diseases which may have the above symptoms;
2. Your preliminary diagnosis;
3. What additional research is needed to clarify the diagnosis for the patient;
4. The most serious complication of the disease;
5. Please describe, drug and drug therapies (diet, drugs, indicating dose), tactics of GP
_________________________________________________________________________________
4. Male 42 years appealed to the GP complaining of severe epigastric pain, nausea, heartburn. The pain
occurs in 20-30 minutes after ingestion and is local. From history: last spring, there were also similar pains.
The patient was not treated, the pain it self passed in a month. On-no: during abdominal palpation there was
a huge local tenderness in the epigastrium. Constipation.
1. List at least four diseases which may be the above symptoms;
2. Your preliminary diagnosis;
3. What additional studies are carried out to confirm the diagnosis;
4. What complications can occur with this disease;
5. Please specify the scheme and the principles of conservative treatment of this disease.
_________________________________________________________________________________
5. The reception was at the GP 18 year old student complains of hunger and night pain in the abdomen,
irradiruyuschie in the spine, occasionally heartburn, acid regurgitation. History of big brother is suffering a
stomach ulcer 12 duodenal ulcer. Objectively: the patient malnutrition, skin and visible mucous membranes
pale, tongue coated. On palpation of the abdomen there was a huge local pain in the epigastric region to the
right. Constipation.
1. List at least four diseases which may be the above symptoms;
2. Your preliminary diagnosis;
3. What additional studies are carried out to confirm the diagnosis;
4. What are the causative factors of aggressive and are crucial to the emergence of this disease;
5. Tactics of GPs. Treatment.
_______________________________________________________________________________
6. A patient 21 years old, student, turned to the GP complaining of heartburn, acid regurgitation, the
severity of pain and dull aching in the pit of stomach after eating, and constipation. Objectively: the patient's
general condition is relatively satisfactory. Consciousness is clear. Position is activated. Skin is pale pink. In
the lungs, vesicular breathing. Cardiac clear, rhythmic. Pulse 84 beats per 1 minute. BP 120/80 mm Hg
Tongue moist, coated with white bloom. The abdomen was soft, painful in the epigastric region. The liver
and spleen were not palpable. Faeces are prone to constipation. Urination is free. The study of gastric
secretion: the total acidity of fasting - 85 titr.. X-ray examination of the stomach: signs of hypersecretion,
diffuse alteration of the relief of the mucous membrane, with thickening of the folds.
1. List at least four diseases which may be the above symptoms;
2. Your preliminary diagnosis;
3. What additional studies are carried out to confirm the diagnosis;
4. Describe in detail (in figures and indicating normal values), what changes are expected in the fractional
study of gastric contents;
5. Tactics GPs. Treatment.
________________________________________________________________________________
7. A patient 42 years old, turned to the GP complaining of severe girdle pains at the epigastrium after a
fatty meal, repeated nausea, vomiting bears no relief. From history: suffering for 10 years, peptic ulcer
disease, occasionally worried about the pain associated with eating and recently changed the nature of pain,
and there were complaints listed above. Objectively: general state of moderate severity, the patient
malnutrition, sclera subikterichnost. Cor - the tones are muted, rhythmic. Pulse 80 beats. 1 min. BP -125 / 70
mm Hg In the lungs, vesicular breathing. The abdomen was soft, tension in the upper abdomen. The liver
and spleen were not enlarged. Frenikus positive sign on the left. CBC - HB-120 g / l, 10 thousand white
blood cells, erythrocyte sedimentation rate 20 mm / hour.
1. List at least three diseases and at least two events at which the above signs and symptoms;
2. Preliminary diagnosis (main complication);
3.Information survey methods;
4.Tactics of GP;
_________________________________________________________________________________
8. Patient K., 33 years old, turned to the GP complaining of unbearable heartburn, hunger pains in the
epigastric region, nausea, diarrhea with abundant liquid feces. In the history of repeatedly treated in
gastroenterology hospital for peptic ulcer disease 12 sc, and there have been episodes of ulcer bleeding. On
examination - peripheral lymph nodes were not enlarged. In the lungs there is vesicular breathing. Cor - high
tones sonorities, rhythmic. Pulse 90 beats in 1 min. BP -100 / 70 mm Hg. Abdomen is soft, painful on
palpation in the gastro-duodenal area. The liver and spleen were not enlarged.
In the study of gastric juice: basal acid output -18mekv/chas with histamine load flow rate figures
revealed total acidity 60 mEq / hour, total acidity of 100 units., Free hydrochloric acid in the basal phase of
80 units. EGDFS 4 ulcers (stomach 1 and 3 s.c. 12) coated with fibrin coating.
1. List at least chytery diseases for which there are the above signs and symptoms;
2. The preliminary diagnosis;
3. Informative survey methods;
4. What changes are in the U.S.;
5. Tactics of GPs.
_________________________________________________________________________________
9. Patient V., 32, appealed to the GP complaining of a sudden appeared last night, severe weakness,
dizziness, nausea and retching, but no vomiting occurred. From history: for many years, often in the spring
and autumn are concerned heartburn, recurrent epigastric pain occurring with in 1.5-2 hours after eating. Last
night was awakened by the urgency to bottom, and then there was a black liquid stools. On-no: the patient
malnutrition, skin and mucous membranes are pale and clean. Cor-tones are muffled, rhythmic. Pulse is 100
beats in 1 min. BP 95/65 mm Hg. In the lungs vesicular breathing is auscultated. Tongue coated with white
bloom at the root of the teeth along the edges of the prints. The abdomen was soft, sensitive in the epigastric
region. The liver and spleen were not enlarged.
1. List at least five diseases and at least two events at which the above signs and symptoms;
2. Preliminary diagnosis (main complication);
3. Informative survey methods;
4. The tactics of the GP;
5. Formulations used for the first order of the patient;
_________________________________________________________________________________
10. Patient M., 21, turned to the GP with complaints of epigastric pain after 1 -1.5 hours after a meal, the
emergence of feelings of fullness in the epigastrium, belching with the smell of "rotten eggs", nausea,
vomiting of food eaten the day before, after vomiting patient feels relieved. From history: epigastric pain,
heartburn, constipation, disturbed in the spring and autumn for the past 4-5 years. Objectively: the patient
malnutrition, the skin is pale, clean, dry, flaky, in the corners of the mouth binding. Cor-high tones
sonorities, rhythmic. Pulse 90 beats. 1 min. Blood pressure 100/70 mm Hg The tongue is coated with a
grayish bloom. The abdomen was soft, painful epigastric auscultation, "splashing". The liver and spleen were
not zoom. Chair - a tendency to constipation.
1. List at least four diseases and at least two complications are observed above signs and symptoms;
2. Preliminary diagnosis (main complication);
3. Informative survey methods;
4. The tactics of the GP;
_________________________________________________________________________________
11. Patient N., 58 years old, turned to the GP complaining of the recent emergence of unmotivated
weakness, lack of appetite, weight loss, a feeling of heaviness and vague epigastric pain, darkening of the
color of feces to "degteoobraznogo." Over the years suffering from gastric ulcer. The last 10 years of
exacerbations was not. 20 years ago suffered hepatitis "A". An objective examination of the patient
malnutrition. The skin and mucous membranes are pale, oprededelyaetsya increase lymph nodes in the left
supraclavicular region. Cor-tones are muffled, rhythmic. Pulse 95 beats. 1 min. Blood pressure 100/70 mm
Hg. In the lungs auscultated vesicular breathing. Tongue coated dirty gray patina. The abdomen was soft,
painful on palpation in the pyloric department.
1. List at least two diseases, and at least three complications are observed above signs and symptoms;
2. Preliminary diagnosis (main complication);
3. Informative survey methods;
4. What is the medical check-up at the GP at the initial stage of the disease in this patient;
5. Tactics GP
_________________________________________________________________________________
12. A patient 27 years old, turned to the GP complaining of a sudden appeared dagger epigastric pain,
cold sweat. In the history of peptic ulcer. Objectively: skin and mucous membranes are pale and clean. Heart
of: the tones are muted, rhythmic. Pulse is 100 beats per minute, blood pressure - 80/50 mm Hg In the lungs,
vesicular breathing. Respiratory rate 24/min. Disappearance of the hepatic dullness on percussion, muscle
tension in anterior abdominal wall.
1. Your primary diagnosis (main complication);
2. Metody studies characteristic changes therein;
3. The tactics of the GP;
________________________________________________________________________________
13. 40 year old man complaining of severe epigastric pain, nausea, heartburn, acid regurgitation,
constipation, poor appetite, irritability. The pain occurs in 20-30 minutes after eating, sometimes on an
empty stomach and is local. From history sick for 2-3 years, it was not treated. When the pain took no-silos,
after the festal meal and allahol. On-no: the patient malnutrition, labile, restless. Heart sounds, rhythmic, on
top of not wired systolic murmur. BP 90/60 mm. Hg. Art. pulse 84 beats in one minute. On palpation of the
abdomen there was a huge local tenderness in the epigastrium. KLA: Hb 106 g / L, 9.2 L × 109, ESR 18 mm
/ hour.
1. List at least five probable diseases for which there are symptoms listed above;
2. Your preliminary diagnosis;
3. List the etiological factors that contribute to this disease (at least five);
4. Tactics GPs and treatment guidelines;
_______________________________________________________________________________
14. 20 year old student complains of hunger and night abdominal pain, radiating to the spine, headaches,
dizziness periodically, and constipation. Sometimes the pain bothers 1.5-2 hours after eating. On-no: patient
malnutrition, anemic, coated tongue, abdominal palpation there was a huge local pain in the epigastric region
to the right. The liver is not increased. UAC: Hb - 100 g / l erythrocytes - 3,0 x 10 ¹ ² / L, WBC - 8,7x 109 /
L ESR - 20 mm / hour.
1. List at least five probable diseases for which there are symptoms listed above;
2. Your preliminary diagnosis;
3. Tactics GPs and treatment guidelines;
________________________________________________________________________________
15. In the SVP to see a GP patient appealed 30 years complained of heartburn and pain in the midline
between the xiphoid process breastbone and the navel, characterized by frequency, seasonality, decreased
after vomiting, weakness. In the words of the patient, the above complaints concerned about the age of 7.
Bad habits: smoking, loves hearty, sour, salty food.
Objectively: the general condition of the patient at the time of inspection is relatively satisfactory, skin
and visible mucous membranes pale, tongue coated. On palpation revealed tenderness in the epigastric
region. BP 120/80 mm. Hg. Art., pulse 76 beats per minute.
The solution according to the principle of a landmark 20 (see Clarification)
№
1
Rating
Assimilation in %
Excellent
100%-86%
Good
85%-71%
2
Case study
50-43 point
42,5- 35,5 35- 27,5
point
point
Satisfactory
70-55%
Not satisfactory
54%-37%
27-18,5
point
Tests.
Tests with two or more correct answers.
1. The appearance of bloody vomiting and black liquid stool in a patient may be due to:
a) chronic gastritis
b) ulcer duodenum 12
c) esophageal varices
r) drug administration of bismuth
e) syndrome Mallory - Weiss
e) irritable bowel syndrome
2. What are the three main factors in the development of peptic ulcer?
a) nervous and mental strain
b) the metabolism of cholesterol
c) chronic gastritis and duodenitis
d) non-compliance with hygiene
e) jetlag food
3. What are the three main places of localization ulcer in the stomach:
a) small curvature
b) in the antral
c) on the sphincter
g) in the bulb
e) in the cardiac department
e) in the fundal
4. 3 specify the characteristic symptoms for 12 duodenal ulcer?
Bad
36% and
less
18 point
a) constipation
b) heartburn
c) night pain
d) diarrhea
e) pain on an empty stomach
5. What are the three characteristics of pain in 12 duodenal ulcer:
a) increased at night
b) the gain on an empty stomach
c) increased after ingestion
d) seasonality
d) seasonality is not typical
e) has no connection with the meal
6. What are the 3 main X-ray signs of ulcers:
a) enhanced evacuation of barium
b) scar deformity
c) hypersecretion on an empty stomach
d) a symptom of a niche
e) there is no right answer
7. Enter the 3 main events for ulcer bleeding from the stomach:
a) glucocorticoid
b) sodium etamzilat
c) aminokapron acid
d) vitamins
e) cytostatics
e) peace
8. What are the 3 main diagnostic methods in peptic ulcer disease:
a) EGDFS
b) X-ray
c) scatoscopy
g) liver ultrasound
d) analysis of gastric juice
e) sigmoidoscopy
9. What are the 3 groups antisecret funds used for the treatment of peptic ulcer disease:
a) antibiotics
b) H2 histamine blockers
c) gastrin receptor blockers
d) antie) sulfonamides
e) M holinoblokatory
10. 3 morphological forms of gastritis:
a) polypoid
b) chronic
c) hypertrophic
g) hemorrhagic
e) hereditary
e) acute
11. In the clinic the prevalence of chronic gastritis syndrome consists of the following 3
a) gastric dyspepsia
b) epigastric pain
c) the neurotic
g) of diarrheal
e) intestinal dyspepsia
e) jaundice
12. Intestinal dyspepsia exacerbation of chronic gastritis characterized by three symptoms
a) pain in the belly button
b) borborygmus
c) breach of the chair
g) flatulence
e) pain along the large intestine
e) melena
13. Highlight 3 morphological forms of chronic duodenitis:
a) surface
b) hypertrophic
c) purulent
g) autoimunnyj
d) fibrous
e) atrophic
c) evidence of a pheochromocytoma
d) the tendency to allergic reactions
e) astenonevroticheskih syndrome
e) hypertrophic gastritis
14. For peptic ulcer, 12 duodenal ulcer is characterized by all of the following complications, except for:
a) pyloric stenosis
b) diarrhea
c) haemorrhage
d) penetration
e) the deterioration of the intestinal conductivity
e) malignancy
№
1
Rating
Assimilation in %
Excellent
100%-86%
Good
85%-71%
Satisfactory
70-55%
Not satisfactory
54%-37%
2
Test
15-12,9 point
12,7-10,6
point
10,5-8,25
point
8,1-5,5 point
Graphic Organizer: pyramid
infectious
bakterial
viral
diarhea
noninfectious
Malabsorbshen s-m
inflammation of the
bowels
protozoy
syndrome of the
irritated bowels
fungous
other reasons
Bad
36% and
less
5,4 point
1.2.2 Graphic Organizer: "pyramid"
Means layering ideas.
Develops and activates the system, creative, analytical thinking.
1. Acquainted with the rules of construction of the scheme. Individually / in pairs build scheme: write the
main problem, then sub-problems, and from each of them assign "small branches" that are essential for a
more detailed consideration of sub-problems or tasks.
With this trace the development of each of the ideas to a considerable depth in detail.
2. Combined in pairs or small groups, and compare their sceme.Unite all scheme
3. Presentation of results.
The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with gastric dyspepsia.
2. The interpretation of laboratory and instrumental studies at gastrik dyspepsia.
Dyspepsia
Gastritis, duodenitis, peptic ulcer disease, biliary dyskinesia, cholecystitis, postcholecystectomical
syndrome, a disease of the operated stomach
№ Rating
Good
Satisfactory
Not satisfactory Bad
Excellent
100%-86%
85%-71%
70-55%
54%-37%
36% and
1 Assimilation in %
less
15-12,9 point
12,75-10,6
10,5-8,25
8,1-5,5-point 5,4 point
2 The practical part
point
point
5. Control forms of knowledge, skills and abilities
- Oral
- The decision of situational problems
- Demonstration of practical skills
- CDS
5.1. Criteria for evaluation of knowledge, skills and practical skills of students.
№
Rating
Assimilation in %
Excellent
100%-86%
Good
85%-71%
1
The theoretical part
17-14,2 point
2
Case Studies
20-17,2
point
50-43 point
Satisfactory
70-55%
Not satisfactory
54%-37%
Bad
36% and
less
14-11 point 10,8-7,4 point 7,2 point
42,5- 35,5
35- 27,5
27-18,5
18 point
poi n t
point
point
3 Test
15-12,9 point
12,7-10,6
10,5-8,25 8,1-5,5 point
5,4 point
point
point
4 The practical part
15-12,9 point
12,75-10,6
10,5-8,25 8,1-5,5- point
5,4 point
point
point
6. The evaluation criteria of the current control
levels of
rating
Characteristics of the student
estimation
points
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not ready
20
for practical employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and skills,
at least one of the following:
He does not know the definition of the term "gastritis"
• Do not know the definition of the terms "peptic ulcer and 12
duodenal ulcer"
• Do not know the cause of abdominal pain
• Do not know the etiology of gastritis and peptic ulcer disease
• Do not know what relates to the factors of protection and
aggression factor in the development of peptic ulcer disease
• Can not tell the main clinical symptoms of gastritis and peptic
ulcer disease
• Can not enumerate the methods of diagnosis of gastritis and peptic
Unsatisfactory
20 - 54,9
ulcer disease
ly
• Do not know the group of drugs for the treatment of gastritis and
peptic ulcer disease (gastric and duodenal ulcer 12)
• Not able to assemble a rational history during the Supervision of
patients with gastritis and peptic ulcer and 12 duodenal ulcer
• During Supervision is not able to objectively assess the condition
of patients with gastritis and peptic ulcer and 12 duodenal ulcer
• Not able to make rational plan of investigation in patients with
gastritis and peptic ulcer disease (gastric and duodenal ulcer 12)
• Not able to make a differential diagnosis of patients with gastritis
and peptic ulcer disease (gastric and duodenal ulcer 12)
• Do not know the complications of peptic ulcer and 12 duodenal
ulcer
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and skills
55-60,9
(see below), but when replying or performing skills makes
serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but
61-65,9
when replying or performing skills makes mistakes (subject to
some error)
The Satisfactory answer high quality.
The Student completely have the base level of the knowledge
and skill:
 Knows the determination of the term "gastritis"
 Knows the determination a term "peptic ulcer of the belly and
duodenum"
satisfactory
 Can explain the reasons of the origin stomachache
55-70,9%
 Knows etiology ofgastritis and peptic ulcer
 Knows that pertains to factor of protection and factor to
aggressions in development to peptic ulcer
 Can tell the main clinical signs a gastritis and peptic ulcer
66-70,9
 Can enumerate the main methods of the diagnostics gastritis and
peptic ulcer
 Knows the groups a preparation for treatment of the gastritis and
peptic ulcer (the belly and duodenum)
 Capable to collect rational anamnesis during supervising beside
sick with gastritis, peptic ulcer of the belly and duodenum guts
 During supervising capable objective to value the condition sick
with gastritis and peptic ulcer of the belly and duodenum guts
 Capable rationally to form the plan of the examination sick with
gastritis and peptic ulcer (the belly and duodenum guts)
 Capable to conduct the differential diagnostics sick with
gastritis and peptic ulcer (the belly and duodenum guts)
 Can enumerate the complications to peptic ulcer of the belly and
duodenum guts.
 During supervising capable objective to value the condition sick
with gastritis and peptic ulcer (the belly and duodenum guts)
 Capable rationally to form the plan of the examination sick with
gastritis and peptic ulcer (the belly and duodenum guts)
 Capable to conduct the differential diagnostics sick with
gastritis and peptic ulcer (the belly and duodenum guts)
 Can interpret the results laboratory-instrumental methods of
the study - can interpret the conclusion EGDFS, X-ray of GIT
with barium beside sick with gastritis and peptic ulcer (the belly
and duodenum guts)
 Capable correct to fill the diary book sick.
Advanced level of the knowledge
Good
71-85,9%
71-75,9
76-80
81-85,9
The Student completely have the base level of the knowledge
and skill (specified in point "66-70,9") + have the following
knowledge and skill:
 Knows etiology, pathogenesis developments gastritis and peptic
ulcer (belly and duodenum)
 Knows categorization a gastritis and peptic ulcer
 Can enumerate the diagnostic methods required for determination
diagnosis gastritis and peptic ulcer
 Knows the main standards of the treatment gastritis and peptic
ulcer (the antysecretory preparations and preparations for
elimination Helicobacter pylori)
 Knows the mechanism of the action medicinal preparation, using
for treatment to peptic ulcer and gastritis
 Can rationally select the medicinal preparations sick depending
on reasons of the origin stomachache.
The student completely have the base level of the knowledge
and skill (see above) + knowledge, specified in point "71-75,9", as
well as have the following knowledge and skill:
 Knows etiology and pathogenesis developments gastritis and
peptic ulcer
 Knows principles primary, secondary and tertiary preventive
maintenance gastritis and peptic ulcer
The student completely have the base level of the knowledge
and skill (see above) + knowledge, specified in point "71-75,9" and
"76-80", as well as have the following knowledge and skill:
 Can tell the cardinal principles of conduct, observations and
monitoring sick gastritis and peptic ulcer of the belly and
duodenum guts in condition RPP or FP.
 Will die to conduct the consultation on questions non-drug and
medicamentous advice with use skill RUMPLED.
 Knows principles an dispansarysationand rehabilitations sick
with stomachache at peptic ulcer of the belly and duodenum
guts in condition RPP or FP
86-90
91-95
Excellent
86-100%
96-100
The Student completely have the base level of the knowledge
and skill (see above) + knowledge, specified in point "81-85,9", as
well as have the following knowledge and skill:
 Knows principles of the treatment sick gastritis and peptic ulcer
of the belly and duodenum guts
 Knows evidences and contraindications preparation, using at
gastritis and peptic ulcer of the belly and duodenum guts
 Is able to give reliable information on stomachache on the
grounds of internet data
The Student completely have the base level of the knowledge
and skill (see above) + knowledge, specified in point "86-90", as
well as have the following knowledge and skill:
 Knows (Sidney and Huston) categorization gastritis. Can explain
the mechanism of the development gastritis and peptic ulcer.
 Knows all groups an antysecretory medicinal facilities, their
evidences and contraindications to purpose.
 Knows that is "gold standards of" diagnostics Helicobacter pylori
 Knows as it is conducted uraesa test, respiratory test, histological
test
The Student completely have the base level of the knowledge
and skill (see above) + knowledge, specified in point "91-95", as
well as have the following knowledge and skill:
 Has Given scientific given on base of the additional literature
(article and internet)
 Knows evidences and contraindications to operative treatment to
peptic ulcer of the belly and duodenum guts, types operative
interference
 Can in detail tell as they are conducted laboratory-instrumental
methods of the diagnostics at peptic ulcer and gastritis, will die
interpret their
 Can in English ask complaints, collect anamnesis and shortly tell
about disease sick with gastritis and peptic ulcer
 Has a pedagogical skill - well understandably present subjects to
auditoriums
The Note: Base level of the knowledge and skill - a minimum of the knowledge, which provides the
principle "safety" for patient.
7. Checking questions
1. Etiology of gastritis.
2. The clinic of gastritis.
3. The categorization of gastritis.
4. The diagnostics of gastritis.
5. Gastritis of the differential diagnostics.
9. The diagnostics of duodenitis.
10. The differential diagnostics of duodenitis.
11. Etiology of peptic ulcer.
12. The clinic of peptic ulcer.
13. The categorization of peptic ulcer.
14. The diagnostics of peptic ulcer.
15. The diagnostics of the difference in peptic ulcer.
8. References
Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т.,
2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010.
Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8.Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru
9. Chronologic contents of the occupation
Time
8.30–
9.30
Arrangements
Actions
morning conference The report man on duty physician
sand man on duty assistents on
maintenance standby.
Material
The histories
disease, overhead
projector.
The detailed report student about
drawn sick.
Length of
occupation
1 hour
9.1510.00
Clinical audit
drawing sick.
45 minutes
10.0510.45
Theoretical
analysis of the
subject
Check source level to qualification
student with use the method "round
table" and decision of the
situational problem. Student
distribute situational problems on
given subject and they must
analyze and give conclusion
Situational
problems, tables,
corresponding to
subject of the
occupation
40 minutes
10.45 11.05.
studypractical skill.
Thes tudent under control of the
teacher must execute the minimum
two practical skills.
Sick or volunteer.
20 minutes
11.0511.45
Supervising sick
in branch
Each student supervises sick
determined chambers.
Sick,
phonendoscope,
tonometer,
history disease
(with data cliniclaboratory
studies).
40 minutes
11.4512.15
Break
30 minutes
12.2013.20
Analysis
thematic sick
Full checkup sick is conducted at
the option of the teacher on subject
of the occupation or patient,
preparing to extract, analysis given
laboratory-instrumental study,
motivation preliminary and final
clinical diagnosis. The plan of the
treatment is defined with dose
preparation.
Sick,
phonendoscope,
tonometer,
history disease
(the data cliniclaboratory
studies).
1 minutes
Practical lesson 3
The Subject: "Stomach ache. The differential diagnostics of nonspecific ulcerous colitis and Kron
disease. The tactics of general practitioner. The principles specialized clinic observations, checking and
rehabilitations in condition RPP or FP. The principles of the preventive maintenance. Principles of
teaching the subject"
Technology of the education.
Study time: 6 hours
Structure of the scholastic occupation
1. The scholastic thematic cabinet of the pulpit.
2. Scholastic allowances, distributing material,
collection of the situational problems and test
3. The hospital chambers.
4. Television set, video equipment, multimedia
Purpose of the scholastic occupation: Teach squall questions of the well-timed diagnostics and
differential diagnostics, choice of the optimum variant medical tacticians under inflammatory disease of
the bowels, conditioned by various reasons, as well as principle of conduct sick in condition primary
section public health, provided by requirements "qualification features general practitioner"
The pedagogical problems:
1.Consider the questions of the
diagnostics nonspecific ulcerous colitis
(NUC), Kron disease..
2.Demonstrate sick with inflammatory
diseases of the bowels, with NUC and
Kron disease.
3.Discuss the data a clinic-laboratoryinstrumental studies under NUC or Kron
disease.
4.Conduct the differential diagnostics
NUC and Kron disease.
5.Address the issues tacticians of conduct
within the framework of qualification
features squall.
6.Discuss the principles of the treatment
(the medicamentous andnon-drug).
7.Discuss the principles of conduct,
observations and monitoring sick in
condition RPP or FP.
8.Discuss the principles primary,
secondary and tertiary preventive
maintenance at data disease.
The results to scholastic activity:
squall MUST know:
1.The mechanism and reasons of the origin NUC and Kron
disease.
2.The clinical manifestations NUC and Kron disease..
3.The diagnostics NUC and Kron disease..
4.The differential diagnostics NUC and Kron disease..
5.The tactician squall.
6.The principles of the treatment (medicamentous andnondrug) at data disease.
7.The principles specialized clinic observations and
monitoring sick in condition RPP or FP.
8.The principles primary, secondary and tertiary preventive
maintenance at data disease.
squall MUST know how:
1.Analyze the complaint data and anamnesis under NUC
and Kron disease.
2.Diagnose, differentiate on clinic and laboratoryinstrumental studies NUC and Kron disease.
3.It is Correct to choose the medicamentousof the facility
for treatment NUC and Kron disease.
4.Advise on non-drugmethod treatments.
5.Conduct monitoring in condition RPP or FP.
Methods of the education
method "snowball", demonstration, video watching,
debate, conversation, decision test and situational problems
Forms to organizations to scholastic
activity
The individual work, work in group, collective, auditorium,
non auditorium
Facilities of the education
The distributing scholastic material visual material, video,
dummy, graphic organizer, histories disease, tables, stands.
Ways and facility to feedback
Flash-questioning, testing, presentation result performing
the scholastic task, filling to histories disease, performing
the practical skill "professional question"
Production chart of the occupation
The Subject: "Stomach ache. The differential diagnostics of nonspecific ulcerous colitis and Kron
disease. The tactics of general practitioner. The principles specialized clinic observations, checking and
rehabilitations in condition RPP or FP. The principles of the preventive maintenance. Principles of
teaching the subject"
Stages of the practical occupation
Form of the occupation
№
Duration
of
Place of the undertaking
training
225
1
Introductory part (motivation of the subject)
10
2
Discussing the subject of the practical occupation with
using new pedagogical technology (the method
"snowball"), as well as demonstration material (the
histories disease, tables, posters, x-rays),
determination source level.
Questioning, discussion
40
Scholastic room, chambers
3
Conclusion of the discussion
10
4
The determination of the task for performing the
practical part - professional question. The explanation
of the positions and recommendation for performing
the task on filling the histories disease.
Discussion
Cabinet of the physician
squall
20
5
Mastering the practical part of occupation under the
direction of teacher.
Prof. question. The
Conversation with sick and
filling to histories disease,
situational problems.
Check up thematic sick in
chamber
20
6
Interpretation examination data sick- complaints,
checkup, palpation, percussion, auscultation sick, as
well as studies anal. of bl. and biochemical analyses
and stating the diagnosis
Histories disease,
laboratory given situational
problems
25
7
Discussion theoretical, practical knowledge student,
fastening the material, determination level
assimilations by estimation of the knowledge.
Spoken questioning, tests,
discussion, determination
practical skill
75
Scholastic room
8
The determination of the conclusion on subject of the
practical occupation, estimation on 100 ball systems
and announcement estimation. The home task of the
following practical occupation (the collection of the
questions).
Information, questions for
independent work.
Scholastic room
25
2. Motivation
The majority sick with enteritis, colitis and other inflammatory diseases of the bowels for the first time
apply for medical help to general practitioner (squall). In this situations effort squall moves on diagnostics of
the inflammatory diseases of the bowels, conditioned by different diseases, for rendering medical help in
condition RPP (FP), or direction in specific permanent establishments. These circumstance are a reason for
enabling given themes in program of preparation squall.
3. Inter object and in-object relationship
Teaching given subject is based on knowledge student basics to anatomies, physiologies, pathological
physiology, pathological anatomy, microbiology, biochemistries, therapy, propedeuticsof the baby diseases,
clinical pharmacology. Got in the course of occupations of the knowledge will are used at passing squall pediatrics and other clinical discipline.
4. Contents of the occupation
4.1. The theoretical part Inflammatory diseases bowels - a general name two diseases - an nonspecific of
the ulcerous colitis (NUK) and Kron disease. The disease NYAK forms 25-50 persons on 100 thousand
populations, Kron disease- 5-15.
As NUK, so and Kron disease usually prone to seasonal-recurrent current. In active phase or period of the
intensification exists the inflammation and all accompanying symptoms, at period of the remissions
symptomatology will grow still or disappears completely.
Simptom inflammatory diseases of the bowels.
The Inflammatory diseases of the bowels are recurrentchronic diseases (that is to say permanent), but this
signifies that exists the interleaving an episode intensifications with bright manifestations and period of the
relative welfare.
The Feature symptomsas a whole depends on struck part of the gastrointestinal tract, symptoms can be
from comparatively light and before heavy.
Usually they are reduced to the following:
 Spasms and stomachache.
 Pale-gray raid on language.
 Blood diarrhea.
 Difficulties at defecation.
 Fever.
 Loss of the appetite.
 Loss of the weight.
 Anemia (in connection with blood loss).
 The complications of the inflammatory disease of the bowels include following:
 Massive ulcerous bleeding.
 Perforation (the breakup) of the bowels.
 Strictures and obstructions: beside people with Kron disease strictures often have an inflammatory
nature, and fixed or fibrosis (formation scar) strictures can require the endoscopic or other surgical
interference for eliminating the obstructions. Under ulcerous colitis stricturescolon must be
perceived as malignant (cancerous) of the change.
 Fistulas (the unnatural holes) and diseases perianal area; more often meeting beside people with
disease Krona, resistant to the main method of the treatment, often happens to resort to operative
interference and always remains high probability of the relapse.
 Toxicsmega colon (the acuteno obstructive sprain of the large intestine). The dangerous
complication for life of the ulcerous colitis, under which is required urgent operation. Fortunately,
rather rare.
 Malignization. The risk of the cancer of the large intestine under ulcerous colitis through 8-10
years after stating the diagnosis well above than in the general population, similar risk of the
disease doggy style at Kron disease with defeat whole made someone look fat bowels. The Risk of
the malignant new formations of the fine bowels increases at Kron disease.
The Other complications:
 Beside small number sick VZK can exist the extra enteric complication.
 Beside persons with VZK possible development arthritis, skin defeats, inflammations eye, liver,
bud, as well as osteoporosis. From all extra enteric of the complications arthritis is the most widespread; the defeats joint, eye and skins often close.
The tactics squall.
- Direct to narrow specialist.
The purpose of the treatment VZK is concluded in suppression of the anomalous inflammatory process
that avoids symptoms and allows fabrics of the bowels be restored. After symptoms are already found under
checking, treatment is oriented on reduction of the frequency flash and on maintenance of the condition to
remissions (the antyrecurrent treatment).
Phased approach is used for treatment of the inflammatory diseases of the bowels.
In the first place under such approach for short length of time are fixed the most aggressive (with
minimum possible side effect) preparations. If they do not bring about relief of the condition, that resorts to
more strong (aggressive) facility.
USE the METHOD "AUROCHS ON GALLERY"
The purpose: involvement in process of the education all student with simultaneous checking of their
knowledge on under discussion to subject.
The main position of the methods. The group is divided on 2-3 small subgroups, which discuss same
problem or situation for the reason set most amount correct answer. Each correct answer is written on ballet
to this group in the manner of snowball. The group got most numberscore, put the more high estimations.
The advantage: emulative principle actuates thinking process and brightens the occupation.
The example. The task on given subject enumerate laboratory-instrumental given at disease, being
accompanied constipation.
This method trains the student to speed of the thinking, allows the teacher objective to value the depth of
the knowledge of the passed material.
1. Key symptoms of NYAK and Kron disease
2. The tactics squall.
3. The principles of conduct in condition of RPP.
№ Estimation
1
excellent
good
satisfactory
not
satisfactory
bad
Assimilation in %
100%-86%
85%-71%
70-55%
54%-37%
36% and
below
Theoretical part
20-17,2
point
17-14,2
point
14-11 point
10,8-7,4
point
7,2 point
t
4.2 Analytical part
4.2.1. The situational problems:
The situational problems:
1. Patient 26 years, addressed to squall with complaint on pains in lower right quadrant belly, diarrheas,
ballooned belly, loss of weight, pains in joint, fever. From anamnesis: is ill 3 months., chair 5 - 6 once at day,
with blood seasonal. At checkup: sick lowered feeding, skin and mucous membrane pale. Heart: tones
average sonority, rhythmic. The pulse 90 ud.in 1 mines. THE HELL 100/60 mms rt.st. The language is
tax(cover)ed by white raid. The belly soft painful in right iliac of the area, where there is small voltage of the
muscles. The Liver and spleen not increased. The chair - a diarrheas. X-ray is defined "symptom of strings".
C.anal. of bl. - neutrophils leukocytosis, anemia, increasing EDV - 38 mms/hr.
1. Enumerate not less five diseases under which exists above specified simptoms;
2. The supposed diagnosis;
3. Informative methods of the study;
4. The tactics squall;
THE ANSWERS.
1. Kron NUC, disease, Disbakteriosis of bowels, 2. Kron disease
3. X-ray of GIT,colonoscopy,procto(sigmoido)scopy, C.anal. of bl, C.anal. of ur.,biochemistry shelters.
4.Consultation of thesurgeon,GKS, cytostatics.
______________________________________________________________________
2. The young person 34 years addressed to squall with complaint on spasmodic stomachache, fluid chair
before 15 once in day, increasing of the temperature before 39 С, being accompanied headache. In
anamnesis: 2 days back ate in cafe, fall ill sharply. Signs dehydration are noted at checkup. heart - a tones
muted, rhythmic. The pulse is 90 beates in 1 mines. The hell 95/60 mm.rt.st.vesicular. Breathing is listened
in lungs. The toungue is covered by white raid. The belly soft, at palpation is defined spasmed and painful
thick bowels. The liver and spleen are not increased. The faeces is jelly-like from slime and shelters of the
type "crimson jelly".
1. Name at least five diseases under which exists above specified simptoms;
2. The supposed diagnosis;
3. Informative methods of the study;
4. The tactics squall.
_____________________________________________________________________
3. Sick 48 years, suffering on length of the row of the years NYAK, examinedsquall on house. With
words native for 2 days complained of reinforcement stomachache, reduction of the frequency of
the chair, increasing of the temperature of the body before 39С. Got the treatment an imodium,
sulfasalasin. About-but: the general condition heavy, consciousness matted, sick dullard. The
Skin and mucous membrane pale. Heart: tones muted, rhythmic. The Pulse 120 ud.in 1 mines.
THE HELL 85/60 mm.rt.st..vesicular Breathing is listened to In light. Breathing 22/mines. The
belly is inflate, painful. Palpated extended thick bowels, peristalsis of the bowels is not listened
to. The liver and spleen not enlarged. At x-raying with barium is noted atony of the bowels.
1. Enumerate not less four diseases under which exists above specified simptoms;
2. The supposed diagnosis (main, complication);
3. Informative methods of the study;
4. The tactics squall.
___________________________________________________________________________
4. The youth 18 years addressed to squall with complaint on chronic diarrheas, increasing after receiving
in food flour product. From anamnesis: suffers from child hood intolerance flour product. At check up of the
sick lowered feeding, the skin and mucous membrane pale. Heart: tones average sonority, rhythmic. The
Pulse 82 ud.in 1 mines. THE HELL Heart100/60 mm.rt.st..vesicular. Breathing is listened in lungs. The
toungue is humid. The belly is soft, inflated to account of the flatulence, without painful. The liver and
spleen not enlarged. The faeces - a diarrheas. An.of blood without deflections. Coprology - steatoreya, scent
smelly.
1. Enumerate at least three diseases under which exists above specified symptoms;
2. The Supposed diagnosis;
3. Informative methods of the study;
4. Definitive method of the study for determining diagnosis;
5. The tactics squall with detailed description of the introduction (the non medicamentous-dietetic and
medicamentous) sick;
5. The woman 40 years, addressed to squall with complaint on increasing of the temperature of the body
before fibril of the numerals, sharp spasmic to pains in lower division of the belly on the left, diarrheas,
spasms. From anamnesis: is ill during 4-5 days, recently returned from journey on Asia. At check up: skin
and mucous membrane pale, clean. Heart: tones average sonority, rhythmic. The Pulse 96 ud.in 1 mines.
THE HELL 110/60 mm.rt.st.vesicular Breathing is listened in lungs. The Belly soft painful on move of the
made someone look fat bowels. The Liver and spleen not enlarged. The Excrement in the manner of rectal of
the sputum - consists of shelters, slime and admixture fester (the excrement is of the form of and scent of the
grated potatoes).
1. Enumerate not less four diseases under which exists above specified symptoms;
2. The supposed diagnosis;
3. Informative methods of the study;
4. The tactics squall.
_____________________________________________________________________6. The man 28 years addressed to squall with complaint on spastic stomachache around bellybutton,
ballooned belly, frequent foamy smelly fluid chair. From anamnesis: returned from aurochs on India. At
checkup skin dark, mucosa pale, clear. Heart: tones average sonority, rhythmic. The Pulse 96 b. in 1 minute.
THE HELL 100/60 mm.rt.st.vesicular. Breathing is listened in lungs. The belly is soft, painful on move of
the fine bowels, around bellybutton. The liver and spleen are not increased.
1. List not less four diseases under which exists above specified symptoms;
2. The Supposed diagnosis;
3. Informative methods of the study;
4. The Tactics squall.
________________________________________________________________________
7. Patient 64 years, addressed to squall with complaint on pains in epigastria of the area spasm nature
through 20 - 40 minutes after meal, ballooned and rumbling in belly, constipations being replaced diarrhea,
loss in weight. In anamnesis: suffers much years by sugar diabetes II type, IBS. The Buildings took the
nitroglycerine whereupon noted certain improvement of the condition. About-but: sick lowered feeding, skin
and mucosa pale, clean. Heart: tones muted, rhythmic. The Pulse 80 ud.in 1 mines. THE HELL - 130/80
mm.rt.st.In light vesicular breathing. The Language dry, is tax(cover)ed by white raid. The belly is soft, at
palpation painful in epigastrium. Systolic noise is listened to auscultation of the abdominal aorta. The liver
and spleen are not increased. The faeces - constipations, being replaced by diarrhea.
1. Enumerate not less five diseases under which exists above specified симптомы;
2. The supposed diagnosis;
3. Informative methods of the study;
4. Definitive method of the study for confirmation diagnosis;
5. The tactics squall with detailed description of the introduction (the medicamentious and non
medicamentious) sick;
________________________________________________________________________
8. Sick 74 years, addressed to squall with complaint on pangs around bellybutton through 20-30 minutes
after meal, lasting more than 2 hours, because of what he became to be afraid to take the food, headaches,
pains for breastbone under physical load. Pain of diarrhea syndrome is accompanied in belly. From
anamnesis suffers IBS, stable angina pectoris of the voltage FK II, sclerotic AG much years. Long time
smokes on one pack of the cigarette at day. Objective: sick lowered feeding, skin and mucosa pale. The
Language dry, is covered by white raid. Heart: tones are muted, accent II tone on aorta. The Pulse 80 p. in 1
min. THE HELL - 170/70 mm.rt.st.In light vezicular breathing. The Belly soft, at palpation painful on move
of the made someone look fat bowels. The Liver and spleen not enlarged. The faeces with slime.
Auscultation: rough systolic noise in point, located on medium of the distance between scaphoid of shoot and
bellybutton. Koprologiy: excrement semyformed, slime, not digested vegetable cellulose, leukocytes.
1. Name at least five diseases under which exists above specified simtom;
2. The supposed diagnosis;
3. Informative methods of the study;
4. Definitive method of the study for confirmation diagnosis;
5. The tactics squall with detailed description of the introduction (the medicamentous and non
medicamentous ) sick;
______________________________________________________________________
9. Sick YA. 32 years, complains of spasm stomachache in left iliac of the area, frequent fluid chair with
blood and pus, spasm, weakness, loss of the mass of the body, high temperature of the body. From
anamnesis: considers it self sick for 4 years. The deterioration of the condition notes for 1,5 months.
Objective: the general condition to average gravity. The Skin covers pale. Lowered feeding.In light vsicular
breathing. The Tones heart muted, rhythmic. The Pulse 100 blows in 1 minute. The Language is covered
whitish-yellow by raid. The Belly inflated, notes pain in left half of the belly, palpated bowels compacted.
The Liver +3-4 refer to emerges from beneath edges of the rib arc.
Anal.of bl.: signs of anemias are revealled, leukocytosis with shift to the left, increase SOYBEAN.
Anal.of ur.: moderate proteinuria.
In shelters: hypoproteinemia, hypoalbuminemia, increasing transaminases, mucoi, sial. of the acids,
fibrin.
The analysis of the excrement: red (blood) cells, leukocytes, slime in good supply.
1. Name at least 4 diseases, accompanied by above-mentioned simptoms;
2. Your preliminary diagnosis;
3. What additional studies required for acknowledgement of the diagnosis;
4. What complications exist at disease;
5. The Tactics squall and principles of the treatment.
_______________________________________________________________________
10. Sick T. 25 years addressed to squall with complaint on growing pains in right iliac of the area,
sickness, retching, increasing of the temperature of the body with shivering, flatulence, diarrhea, with
admixture shelters sometimes. From anamnesis: considers itself sick for 2 weeks. The Disease empty-handed
does not link. Objective: the general condition to average gravity. Lowered feeding. On the part of light and
heart without particularities. The Language humid, is tax(cover)ed. The Belly soft painful in right iliac of the
area, is felt thickened, painful terminal length of the small intestine.
1.Define the minimum 4 diseases, under which can be above-mentioned simptoms;
2.Your preliminary diagnosis;
3.What additional studies required for acknowledgement of the diagnosis;
4.What change you expect under these study;
5.Indicate the method of the study, having solving importance when stating the diagnosis;
6.The tactics squall. The treatment.
___________________________________________________________________
The Tests.
1. Indicate the base preparations for treatment NUK, except:
a) Sulfasalasine
b) salofalki
s) GKS
g) antacids
d) cytostatics
2. Choose the preparations for treatment disbacteriosis, except:
a) Bificol
b) bifidumtrin
f) lactobacterin
g) biseptol
d) bactisubtil
3. Indicate the signs of the breach of the suction fat, except:
a ) steatoreya
b) gipoholesterinemiya
v) deficit masses of the body
g) deficit fat-soluble vitamin
d) creatorea
4. What organ is not struck under NUK:
a) iliac
b) rectum
v) sigma
g) descended division of the made someone look fat bowels
d) belly
5. Indicate the signs typical of chronic NUK, except:
a) diarrhea
b) pain
v) intestine bleeding
g) spasms
d) retching
6. Indicate the organs which are struck under NUK, except
a) liver
b) joints
v) skin
g) light
d) of the eye
7. Choose the preparations which are shown under light and medium-weight current NUK, except:
a) sulfasalasin
b) salaisopiradasin
v) almagel
g) vitamins
d) albumin
8. What preparation is not used under heavy current chronic NUK except
a) glucocorticoids
b) retabolil
v) nerobolil
g) operative treatment
d) trihopol
9. Choose simptoms, not typical of NUK, except:
a) vomiting
b) arterial hypertension
v) sheep excrement
g) diarrhea,interleaving with constipation
d) diarrhea
10. Indicate the diseases, with which necessary to differentiate NUK, except:
a) holera
b) salimonellez
v)Kron’s disease
g) cancer made someone look fat division of the bowels
d)amebiaz
11. Indicate simptoms, not typical of chronic enteritis, except:
a)weight loss
b) sheep excrement
v)spasmic pains
g) enteric bleeding
d)spastic pains
12. Indicate the signs, not typical of putrefactive of the dyspepsias, except:
a)foam excrement with tart scent
b)meteorizm
v) spasm pains
g) stool masses light-wanted colour
d)diarrhea
13. Indicate the division of GIT, struck under NUK, except:
a)direct gut
b) transverse-colon
v)sigmoid
g) spleen
d) cecum
14. Under NUK are most often struck, except:
a) mucosa
b) liver
v) joints
g) kidneys
d) skin
4.2.2 Graphic organizer: "Venn diagram "
 Is used for comparison or collations or opposition 2-3х aspect and show their both devil.
 Develops the system thinking, skill to compare, match, conduct the analysis and syntheses.
 Get acquainted with rule of the building of the diagram Wreath. Individually / in vapour(pair) build the
diagram a Wreath and fill the part disjoint circle (H) Unite in pair(vapour)s, compare and complement
their own diagrams.
In place of the intersection circle form the list that devil, which, on their glance, are general for
information 2-3х circle (hh/hhh).
Сommunity
Venn diagram
Nothing
common
Something
common
Much
common
4.3. Practical part list skill, which squall must have after termination occupation on given to themes
1.Check up sick with diseases, being accompanied gastrointestinal dyspepsia, stomachache
2. Interpretation analysis, given laboratory-instrumental studies, (clinical and biochemical blood test,
urines, excrement, emetic of the masses, X – ray of the study GIT, EFGDS, procto(sigmoido)scopy,TIE
liver, bilious bubble, pancreas, analysises of the gastric juice, duodenal of the flexing) sick with diseases
accompany gastrointestinal dyspepsia (the syndrome of the irritated large intestine, enteritises, colitises,
Kron disease, NUK,liver problem, dysbacteriosis).
3. Drawing medicinal preparation depending on etiology with diseases, being accompanied
gastrointestinal dyspepsia, stomachache (the syndrome of the irritated large intestine, enteritises, colitises,
Kron disease, NUK, liver problem, dysbacteriosis).
№ Estimation
excellent
good
satisfactory
not satisfactory
adoption в %
100%-86%
85%-71%
70-55%
54%-37%
practical part
15-12,9 point
12,75-10,6
point
10,5-8,25
point
bad
36% and
bellow
8,1-5,5- point 5,4 point
5. Forms of the checking the knowledges, skills
- Verbally -In writing
-A Decision of the situational problems
-a Demonstration masterred practical skill
5.1. The criteria estimation of knowledges, practical skills of student.
Criteria for evaluation of knowledge,skills and practical skills of students.
satisfactory
excellent
good
№ evaluation
Assimilationin%
100%-86%
85%-71%
70-55%
1
The theoretical part
17-14,2 point
14-11 point
2
Case Studies
3
Test
4
The practical part
20-17,2
point
50-43
point
15-12,9
point
15-12,9 point
42,5- 35,5 point 35- 27,5 point
not
satisfactory
bad
54%-37%
36% or
less
10,8-7,4 point 7,2 point
18 point
12,7-10,6 point 10,5-8,25 point
27-18,5
point
8,1-5,5 point
12,75-10,6 point 10,5-8,25 point
8,1-5,5- point
5,4point
5,4 point
6. Criteria of the estimation of the current checking
Level
Rating ballet
Job data of the student
estimation
20
Not
satisfactory
20 - 54,9
The Ballet of the presence on practical occupation. The full
absence level knowledge and not skill to execute the practical
skill - a student absolutely not ready to practical occupation.
The Student answers unsatisfactorily.
The Students does not have the base level of the knowledge and
skill, at least one of listed below:
 Does not know etiology, pathogenesis developments NUK and
Kron
 can not enumerate main methods of the diagnostics NUK and
Kron
 does not know categorization NUK and disease Kron
 has a no beliefs about clinic and current above enumerated
diseases
 does not know groups a preparation for treatment NUK, Kron
disease
 not capable to collect rational anamnesis during supervising
sick with stomachache
 During supervising not capable objective to value condition
sick with stomachache
 not capable rationally to form plan of the examination sick with
Kron disease and NUK
 not capable to conduct differential diagnostics sick with
stomachache
Provision base level knowledges and skill
55-60,9
61-65,9
Satisfactory
55-70,9%
66-70,9
The satisfactory inferior answer.
The student tries to have a base level of the knowledge and skill (
look down), but at answer or execution skill allows the serious
mistakes.
The satisfactory answer average degree.
Student have base level of the knowledge and skill ((look down),
but at answer or execution skill allows mistakes (possible
separate inaccuracy)
The satisfactory answer high quality.
The student completely have the base level of the knowledge and
skill:
 Knows etiology, pathogenesis developments NUK and Kron
 Can enumerate the main methods of the diagnostics NUK and
Kron
 Knows the categorization NUK and Kron disease
 Has a beliefs about clinic and current above enumerated
diseases
 Knows the groups a preparation for treatment NUK, Kron
 Capable to collect rational anamnesis during supervising sick
with stomachache
 During supervising capable objective to value the condition
sick with stomachache
 Capable rationally to form the plan of the examination sick
with disease Kron and NUK
 Capable to conduct the differential diagnostics sick with
stomachache.
 Can interpret the results laboratory-instrumental methods of
the study: the general blood test beside sick with NUK and
Kron, interpret the conclusion of the general analysis of the
excrement, X-ray GIT with barium, colonoscopy.
 Capable correct to fill the diary book sick with stomachache.
Advanced level of the knowledge
71-75,9
Good
The student completely have the base level of the knowledge and
skill (specified in point "66-70,9") + have the following
knowledge and skill:
 Knows main moments pathogenesis developments disease Kron
and NUK
 Knows categorization of Kron disease and NUK
 Knows mechanism of the action medicinal preparation, using
for NUK and Kron disease
 Can rationally select medicinal preparations sick depending on
reasons of the origin stomachache
71-85,9%
76-80
81-85,9
86-90
91-95
Excellent
The student completely have the base level of the knowledge and
skill (see above) + knowledge, specified in point "71-75,9", as
well as have the following knowledge and skill:
 Can in detail tell pathogenesis developments NUK and
disease Krona
 Knows principles primary, secondary and tertiary preventive
maintenance stomachache at Kron disease and NUK
The sudent completely have the base level of the knowledge and
skill (see above) + knowledge, specified in point "71-75,9" and
"76-80", as well as have the following knowledge and skill:
 Can tell the cardinal principles of conduct, observations and
monitoring sick with Kron disease and NUK in condition RPP or
FP.
 Will die to conduct the consultation on questions non-drug and
drug advice with use skill MLO beside sick with stomachache.
 Knows principles an clinical examination and rehabilitations
sick with Kron disease and NUK in condition RPP or FP

The student completely have the base level of the knowledge and
skill (see above) + knowledge, specified in point "81-85,9", as
well as have the following knowledge and skill:
 Knows principles of the treatment of Kron disease and NUK
 Knows evidences and contraindications preparation, using at
data disease
 Will die to give reliable information on stomachache on the
grounds of internet data
The student completely have the base level of the knowledge and
skill (see above) + knowledge, specified in point "86-90", as
well as have the following knowledge and skill:
 Can in detail tell change, which possible find in
laboratory-instrumental study at Kron disease and NUK
 Conducts differential diagnostics a stomachache under
different pathology GIT and between Kron disease and
NUK
86-100%
96-100
The student completely have the base level of the knowledge and
skill (see above) + knowledge, specified in point "91-95", as
well as have the following knowledge and skill:
 Has Given scientific given on base of the additional
literature (the article and internet)
 Knows the evidences and contraindications to operative
treatment NUK and Kron disease
 Can on english to ask the complaints, collect anamnesis
and short tell about disease sick with NUK and Kron
disease
 Has a good pedagogical skill of the presenting the
material to auditoriums.
The Note: Base level of the knowledge and skill - a minimum of the knowledge, which provides the
principle "safety" for patient.
7.Control questions
1. Etiology and pathogenesis of NUK and Kron disease.
2. The clinic of NUK and Kron disease.
3. The diagnostics of NUK and Kron disease
4. The differential diagnostics of NUK and Kron disease.
5. The laboratory studies under NUK and Kron disease.
6. The instrumental studies under NUK and Kron disease.
8. References
Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8.Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа,
2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru
REQUIREMENTS TO KNOWLEDGES AND SKILLS OF STUDENTS WHILE TEACHING
STUDENTS ON THE BASE OF SOLVING THE PROBLEM OF PATIENTS WITH
GEPATOMEGALY
Purpose: Teach students to solve by syndrome the problem of patients with hepatomegaly, as well
as principle of their conduct in condition primary part public health within the framework of
qualification features squall
The primary tasks of the education:
 Train the student to decision of the problem, connected with hepatomegaly.
 Train the student to well-timed diagnostics at presence of the problem, connected with
hepatomegaly.
 Train the student differentiate disease, being accompanied with hepatomegaly.
 Improve the necessary knowledge, skills and practical skills at decision of the problem patient
with hepatomegaly (the collection to information, revealing the problem and physical checkup, as
well as skill validly to fix laboratory-instrumental methods of the study);
 Train the student validly to choose the tactician of conduct;

Train the student validly to realize medical-preventive measures and observation in condition
RPP and FP.
At analysis given problems sick key moment estimations of the knowledge student must be:
 Skill to select the main problem, which was reflected on quality of the life’s sick.
 Skill to assign the auxiliary questions rational anamnesis.
 Skill to select presence a factor risk.
 Skill to enumerate the diseases or conditions, which can be a reason given problems.
 Skill validly to conduct physical checkup.
 Skill of the motivated purpose laboratory-laboratory studies in condition RPP or FP.
 Skill to select need of the additional studies outside the RPP or FP.
 On the grounds of got information skill to install the main reason (the diagnosis) given problems.
 Skill to define the tactician of conduct on the grounds of qualifying features squall.
 Skill to give the non-drug advices.
 Skill to define the drug treatment on the grounds of proof of medicine " Skill to define the
preventive measures at a rate of primary part public health.

Skill to define the principles an medical examination and rehabilitations sick in condition RPP or
FP.
That must know the student at decision of the problem patient with hepatomegaly:
List of the knowledge
Base level
№
List of the diseases, which run with hepatomegaly
Student must know as minimum 10
most often met diseases
2
List of the most dangerous diseases, which run with
hepatomegaly
Student must know as minimum 5
diseases
3
List of the conditions, requiring conduct in condition RPP or
JV (1-category)
According to qualifying features
squall
4
List of the conditions, requiring consultations of the narrow
specialist or hospitalization (2-category)
According to qualifying features
squall
5
List of the studies, requiring undertaking in condition RPP or
JV (3.1-category)
According to qualifying features
squall
6
List of the studies, requiring directions for limits RPP or JV
(3.2-category)
According to qualifying features
squall
According to qualifying features squall
The student must know the
distinguishers and manifestations
of each disease, as well as criteria
of their diagnostics.
Ways of the issue virus hepatitis
Student must know mechanism of
the issue to infections
Symptoms defeats liver and internal organ
Student must know sign of the defeat
Factors result laboratory-instrumental studies
Student must know:
- a normal factors, as well as their
shifts at pathology.
1
7
8
9
10
11
Medical tactics
The student must know the methods
and principles of the treatment
(including non-drug).
Principles primary, secondary and tertiary preventive
maintenance
Student must know main actions
required for primary, secondary
and tertiary preventive
maintenance
Principles medical examination and rehabilitations of the
diseases, running with hepatomegaly in condition RPP or JV
(4-category)
Student must enumerate main
actions on medical examination
and rehabilitations
12
13
That must know how the student at decision of the problem patient with hepatomegaly:
List skill
Base level
№
1
2
3
4
5
6
7
Question sick and his(its) relative
The student must know how to assign the laconic
questions of the rational question, which really helps
the probable diagnosis in installing.
The student must know how goal-directed to
reveal and value the complaints of the patient.
The student must know how to analyze anamnesis
diseases: begin diseases, the first symptoms, causal
their relationship and track record of the
development.
The student must know how to analyze anamnesis
life’s: discovery factor risk, health of the parents and
nearest relative.
Reveal factors of the risk
Student must know how to reveal operated and
uncontrolled factors of the risk as under question
sick, so on the grounds of objective approach
Calculate index a mass/bodies
Conduct check up of the skin
General check up
Check up mouth
Conduct palpation, percussion and
auscultation organ of the breathing.
The student must know how to reveal the signs:
- insufficiency of the weight
- raised weight.
The student must know how to find presence:
-pallor
- icteritiousness, -presence appearance of skin
rash
- compactions
- telangiectasia.
The student must know how to reveal:
- a liver palm, -gynecomastia,
- cachexia.
The student must know how to value the
language.
The student must know how to value:
- an excursion of the thorax
- a vocal flutter
- a change the pulmonary sound and their
interpretation
- a types of the breathing
- presence of respiratory noise and wheeze
8
Conduct palpacia, percussia and auscultation
heartily-vessels system.
The student must know how to reveal the signs:
- hypertrophy right belly Student must know how
to value:
- a tones heart;
- at presence warm hearted noise, know how to
reveal their epicenter, and attitude to phase of warm
hearted activity (systolic or diastolic noise);
- know how differentiate functional warm hearted
noises from organic.
- a noise of friction pericardium
General inspection of the abdomen
of:
9
10
The student must be able to detect the presence
Conduct surface abdominal palpation
11
Hold deep abdominal palpation
12
Conduct percussion liver
-ascites
-flatulence
-spider veins
- venous collaterals
- injuries and bruises
The student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the
muscles of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
The student should be able to:
- To evaluate all available structures in the
abdomen
The student should be able to:
- Define the boundaries of the liver Kurlov
13
Conduct palpation of the liver and
gall bladder
The student should be able to:
- To evaluate the properties of the liver and gall
bladder.
Hold spleen palpation
The student should be able to:
- Identify splenomegaly
inspect the limb
The student should see the limbs and body, and to
be able to detect:
- Generalized edema. Fingers should be able to
put pressure on the dorsum of the foot and discover:
- There is a pit or not.
Interpret clinical, instrumental and
biochemical analyzes
The student must be able to identify features:
- Increase or decrease in performance from the
norm.
ECG and decode it
The student must be able to record the ECG with
the incremental principle.
Student should be able to decipher the results of
the ECG and identify signs:
- MI
14
15
16
17
18
Differentiate disease accompanied with
hepatomegaly
19
Give non-medical advice
20
Rational use of medicines in the treatment of
diseases that occur with hepatomegaly
21
Conduct monitoring and surveillance of
patients
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory and
instrumental investigations)
The student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products
with proven effectiveness.
When choosing drug student should be able to
evaluate:
- Efficiency
- Safety
- Eligibility
- Economy.
Student should be able to carry out monitoring
and control states in RPP and FP.
Practical lesson № 4
Topic: "Hepatomegaly. Differential diagnosis of chronic hepatitis and cirrhosis. Tactics of GPs.
Indications for referral to a specialist or hospital in the profile department. The principles of
treatment, follow-up, monitoring and rehabilitation in RPP or FP. Principles of prevention. Principles
of teaching tools "
Education technology
Study time: 6 hours
The structure of the training
1. Training room.
2. Training manuals, handouts, a collection of case
tasks and tests
3. Hospital wards.
4. TV, video equipment, multimedia
The purpose of the training session: Getting GPs diagnosis and differential diagnosis, conduct best option
for treatment policy hepatomegaly caused by various diseases, as well as the principles of management of
patients in primary care, provided the requirements of "Qualification characteristics of a general
practitioner"
Pedagogical objectives:
Learning outcomes:
1. Consider diagnosis of chronic hepatitis and
GPs should know:
cirrhosis of the liver
1. The mechanism and causes of hepatomegaly.
2. Demonstrate patients with chronic hepatitis and
2. Clinical manifestations of chronic hepatitis and
liver cirrhosis
cirrhosis of the liver.
3. Discuss the results of clinical, laboratory and
3. Diagnosis of chronic hepatitis and cirrhosis of
instrumental studies in chronic hepatitis and
the liver.
cirrhosis of the liver
4. Differential diagnosis of chronic hepatitis and
4. Make a differential diagnosis of diseases
liver cirrhosis
associated with hepatomegaly.
5. Tactics of GPs.
5. Discuss the principles of treatment (non-drug
6. The principles of treatment (drug and non-drug)
and drug).
for these diseases.
6. Discuss the principles of management,
7. Principles of follow-up and monitoring of
supervision and monitoring of patients in a
patients in a hovercraft, or joint venture.
hovercraft or a joint venture.
8. The principles of primary, secondary and tertiary
7. Discuss the principles of primary, secondary and prevention in these diseases.
tertiary prevention in these diseases.
GPs should be able to:
Training methods
Forms of educational activity
learning Tools
Ways and means of feedback
1. Data analysis and history of complaints for the
diagnosis of chronic hepatitis and liver cirrhosis
2. Diagnose, to differentiate on clinical and
laboratory research tool chronic hepatitis and
cirrhosis of the liver.
3. To choose a treatment strategy for specific
hepatomegaly
4. Choose products with proven effectiveness.
5. Advise on non-medicated treatments.
6. To monitor the RPP or in joint venture.
The method of "snowballs", a graphic organizer - a
conceptual table, display, video viewing,
discussion, conversation, decision tests and
situational problems
Individual work, group work, team, classroom,
extracurricular.
Distributing educational materials visuals, videos,
models, graphic organizers, kits medical charts,
tables, and benches.
Quiz, test, presentation of the results of the training
task, filling medical records, execution of practical
skills "professional questioning"
Technology chart classes
Topic: "Hepatomegaly. Differential diagnosis of chronic hepatitis and cirrhosis. Tactics of GPs.
Indications for referral to a specialist or hospital in the profile department. The principles of
treatment, follow-up, monitoring and rehabilitation in RPP or FP. Principles of prevention. Principles
of teaching tools. "
№
Stages of training session
1
2
Intro (study subject)
Discussion of the topic of practical
lessons with new educational
technology (procedure "snowballs"), as
well as demonstration material (sets of
medical charts, tables, posters, x-ray),
the definition of the initial level.
conclusion discussion
Job definition for the practical part professional questions. Explanation of
the provisions and recommendations for
the job to fill medical records.
The development of practical training
under the guidance of a teacher.
Forms of training
Place
3
4
5
6
7
Interpretation of the survey data of
patients, complaints, inspection,
palpation, percussion, auscultation of
patients, as well as research an. Of
blood and biochemical analysis and
diagnosis
Discussion of the theoretical and
Survey, discussion
Duration of
lessons
225
10
40
Training room, surgeries of GPs
discussion
10
20
Consulting room GP
Prof. questioning. Conversation with
patients and filling medical card,
case studies.
Reception of patients in the clinic,
home inspection
Medical history,
laboratory data situational problems
Oral examination, tests, discussion,
20
25
75
practical knowledge of the students,
identification of practical skills
securing material, the level of learning
assessment.
Training room in the clinic
8
Defining output on practical training,
Information, questions for homework. 25
evaluation of 100-point scale, and ad
Training room in the clinic
evaluations. Homework the next
practice session (a collection of
questions).
2. Motivation
The majority of patients treated with hepatomegaly first medical attention to a general practitioner (GP).
In this situation, the force sent to GPs diagnose hepatomegaly due to chronic hepatitis and cirrhosis of the
liver. In case of hepatomegaly GPs must, not only to diagnose, but it needs to identify the reasons behind the
disease to provide medical care in the FP or referral to a specialized hospital. These and other circumstances
are the basis for the inclusion of this subject in the training of GPs.
3. Intra and interdisciplinary communication
Teaching of the subject is based on the knowledge of students the basics of anatomy, physiology,
pathophysiology, pathology, microbiology, biochemistry, internal medicine, propaedeutics childhood
diseases, clinical pharmacology. Acquired during the course knowledge will be used during the passage of
the GP - pediatrics and other clinical disciplines.
4. Content classes
4.1. The theoretical part
While investigating the theme you must pay attention to the following aspects.
Cirrhosis (from French kirros - red) - diffuse process characterized by fibrosis and reorganization of the
architectonics of the liver, leading to the formation of structurally abnormal nodes.
Currently, the international gastroenterology committee recommended in clinical hepatology following
classification cirrhosis:
Classification of liver cirrhosis (Los Andzhelec, 1994.)
Etiology: viral, alcoholic, autoimmune, metabolic, альфаантитрипсиндефицитный, holestogenny
(primary, secondary), cryptogenic.
On morphology: portal, postnecrotic, postgepatitny, laennekovsky, metabolic, biliary, melkouzlovoy,
SKD.
Payment Information: correction, subcompensated, uncompensated.
Diagnosis of cirrhosis of the liver, as well as chronic hepatitis is to identify the main clinical and
biochemical syndrome and your use of these imaging studies. Bear in mind that hepatomegaly is more
common biliary cirrhosis, and in these cases the predominant cholestatic syndrome (hyperbilirubinemia,
increased alkaline phosphatase in the blood, jaundice, itching, xanthelasma, etc.). With portal cirrhosis
hepatomegaly observed in the initial stages of the disease, followed by a decrease in the size and appearance
of splenomegaly. Dominated by other signs of portal hypertension (telangiectasias, varicose veins,
splenomegaly, ascites, etc.)., Jaundice may be absent.
USING "snowballs"
1. Determination of hepatitis.
2. Diagnostic algorithm for all types of hepatitis.
3. Determination of liver cirrhosis
4. Classification of liver cirrhosis.
Answers:
1. Chronic hepatitis and inflammatory diseases of the liver, accompanied by the growth of connective
tissue in the portal tracts without the formation of false lobules.
2. Diagnostic algorithm for all types of hepatitis consists of three stages: I stage-focused katanamnez and
detection of clinical signs of liver (hepatomegaly, jaundice, telangiectasias, "spider veins"), laboratory
diagnosis: a study of bilirubin, ALT and AST, lactate dehydrogenase, sublimate and thymol and the protein
spectrum of blood, identification of specific antegenov.
Phase II-tool: liver ultrasound, radiogepatografiya, laparoscopy
II (the most important step) - morphological study of the liver using light optical, immunological and
electron microscopic analysis
3. Cirrhosis (from French kirros-red) - diffuse process characterized by fibrosis and reorganization of the
architectonics of the liver, to form rprivodyaschy structurally abnormal nodes
4. Etiology: viral, alcoholic, autoimmune, metobolichesky, альфаантитрипсиндефицитный,
holestogenny (primary, secondary), cryptogenic.
On morphology: portal, postnecrotic, postgepatitny, laennekovsky, metobolichesky, biliary, small
knotted, SKD.
Payment Information: correction, subcompensated, decompensated.
№ Estimation
excellent
good
satisfactory
not
satisfactory
Assimilation in %
100%-86%
85%-71%
70-55%
54%-37%
36% and
below
Theoretical part
20-17,2
point
17-14,2
point
14-11 point
10,8-7,4
point
7,2 point
bad
The analytical part of
4.2. Case studies:
Case studies:
1. Patient M., 16, turned to the GP complaining of general weakness, trembling of the hands and feet, loss
of appetite, intermittent yellowing skin and mucous. According to his mother the last 2 years was slow in
conversation, movements, moody and irritable. OBJECTIVE: patient malnutrition, "liver" palm, light scleral
jaundice. In the lungs, vesicular breathing. Heart sounds average sonority, rhythmic. BP 120/70 mmHg Pulse
80 beats in 1 min. Liver protruding from under the costal arch to 1 cm thick, the edges are sharp. Spleen + 3
cm, dense, painless. There is a small ascites. On the periphery of the cornea eye deposition observed greenish
- brown pigment.
1.Enumarate at least four diseases in which there is the above mentioned symptoms;
2. Presumptive diagnosis;
3. Informative methods of research;
4. Specify tests have reschayuschy value diagnostics for this disease;
5. Tactics of GPs;
_________________________________________________________________________
2. Patient L., 28 years turned to the GP complaining of yellowing of the sclera, right upper quadrant pain,
dark urine. History of such events periodically observed his father and older brother. Objectively: general
rather satisfactory. Abdomen soft, sensitive in the right upper quadrant. Liver + 1 cm, the average density.
The spleen is not enlarged. In the lungs, vesicular breathing. Heart sounds average sonority, rhythmic. BP
110/70 mmHg Pulse 80 beats in 1 min. The blood bilirubin total. - 60 mmol / L, direct - 45 mmol / l, indirect
- 15 mmol / l. Complete blood count with no abnormalities. Liver enzymes were normal. Liver biopsy
detected mainly in the center slices coarsely grained greenish - brown nonferrum pigment structure of the
liver is not compromised.
1. Enumarate at least six congenital and purchasing diseases in which there is the above mentioned
symptoms;
2. Presumptive diagnosis;
3. Informative methods of research;
4. Tactics of GPs.
________________________________________________________________________
3. Patient L., 42, turned to the GP complaining of frequent stools with blood in an "raspberry jelly", fever,
pain in the sigmoid, which came five days after arriving back from a trip. Admission chloramphenicol house
gave the clinical effect, but the second day was marked in the right upper quadrant pain, dark urine and
icterus sclera. On palpation the abdomen revealed a slightly enlarged painful liver (+ 2.5 cm). The spleen is
not enlarged. In the lungs vesicular breathing. Heart sounds average sonority, rhythmic. Blood pressure
130/70 mm Hg Pulse 80 beats in 1 min.
1. Enumarate at least six diseases in which there is the above mentioned symptoms;
2. Presumptive diagnosis;
3. Informative methods of research;
4. Tactics of GPs.
________________________________________________________________________
4. Patient M., 43, the driver, is not married, he turned to the GP complaining of periodic blunt, sometimes
worsening pain in the right upper quadrant, weakness, loss of appetite, nausea, diarrhea, subfebrile
temperature, appearance icteric sclera color, sputum . Of history: the above symptoms first appeared 5-6
years ago. Bad habits - lots of smoke, abuse alcohol. On examination: the patient is somewhat higher power.
Pale skin with a touch of jaundice, the skin of the palms intense pink, sclera subikteric and injected. On the
face expanded mesh surface vessels. Cor - borders expanded by 1.5 cm to the left of the left midclavicular
line. Heart: The muted tones, rhythmic. Pulse 80 beats. in 1 min. Blood pressure of 150/90 mm Hg In the
lungs auscultated forced expiratory in the lower wheezing. Abdomen is soft, sensitive in the right upper
quadrant. The liver is enlarged 3 cm, the surface is smooth, the edge - round, texture medium density.
In an.of bl: HB - 110 g / l, er - 3.8 h1012, l - 10 h109, n / I - 7, / I - 70, ESR - 30 mm / h;
Biochim. en. blood obsch.belok - 90 g / L, 1 globulins - 6%, 2 globulins - 10%, globulins - 16%,
globulins - 30%, PB - 80%, bilirubin - 68.2 mmol / L ALT - 3.72 mmol / L, thymol test 10 units, NbsAg
negative.
1. Enumaraite at least five diseases in which there are the above mentioned symptoms;
2. Presumptive diagnosis (primary, competing, co-existing);
3. Informative methods of research;
4. Tactics of GP detailing administration (non-medical and medical) patients.
_____________________________________________________________________
5. Sick, 55 years turned to the GP complaining of heaviness in the right hypochondrium, bitter taste in the
mouth, increased abdomen, general weakness. Anamnesis: frequently abused alcohol, splenomegaly. On
examination: pale skin with the same. A few years ago, was diagnosed with cirrhosis of the liver, alkogol
etiology, portal hypertension, ascites ltushnym shade, gynecomastia. On the skin of the abdomen network
venous collaterals. Stomach increased by ascites. Liver + 6 cm thick nodular, with irregular contours, the
edge is pointed. The spleen is enlarged (+ 1 cm). Availability gemorraidal nodes. Observed phenomena
encephalopathy stage 3. PTI 40%.
1. Specify stage liver cell dysfunction Child Pugh classification;
2. On basis of what data set stage liver cell dysfunction Child Pugh classification and what stages are
distinguished;
3. What are the additional methods necessary for the presence of portal hypertension;
4. Which deviations are detected in these surveys.
_______________________________________________________________________
6. Sick 84 years at a reception at the GP complaining of pain and a feeling of pressure in the chest,
sometimes in the night, a violation of swallowing, belching air, food regurgitation, vomiting, drooling, loss
of appetite, aversion to meat. Objectively: the patient malnutrition. Clear conscience. Integuments earthy
gray. Palpable enlarged cervical lymph nodes. In the lungs, vesicular breathing muffled heart sounds,
rhythmic. Rhythmic pulse, 100 beats in one minute. Blood pressure 130/70 mm Hg Tongue coated with
white bloom. The abdomen is soft and painless. The liver is enlarged dense, hilly. The spleen is not palpable.
Chair prone to constipation. Urination is free.
KLA: revealed anemia, ESR-56 mm / hour.
1. List at least four diseases for which there are the above symptoms;
2. Your preliminary diagnosis;
3. What is the most frequent and early symptom of the disease;
4. Method of research, which is crucial to the diagnosis;
5. Treatment. Tactics of GPs.
_______________________________________________________________________
7. Patient M., 50 years turned to the GP complaining of heaviness in the right hypochondrium, bitter taste
in the mouth, increased abdomen, general weakness. Anamnesis: frequently abused alcohol. On examination:
pale skin with a touch of jaundice, gynecomastia. On the skin of the abdomen network venous collaterals.
Stomach increased by ascites. Liver + 6 cm thick nodular, with irregular contours, the edge is pointed. The
spleen is enlarged (+ 1 cm). Availability gemorraidalnyh uzlov.Nablyudaetsya phenomenon encephalopathy.
1. Enumerate least four diseases in which there are the above mentioned symptoms;
2. Presumptive diagnosis;
3. Informative methods of research;
4. What changes in the ultrasound confirms a presumptive diagnosis;
5. Tactics of GPs.
_________________________________________________________________________
8. Patient L., 76, turned to the GP complaining of icteric coloration of the skin and sclera with severe
itching, intermittent fever. From history: 30 years ago, malaria was sick. 2 years ago bothered paroxysmal
pain in the right upper quadrant with chills, jaundice intermittent that passed after injection antispasmodics.
Objectively: skin and mucous icteric, traces of scratching the skin. On palpation the abdomen revealed an
enlarged liver dense + 2 cm spleen is not enlarged. In the lungs vesicular breathing. Heart sounds are
muffled, rhythmic. Blood pressure 130/70 mm Hg Pulse 70 beats per minute. CBC - HB-110 g / l, Eritrea. 3.6 * 1012, leukocyte. - 11 * 109, ESR-23 mm / hour.
1. Enumerate least three diseases in which there are the above mentioned symptoms;
2. Presumptive diagnosis;
3. Informative methods of research;
4. Tactics GPs.
________________________________________________________________________
9. Patient M., 24 years turned to the GP complaining of general weakness, jaundice color appearance of
the sclera, and nausea. From history it was found that from the age of 6 after suffering a viral hepatitis have
similar symptoms - after a cold, stressful situations. According to his mother the boy's father repeatedly
examined at the Infectious Diseases Hospital with suspected infectious hepatitis, but the diagnosis was not
confirmed. On examination, the skin and mucous subikteric. In the lungs, vesicular breathing. Heart sounds
average sonority, rhythmic. BP 110/70 mmHg Pulse 80 beats in 1 min. Abdomen palpation soft. Liver
protruding from under the costal arch to 1 cm, slightly sensitive. The spleen is not enlarged. Complete blood
count with no abnormalities. The blood bilirubin total. - 60 mmol / L, direct - 5 mol / L, indirect - 55 mmol /
l. Liver enzymes were normal. In urine, bile pigments are not found.
1. Enumerate at least six acquired and congenital diseases of the liver and bile removes
ways in which the symptoms are observed above;
2. Presumptive diagnosis;
3. Informative methods of research;
4. Any provocative test recommended for confirmation of the diagnosis;
Tactics GP detailing administration (non-medical and medical) patients.
_________________________________________________________________________
10. Patient M., 22 years old complained of trembling hands and feet, loss of appetite. On examination,
marked tremor of the hands, slow and slurred speech. Palm "liver", the skin is dry, icteric sclera, on the front
of the chest and abdomen, "spider veins." Language bright - red. Liver 2 cm, painful, small ascites.
Consulting ophthalmologist: on the periphery of the cornea revealed Kayser-Fleischer ring. BP 100/80
mmHg
1. List at least three diseases for which there are the above symptoms;
2. Your preliminary diagnosis;
3. More research is needed to establish the diagnosis;
4. What neurological symptoms characteristic of the disease;
5. Tactics of GPs. Treatment.
Tests.
Of these one for postnecrotic cirrhosis of the liver is characterized by:
a) jaundice is a leading and constant symptom exacerbation
b) liver failure are ahead razvigie portal hypertension
c) the liver is enlarged, but quickly decreases, the surface uneven, uneven edge
d) the surface of the liver nodular rough edges
e) increasing the prothrombin index
2. Of the above items for biliary cirrhosis is not typical:
a) persistent jaundice
b) a pronounced itching
c) portal hypertension appears in the early stages of the disease
d) hepatic failure develops in the late stages of the disease
e) fingers in a "clubbing"
3. With what disease syndrome cytolysis expressed the most:
a) hereditary spherocytosis
b) Gilbert's syndrome
c) chronic active hepatitis
d) cholelithiasis
e) cirrhosis
4. In a patient with biliary cirrhosis deteriorated. There drowsiness, confusion, increased jaundice, liver
decreased in size and the patient lost consciousness, there was breathing Kusmaulya, areflekesiya. What's
wrong with the patient?
a) cholestasis
b) hepatic coma
c) gastrointestinal bleeding
d) portal hypertension
e) the hepato-renal syndrome
5. With the threat of hepatic coma should be limited to:
a) carbohydrates
b) proteins
a) fats
d) liquid
e) minerals
6. In the diagnosis of cirrhosis is crucial:
a) the level of albumin
b) the level of bilirubin
c) thymol test
d) the level of transaminases
e) none of the above answers
7. Which one of the most characteristic symptoms appear early in biliary cirrhosis of the liver:
a) bleeding gums
b) enlargement of the spleen
c) itching
d) increase of ALT and AST
d) increase of cholinesterase
8. Ascites in liver cirrhosis is formed by:
a) secondary hyperaldosteronism
b) hypoalbuminemia
c) portal hypertension
d) all of the above
e) none of the above
9. Which of the following symptoms appear early in biliary cirrhosis of the liver?
a) bleeding from esophageal varices
b) bleeding from the gut
c) portal hypertension
d) cholestasis
e) hepatic failure
№
1
Evaluation
assimilation in %
excellent
100%-86%
good
85%-71%
2
Test
15-12,9 Point
12,7-10,6
Point
satisfactory
70-55%
not satisfactory
54%-37%
10,5-8,25
Point
8,1-5,5 Point
bad
36% and
below
5,4 Point
4.2.2 Graphic Organizer: CLUSTER.
Cluster (cluster - bundle, the bundle) - a way to map the information - gathering ideas around of any
major factor for determining the meaning and focus of the assembly.
Encourages mainstreaming knowledge helps freely and openly engage in the thought process of the new
association presentation on the topic.
Acquainted with the rules for the cluster. In the center of the chalkboard or a large piece of paper written
in a key word or topic name of 1-2 words.
By association with the keyword attribute the side of it in the circles smaller "satellite" - the words or
sentences that are related to the topic. Connect their lines with the "main" word. These "satellite" can be
"small satellites", etc. record goes before the allotted time or until exhausted ideas.
Exchanged between clusters for discussion.
primary
diseases
seconda
ry
defeats
holestasis
fibrosis
hepatome
galia
stagnant
liver
Pigment
hepatosis
VilsonKonovalo
v desise
fruktoze
mia
galactoze
mia
4.3. The practical part
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with diseases that are accompanied by jaundice and hepatomegaly.
2. Interpretation of analyzes of laboratory and instrumental studies (clinical and biochemical analysis of
blood, urine, feces, gastrointestinal radiographic studies, EFGDS, ultrasound of the liver, gallbladder,
pancreas, scan, gepatografiya, analysis of duodenal sounding) patients with diseases soprovozhdayushihsya
hepatomegaly and jaundice (hepatitis, cirrhosis, cholecystitis, fatty liver disease, hemochromatosis, Wilson's
disease, Budd-Chiari syndrome, congestive heart failure, leukemia, acute and chronic infectious diseases,
infectious disease, hepatitis B, C, D, E, leptospirosis, yellow fever, infectious mononucleosis,
tifoparatifoznye infections, malaria, constitutional, hemolytic, hepatic, cholestatic jaundice).
3. Billing drugs depending on the etiology of disease, accompanied by hepatomegaly and jaundice.
№
evaluation
assimilation in %
excellent
100%-86%
good
85%-71%
satisfactory
70-55%
not satisfactory
54%-37%
4
The practical part
15-12,9 Point
12,7-10,6
Point
10,5-8,25
Point
8,1-5,5 Point
bad
36% and
below
5,4 Point
5. Control forms of knowledge, skills and abilities
• Verbally
• In writing
• The decision of situational problems
• Demonstration of skills mastered
5.1. Criteria for evaluation of knowledge, skills and practical skills of students.
№ evaluation
excellent
good
satisfactory
not satisfactory
assimilation in %
100%-86%
85%-71%
70-55%
54%-37%
1
The theoretical part
20-17,2 Point
17-14,2 Point
14-11 Point
2
situational problems
50-43 Point
3
Test
15-12,9 Point
4
The practical part
15-12,9 Point
42,5- 35,5
Point
12,7-10,6
Point
12,75-10,6
Point
35- 27,5
Point
10,5-8,25
Point
10,5-8,25
Point
10,8-7,4
Point
bad
36%and
below
7,2 Point
27-18,5
18 Point
Point
8,1-5,5 Point 5,4 Point
8,1-5,5- Point 5,4 Point
6. The evaluation criteria of the current control
levels of
estimates
rating
scores
Characteristics of the student's work
20
Point of presence on the practical lesson. Complete lack of knowledge
and ability to perform practical skills - the student is not ready for the
practical sessions.
Student answers unsatisfactory.
Students do not possess the underlying levels of knowledge and
skills, at least one of the following:
• It can not transfer diseases associated with hepatomegaly
• Do not know the definition of the disease, "chronic hepatitis",
"cirrhosis"
• Do not know the causes, the etiology of hepatitis and liver cirrhosis
• It can not enumerate the methods of diagnosis of hepatitis and
liver cirrhosis
• Do not know the group of drugs for the treatment of
Not
hepatitis, cirrhosis
20 - 54,9
satisfactory
• Not able to build a rational history during supervision of
patients with the syndrome of hepatomegaly
• During supervision can not objectively evaluate the condition
of patients with hepatitis.
• While supervision is not able to assess the severity of a patient
with liver cirrhosis
• Not able to rationally plan surveys to patients with
hepatitis, cirrhosis,
• Not able to make a differential diagnosis of patients
with hepatomegaly
Providing basic knowledge and skills
Satisfactory answer to poor quality.
The student tries to hold the basic knowledge and skills
55-60,9
(see below), but when replying or performing skills makes
serious mistakes.
Moderately satisfactory answer.
The student has the basic knowledge and skills (see below),
61-65,9
but when replying or performing skills makes mistakes (twin errors)
Satisfactory response quality.
The student is fully owned baseline knowledge and skills:
• Can list the diseases associated with hepatomegaly
• Does a particular disease "chronic hepatitis", "cirrhosis"
• Knows the causes, the etiology of hepatitis and liver cirrhosis
• Can list the main methods of diagnosis of hepatitis and liver cirrhosis
• Does the group of drugs for the treatment of hepatitis, cirrhosis
satisfactory
• Able to build a rational history during supervision of patients with
55-70,9%
the syndrome of hepatomegaly
• During supervision able to objectively assess the condition
of patients with hepatitis.
• During supervision is able to assess the severity of a patient
66-70,9
with liver cirrhosis
• Able to efficiently plan a survey of patients with hepatitis, cirrhosis,
• Able to make a differential diagnosis of patients with hepatomegaly
• Able to make a differential diagnosis of patients with hepatomegaly
• Can interpret the results of laboratory and imaging studies –
may indicate the presence of leukocytosis, elevated erythrocyte
sedimentation rate can interpret biochemical blood conclusion
EGDFS liver cirrhosis, liver ultrasound, and the conclusion of
the abdominal cavity with hepatitis and cirrhosis of the liver
• Able to correctly fill in the patient diary.
Advanced knowledge
The student is fully owned baseline knowledge and skills (listed in
"66-70,9") + has the following knowledge and skills:
good
• Know the main points of the pathogenesis of chronic hepatitis and
71-75,9
liver cirrhosis
• Does the classification of liver disease
76-80
81-85,9
86-90
excellent
91-95
86-100%
96-100
• Does the classification of liver cirrhosis by Child Pugh
• Knows the major clinical syndromes in chronic hepatitis
• Does the mechanism of action of drugs used for the treatment
of hepatitis and cirrhosis of the liver
• It may rationally choose the drugs to the patient, depending
on the cause of hepatomegaly
The student is fully owned baseline knowledge and skills (see above)
+ the knowledge referred to in paragraph "71-75,9" and has
the following knowledge and skills:
• Can tell in detail the pathogenesis of hepatitis and liver cirrhosis
• Knows the principles of primary, secondary and tertiary prevention
of chronic hepatitis
• Can describe the clinical picture of chronic hepatitis and liver cirrhosis
The student is fully owned baseline knowledge and skills (see above)
+ the knowledge referred to in paragraph "71-75,9" and "76-80" and has
the following knowledge and skills:
• Knows all groups of drugs used to treat liver cirrhosis
• Knows all options cirrhosis Child-Pugh
The student is fully owned baseline knowledge and skills (see above) +
the knowledge referred to in paragraph "81-85,9" and has the following
knowledge and skills:
• Knows the principles of treatment of chronic hepatitis and liver
cirrhosis
• Knows the indications and contraindications of drugs used in these
diseases
• Is able to provide reliable information on the Internet on the basis of
hepatomegaly data
• Knows the primary, secondary, tertiary prevention of chronic hepatitis
The student is fully owned baseline knowledge and skills (see above)
+ the knowledge referred to in paragraph "86-90" and has the following
knowledge and skills:
• Does the classification of chronic hepatitis
• Does the mechanism of liver ascites in liver cirrhosis
• Able to build a rational history during supervision of patients with
chronic hepatitis and liver cirrhosis
• Can correctly identify the type of cirrhosis by Child Pugh
• During supervision able to objectively assess the condition of
patients with liver cirrhosis
• Able to plan a rational examination of patients with hepatomegaly
• Able to make a differential diagnosis of patients with hepatomegaly
• Able to correctly fill out the diary patients with hepatitis and cirrhosis.
The student is fully owned baseline knowledge and skills (see above)
+ the knowledge referred to in paragraph "91-95" and has the
following knowledge and skills:
• to provide scientific data on the basis of additional literature
(articles and internet)
• Know the indications and contraindications for surgical treatment
of liver cirrhosis
• Can be in English ask complaints, gather medical history and
talk briefly about the disease to the patient with hepatitis and cirrhosis
Note: The basic knowledge and skills - a minimum of knowledge that provides a principle of "security"
for the patient.
7. Test questions
1. The etiology of chronic hepatitis and liver cirrhosis
2. Clinic of chronic hepatitis and liver cirrhosis
3. Diagnosis of chronic hepatitis and liver cirrhosis
4. Differential diagnosis of chronic hepatitis and cirrhosis of the liver.
5. Tactics of GPs in chronic hepatitis and cirrhosis of the liver.
8. Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.
Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2. Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3. Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4. Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5. Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6. Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7. Диагностика болезней внутренних органов. Окороков А.Н..2005.
8. Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
9. Chronological content classes
time
8.30–
9.30
activity
Morning
conference
9.1510.00
10.0510.45
Clinical audit is
written out sick.
Theoretical
analysis of topics
10.45 11.05.
study practical
skills.
11.0511.45
Supervision of
patients
in the department
11.4512.15
break
contents
The report of the doctor on
duty and duty subordinators
on duty.
A detailed report of the
student prescription patients.
Checking the initial level of
preparedness of students
using a "brainstorming."
Students are heard case
studies on the subject, they
have to analyze and give an
opinion
Student under the supervision
of a teacher must complete a
minimum of two skills.
Each student is in charge of a
particular patient ward.
materials
History, ECG,
overhead.
lesson time
1 hour
45 minutes
Case studies,
table, corresponding
to a subject class,
educational boards.
40 minutes
Patient or
volunteer.
20 minutes
Sick, stethoscope,
blood pressure
monitor, medical
history (with data of
clinical and
laboratory research).
40 minutes
30 minutes
12.2013.20
Analysis of casepatients
At the option of the teacher
conducted a full inspection of
the patient on activity or
patients who are preparing to
leave the hospital, data
analysis laboratory and
instrumental studies, study
the preliminary and final
clinical diagnoses.
Determined by the treatment
plan with the doses of drugs.
Sick, stethoscope,
blood pressure
monitor, medical
history (data of
clinical and
laboratory research).
60 minutes
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
BASED ON SOLVING PROBLEMS OF PATIENTS
WITH JAUNDICE
Purpose: To teach students of 6-7 courses to solve problems of patients with jaundice, as well as the
principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:
• giving students solving problems associated with jaundice.
• giving students timely diagnosis when there is a problem associated with jaundice.
• To teach students to differentiate the disease, accompanied with jaundice.
• Improve the knowledge, skills, and practical skills in solving problems of patients with jaundice
(gathering information, identifying problems and physical examination, as well as the ability to reasonably
prescribe laboratory and instrumental methods of investigation);
• To teach students to reasonably choose the tactics;
• To teach students to exercise reasonable medical and preventive measures and surveillance in a
hovercraft and SP.
During analysis of the problem of patients the key points of assessing students must be:
• Ability to identify the main issues that affect the quality of life of patients.
• Ability to ask support questions rational history.
• The ability to distinguish the presence of risk factors.
• The ability to transfer a disease or condition that may be causing the problem.
• The ability to reasonably conduct physical examination.
• Ability to use sound laboratory and laboratory studies in RPP or FP.
• Ability to identify the need for additional studies outside RPP or FP.
• Based on this information the ability to identify the root cause (diagnosis) of the problem.
• The ability to determine the tactics based on the qualifying characteristics of GPs.
• Ability to provide non-medical advice.
• The ability to identify drug therapy on the basis of evidence-based medicine
• Ability to identify preventive measures at the primary care level.
• Ability to define the principles of clinical examination and rehabilitation of patients in RPP or FP.
What the student needs to know to solve the problems of patients with obstructive jaundice:
№
List Knowledge
1.
2.
3.
According to characteristics of the GP qualifying
According to the characteristics of the GP qualifying
The list of conditions that require management in RPP or
FP (1 category)
Base level
The list of diseases that occur
with jaundice student should know
at least 10 of the most common
diseases
A list of the most dangerous
diseases that present with jaundice
student should know at least 5
diseases
According to the characteristics
of the GP qualifying
4.
The list of states that require a specialist consultation or
hospitalization (category 2)
5.
A list of studies requiring in RPP or FP (3.1 category)
6.
The list of research areas requiring outside RPP or HP (3-2
category)
7.
Key points (criteria) diagnosis, with jaundice occurring
8.
Modes of transmission of hepatitis
9.
Types of jaundice
10.
Symptoms of internal organ
11.
Signs of ascites
12.
Indicators of laboratory results
13.
Therapeutic tactics
14.
The principles of primary, secondary and tertiary
prevention
15.
The principles of clinical examination and rehabilitation of
disorders that occur with jaundice in RPP or FP
(category 4)
According to the characteristics
of the GP qualifying
According to the characteristics
of the GP qualifying
According to the characteristics
of the GP qualifying
student must know features and
manifestations of each disease, and
the criteria for their diagnosis
A student must know the
mechanism of transmission
student must know the
mechanical features, parenchymal
and hemolytic jaundice.
student should know the signs of
defeat
student must list the major
manifestations
The student should know:
- Normal values, as well as their
changes in pathology.
student should know the
techniques and principles of
treatment (including non-drug).
The student should know the
basic activities required for the
primary, secondary and tertiary
prevention
The student must list the main
activities for clinical examination
and rehabilitation
What the student should be able to do to solve the problems of patients with obstructive jaundice:
The list of skills
Ask the patient and his relatives
Identify risk factors for
General inspection
Baseline
Student should be able to ask questions of
management concise questions that really helps to set
the probable diagnosis.
The student should be able to specifically identify
and assess the patient's complaints.
The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics of
their development.
The student must be able to analyze the history of
life: the identification of risk factors, the health of
parents and close relatives.
student must be able to identify unmanaged and
uncontrolled risk factors such as on questioning the
patient, so on the basis of an objective approach
the student must be able to identify:
- Liver palms
-Gynecomastia
- Cachexia.
Oral examination
Perform a visual inspection of skin
To conduct palpation, percussion and
auscultation of the respiratory system
To conduct palpation, percussion and
auscultation of the cardiovascular
system
General inspection abdomen
Conduct a superficial abdominal
palpation
Conduct a deep abdominal palpation
Conduct liver percussion
To conduct palpation of the liver and
gall bladder
To conduct palpation of the spleen
Calculate the index weight / body
Inspect the limb
Interpret the clinical and biochemical
analyzes
Differentiate the disease, accompanied
with jaundice
student should be able to appreciate the language .
student should be able to detect the presence of:
Pale- Ikterichnost,
-The presence of rash
- Seals
- Telangioektazii.
The student must be able to assess:
- A tour of the chest
- Voice trembling
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify signs:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
- If the heart murmur, be able to identify their
epicenter, and relevant to the phase of cardiac
(systolic or diastolic murmur);
- To be able to differentiate functional from
organic heart murmur.
student should be able to detect the presence of:
-Ascites
-Flatulence
-Spider veins
- Venous collaterals
- Injuries and bruises
student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the
muscles of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
student should be able to:
- To evaluate all available structures in the
abdomen
student should be able to:
- Determine the limits of the liver Kurlov
student should be able to:
- To evaluate the properties of the liver and gall
bladder.
student should be able to:
- Identify splenomegaly
student should be able to identify the signs:
- Underweight
- Increased weight
student should explore the limbs and body, and to
be able to find:
- Generalized edema. Fingers should be able to put
pressure on the dorsum of the foot and discover:
- There is a hole or not.
student should be able to identify the signs:
- Increase or decrease in performance from the
norm.
student should be able to differentiate the disease
on the basis of the distinctive features (history,
Post a non-drug councils
Rational use of medicines in the
treatment of diseases that occur with
jaundice
Conduct monitoring and surveillance
of patients
physical examination, laboratory and instrumental
investigations)
student should be able to:
- Educate patients on self-monitoring
- Advise on diet
- Advise on healthy lifestyles
student should be able to choose drugs with proven
efficacy.
When selecting a drug student should be able to
evaluate:
- Efficiency
- Safety
- Eligibility
- Profitability.
student should be able to carry out monitoring and
control status in SAP and SP.
Practical lesson 5
"Jaundice. Differential diagnosis of gallstone disease with tumors of the biliary-pancreatic areas
(tumors of the liver, gallbladder, pancreas). Tactics GPs. The principles of clinical supervision, control
and rehabilitation in RPP or FP. The principles of prevention. The principles of teaching topics. »
Learning Technology
Study time: 6 hours
The structure of lesson
1. Training room.
2. Teaching aids, handouts, a collection of case
studies and tests
3. Hospital wards.
4. TV, video equipment, multimedia
1.
Teach GP diagnosis and differential diagnosis, conducting best option for treatment policy
of obstructive jaundice caused by various diseases, as well as the principles of management of
patients in primary care, provided the requirements of the "Qualification characteristics of the GP"
Pedagogical objectives:
1. Consider the issues of diagnosis of
cholestatic jaundice - extrahepatic
2. Consider the issues of diagnosis of
cholestatic jaundice - intrahepatic
3. Demonstrate patients with cholestatic
jaundice.
4. Discuss the results of clinical,
laboratory and instrumental studies in
cholestatic jaundice.
5. Differential diagnosis of diseases
associated with jaundice - extrahepatic:
cholangitis, choledocholithiasis, stricture of
bile duct cancer, bile duct cancer,
pancreatic head cancer, gallbladder,
ascariasis, intrahepatic: preparatogenny
cholestasis, primary and secondary biliary
cirrhosis, liver tumors.
6. Discuss the tactics in the qualifying
characteristics of GPs
7. Discuss the principles of treatment
(non-drug and drug).
8. Discuss the principles of
management, supervision and monitoring
of patients in RPP or FP.
9. Discuss the principles of primary,
secondary and tertiary prevention in these
diseases.
Learning outcomes:
The student should know:
1. The mechanism and causes of obstructive
jaundice.
2. Clinical manifestations of obstructive
jaundice.
3. Diagnosis of obstructive jaundice.
4. Differential diagnosis of obstructive jaundice.
5. The principles of treatment (medication and
non-medication) in these diseases.
6. Principles of follow-up and monitoring of
patients in RPP or FP.
7. The principles of primary, secondary and
tertiary prevention in these diseases.
The student should be able to:
1. Analyze the data and history of complaints for
the diagnosis of obstructive jaundice
2. Diagnose, differentiated by clinical and
laboratory research tool various kinds of mechanical
jaundice.
3. Choose drugs with proven efficacy
4. Advise on non-drug therapies.
5. To monitor in RPP or FP.
methods work in small groups, Graphic Organizer fishbone
Forms of organization of learning activities
Individual work, group work, team
Training manuals, training materials, ECG patients,
Learning Tools
slides, video and audio recordings, medical history
Quiz, testing, presentation of the results of the
Ways and means of feedback
learning task, filling medical records implementation of
practical skill "professional debriefing"
The method of training
Flow chart classes
"Jaundice. Differential diagnosis of gallstone disease with tumors of the biliary-pancreatic areas
(tumors of the liver, gallbladder, pancreas). Tactics GPs. The principles of clinical supervision, control
and rehabilitation in RPP or FP. The principles of prevention. The principles of teaching topics. »
№
Stages number of practical classes
1
Introduction (theme explanation)
2
The discussion of practical lessons with the use of new
educational technologies (method of "three-step
interview"), as well as demonstration material (sets of
medical charts, tables, posters, x-ray), the definition of the
initial level
3
Displays the discussion
Form of training
Survey, discussion
Duration
225
10
40
classroom
10
4
5
Determination of tasks to perform the practical part professional questioning. Explanation of the provisions
and recommendations for the job by filling in the history
of the disease.
The development of practical training under the guidance
of the teacher.
Discussion
20
Survey in wards
Prof. questioning. A
conversation with patients
and filling medical history,
situational problems.
20
Survey in wards
6
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research biochemical analysis and diagnosis
Medical history,
laboratory data situational
problems
25
7
Discussion of theoretical and practical knowledge of the
students, fixing material, the level of learning assessment
Oral examination, tests,
discussion, identification of
practical skills
75
8
Classroom
Determination of the output on the practice session, the
Information, questions for 25
assessment on a 100-point system, and ad evaluations.
homework.
Homework next practice session (a collection of
Classroom
questions).
2. Motivation
The majority of patients with jaundice (mechanical or cholestatic), seek medical attention. In this
situation, the force of a general practitioner (GP) is directed to the diagnosis of jaundice (extrahepatic:
cholangitis, choledocholithiasis, stricture of bile duct cancer, bile duct cancer, pancreatic head cancer,
gallbladder, ascariasis, intrahepatic: preparatogenny cholestasis, primary and secondary biliary cirrhosis
liver, neoplasms of the liver) caused by various diseases. In case of jaundice GPs must not only diagnose, but
he needs to determine the reasons behind the disease to provide medical care in a hovercraft (SP), or referral
to specialized hospitals. These and other conditions are the basis for the inclusion of this subject in the
training of GPs.
2. Intra and interdisciplinary communication.
The teaching of this subject is based on the knowledge of students of basic anatomy, histology and
cytology with embryology, biology, normal physiology, biochemistry,. Pathological Anatomy, Pathological
Physiology, Topographic anatomy and operative surgery, internal medicine Propedeutics, Tuberculosis.
Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy, Hospital
Therapy, Orthopedics
4. The content of classes
4.1. The theoretical part
When parsing threads need to pay attention to the following aspects.
At long extrarenal cholestasis due to high pressure inside the biliary system structural changes occur in
the intrahepatic bile ducts.
The main criteria of cholestasis - hyperbilirubinemia, increased a
glyutamintranspeptidazy, cholesterol and bile acids. Cholestasis causes destruction of hepatocytes.
The predominant symptom - jaundice, which is often preceded by itching. Jaundice occurs early and
gradually increases, it is accompanied by Ahola stool, steatorrhea, signs of deficiency vit A, D, and K.
Blood: leukocytosis with a shift vlvo, ESR increase, deterioration in liver function tests.
Liver increased sealed, often has an uneven surface.
Diagnosis: retrograde cholangiography.
Treatment: the restoration of patency of the bile ducts is carried out surgically.
Neoplasms of the liver.
Liver tumors can be benign and malignant cells derived from liver or metastatic.
1) primary hepatocellular carcinoma - is characterized by fever of unknown etiology, anemia, weight loss,
increased levels of transaminases, alkaline phosphatase.
A history can be brought before the viral hepatitis B.
Diagnosis is difficult. An important symptom - lasting pain (discomfort) in the right upper quadrant and
rapid weight loss. Help in dignostika ultrasound, radioisotope scan and CT scan of the upper abdomen.
Finally, the diagnosis is made by biopsy of the liver.
Treatment: Combination therapy including radical surgery and subsequent chemotherapy.
2) Metastatic liver disease
Up to 90% of malignant liver tumors are metastatic. Metastatic adenocarcinoma found in ovarian tumors,
pancreatic cancer, tumors of the gastrointestinal tract, small cell lung cancer.
Diagnosis: malignant epithelial tumors of the liver was dete
-fetoprotein and
fetoprotein - a primary cancer of the liver.
Diseases that lead to cholestatic jaundice:
1. Gallstone disease: the common bile duct stone, stone hepatic duct, cystic duct stone.
2. Inflammatory diseases: acute and chronic cholecystitis, cholangitis, acute pancreatitis, chronic
pancreatitis.
3. Malignant tumors: cancer of the liver, gallbladder cancer, bile duct cancer, cancer of the major
duodenal papilla, pancreatic cancer, Hodgkin's disease.
Thus the differential diagnosis must take into account the specific conditions of the clinic at the similarity
of the features of obstructive jaundice.
Choledocholithiasis - are the major causes of obstruction of the common bile duct stones, inflammatory
swelling of the mucous membrane of the bile duct, bile duct compression of the swollen head of the
pancreas. The following forms of the disease: the yellowness of-pain, icteric, pancreatic, yellowness ofholetsistitnaya, icteric, painless, yellowness of-septic.
Diagnosis is based on the characteristic triad of symptoms: pain in the right upper quadrant, a rapidly
developing fever, jaundice, fever with shaking chills. What matters is palpable gallbladder, leukocytosis in
the peripheral blood. The diagnosis is confirmed by ultrasound and retrograde holetsistografii.
Treatment: atropine stops the attack, platifillina, papaverine, shpy dibazola, aminophylline, dipyrone is
administered antibiotics. With repeated attacks - surgery.
Cholangitis (angiocholitis) Clinic: adrift cholangitis divided into acute, chronic, sklerozitsiruyuschy,
septic.
Recognition of cholangitis is difficult. Taking into account the complaints and pressing pain in the right
upper quadrant, occasional bouts of colic, fever, mild jaundice, leukocytosis with a marked shift to the left of
the formula, increased erythrocyte sedimentation rate. Ultrasonography - expansion of the bile ducts in the
form of convoluted tubular structures; retrograde cholangiography.
Treatment: remove obstruction of the bile ducts, infusion, medical therapy, detoxification of the body.
Bile duct cancer - localized in the major duodenal papilla. Cancer occurs with pain resembling colic,
radiating to the back, the front wall of the chest. Ultrasonography - the whole system of bile ducts expanded.
Diagnosis: laparoscopy. Treatment: Surgery.
Diagnostic search of a general practitioner in the presence of jaundice should be directed at establishing
the localization of obstruction and its nature. This takes into account that the hemolytic jaundice
characterized by a lemon-yellow (pale) color shade of skin and mucous membranes, splenomegaly,
reticulocytosis, unconjugated (indirect), bilirubinemia, urobilinogenuriey. The most reliable of hemolysis can
be judged by the shortening of the duration of life of red blood cells (studied with radioactive chromium).
For cholestatic (mechanical, subhepatic) jaundice greenish-gray color of the skin and mucous membranes,
hepatomegaly, conjugated (direct) hyperbilirubinemia, cholestatic syndrome, xanthoma xanthelasmas,
bilirubinuria, dark urine and stool aholichny.
The general practitioner on the basis of clinical and laboratory examination can make a preliminary
diagnosis and should direct the patient to the hospital for a comprehensive survey of treatment.
Checking the initial level of preparedness of students working in small groups
Purpose: This method is used to stimulate the exchange of ideas, increases the degree of involvement of
the participants, teaches argue and defend their own point of view.
Action: Pre-prepared questions, equal count of students in the group. Each group is given one job.
1) The main laboratory criteria cholestasis.
2) The most informative method of diagnosis and treatment of cholestasis.
3) The most characteristic features of obstructive jaundice.
The evaluation criteria
№ evaluation
assimilation in %
excellent
100%-86%
good
85%-71%
satisfactory
70-55%
not satisfactory
54%-37%
3
15-12,9 Point
12,7-10,6
Point
10,5-8,25
Point
8,1-5,5 Point
test
bad
36% and
below
5,4 Point
4.2. The analytical part
4.2.1.Situational tasks:
1. 20 year old boy at a reception at the GP complaining of pain in the right upper quadrant, nausea,
vomiting, weakness, headaches and memory loss. From history we found out that he was behind in the
mental development of their peers, poorly at school. As a child, had been treated for chronic hepatitis.
Recently, the condition has worsened, the patient was hospitalized in the gastroenterology department. An
objective examination of the patient malnutrition, pale, on the sclera are white ringed spots. When the
conversation turns dementia patient. On palpation of the abdomen, tenderness in the liver area. Liver +5-6
cm margin maloboleznenny, hard. The rest of the spleen 2 cm abdominal palpation painless. Chair inclined
constipation.
On examination, an ophthalmologist at the periphery of the cornea revealed Kayser-Fleischer ring.
Analysis of the blood: anemia, leukopenia, and thrombocytopenia in urine: hematuria, proteinuria,
glucosuria.
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional tests are recommended to confirm the diagnosis, which are crucial;
4. GPs tactics and principles of treatment.
ANSWERS:
1. Wilson Konovalov desis. Hemochromatosis, cirrhosis of the liver, hronich.gepatit
2. Wilson's disease Konovalov.
3.uroven iron in the blood. Copper levels in the blood, blood biochemistry, OAkrovi, urine
4.D-penicillamine, cupping, Kuprino.
________________________________________________________________________
2. Patient S., 36 years old, turned to GPs. From history we found that was repeatedly treated in a hospital
about liver disease in the last 6 years the patient showed an increase in liver non-permanent pain in the right
upper quadrant, the dark color of the skin and lack of hair on the face. On examination, the gray-jaundiced
color of the skin, severe weakness, thirst. Reduction of blood pressure to 90/60 mm Hg Liver +8-10 see,
moderate ascites. Bilirubin -38 mmol / l sugar -16 mmol / l sugar in urine - 6%.
Serum iron - 60 mmol / l.
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to make the diagnosis;
4. The method of investigation, which is crucial for diagnosis and normal levels;
5. GPs tactics and principles of treatment.
____________________________________________________________________________
3. Patient L., 49 years old at the reception GPs. From history we noted that suffers from diabetes type I
diabetes in childhood. Increased supply. Last 5 years old notes in the right upper quadrant pain, nausea, bitter
taste in the mouth. Repeatedly treated in a hospital. The last 2 days has worsened the condition, there was a
severe weakness, decreased performance, and pain in the right upper quadrant. An objective examination of
the skin is pale, low power, astenik. The abdomen was soft, painful in the liver, liver + 4 cm, medium density
maloboleznenno, the spleen is not enlarged, there is flatulence. The chair is unstable.
Blood Sugar -12 mmol / l, urea 5%. Liver function test - normal.
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to establish the diagnosis;
4. The method of investigation, which is crucial for diagnosis;
5. Tactics of GPs and treatment guidelines (provide details on non-drug and drug treatments).
_________________________________________________________________________
_________________________________________________________________________
4. Patient S., 55 years old, turned to the GP with complaints of pain in the right upper quadrant,
dyspepsia, skin itching and jaundice of the sclera. From history we know that the patient throughout their
lifetime use of fatty food, lots of alcohol. He was treated at the hypoacid gastritis and spastic colitis. 10 years
ago was found to increase the liver, Akhil, a tendency to constipation, diarrhea successive. He was treated
repeatedly for chronic hepatitis. Weight 110 kg, light yellowness of the sclera, normal skin color. Liver 3 cm
thick edge. The spleen was not palpable.
Analyses: thymol test - 7.3 IU. If you study with Rose Bengal labeled J, revealed a diffuse decrease in the
absorption of paint all over the liver.
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to establish the diagnosis;
4. List the 5 groups of syndromes (specifically indicate the characteristic symptoms for each syndrome)
observed in this pathology;
5. Tactics of GPs. Treatment.
5. Patient M., 22 years old complains of trembling hands and feet, loss of appetite. On examination, there
is hand tremors, slow and slurred speech. Palm "liver", the skin is dry, icteric sclera, the front surface of the
chest and abdomen, "spider veins". Tongue is bright - red. Liver 2 cm, painful, small ascites. Consulting
ophthalmologist: on the periphery of the cornea revealed Kayser-Fleischer ring. BP 100/80 mmHg
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to establish the diagnosis;
4. What neurological symptoms characteristic of this disease;
5. Tactics of GPs. Treatment.
___________________________________________________________________________
6. Patient A., 34 years old complains of pain in the right and left hypochondria worse when walking,
fever and chills, frequent nosebleeds, rapid weight loss. 10 years ago suffered a severe flu, after which there
were abdominal pain and dyspepsia. On examination, icteric sclera, skin with a bronze tint, oral mucosa is
dark. The abdomen is swollen, massive ascites, which is difficult due to palpation of the liver and spleen. 4
cm liver, spleen, 3 cm
In assays anemia, leukopenia, and a sharp increase of ESR (40 mm / hr) Blood Sugar 7 mmol / l, 1% in
the urine.
1. List at least three diseases in which the above symptoms are observed;
2. Your preliminary diagnosis;
3. Additional research is needed to establish the diagnosis;
4. Specify the leading trait characterizing the disease;
5. Tactics of GPs. Treatment.
_________________________________________________________________________
7. Patient K. 38 years, appealed to the GP complaining of bouts of severe weakness in a cold sweat,
dizziness, nausea, palpitations after 10-15 min. after meals, especially after the sweets. From history: the
patient was operated on for BU 12 sc The patient's condition improved in a horizontal position, and therefore
tries to lie down immediately after eating. On examination, the patient malnutrition, skin and mucous
membranes pale and clean. In the lungs auscultated vesicular breathing. Heart of: high tones sonorities,
rhythmic. Pulse is 100 beats in 1 min. Blood pressure 100/60 mm Hg. At the root of the tongue is coated
with white bloom. The abdomen was soft, painful in the epigastric region. The liver and spleen were not
zoom.
1. A presumptive diagnosis;
2. Additional methods of research;
3. The tactics of the GP with a detailed description of administration (medical and non-medical) patients;
________________________________________________________________________
8. Patient S. 59, appealed to the GP complaining of heaviness in the right upper quadrant, itching, loss of
appetite, poor tolerance of fatty foods, belching, nausea, constipation, discolored feces. From history: 16
years ago, underwent viral hepatitis, itching of the skin disturbs one month, during which time due to poor
appetite lost 4 kg. OBJECTIVE: yellowness of the skin, with traces of scratching, lymph nodes were not
palpable. In the lungs vesicular breathing. Pulse 65 beats / min, rhythmic. A / P 110/70 mm Hg Heart sounds
are sonorous. The tongue is red. The abdomen was soft, tenderness in the right upper quadrant. The liver
extends from under the costal margin of 2 cm and soft. Spleen probe fails. Blood test: er - 3700000, Nv - 78
g / l, tsv.pok. - 0.9, Lei. - 8.0 thousand, ESR - 23 mm / hour. Urinalysis: response to positive bile pigments.
1. Enumerate at least four diseases in which there are above mentioned symptoms;
2. A presumptive diagnosis (main complication);
3. Informative research methods;
4. The tactics of the GP;
________________________________________________________________________
9. Patient M., 16 years appealed to the GP with complaints of general weakness, trembling of the hands
and feet, loss of appetite, yellowing of the periodic skin and mucous membranes. According to his mother
the last 2 years was slow in conversation, movements, moody and irritable. Objectively: the patient
malnutrition, "liver" palm, easy yellowness of the sclera. In the lungs, vesicular breathing. Heart sounds are
average sonorities, rhythmic. BP 120/70 mmHg Pulse 80 beats per 1 minute. The liver extends from under
the costal arch to 1 cm thick, the edges are sharp. Spleen + 3 cm, plotnovata, painless. There is a small
ascites. On the periphery of the cornea is observed deposition greenish - brown pigment.
1. Enumerate at least four diseases in which there is the above mentioned symptoms;
2. A presumptive diagnosis;
3. Informative research methods;
4. Enter analyzes, which have important diagnostic value for this disease;
5. The tactics of the GP;
_________________________________________________________________________________
10. Patient L., 28, turned to the GP complaining of yellowing of the sclera, in the right upper quadrant
pain, dark urine. History of such events periodically observed his father and older brother. Objectively:
general condition is relatively satisfactory. The abdomen was soft, sensitive in the right upper quadrant.
Liver + 1cm high density. The spleen is not enlarged. In the lungs, vesicular breathing. Heart sounds are
average sonorities, rhythmic. BP 110/70 mmHg Pulse 80 beats per 1 minute. Total bilirubin in the blood. 60 pmol / liter, straight - 45 pmol / l, indirect - 15 pmol / l. Complete blood without pathology. Liver
enzymes were normal. Liver biopsy found mainly in the center of lobules coarsely grained green nezhelezosoderzhaschy brown pigment, the structure of the liver is not broken.
1. Enumerate at least six and purchasing congenital diseases in which there is the above mentioned
symptoms;
2. A presumptive diagnosis;
3. Informative research methods;
4. Tacticsof GPs.
__________________________________________________________________________________
11. Patient M., 50 years old approached the GP complaining of heaviness in the right upper quadrant,
bitter taste in the mouth, increased abdomen, general weakness. From history: it is often abused alcohol. On
examination: pale skin with a touch of jaundice, gynecomastia. On the skin of the abdomen network of
venous collaterals. Belly increased by ascites. Liver + 6 cm thick nodular, with irregular contours, the edge is
pointed. Spleen increased (+ 1 cm). The presence hemorrhoidal knots. There is phenomenon encephalopathy.
1. Enumerate at least four diseases in which there are above mentioned symptoms;
2. A presumptive diagnosis;
3. Informative research methods;
4. What changes in the ultrasound confirms a presumptive diagnosis;
5. Tactics GPs
__________________________________________________________________________________
12. Patient L., 76, turned to the GP complaining of icteric coloration of the skin and sclera with severe
itching, intermittent fever. From history: 30 years ago had malaria. 2 years ago bothered attacks of pain in
the right upper quadrant with chills, jaundice interleaving nature that have passed after the injection of
muscle relaxants. Objectively: skin and mucous icteric, there are traces of scratching the skin. On palpation
of the abdomen revealed an enlarged liver dense + 2 cm spleen is not enlarged. In the lungs vesicular
breathing. Heart sounds, rhythmic. BP 130/70 mmHg. Pulse 70 bpm. CBC - HB-110 g / l, Eritrea. - 3.6 *
1012, a white blood cell. - 11 * 109, ESR-23 mm / hour.
1. Enumerate at least three diseases in which there are above mentioned symptoms;
2. A presumptive diagnosis;
3. Informative research methods;
4. Tactics of GPs.
Tests:
1. Obstructive jaundice is characterized by:
a) increase the alkaline phosphatase
b) increase acid phosphatase
c) The increase in prothrombin index
g) reduction of alkaline phosphatase
d) a decrease in prothrombin index
2. A woman 50 years old, obese, suddenly there was an attack of intense pain in the right upper quadrant
radiating to the right supraclavicular region. The patient is restless. On examination: normal skin color,
tenderness at the point of the gall bladder, positive symptom Ortner, the body temperature is normal, blood
tests without pathology. It is most likely that the patient:
a) acute cholecystitis, cholangitis
b) exacerbation of chronic cholecystitis
c) gallstone disease, cystic biliary colic
g) the aggravation of peptic ulcer 12 duodenal ulcer
e) the penetration of gastric ulcers in the round ligament of the liver
3. The reasons postholecistectomi syndrome is not considered to be:
a) The formation of stones in the common bile duct
b) the "forgotten" bile duct stones
c) constrictive duodenal papillitis
d) chronic pancreatitis, an unrecognized preoperatively
d) biliary bile duct
4. The causes of jaundice after cholecystectomy for cholelithiasis, some time after the "light gap" can not
be:
a) Gilbert's syndrome
b) constrictive duodenal papillitis
c) cicatricial narrowing of the common bile duct
d) newly formed rock in general duct
e) cancer of the pancreatic head
5. The increase in alkaline phosphatase in the blood of the most typical:
a) prostate cancer
b) for the major duodenal papilla cancer
c) for mumps
g) for 12 perforation of ulcer of the duodenum
e) for gastric ulcer perforation
6. For cancer of the gall bladder is most characteristic combination:
a) with choledocholithiasis
b) with a stone in the common bile duct
c) with cirrhosis
g) cholelithiasis
d) Biliary bile duct
7. An indicator of cholestatic syndrome in the pathology of the liver is:
a) ALT (alanine aminotransferase)
b) thymol test
c) Lactate
d) γ-globulin serum
d) alkaline phosphatase
8. For Gilbert disease is not common:
a) the presence of reticulocytosis
b) hyperbilirubinemia
c) albumins OK
d) alkaline phosphatase OK
e) prothrombin index is normal
9. The most informative test, allowing to carry out differential diagnosis between chronic persistent
hepatitis and benign hyperbilirubinemia is:
a) Coombs test
b) a liver biopsy
c) The sample is restricted energy intake
d) treatment of ex juvanibus, phenobarbital
d) determination of bilirubin
10. From listed for chronic persistent hepatitis is characterized by:
a) portal hypertension symptoms including splenomegaly
b) persistent elevation of aminotransferases (3 times or more)
c) hyper-γ-globulinemiya (over 30%)
d) reducing prothrombin index (below 75%)
e) hyperbilirubinemia
11. The signs of cholestatic syndrome does not apply:
a) hyperbilirubinemia due konyungirovannogo (direct) bilirubin
b) an increase in alkaline phosphatase
c) an increase of cholesterol and β-lipoprotein
g) xanthelasmas and itchy skin
e) uvelechenie timolvoy sample
12. For chronic active hepatitis has been characterized by:
a) jaundice and hepatomegaly
b) uvelechenie alkaline phosphatase
c) the increase in ESR
d) an increase in AST and ALT
d) hyper γ-globulinemiya
13. Icteric coloration of the palms and soles without icteric sclera observed:
a) with jaundice
b) at carotenemia
c) in toxic hepatitis drug
g) OK
d) hemolytic jaundice
14. Which of the drugs in use leads to acute hepatitis drug:
a) tubazid
b) izolanida
c) methotrexate
g) furadonina
d) paracetamol
15. To cirrhosis of the liver is not characterized by:
a) Ascites
b) splenomegaly
c) varicose veins peschivoda
d) expansion of the superficial veins belly of the "head of Medusa"
e) giperalbuminemii
16. From listed for makronodulyarnogo (postnecrotic) cirrhosis of the liver is characterized by:
a) Jaundice is a leading and constant symptom exacerbation
b) the functional failure of the liver ahead razvigie portal hypertension
c) The liver is enlarged, but rapidly decreases, the surface bumpy, uneven edge
g) the surface of the liver bumpy rough edges
e) increasing the prothrombin index
17. From listed for biliary cirrhosis is not typical:
a) persistent jaundice
b) a pronounced itching
c) portal hypertension occurs in the early stages of the disease
g) liver failure develops in the late stage of the disease
d) the fingers as "drumsticks"
18. Hepatic coma in patients with cirrhosis may be triggered by all except:
a) intercurrent infection
b) receiving lactulose
c) large doses of diuretics
d) bleeding
d) the surgical intervention
The evaluation criteria
The maximum
18-17
16-15 points
14-13 points
12 points
score 20-19 points
points
Excellent
Good
Satisfactory
not satisfactory
bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
4.2.2.Graphic organizer "fishbone".
The purpose of the scheme "fishbone" to describe the whole range of field problems and try to solve it,
develops and activates the system, creative, analytical thinking.
Progress chart: students get acquainted with the rules of construction of the scheme. Individually or in
pairs to write down the top bone wording of sub-problems and on the bottom - the facts prove that these
problems exist.
Together in a mini group, compare and complement your scheme.
Next, conduct a presentation of the results. Presentation of the completed scheme to demonstrate the
relationship of sub. Their comprehensive.
dysphagia
diagnosis
worn clinic
similar symptoms
latent within
simulation
Lack of Lab
economic
The doctor illiterate
The doctor
inconsiderate
patient in time has
not come
lack of equipment
The doctor careless
The doctor
nonprogressive
dysphagia
diagnostics
nurse negligence
nurse illiterate
???????????
nurse non-executive
The maximum score
20-19 points
Excellent
18-17 points
14-13 points
Good
16-15
points
Satisfactoryy
100%-86%
85%-73%
70-56%
53%-46%
12 points
Unsatisfactory
43% or less
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with diseases that are accompanied by jaundice.
2. Interpretation of the analyzes, the data of laboratory and instrumental studies (clinical and biochemical
analyzes of blood, urine, feces, gastrointestinal radiographic studies, EFGDS, ultrasound of the liver,
gallbladder, pancreas, scanning, gepatografiya, analysis of duodenal intubation) of patients with diseases and
are accompanied by jaundice (hepatitis, cirrhosis, cholecystitis, fatty liver, hemochromatosis, Wilson's
disease, Budd-Chiari syndrome, congestive heart failure, leukemia, acute and chronic infectious diseases,
infectious disease, hepatitis B, C, D, E, leptospirosis, yellow fever , infectious mononucleosis,
tifoparatifoznye infections, malaria, constitutional, hemolytic, hepatic, cholestatic jaundice).
3. Prescription of drugs depending on the etiology of disease, soprovozhdayushihsya jaundice.
Jaundice
Cholelithiasis, biliary-pancreatic tumor area (tumors of the liver, gallbladder, pancreas)
№ Phase
Indicators /
This is not
Achieved
number
interpretation
Curation of the patient
Complete blood
General analysis of urine
ALT, AST
bilirubin
Total protein, protein fraction
thymol test
markers of hepatitis
Ultrasound of the liver, gallbladder,
pancreas
infectious disease consultation
Consultation hematologist
surgical consultation
completely
0
50
0
0
0
0
0
20
10
10
10
100
consulting oncologist
Differential diagnosis
Justification diagnosis
Tactics GPs and prescription of treatment
Recommendations
TOTAL
The maximum score
20-19 points
Excellent
18-17
points
Good
16-15 points
14-13 points
12 points
Satisfactory
Not satisfactory
Bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
5. NUMBER AND TYPES OF CONTROL MEASURES FOR assessing students
• Verbally
• In writing
• The decision of situational problems
• Demonstration of practical skills mastered
5.1. Criteria for evaluation of knowledge,skills and practical skills of students.
№ Rating
1
2
Assimilation
in%
The theoretical
part
Case Studies
3
Test score
4
The practical
part
Excellent
Good
Average
Poor
Unsatisfactory
100%-86%
85%-71%
70-55%
54%-37%
20-17,2
points
50-43 points
17-14,2
points
42,5- 35,5
points
12,7-10,6
points
12,75-10,6
points
14-11 points
10,8-7,4
points
27-18,5
points
8,1-5,5
points
8,1-5,5points
36% and
below
7,2 points
15-12,9 points
15-12,9
points
35- 27,5
points
10,5-8,25
points
10,5-8,25
points
6. The evaluation criteria of the current control
Levels of
Rating
Characteristics of student scores
18 points
5,4 points
5,4 points
estimates
20
Not
satisfactory
20 - 54,9
Points of presence in the lab. Complete lack of knowledge and
ability to perform a skill - the student is not ready for practical
employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and skills,
at least one of the following:
• Do not know how to conduct palpation and percussion of the
liver
• Do not know the main clinical manifestations of gallstone
disease, the main symptoms of liver tumors, gall bladder, pancreas
• Do not know the pathogenesis of jaundice in cholelithiasis,
biliary-pancreatic tumors zone
• Can not enumerate the methods of diagnosis of cholelithiasis,
tumors of the gallbladder,
• Not able to assemble a rational history during the Supervision of
patients with gallstone disease, tumors of the gallbladder and
pancreas
• During Supervision is not able to objectively assess the
condition of patients with jaundice
• Not able to make rational plan of investigation in patients with
jaundice
• Not able to make a differential diagnosis of patients with
jaundises
Providing basic knowledge and skills
55-60,9
61-65,9
Satisfactory
55-70,9%
66-70,9
Satisfactory answers of low quality.
The student tries to hold the basic levels of knowledge and skills
(see below), but when replying or performing skills makes serious
mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but when
replying or performing skills makes mistakes (subject to some
error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of knowledge and
skills:
• Knows how to perform percussion and palpation of the liver
• Knows the main clinical manifestations of gallstone disease, the
main symptoms of liver tumors, gall bladder, pancreas
• Knows the pathogenesis of jaundice in cholelithiasis, biliarypancreatic tumors zone
• Can list the main methods of diagnosis of cholelithiasis, tumors
of the gallbladder,
• Able to build a rational history during the Supervision of patients
with gallstone disease, tumors of the gallbladder and pancreas
• During Supervision able to objectively assess the condition of
patients with jaundice
• Able to be rational plan of investigation in patients with jaundice
• Able to make a differential diagnosis of patients with zheluhami
• Able to build a rational history during the Supervision of patients
with gallstone disease and tumors of the gallbladder, pancreas
• During supervision able to objectively assess the condition of
patients with jaundice
• Able to be rational plan of investigation in patients with
gallstone disease, tumors of the gallbladder and pancreas
Advanced level of knowledge
good
71-75,9
71-85,9%
76-80
81-85,9
86-90
Student is wholly owned by the basic levels of knowledge and
skills (listed under "66-70,9") + has the following knowledge
and skills:
• Able to make a differential diagnosis of patients with jaundice
• Can interpret the results of laboratory and imaging studies - may
indicate the presence of leukocytosis, elevated erythrocyte
sedimentation rate, can interpret the conclusion of ultrasound
and CT scan. Able to correctly fill in the patient diary.
• Knows the mechanism of action of drugs used for the treatment
of gallstone disease
Student wholly owns the basic levels of knowledge and skills (see
above) + knowledge referred to in paragraph "71-75,9", and also
owns the following knowledge and skills:
• Knows the pathogenesis of jaundice
 • Knows the principles of primary, secondary and tertiary
prevention of jaundice in cholelithiasis, biliary-pancreatic
tumors zone
student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "7175,9" and "76-80", and also owns the following knowledge and
skills:
• Can tell the basic principles of management, supervision and
monitoring of patients with gallstone disease and tumors of the
biliary-pancreatic area in SAP or joint venture.
• Is able to advise you on the boards of non-drug and drug-using
skills of IPC.
• Knows the principles of clinical examination and rehabilitation
of patients with jaundice in a hovercraft or joint venture
Student wholly owns the basic levels of knowledge and skills
(see above) + knowledge referred to in paragraph "81-85,9", and
also owns the following knowledge and skills:
• Know the indications for conservative and surgical treatment
of cholelithiasis and biliary-pancreatic tumors zone.
• Detail tells the differential diagnosis of various diseases
associated with jaundice, and between cholelithiasis and biliarypancreatic tumors zone
• Able to provide accurate information on diseases involving
jaundice on the basis of Internet data
Excellent
86-100%
91-95
The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "86-90",
and also owns the following knowledge and skills:
• Know the classification of tumors of the gallbladder, liver,
pancreas by TNM?
• Can explain the mechanism of jaundice in various diseases.
• Knows the principles of follow-up, monitoring, and
rehabilitation of patients with gallstone disease and tumors of the
biliary-pancreatic area

96-100
Student wholly owns the basic levels of knowledge and skills (see
above) + knowledge referred to in paragraph "91-95", and also
owns the following knowledge and skills:
• to provide scientific data on the basis of additional literature
(articles and Internet)
• Know the indications and contraindications for surgical
treatment for gallstone disease
• Know what treatment is required in patients with tumors of the
biliary-pancreatic area
• Can be in English ask complaints, gather medical history and
talk briefly about the disease to the patient with cholelithiasis and
biliary-pancreatic tumors zone
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle
of "security" for the patient.
7. Test Questions
1. Cholestatic etiology (mechanical) jaundice - extrahepatic.
2. Clinic cholangitis, choledocholithiasis, bile duct strictures, gallbladder cancer, cancer of the head of the
pancreas, gallbladder cancer, ascariasis.
3. Diagnosis of cholangitis, choledocholithiasis, bile duct strictures, gallbladder cancer, cancer of the head
of the pancreas, gallbladder cancer, ascariasis.
4. Differential diagnosis of intrahepatic and extrahepatic jaundice.
5. Cholestatic etiology (mechanical) jaundice - intrahepatic.
6. Clinic preparatogennogo cholestasis, primary and secondary biliary cirrhosis, liver neoplasms.
7. Diagnosis preparatogennogo cholestasis, primary and secondary biliary cirrhosis, liver neoplasms.
8. Tactics GPs in mechanical jaundice.
8. Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8.Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
9. Chronological content classes
Time
The content
Event
Materials
8.30–
9.30
Morning
Conference
Report on duty doctors and
attendants on duty subordinators.
History, overhead
projector..
9.1510.00
10.0510.45
Clinical audit to
prescribe patients.
Theoretical
analysis of the
topics
10.45 11.05.
Study of practical
skills..
11.0511.45
Curation of
patients
A detailed report on the students'
prescription patients.
Checking the initial level of
preparedness of students using the
method of working in small groups.
Students heard case studies on the
subject, they have to analyze and
give an opinion
Student under the supervision of a
teacher must complete at least two
practical skill.
Each student in the department in
charge of a particular patient wards.
11.4512.15
12.2013.20
Break
Analysis of casepatients
lesson time
1
45 minutes
Situational tasks,
tables, relevant
theme of
employment, training
board.
40 minutes
The patient or
volunteer.
20 minutes
The patient,
stethoscope,
sphygmomanometer,
medical history (with
data of clinical and
laboratory findings).
40 minutes
30 min
Optional teacher conducted a full
examination of the patient on the
theme of employment or patients
preparing for discharge, data
analysis, laboratory and instrumental
studies, the rationale for the
preliminary and final clinical
diagnoses. Determined by the
treatment plan with the doses of
drugs.
The patient,
stethoscope,
sphygmomanometer,
medical history (data
of clinical and
laboratory findings).
1
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
BASED ON SOLVING THE PROBLEMS OF PATIENTS WITH CARDIAC NOISE AND
CARDIOMEGALY
Purpose: To teach undergraduate courses solving the problems of patients with cardiac noise and
cardiomegaly, and the principles of their management in primary health care in the qualifying
characteristics of GPs
Key learning objectives:
• Train students in solving problems associated with cardiac noise and cardiomegaly
• giving students timely diagnosis when there is a problem associated with cardiac noise and
cardiomegaly.
• To teach students to differentiate the disease, accompanied with cardiac noise and cardiomegaly.
• Improve the knowledge, skills, and practical skills in solving problems of patients with cardiac noise
and cardiomegaly (gathering information, identifying problems and physical examination, as well as the
ability to reasonably prescribe laboratory and instrumental methods of investigation);
• To teach students to reasonably choose the tactics;
• To teach students to exercise reasonable medical and preventive measures and surveillance in a
hovercraft and SP.
During analysis of the problem of patients the key points of assessing students must be:
1) The ability to identify the main issues that affect the quality of life of patients.
2) Ability to ask support questions rational history.
3) The ability to distinguish the presence of risk factors.
4) The ability to transfer a disease or condition that may be causing the problem.
5) The ability to reasonably conduct physical examination.
6) Ability to use sound laboratory and laboratory research in MRA or joint venture.
7) The ability to identify the need for additional studies outside SVP or joint venture.
8) Based on this information the ability to establish the root cause (diagnosis) of the problem.
9) Ability to determine the tactics based on the qualifying characteristics of GPs.
10) The ability to provide non-medical advice.
11) The ability to identify drug treatment based on evidence-based medicine
12) Ability to identify preventive measures at the primary care level.
13) The ability to define the principles of clinical examination and rehabilitation of patients in a
hovercraft or a joint venture.
What the student needs to know to solve the problems of patients with heart noises and cardiomegaly:
№
1
2
3
4
The list of knowledge
The list of diseases that occur with cardiac noise and
cardiomegaly.
A list of the most dangerous diseases that occur with cardiac
noise and cardiomegaly.
The list of states that require management in a hovercraft or
SP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
5
A list of studies requiring in RPP or HP (3-1 category)
6
The list of research areas requiring outside RPP or HP (3.2category)
7
Basic hemodynamic changes in heart diseases
8
The main symptoms of heart failure in a small circle
basic level
The student should know at least
10 of the most common diseases
The student should know at least
5 diseases
According to the characteristics
of the GP qualifying
According to the characteristics
of the GP qualifying
According to the characteristics
of the GP qualifying
According to the characteristics
of the GP qualifying
The student should know:
- Mechanisms of hypertrophy of
the heart
- Signs of compensation and
decompensation
The student must list.
9
The main symptoms of heart failure in a large circle
10
Key points (criteria) diagnosis, occurring with cardiac noise
and cardiomegaly
11
Symptoms of internal organs
12
Signs of heart failure
13
signs of ascites
14
Indicators of laboratory and instrumental methods of
investigation
15
Treatment policy
16
The principles of primary, secondary and tertiary prevention
17
The principles of clinical examination and rehabilitation of
patients in a hovercraft or SP (4-category)
The student must list.
A student must know features
and symptoms of each disease,
and the criteria for their
diagnosis.
Student should know signs of
heart, lung, liver, spleen, kidney.
The student must list the major
manifestations
The student must list the major
manifestations
The student should know:
- Performance standards
The student must know the
techniques and principles of
treatment (including non-drug).
The student should know the
basic activities required for
primary, secondary and tertiary
prevention
The student must list the main
activities for clinical examination
and rehabilitation
What the student should be able to do to solve the problems of patients with heart noises and
cardiomegaly:
list of skills
1
Ask the patient and his relatives
2
Identify risk factors
3
Calculate the index weight / body
4
Measure blood pressure.
5
An inspection of the skin
6
Explore the pulse of the carotid, radial and
femoral arteries
basic level
• The student should be able to ask questions of
rational concise questions that really helps to set
the probable diagnosis.
• The student must be able to specifically identify
and assess the patient's complaints.
• The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the
dynamics of their development.
• The student must be able to analyze the history
of life: identification of risk factors, the health of
parents and family members.
The student must be able to identify unmanaged
and uncontrolled risk factors as on questioning
patient, based on an objective approach
The student must be able to identify features:
- Underweight
- Increased weight.
Student should be able to hold tonometry with the
incremental principle.
The student must be able to detect the presence of:
pale- Cyanosis,
- Icterus,
-the presence of rash
The student must be able to detect:
- The presence or absence of a pulse
The student must be able to evaluate the
7
Conduct palpation, percussion and
auscultation of breath.
8
Palpation of the heart to hold
9
Conduct percussion heart
10
Conduct cardiac auscultation
11
An inspection, palpation, percussion, belly
12
inspect the limb
13
To inspect the bones and joints
14
Examine the thyroid gland.
15
Interpret the clinical and biochemical
16
Interpret the X-ray picture of light
17
ECG and decode it
properties of the radial artery.
The student must be able to assess:
- A tour of the chest
- Voice trembling
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify:
- Cardiac impulse
- Systolic and diastolic tremor
The student must be able to evaluate the apical
impulse.
The student must be able to identify:
- The boundaries of the relative and absolute
dullness of heart
- The boundaries of the vascular bundle
- The diameter of the heart
and waist-configuration of the heart.
The student must be able to identify:
- Signs of hypertrophy of the heart
- Mitral configuration
-aortic configuration
The student must be able to identify:
- Easing I and II Tone
- I gain tone at the top
- Accent II tone of the aorta or pulmonary artery
- Systolic and diastolic murmur, and to identify
their epicenter
Be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
-ascites
The student must be able to identify:
- hepatomegaly
The student must be able to assess:
- All available structures in the abdomen
The student should see the limbs and body, and to
be able to detect:
- Local or generalized edema. Fingers should be
able to put pressure on the dorsum of the foot and
discover:
- There is a pit or not.
The student must be able to detect:
- The presence of the articular syndrome
Student should be able to inspect and palpate the
thyroid gland and identify signs of increase, as
well as to distinguish the degree of goiter
The student must be able to identify features:
- Organ damage
The student must be able to identify features:
- Change the size of the heart
The student must be able to record the ECG with
the incremental principle.
Student should be able to decipher the results of
the ECG and identify signs:
- Hypertrophy of the heart
18
19
Differentiate disease accompanied with
cardiomegaly and heart noise
Give non-medical advice
Rational use of medicines in the treatment of
20 diseases that occur with cardiac noise and
cardiomegaly.
21
Conduct monitoring and surveillance of
patients
- Arrhythmia
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory and
instrumental investigations)
The student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
7. 1. The student should be able to choose
products with proven effectiveness.
8. 2. When choosing drug student should be able
to evaluate:
9. - Efficiency
10. - Safety
11. - Eligibility
12. - Economy.
The student must list the principles of
management and surveillance of diseases that
occur with cardiac noise and cardiomegaly in a
hovercraft, or joint venture.
Practical lesson number 10.
Theme: "Heart sounds and cardiomegaly. Differential diagnosis of the presence of noise at the apex
of the heart. Assessment of functional (myocardial, anemic, changing the blood, fever) and organic
(failure of the mitral valve stenosis, mitral, mitral valve prolapse), heart murmurs. Tactics GPs.
Principles of Teaching Tools. "
Education technology
Study time: 6, number of students 4 hours 08.10
1. Training room.
2. Training aids
The structure of the training session
3. Hospital wards.
4. TV, video equipment, overheyt, multimedia. ECG
machine, a computer with a presentation session.
The goal of lesson: Teach students the differential diagnosis of noise on the apex of the heart (organic and
functional), establishing their causes, and the diagnosis of acquired mitral valvular disease.
Pedagogical objectives:
Learning outcomes:
1. 1. Consider the differential diagnosis
GPs should know:
of noise at the top of the heart (organic
1. The causes of the noise at the top of the heart (organic and
and functional).
functional)
2. Demonstrate patients with noise at the
2. Clinical manifestations of disease with fuktsionalnye noise
top of the heart (organic and functional).
at the top of the heart.
3. Consider laboratory and instrumental
3. Clinical manifestations of disease with organic noises on
studies in the presence of noise at the
the apex of the heart.
apex of the heart (organic and functional). 4. Diagnosis of various diseases with the noise at the top of
4. Teach students Clinical management of
the heart.
patients in the presence of noise on the
5. Differential diagnosis of various types of acquired mitral
apex of the heart (organic and functional).
heart defects.
5. Clarify the indications and
6. Tactics GPs in mitral valvular disease.
contraindications to surgery for mitral
7. Indications and contraindications for surgery.
heart defects.
GPs should be able to:
1. Data analysis and history of complaints for the diagnosis
of diseases with fuktsionalnye and organic noises at the top
of the heart.
2. Diagnose diseases fuktsionalnye and organic noises at the
top of the heart.
3. Differentiated by clinical data and laboratory and
instrumental studies of diseases with fuktsionalnye and
organic noises on the apex of the heart.
4. Tactics of diseases with fuktsionalnye and organic noises
on the apex of the heart in a hovercraft or a joint venture.
Training Methods
Forms of educational activity
Learning Tools
Ways and means of feedback
Lectures, case studies, tests, demonstrations, entertainment
experience, discussion, conversation, learning game
brainstorm.
Individual work, group work, team, classroom,
extracurricular.
Training manuals, handouts, a collection of case tasks and
tests, set EKG.Televizor, video equipment, multimedia.
Quiz, test, presentation of the results of the training task,
filling in outpatients, the implementation of practical skill
"ECG monitoring, decoding ECG"
Theme: "Heart sounds and cardiomegaly. Differential diagnosis of the presence of noise at the apex
of the heart. Assessment of functional (myocardial, anemic, changing the blood, fever) and organic
(failure of the mitral valve stenosis, mitral, mitral valve prolapse), heart murmurs. Tactics of GPs.
Principles of teaching about the "tactics of GPs.
1.
№
Technology chart classes.
Stages of practice session
Forms of training
Duration
225
Place
1
Intro (study subject)
2
Discussion of the topic of practical classes using the new
educational technologies ("three-step interview"), as well as
demonstration material (tables, posters,
rentgenogrammy.EKG), determining the initial level.
3
4
5
conclusion discussion
Job definition for the practical part - professional questions.
Explanation of the provisions and recommendations for the
job to fill history
The development of practical training under the guidance of
a teacher.
6
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients, as
well as research
7
Discussion of the theoretical and practical knowledge of the
students, securing material, the level of learning assessment.
8
Defining output on practical training, evaluation of 100point scale, and ad evaluations. Homework the next practice
session (a collection of questions).
10
Survey, discussion
40
Classroom skills
discussion
10
20
Classroom
Prof. questioning.
Conversation with
patients and filling
medical history, case
studies.
Cardiology,
rheumatology
department clinics
Medical history,
laboratory data
situational problems
20
25
Oral examination, tests,
75
discussion, identification
of practical skills
Cardiology and
rheumatology
department clinics
Information, questions
for homework.
Classroom
25
2. Motivation
Doctor of first contact must identify during routine inspections of patients with noise in the apex of the
heart, which often are a direct sign of heart disease. But these noises can be functional or organic. In this
situation, the effort is directed at clarifying the GP noise causes, diagnosis and establishment types of heart
disease (the presence of organic noises). In the case of diagnosis of heart diseases will decide on the
definition of a group of patients to be treated in a hovercraft or a joint venture, or referral to specialized
hospitals. These and other circumstances are the basis for the inclusion of this subject in the training of GPs.
Intra and in object communication
Anatomy, histology and cytology with embryology and biology, normal physiology, biochemistry,
pathology, physiopathology, topographic anatomy and operative surgery, internal medicine propaedeutics,
radiology and nuclear medicine, physical therapy, endocrinology, faculty therapy, in-hospital treatment.
4.Content of training
4.1 The theoretical part
In the theoretical part of the training series includes:
Cardiomegaly significant increase in the size and mass of the heart. The increase may be one, several or
all of the chambers of the heart. The size and configuration of the heart depends on gender, age of the person,
etc. Therefore, the term "cardiomegaly" is to some extent a relative concept.
Often general practitioners have to deal with conditions and diseases that are accompanied by an increase
in heart size. Therefore, to determine the cause, assess the severity and prognosis, as well as choose the right
medical tactics of the patient is essential.
Many diseases and conditions can cause an increase in heart size.
Reasons kardiomegali true:
Ischemic heart disease, myocardial infarction, myocardial infarction, left ventricular aneurysm,
hypertension, cardiomyopathy, congenital and acquired heart disease, myocarditis, pericarditis.
Myocardiodystrophy caused by diseases of the endocrine system.
Caused by electrolyte disturbances (lack of phosphorus, magnesium).
Chronic lung disease, heart tumors, severe anemia, Mt. kidney failure.
Physiological causes of cardiomegaly
Pregnancy, "the heart of an athlete."
Reasons psevdokardiomegalii
Pericardial effusion, high standing diaphragm (with an increase in intra-abdominal pressure,
hepatomegaly, etc.).
Exudative pleurisy with large amounts of exudate.
Straight back syndrome (lack of physiological curvature of the spine, sunken sternum).
Myocarditis - inflammation of the heart muscle diseases of different etiologies.
Diagnosis of myocarditis.
Based on the presence of clinical symptoms of heart disease and the results of additional research
methods.
1. Peripheral symptoms include pallor, cyanosis of the lips, fever.
2. Symptoms of the cardiovascular system:
• pain relief (long blunt, stabbing pains in the heart of the lack of effect of nitrates);
• Objective evidence of heart disease: the weakening of the apical impulse, expanding the boundaries of
the heart, diastolic gallop rhythm or (and) systolic murmur, voiceless heart sounds, blood pressure reduction,
the violation rate and rhythm of cardiac activity;
• Signs of cardiovascular disease by left ventricular or type (s) for the type of right ventricular (shortness
of breath, swelling of the neck veins, rales over the lungs, liver enlargement, swelling in the legs);
3. Communication with the disease and the availability etiofaktorom prodromal period.
4. These additional methods of research supporting heart disease:
 ECG transient ST-segment changes and tooth T;
 echocardiography and X-ray of the heart - increase the size of the heart;
 acute phase reactant: accelerated ESR, eosinophilia, neutrophilic leukocytosis, an increase of sialic
acid, fibrinogen, positive C-reactive protein, an increase disproteinemia globulin fraction, increased
cardiac isoenzymes.
Anemia - a condition characterized by a decrease in hemoglobin per unit volume of blood. Anemia can be
a separate disease or manifestation or complication of other diseases (syndromes). The causes and
mechanisms of development are different.
Clinical symptoms: 1. Fatigue, decreased performance, dizziness, tinnitus, dizziness, palpitations, loss of
appetite, difficulty in swallowing, impaired menstruation. 2. Pale and dry skin, visible mucous membranes,
hair loss, brittle nails and ischerchennnost, cracks in the corners of the mouth. 3hypotension, tachycardia,
increased left border of the heart, tone deafness, systolic murmur at the apex, reducing the T wave and STsegment.
Mitral insufficiency
Etiology: rheumatic fever, bacterial endocarditis, atherosclerosis, systemic connective tissue disease.
Clinic: Under the compensation no complaints.
In decompensated - shortness of breath, palpitations, irregular and pain in the heart, with the development
of pulmonary congestion - cough, coughing up blood, seizures, cardiac asthma, swelling in the legs,
acrocyanosis, increased painful liver, swelling of the neck veins. On examination: facies mitralis; «heart
hump" (if parkas from childhood), the displacement of the apical impulse to the left - reinforced, poured. For
percussion: increasing the relative dullness of the heart to the left and up. Auscultation: I weakening tone at
the top (to the lack of it), often auscultated at the apex III tone, accent and splitting II tone of the pulmonary
artery systolic murmur at the apex soft blowing or rough touch with a musical based on the severity of
valvular defect, held in armpit, and if the front - left edge of the breast.
Radiography in anteroposterior projection: Fourth rounding arc along the left contour bulging third arc in
the first oblique and left lateral views (the deviation of the esophagus in an arc with a radius greater than 6
cm). Fluoroscopy: a symptom of systolic expansion - with severe mitral regurgitation observed bulging of
the left atrium, where the heart moves contrast esophagus in an arc with a large radius. It is also possible the
phenomenon of bulging left atrial appendage of the heart on the right path, and koromysloobraznoe
movement at the contact with the contour of the LV LP, expanding roots of the lungs with indistinct outlines.
ECG - LVH and LA, left bundle branch block. PCG - reduced amplitude tones over the top I, III takes up
the whole tone of the systole, school linked to I tone decreases.
Echocardiography - discordance movement front and rear doors, signs of fibrosis and calcification. The
increase in speed of the front doors, signs of fibrosis.
Mitral stenosis - narrowing of the left ateroventrikulyarnogo holes (normally 6.4 cm2, the "critical area" 1-1,5 cm2).
Etiology: rheumatism, diseases Lyutembashe component. Under compensation complaints patients may
be absent, decompensated appear dry cough, hemoptysis, palpitations, irregular heart function, swelling in
the legs, stabbing pains in the heart, in severe decompensation - pain and heaviness in the right upper
quadrant, ascites. On examination - "facies mitralis", acrocyanosis, children poor physical development,
infantilism, "heart hump", epigastric pulsation through the right ventricle, the absence of the apical impulse,
diastolic tremor.
Percussion: the border of the heart increased upward and to the right; auscultation: I popping sound over
the top of the heart, click the opening of the mitral valve, the accent II tone of the LA preprotodiastolichesky
noise over the top.
PCG - reinforced with a large amplitude of the tone II aircraft, click open the MC
премезопротодиастолический noise. ECG - LP and RV hypertrophy.
X-ray examination: mitral configuration of the heart when contrast esophagus in the lateral projection, the
displacement of the esophagus in an arc of small radius, oblique arc LV.
Echocardiography - unidirectional motion forward and back forward mitral valves diastole, reduced rate
of early diastolic opening front doors, reduced range of motion anterior leaflet, LV is not expanded, well
lotsiruetsya right ventricle hypertrophy LP, congestion in the pulmonary circulation. The method used to
determine stenosis and the presence of fibrosis and calcification of the valves.
In practice physician recognition of mitral stenosis is primarily based on auscultatory data. However, in
some cases of mitral stenosis it auscultatory signs (LH on top, slapping tone I) may be missing, which is
common in the elderly, atrial fibrillation, and especially when the combination of these factors. In such
cases, the idea of the possibility of MS can occur when listening to the tone of opening MK expressed
dextrogram ECG - a typical configuration for this evil heart. These changes auscultatory paintings can be
weak expression of mitral stenosis or a change of heart muscle due to coronary artery disease. Along with
this, the characteristics of MS auscultatory appear in a number of other pathological conditions. So,
presystolic murmur at the apex is sometimes defined in aortic insufficiency (noise Flint), with tricuspid
stenosis, when the maximum noise can listens projected MK, with severe pulmonary hypertension of various
origins, along with noise-Graham Still. When a mitral stenosis and mitral insufficiency MO area 0.5 cm2,
and no more than 1 cm2, regurgitation wave is negligible. The clinical picture is similar to pure MS. Against
this background, clearly draws attention certain signs of regurgitation: NL top, reinforced apical impulse, I
can clap your tone or impaired, as is typical for MN.
Mitral valve prolapse-bulging, bulging or even reversing one or both leaves the device into the cavity of
the left atrium.
Clinic: Subjective symptoms: pain in the heart, especially during the unrest, not associated with physical
activity, not cropped nitroglycerin are ongoing disruptions in the heart, the heart beat. Auscultation-isolated
mezodiastolichesky or late systolic click, or only late school, or a combination of both. Systolic click and
school increases and decreases in the vertical-horizontal.
ECG may be determined by flattening, or two-humped, or negative T waves in leads II, III, at least in V5V6 and tall T waves in V1-V2. Additional study of PCG and echocardiography.
Tactics of GPs. Treatment own faults can only be surgical. To clarify the indications for this treatment
need timely expert advice-heart surgery. Conservative therapy is reduced to the prevention and treatment of
relapse of the basic process and complications, treatment and prevention of heart failure, as cardiac
arrhythmias. Of great importance are timely and adequate career guidance and job placement patient.
Medical therapy is ineffective. In the later stages - nitrates, calcium antagonists. Perhaps surgery
(commissurotomy, implantation of an artificial valve).
Criteria
cause
Relation to the
phase noise of
cardiac activity
character
for the duration
From the
intensity
Place the best
hearing,
irradiation
treatment
Functional
If any function unaltered valves.
Increase in the rate of blood flow or
decreased blood viscosity:
anemia, changes in blood during
fever, pregnancy.
In most cases, the systolic
Fickle, can appear and disappear at
different positions of the body after
exercise, in different phases of breathing,
gentle blowing.
impermanence
Usually not intense
Listened in a limited area and held
away from the place of origin
does not require
The method of "three-step interview."
The steps are:
All the students are divided into three groups:
- The first group of students - the sick;
- The second group of students - the doctors;
- The third group of students - the experts.
Organic
Anatomical changes in the structure of the
heart valves:
mitral insufficiency,
stenosis of the mitral orifice,
mitral valve prolapse.
Systolic murmur appears with Itonom
during a pause of the heart, it coincides with
the apical impulse and pulse of the carotid
artery.
Diastolic murmur occurs after the tone in
vremyadlinnoy II breaks the heart:
-protodiastolic
-mezodiastolichesky
-presystolic
rough, scraping Peel, sometimes music
Prolonged
Decreasing, and growing
When mitral valve systolic murmur best
auscultated at the apex of the heart, by the
dense muscle of the left ventricle, he may
be held in axillary area, or in the course of
reverse blood flow from the left ventricle
into the left atrium: the second and third
intercostal space up along levogokraya
sternum.
Mitral stenosis auscultated diastolic murmur
in a limited area in the top
serdtsa.provodnoy the armpit.
With mitral valve prolapse - late systolic
murmur - click.
Treatment of underlying disease.
Each group consists of three students, distributed as follows: "doctor", "sick", "judge - general
practitioner."
"Patient" to anonymously report a diagnosis, each group for 10-15 minutes has been discussing. "Expert"
- doctor evaluates students' actions as "sick" and "doctors" and brings to the table:
- Was done correctly;
- What went wrong;
- As it should be done.
Doctor - to collect complaints, medical history by questioning, an inspection, palpation, percussion,
auscultation patient. Based on the data collected to be able to set the diagnosis, make a differential diagnosis
and justify the final diagnosis.
In addition, the physician should sensitization explanation that this disease, the impact of social aspects of
life, the value of nutrition and long-term treatment in this disease.
Expert advice in the map show the stages of discussion, and the time during which the work is carried out.
After the end of the work done by the expert evaluation of the activities. Publicly announced the findings
of the group.
The maximum score
20-19
excellent
18-17 score
16-15 score
14-13 score
12 score
good
satisfactory
not
satisfactory
53%-46%
bad
100%-86%
85%-73%
70-56%
43% or less
4.2.Analitical part
4.2.1. Case studies:
1. Patient, 37 years old, asked the GP complaining of fever to 38.50 for 2 weeks of shortness of breath,
palpitations, with little physical. stress, pain in large joints, leading to swelling in the legs. From history: over
20 years suffer from rheumatism. In the last 2 years were impaired heart rate. On examination: the general
state of moderate severity. Auscultation in the lower parts of both lungs auscultated fine moist rales.
Respiratory rate is 24 per minute. Heart-tones are muted, arrhythmic, systolic and diastolic murmur at the
apex, HR -132, -110 pulse beats min., BP 90/60mm.rt.st. On the ECG P wave is absent. Electrical axis
rejected right. Distance RR different from V1 to V6 negative prong T.
1. Your proposed full diagnosis;
2. What research is needed to confirm the diagnosis;
3. List at least three functional characteristics of noise;
4. The differential diagnosis
5. Introduction tactic to the patient
6. List the main groups of drugs used for the treatment of this patient evidence-based medicine.
_____________________________________________________________________________________
2. Patient 19 years. Concerned about joint pain, shortness of breath and palpitations on exertion, dry
cough at night, fever. Since childhood suffering xp. tonsillitis. On-no: Skin pale blush on shekah, cyanosis of
the lips, acrocyanosis. In the lungs, the weakening of vesicular breathing in the lower single wet finely
wheezing. Heart borders expanded to the top right. Auscultation: heart sounds are muffled, on top of
clapping I tone protodiastolic noise, stress and II split tone on the pulmonary artery. Heart rate and heart rate
- 120 beats / min, regular, blood pressure 90/70 mmHg Abdomen soft and painless. The liver and spleen
were not palpable.
1. Your proposed full diagnosis;
2. What research is needed to confirm the diagnosis;
3. List the types of noise and diastolic time the appearance of relative heart sounds;
4. Tactics and the introduction of patient treatment.
________________________________________________________________________________
3. Patient 25 years. Complaints: palpitations, stabbing pains in the heart, shortness of breath on exertion,
pain and swelling in large joints. In history - frequent colds. On-no: state rather satisfactory. In the lungs,
vesicular breathing, no wheezing. Heart borders expanded to the left. Auscultation: on top of the weaker tone
and I systolic murmur, which takes place on akssilyarnuyu area, accent II tone in the pulmonary artery, pulse
84 beats / min. BP 120/70 mmHg The abdomen is soft and painless. The liver and spleen were not palpable.
KLA: hemoglobin 110 g / L, erythrocyte 3.8 h1012 / l Lake. 9.5 h109 / l, erythrocyte sedimentation rate 30
mm / hour. Seromukod - 100 mmol / L, ASO -1:500 AE.
1. List at least five diseases are accompanied by functional and organic noises in the apex;
2. Your prospective diagnosis;
3. Survey plan;
4. Tactics GPs and treatment.
__________________________________________________________________________________
4. 35 year old woman turned to the GP complaining of intermittent, stabbing pains in the heart,
palpitations, feeling short of breath during emotional or physical stress, fatigue, dizziness. Anamnesis:
suffering xp. pyelonephritis. Married. 4 of pregnancy and childbirth. On-no: state rather satisfactory. In the
lungs, vesicular breathing, no wheezing. The boundaries of the heart: the right to the right edge of the
sternum, upper III intercostal space on the left, the left by 1 cm medially from the left midclavicular line V
intercostal space. Auscultation: heart sounds are muffled, on top of a short systolic murmur. Pulse 78 beats /
min. BP 100/60 mmHg The abdomen is soft and painless. The liver and spleen were not palpable. KLA:
hemoglobin 86 g / l, erythrocytes 2.6 h1012 / l Lake. 6.5 h109 / l, erythrocyte sedimentation rate 12 mm /
hour.
1. List at least five diseases are accompanied by the above listed symptoms;
2. Your prospective diagnosis;
3. What additional laboratory tests must be carried out to confirm the diagnosis;
4. Tactics GPs and treatment.
__________________________________________________________________________________
5. 28 year old man turned to the GP with complaints: for long compressive pain in the heart during the
unrest, not related to physical activity and not cropped nitroglycerin, palpitations, shortness of breath on
exertion. Until now considered themselves healthy. Sports. On-no: satisfactory condition. In the lungs,
vesicular breathing, no wheezing. The boundaries of the heart in the aisles norm. Auscultation: sounds are
clear, late systolic murmur at the apex. Pulse 80 beats / min. BP 120/70 mmHg The abdomen is soft and
painless. The liver and spleen were not enlarged. No peripheral edema.
1. List at least five diseases are accompanied by the above listed symptoms;
2. Your preliminary diagnosis;
3. Specify bloodless instrumental examination to confirm the diagnosis;
4. The changing nature of systolic murmur depending on the position of the patient;
5. Tactics GPs.
___________________________________________________________________________________
6. Patient S. 42, welder. Complaints about the fever, chills, pain in the left side of the chest, shortness of
breath, cough with rusty sputum. The disease is linked with hypothermia at work 2 days ago. On-no: the
patient of moderate severity. Cyanosis of the lips, blush on his left cheek. Temperature of 39.20 C. On the
left chest is lagging behind in the act of breathing, voice trembling hard, determined dullness to percussion
lung sounds below the angle of the scapula. Auscultation: gentle crackles. Respiratory rate 30 per minute.
Heart tones sounding, systolic murmur at the apex, the accent II tone of the pulmonary artery. Arrhythmic
pulse through ekstrasistolly, 120 beats / min. KLA: Hb-130 g / l., Er.-4 5h1012 / L, CP-0, 9, L-17, 0 h109 / l,
e-2% p/ya-8% s/ya- 76% limf. 10%, ESR-36 mm / hour.
1. Your reservation is complete diagnosis;
2. List at least 3 diseases, which auscultated accent II tone of the pulmonary artery;
3. Additional methods of research;
4. Tactics of GPs and treatment.
_____________________________________________________________________________________
7. 72 year-old patient complained of shortness of breath, palpitations, with little physical. load, recurrent
pain in the heart, headaches, dizziness, tinnitus, mild swelling in the legs. Of history in the last 3-4 years,
says high blood pressure to 180/90 mm Hg, then takes 1 tablet. Adelfan. Previously considered themselves
healthy.
On-no: The general condition rather satisfactory. Integuments clean, pale pink. Above the light vesicular
breathing, no wheezing. The boundaries of the heart enlarged to the left. Heart sounds are muffled, rhythmic,
systolic murmur at the apex and the aorta. Heart rate and heart rate 80 beats / min. The liver and spleen were
not palpable.
1. Your complete a preliminary diagnosis;
2. Additional methods of research;
3. List at least three diseases in which the observed increase in systolic blood pressure (a) and a systolic
murmur at the apex (b);
4. GPs tactics and principles of treatment.
The maximum score
20-19
excellent
100%-86%
18-17 score
16-15 score
14-13 score
12 score
good
satisfactory
bad
85%-73%
70-56%
not
satisfactory
53%-46%
43% or less
Tests.
1. With the combination of the prevalence of mitral valve lesion failure does not occur:
a) I gain tone
b) the weakening of the tone I
c) the presence of a pathological III tone
g) was poured, reinforced, shifted to the left and down the apical impulse
d) the presence of regurgitation systolic murmur at the apex, which is done in the axillary region
2. By X-ray prizakam mitral stenosis does not include:
a) smoothed waist heart (bulging II and III of the arcs on the left)
b) the deviation of the esophagus, barium contrast, in the left side and in the 1st oblique position at the
level of the left atrium
c) shading retrokardinalnogo uvedicheniya space because the left ventricle
d) the restriction of the retrosternal space because of right heart
d) expansion of branches of the pulmonary artery
3. Flint noise is accompanied by:
a) mitral insufficiency
b) aortic stenosis
c) tricuspid insufficiency
d) pronounced aortic insufficiency
e) pulmonary stenosis
4. Pansystolic noise, worse on inspiration (noise Rivero - Carvallo), characterized by:
a) for mitral insufficiency
b) for tricuspid insufficiency
c) for aortic stenosis
d) for aortic stenosis
e) for pulmonary artery stenosis
5. Tachyarrhythmias most complicated:
a) mitral stenosis
b) stenosis of the aortic
c) tricuspid insufficiency
d) coarctation of the aorta
e) mitral insufficiency
6. The most characteristic feature of mitral stenosis
a) 1-popping color and noise at the top protodiastolic
b) systolic murmur and relaxation of the 1-tone at the top
c) left ventricular hypertrophy
d) left bundle branch block
d) focus 2-tone of the aorta
7. Surgical treatment is indicated in square holes mitralgo
a) 0.5 cm ²
b) 1 sq. cm
a) 1.5 cm ²
d) 2 cm ²
d) 4 cm ²
8. Arrhythmia characteristic of mitral stenosis
a) fibrilloflutter
b) the migration of the pacemaker
c) supraventricular ekstrasistoltya
g) AV-blockade
e) bundle-branch block blockade
9. Auscultatory sign of mitral valve insufficiency
a) systolic murmur at the apex of the heart
b) I-gain tone at the top
c) the rhythm of quail
d) gallop
e) protodiastolic noise at the top
10. Not typical of mitral stenosis
a) severe heart waist
b) atrial fibrillation
c) pulmonary hypertension
d) hemoptysis
d) the weakening of the first tone
e) systolic murmur at the apex of the heart
11. Auscultatory sign of failure is not characteristic of the MC
a) presystolic murmur at the apex
b) reducing the I-Tone at the top
c) II-tone emphasis on the pulmonary artery
d) irradiation of noise in the left armpit
e) 1-slapping tone at the top
e) the rhythm of quail
12. Not typical of mitral stenosis:
a) systolic murmur of the aorta
b) right ventricular hypertrophy
c) Pulmonary Hypertension
d) atrial fibrillation
e) left ventricular hypertrophy
e) systolic murmur at the apex
13. Auscultation patient mitral stenosis is not typical:
a) systolic murmur at the apex
b) I-slapping tone at the top
c) emphasis II-tone of the aorta
d) click opening of the mitral valve
e) systolic murmur at the apex
e) diastolic murmur of the aorta
14. A patient 42 years. Anamnesis: sickly chronic tonsillitis. OBJECTIVE: cyanosis on the lips. The
boundaries of the heart enlarged to the left. Auscultation at the top of the weakening of I-tone, systolic
murmur, which is held in the left armpit, accent II-tone on the pulmonary artery.
15. For what heart disease is characterized by these changes?
a) mitral stenosis
b) aortic stenosis
c) mitral insufficiency
d) aortic insufficiency
e) pulmonary stenosis
16.What is the characteristic of ECG:
a) RV1> R2> RV3
b) R3> R2> R1
a) R2> R1> R3
g) R1> R2> R3, deep Q wave
d) R1> R2> R3, R teeth missing
17. Tactics of GPs:
a) consulting cardiologist
b) physiotherapy
c) consulting cardiologists
d) treatment and supervision in a family health center (rural medical centers)
d) forward to the MLEC
18. A patient 30 years appealed to the GP complaining of discomfort in the region of the heart,
palpitations, shortness of breath, a feeling of heaviness in the right hypochondrium, expressed acrocyanosis,
swelling in the legs, objectivity: the borders of the heart shifted to the right and up. At the top I flapping tone,
systolic and presystolic noise, accent II tone on the pulmonary artery. The liver performs at 3 see CBC: Hb90, E-3, 1; SOE-10mm/chas
19. What is a heart disease patient:
a) mitral stenosis and insufficiency
b) the failure of the mitral valve
c) mitral valve stenosis
d) aortic valve regurgitation
e) ventricular septal defect
20. What complications in patients:
a) NC II B
b) NC I
a) NC II A
g) NC III
21. What are the changes of rhythm are possible in the patient:
a) atrial fibrillation
b) paroxysmal tachycardia
c) bundle-branch block
d) complete AV block
d) WPW syndrome
Maximal ny score
20-19 points
Excellent
100%-86%
18-17 points
16-15 points
14-13 points
12 points
Good
85%-73%
satisfactory
70-56%
not satisfactory
53%-46%
bad
43% or less
4.2.2. Graphic Organizer: Conceptual table
• Conceptual table provides a comparison of the phenomena, concepts, attitudes, etc., with the same two
or more aspects.
• Develop systems thinking, the ability to structure. Organize information.
Acquainted with the rules of the conceptual table. Determine what not compare, distinguish the
characteristics that will be a comparison.
Individually or in mini-groups build and fill the table conceptual
• Vertical is that not compare
• Horizontal - different characteristics that are compared.
diastolic and
Diastolic
systolic
Noise at the top
Associated
malformations
Mitr.otverst stenosis.
Prolapse Met. Valve
The group is divided into two small groups, the participants each small group evaluate the work of a small
group of other students. Each correct answer is worth 15 points.
Group
№
Correct and
clear answer (5)
visibility (5)
announcemen
t of
regulation
(2,5)
Most
members of
the group
(2,5)
Total
points
1.
2.
Maximal ny score
20-19 points
Excellent
100%-86%
18-17 points
16-15 points
14-13 points
12 points
Good
85%-73%
Satisfactory
70-56%
Not satisfactory
53%-46%
bad
43% or less
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
• Professional questioning
• percussion and auscultation of the heart
Objective: To teach the students ability to come into contact with patients mitral valvular disease,
methods of ethics. Improve the skills of percussion and auscultation of the heart.
Unfulfilled
Fully complied
№ Stages
1
Greet the the patient respectfully and kindly, ask to stay
comfortable. Introduce yourself to the patient.
2
Find out the cause of treatment: the availability of
complaints, routine inspection
3
Collect history:
• the name, age, marital status;
• complaint; hereditary diseases;
• illness in the family, past illnesses;
• the existence of bad habits;
• duration of the disease and its course;
• what inspection took place
• what kind of treatment received
4
Explain that this information is useful to you in order to
help choose the method of the study, while ensuring
confidentiality.
5
Spend a clinical examination of the patient:
physical examination, palpation, percussion;
auscultation.
6
Select the advanced research methods on the testimony:
• ECG;
• EHOKS;
• R spectroscopy of the chest with contrast of the esophagus;
• Complete blood and urine tests.
• acute-phase sample.
7
Tell the patient about the existing methods of studying
the disease briefly, explaining his choice.
8
Ask the patient to repeat the instructions to ensure proper
assimilation of information. Politely say goodbye to the
patient and assign the next visit.
Total
(0баллов)
0
(100балл)
10
0
10
0
20
0
10
0
20
0
10
0
10
0
10
0
100
5. Control forms of knowledge, skills and abilities
- Oral
- Decision of situational problems
- Demonstration of practical skills
- CDS
6. The evaluation criteria of the current control
Rating
Levels of estimates
Characteristics of the student
points
Point of presence on the practical session. Complete
lack of knowledge and ability to perform practical
20
skills - the student is not ready for the practical
sessions.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge
and skills, at least one of the following:
• Do not know the clinical signs of disease with
functional noise on top.
• Do not know the clinical manifestations of disease
20 –
Not satisfactory
with organic noise on top of the heart.
54,9
• Do not know the causes of noise on top.
• Do not know the diagnosis of various diseases with
noise on top.
• Can analyze data complaints and history of diseases
with functional and organic noise on top of the heart.
Satisfactory
55-70,9%
• Not able to build a rational history during
supervision of patients.
• During Supervision is not able to objectively assess
the condition of patients.
• Do not rationally be able to plan a survey of patients
in a hovercraft or a joint venture.
Providing basic knowledge and skills
Satisfactory answer to poor quality.
The student tries to hold the basic levels of
55-60,9
knowledge and skills (see below), but when replying
or performing skills make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see
61-65,9
below), but when replying or performing skills make
mistakes (subject to certain errors
Satisfactory answer quality.
The student is wholly owned by the basic levels of
knowledge and skills:
• Know the clinical signs of mitral stenosis, mitral
valve insufficiency, mitral valve prolapse.
• Can differentiate between different types of
acquired mitral for subjective, objective, and
laboratory and instrumental data
• Able to build a rational history during the
Supervision of patients with acquired heart disease.
• During Supervision able to objectively assess the
66-70,9
condition of patients with heart defects.
• Can interpret the results of laboratory and
instrumental methods of research - may indicate the
presence of hypercholesterolemia, leukocytosis,
elevated IBS and ESR.
• Can show the technique of ECG recording
• Able to efficiently make a plan of examination of
patients with defects in a hovercraft or a joint
venture.
• Able to correctly fill in the patient diary.
Advanced knowledge
71-75,9
Good
76-80
71-85,9%
81-85,9
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has
the following knowledge and skills:
• Know the classification of defects
• Know the tactics of GPs in mitral defects.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge
referred to in paragraph "71-75,9", and also owns the
following knowledge and skills:
• Know the indications and contraindications for
surgical treatment.
• Knows the principles of primary, secondary and
tertiary prevention.
The student is fully owned baseline knowledge and
skills (see above) + the knowledge referred to in
paragraph "71-75,9" and "76-80" and has the
following knowledge and skills:
• Principles of management, supervision and
monitoring of patients with defects in a hovercraft or
a joint venture.
86-90
Excellent
91-95
• Able to hold a consultation on the boards of nondrug and drug using IPC skills.
• Principles of clinical examination and rehabilitation
of patients with defects in a hovercraft or joint
venture
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge
referred to in paragraph "81-85,9", and also owns the
following knowledge and skills:
• Know the indications and contraindications for
angiography
• Is able to provide reliable information about the
evils of the Internet on the basis of data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge
referred to in paragraph "86-90", and also owns the
following knowledge and skills:
• Can be monitored in a hovercraft or a joint venture.
86-100%
96-100
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge
referred to in paragraph "91-95", and also owns the
following knowledge and skills:
• provide scientific data from the literature (articles
and internet)
• Knows the indications and contraindications for
stenting and CABG
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle of
"security" for the patient.
7. Control questions
1. Aetiopathogenesis mitral valvular heart disease.
2. Clinic and diagnostic criteria for mitral stenosis.
3. Clinic and diagnostic criteria for mitral valve insufficiency.
4. Clinic and diagnostic criteria for mitral valve prolapse.
5. Differential diagnosis of functional and organic noises in the apex of the heart.
6. Indications and contraindications for commissurotomy.
7. Tactics GPs in mitral valvular disease.
8. Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8.Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
9. Chronological content of classes
Time
Event
Content
8.30– 9.30
Morning
conference
Report man on duty of doctor
and man on duty cubordinator
on maintenance stand .
9.15-10.00
Clinical audit is
written out sick.
10.05-10.45
Theoretical
analysis of the
topic
10.45 -11.05.
Study of practical
skills.
11.05-11.45
Curation of
patients
The Department
of Cardiology
and Cardiac
A detailed report of the
student prescription
patients.
Checking the initial level of
preparedness of students
using the "tour of the
gallery," and the decision of
the situational problem.
Students heard case studies
on the topic, and they need
to analyze and give an
opinion.
Student under the supervision
of a teacher must complete
at least two practical skill.
Each student is supervised by
a particular patient wards.
11.45-12.15
12.20-13.20
break
Analysis of casepatients
At the choice of the teacher
conducted a full
examination of the patient
on the theme of
employment or patients
preparing for discharge,
data analysis, laboratory
and instrumental studies,
the rationale for the
preliminary and final
clinical diagnoses.
Determined by the
treatment plan with the
doses of drugs.
Materials
The report of the
doctor on duty and
off duty on duty
subordinators
Duration of
training
1 hour
45 minutes
Case studies,
educational boards,
tables,
corresponding to a
subject class.
40 minutes
The patient or
volunteer.
20 minutes
The patient,
40 minutes
stethoscope,
sphygmomanometer
, medical history
(with data of clinical
and laboratory
findings).
30 min.
Sick, stethoscope, 1 hour
blood pressure
monitor, medical
history (data of
clinical and
laboratory research).
Practical lesson 11.
Theme: "Heart sounds and cardiomegaly. Differential diagnosis in the presence of noise in the
aorta. Acquired aortic valves (rheumatic fever, infective endocarditis, atherosclerosis) and the aorta.
Tactics GPs. The principles of treatment, follow-up, control and rehabilitation in a hovercraft or a
joint venture. The principles of prevention. The principles of teaching topics.»
Technology of the education
Study time: 6,4 hours
The structure of the training session
Number of tourists 8-10
1. Training room.
2. Training aids
3. Hospital wards.
4. TV, video equipment, computer, overheyt, multimedia.
5. Complete sets of tables, guidelines, video;
3. TCO:.
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis, selection
of the optimal treatment strategy options for acquired aortic valvular disease of various etiologies, and
principles of management of patients in primary care, provided the requirements of the "Qualification
characteristics of the GP"
Pedagogical objectives:
Learning outcomes:
1. Consider the diagnosis and differential
The general practitioner (GP) should know:
diagnosis of acquired aortic heart
GPs should be aware of:
defects (isolated and combined,
1. Clinical manifestations of acquired aortic heart defects.
rheumatic, septic, sclerotic).
2. Diagnosis of various types of acquired aortic heart
2. Demonstrate patients with acquired
defects.
aortic heart defect.
3. Differential diagnosis of various types of acquired
3. Clinical and laboratory data and
heart disease.
research tools in the diagnosis of
4. GP tactics for aortic valvular disease (isolated and
acquired aortic heart defects (isolated
combined, rheumatic, septic, sclerotic).
and combined, rheumatic, septic,
5. Indications and contraindications for surgical
sclerotic).
treatment.
4. Explain the indications and
6. The principles of treatment (medication and noncontraindications for surgical treatment
medication) in these diseases.
for aortic valvular disease.
7. Principles of follow-up and monitoring of patients in a
5. Discuss questions about tactics in the
hovercraft, or joint venture.
qualifying characteristics of GPs
8. The principles of primary, secondary and tertiary
6. Discuss the principles of treatment
prevention in these diseases.
(medication and non-medication).
7. Discuss the principles of management,
GPs should be able to:
supervision and monitoring of patients
1. Analyze the data and history of complaints for the
in a hovercraft or a joint venture.
diagnosis of acquired aortic heart defects.
8. Discuss the principles of primary,
2. Diagnose aortic valvular heart disease.
secondary and tertiary prevention in these
3. Differentiated by clinical and laboratory data of
diseases.
instrumental studies acquired aortic valvular heart disease
(isolated and combined, rheumatic, septic, sclerotic).
4. Choose drugs with proven efficacy
5. Advise on non-drug therapies.
6. To monitor in a hovercraft or a joint venture.
Lecture, case studies, tests, demonstration, entertainment
Training methods
experience, discussion, conversation, brainstorming
training game.
ndividual work, group work, team, classroom,
Forms of educational activity
extracurricular.
Training manuals, handouts, a collection of case tasks
Learning tools
and tests, set EKG.Televizor, video equipment,
multimedia.
Quiz, test, presentation of the results of the learning task,
Methods and feedback means
filling medical history, perform a practical skill "ECG
monitoring, deciphering ECG"
Technology chart classes
"Heart sounds and cardiomegaly. Differential diagnosis in the presence of noise in the aorta.
Acquired aortic valves (rheumatic fever, infective endocarditis, atherosclerosis) and the aorta. Tactics
GPs. The principles of treatment, follow-up, control and rehabilitation in a hovercraft or a joint
venture. The principles of prevention. The principles of teaching topics. »
№
Stages of the practice session
Forms of employment
Venue
1
2
3
4
5
Chapeau (justification themes)
Discussion of the topic of practical classes
using the new educational technologies ("threestep interview"), as well as demonstration material
(tables, posters, rentgenogrammy.EKG),
determining the initial level.
Conclusion of discussion
Job definition for the practical part professional questions. Explanation of the
provisions and recommendations for the job to fill
history
Interpretation of the survey data of patients,
complaints, inspection, palpation, percussion,
auscultation of patients
7
Discussion of theoretical and practical
knowledge of the students, securing the material to
determine the level of assimilation of knowledge
assessment.
40
Classroom skills
discussion
10
20
Classroom
The development of practical training under the
Prof. questioning.
guidance of a teacher.
Conversation with patients
and filling medical history,
case studies.
6
8
The survey, discussion
During of
training
225
10
Cardiology,
rheumatology department
clinics
History of illness,
laboratory data situational
problems
Oral examination, tests,
discussion, identification of
practical skills
Cardiology and
rheumatology department
clinics
Information, questions for
homework.
Classroom
20
25
75
Defining output on practical training,
25
evaluation of 100-point scale, and ad evaluations.
Homework next practice session (a collection of
questions).
1. Motivation
Doctor of first contact must identify during routine examinations of patients with noises in the heart,
which are often a direct sign of heart disease. In this situation, the force directed to the SPM and establishing
diagnostics varieties of heart disease. In the case of diagnosis of heart diseases will decide on the definition
of a group of patients to be treated in a hovercraft or a joint venture, or referral to specialized hospitals.
These and other conditions are the basis for the inclusion of this subject in the training of GPs.
Intra 3.Mezhpredmetnye and communication
Anatomy, histology and cytology with embryology, biology, normal physiology, biochemistry,
pathological anatomy, pathological physiology, topographic anatomy and operative surgery, propaedeutics
internal medicine, radiology and nuclear medicine, physiotherapy, cardiology, endocrinology, faculty
therapy, in-hospital treatment.
4. The content of classes
4.1. The theoretical part
Aortic stenosis.
Etiology: rheumatic fever, bacterial endocarditis, atherosclerosis, congenital aortic stenosis. Pathological
substrate: fusion and seal the valve leaflets and the deposition of calcium salts in them.
Pathogenesis: The obstruction to blood flow from the left ventricle leads to an early left ventricular
hypertrophy.Clinic: Under no compensation subjective manifestations. Decompensation complaints of
dizziness, syncope, angina. By reducing the contractility of the left ventricle - the heart attacks of asthma.
Inspection: pale skin and mucous membranes, lift the apex beat, shifted to the left and down. Systolic jitter in
the second intercostal space to the right of the sternum in the chest, reinforced cardiac impulse, increasing its
area, shift down and to the left. Small slowly rising pulse rate, decreased blood pressure (especially
sistoldichesky) and pulse pressure. Auscultation: a rough school of the aorta and at Botkin with holding onto
the carotid artery, the interscapular region, jugular fossa, better heeded in the horizontal position on the
exhale. I weakening tones on top, weakening or disappearance of II tone of the aorta.
PCG: diamond NL aorta, reducing II tone of the aorta, reducing the I tone at the top.
ECG-LVH and overload syndrome of the left ventricle.
Radiologically - aortic configuration of the heart, increased left ventricular limited poststenotic
enlargement of the ascending aorta, the slow ripple voltage at fluoroscopy.
Echocardiography-thickening of the aortic valve with multiple echoes in them, reducing systolic
differences between the valves systole, the detection of LVH and the back of the left ventricular end-diastolic
dimension of the cavity for a long time remained normal.
To recognize the defect is of great importance in the detection of secondary school II intercostal space,
and sometimes in groups I and III intercostal space to the right of the sternum is especially true systolic
tremor in the same area. II tone is weak, and the maximum is determined by the noise at the top or at the left
edge of the sternum, which requires differentiation of MK deficiency, microlight, VSD. In such cases, helps
careful auscultation and echocardiography and PCG. In contrast, MN, in aortic stenosis, I kept the tone at the
top, and II tone of the aorta is weakened, School rough, diamond-shaped, as opposed to decreasing noise
mitral regurgitation.
In contrast to the ALS II in aortic vice tone weakened the aorta, not the aircraft.
When Ro-increasing study of the left, not the right ventricle. In contrast, ventricular septal defect, aortic
stenosis at school is held on the neck vessels, II tone of the aorta is weakened.
School can auscultated: atherosclerosis of the aorta caused by hypertension, syphilis or failure of the
aortic valve. In these cases, the school is not rude, usually short, not enhanced in the mid-systole, II tone
saved.
Aortic insufficiency - a pathological condition in which the semilunar valves do not close completely
during diastole, the reverse flow of blood from the aorta into the left ventricle.
Substrate - deformation of semilunar valves or expansion of the fibrous ring.
Etiology: rheumatic heart disease, syphilis, atherosclerosis, aneurysm of the aorta.
Clinic: Subjectively, sensations, tremors, pain in the heart, pulsation of the neck, head, headache,
dizziness, fainting; decompensation - shortness of breath, pain in the right upper quadrant, swelling, and
fatigue. Inspection: pale skin, decompensated - acrocyanosis, swelling in the legs, shortness of breath,
pulsation of the large arteries, rocking the head (symptom Musset), tremor and systolic retraction or
undulating movement of the chest wall to the heart, contraction of the pupil during systole and diastole in the
expansion of (a symptom Landolfi), capillary pulse. Palpation of the heart - an energetic, resistant,
ascending, a dome-shaped apex beat 6-7 intercostal space, the expansion of the boundaries of the heart to the
left and down.
Auscultation: diastolic murmur in II intercostal space to the right of the sternum or at Botkin. School
relative aortic stenosis auscultated the right of the sternum I weakening tone at the top and the weakening II
tone of the aorta. You can identify presystolic noise Flint. Auscultation of the femoral artery bugged dual
tone Traube, with compression of the artery - a double noise Vinogradova - Duroziez. Pulse, fast rising and
falling, high pulse pressure, diastolic pressure.
PCG - high frequency diastolic murmur, decreasing, starting directly from the II tone, with the epicenter
at Botkin, School of the aorta, reducing the I tone at the top, decrease II tone of the aorta.
ECG-LVH, deep Q wave in the left chest leads, LP and left ventricular overload.
Ro - spectroscopy of the chest: aortic configuration of the heart, increased left ventricular enlargement of
the ascending aorta, deep and fast ripple left ventricle and the aorta.
Echocardiography - increased LV cavity, increased trips septal infarction and left ventricular posterior
wall, increasing the diameter of the aortic root. In the lumen of the aorta during diastole there is a lack of
diastolic closing of the valve leaflets, and flutter. Increasing the amplitude of motion of the walls of the aorta,
changing the shape of the front MK mitral leaflet in diastole and its vibration.
The combination of aortic valve insufficiency and aortic stenosis.
Rheumatic aortic heart disease is most often a combination of aortic stenosis and aortic insufficiency.
This combination of auscultation determined systolic and diastolic murmur at Botkin and in II intercostal
space on the right.
NL rough timbre, held in the jugular fossa and carotid artery. Can be determined by palpation systolic
jitter II intercostal space to the right of the sternum.
I and II tones attenuated. ECG - signs of left ventricular hypertrophy with ST changes and T-wave in
leads I, AVL, V5, V6. All direct and indirect symptoms are not always able to help your doctor decide on the
prevalence of stenosis or insufficiency. Significantly greater blood pressure information is provided by the
study. In the case of prevalence of aortic regurgitation it is reduced, a decrease in diastolic blood pressure
and heart rate characteristic changes. When X-ray - increased pulsation of the aorta and left ventricle, aorta
diffusely enlarged. With the predominance of stenosis diastolic pressure is normal, pulse is not significantly
changed. On the X-ray - a local expansion of the ascending aorta-poststenotic; pulsation of the distal aorta.
More accurate information about the prevalence of stenosis or insufficiency may be obtained by
echocardiography, angiocardiography.
Differential diagnosis of aortic defects
Recognition failure of the aortic valve is usually straightforward when diastolic noise at Botkin or the
aorta, increasing the LV and certain peripheral symptoms of this defect (high pulse pressure, increasing the
pressure difference between the femoral and brachial arteries of 60-100 mm. Hg, characteristic change rate).
However LH and the aorta at Bodkin may be functional, such as uremia. When combined valvular disease
and aortic insufficiency small defect detection difficult. In these cases, echocardiography helps - study
dopplerkardiografiey. The greatest difficulties arise in determining the etiology of vice.
Rheumatic fever: the frequent combination with mitral and aortic stenosis.
Bacterial endocarditis: the appearance of other signs of endocarditis.
EchoCG existence of another wrinkle to the development of aortic insufficiency.
Syphilis: the formation of defect in 10 -25 years after infection, and other manifestations of syphilis, a
positive Wassermann reaction.
Also conduct a differential diagnosis with diseases such as congenital aortic valve double door,
ankylosing spondylitis, Reiter's syndrome, SLE, SSc, chest trauma, atherosclerosis of the aorta, aortic
aneurysm, Marfan syndrome, nonspecific aortoarteriit.
Infective endocarditis IE-inflammatory infection of the endocardium, characterized by the localization of
the pathogen on the valves of the heart, at least in the near-wall-endocardium and accompanied, as a rule,
bacteremia and failure of various organs and systems.
Classification of IE
1.Etiologic characteristics: Gram-positive bacteria (streptococci, staphylococci), gram-negative bacteria
(Escherichia coli, Pseudomonas aeruginosa, Klebsiella, Proteus), bacterial coalition, L-shaped fungi
(Candida, Histoplasma capsulatums, Aspergillus), coxsackie viruses.
The pathogenic phase of infectious and toxic, immunological, dystrophic.
2.Stepen activity: high (III), moderate (II), the minimum (I).
3.Variant flow: acute, subacute, abortifacient (recovery), chronic (recurrent).
4.Kliniko-morphological form: primary (on intaknyh valves), secondary (against defects).
5.Veduschaya organ pathology: Cardiac: myocardial infarction, vice, myocarditis, arrhythmia, NC.
Vessels: gemorogii, vasculitis, thromboembolism. Kidneys: diffuse or focal nephritis, kidney failure. Liver:
hepatitis, cirrhosis. Spleen: enlarged spleen, heart attack, an abscess. Lightweight: pneumonia, heart attack,
an abscess. Nervous system: meningoentsifalit, hemiplegia, brain abscess.
Clinical symptoms:
1. Fever with chills and sweating. 2. Severe intoxication: fatigue, anorexia, headache, myalgia, arthralgia,
weight loss. 3. Skin pale - yellow, defined petechiae, symptom-Lukin petechiae on the conjunctiva of the
lower eyelid, Janeway spots, red and purple to 5 mm diameter spot on the hands, feet, torso, Osler nodes the size of a pea on the palmar and plantar surfaces. 4. Clubbing ("drumsticks") and nail ("hour glass"). 5.
Auscultation of the heart: the most important feature of developing endocarditis - protodialichesky sound,
best heard at Botkin in the vertical position of the patient or on his left side. The noise at the beginning of a
soft, short, intermittent, in a subsequent longer acquiring sawing character. Musical character of the noise
(screeching-like squeak) indicates perforation or avulsion aortic valve. Often, the first sign of endocarditis is
auscultatory systolic murmur at Botkin due polypous vegetations on the aortic valve. With the development
of IE on the background of already formed rheumatic there are new sounds that were not there before. In the
primary IE highest in frequency is isolated valvular insufficiency of the aortic valve, the second - combined
lesion aortic and mitral valves, the third - isolated mitral valve disease. In secondary IE against rheumatism
highest in frequency belongs to the defeat of the combined aortic and mitral valves, the second - isolated
mitral valve disease. 6. Thromboembolism: emboli in the splenic, renal, pulmonary, coronary, cerebral
arteries, and others with the development of myocardial relevant authorities. 7. Image liver, spleen, and
lymph nodes. Renal disease (diffuse glomerulonephritis): microscopic hematuria, proteinuria, cylindruria,
hypertension. CNS: meningoencephalitis, subarachnoid hemorrhage, thromboembolism, cerebrovascular
psychosis.
Laboratory and instrumental study: UAC (hypochromic anemia, leukopenia, when complications leukocytosis with a left shift, monocytosis, thrombocytopenia, increased erythrocyte sedimentation rate),
(microscopic hematuria, proteinuria, tselindruriya) TANK (increase in gamaglobulinov, sialic acid, fibrin,
positive sulemovaya , thymol and formolovaya samples), a positive Wassermann reaction. Blood cultures for
sterility - one of the main methods of verification of the diagnosis of IE. Identification of the causative agent
is installed, the etiology of the disease.
Change echocardiography allows early reveal thickening of the aortic valve and vegetation, to clarify the
nature of the heart defect.
Tactics GPs. Need to send a patient to a specialist in a hospital. Treatment own faults can only be
surgical. To clarify the indications for this treatment need timely expert advice-heart surgery. Conservative
therapy is reduced to the prevention and treatment of relapse of the basic process and complications,
treatment and prevention of heart failure, as cardiac arrhythmias. Of great importance are timely and
adequate career guidance and job placement patient. Medical therapy is ineffective. In the later stages nitrates, calcium antagonists. Perhaps surgery (commissurotomy, implantation of an artificial valve)..
Sex, age
Cause
Tones
Noises
The best point of
listening
Aortic stenosis
In people older than 40 - 45 years old,
but sometimes at a younger age. In
men, there are 3-4 times more often
than women.
Rheumatism, atherosclerosis, bacterial
endocarditis, congenital subvalvular
or infundibular narrowing of the aorta
as a consequence of altered
proliferation of fibro-muscular tissue.
I Easing II tone at the top of the tone of
the aorta is weakened due to a
decrease in systolic blood pressure
and changes in the aortic valve
auscultated rough systolic murmur,
which is held on the neck vessels.
Aortitis
Young age, get sick more often men
Rheumatoid dicliditis, bacterial endocarditis,
aortic atherosclerosis, syphilitic aortitis,
dissecting aorta, chest injuries.
I weakening tones on the apex of the heart, II
tone can be maintained over the aorta or even
accentuated.
Diastolic murmur in the aorta and at BotkinErb: usually mild, blowing, protodiastolic, by
the end of diastole.
In the second intercostal space at the right of
the sternum, at all points of the heart
In the second intercostal space at the
right of the sternum, at all points of
the heart
Appearance of the
In the second intercostal space at the
In the second intercostal space at the right of
patient
right of the sternum, at Botkin-Erb
the sternum, at Botkin-Erb
USING "Tour of the gallery."
Goal: Education students critical evaluation of information and the identification of the completeness of
knowledge on the subject.
Action: Each small group invited to the one problem they solve for 10 min in writing and then exchange
tasks. Identified errors of the previous group, and additions made to the answers discussed by all members of
the adoption of the final version of the responses. Methodology "tour of the gallery" requires students to
maximum concentration and a good theoretical background for this section. Three small groups are given on
a question:
1. Differential diagnosis of functional and organic noise
2. Clinical signs in mitral valve insufficiency
3. Clinical and hemodynamic features of mitral stenosis
4. Diagnostic features of mitral valve prolapse.
Answers: see the theoretical part.
Thus, for 30-40 minutes teacher gets an idea of the level of training of students on various sections of
topics and their ability to defend their views.
The analytical part of the class is advisable to continue using case studies.
In the practical part in the cardiology department is conducted under the supervision of a teacher-student
curation of patient so-called educational practice.
To prepare thematic bypass patients 1-2 with noise in the apex of the heart (mitral valve defects,
atherosclerosis, anemia, mitral valve prolapse). This requires a sufficient history minimum surveys.
Requires special attention from the teacher correctness of the history and diaries Subordinators.
The method of "Web"
Value of the method lies in the web that students after an analysis of the theoretical material to prepare
yourself questions and answer them yourself passing each other a ball of yarn (which results in a spider's
web). Score to ask questions and reply to it is controlled by the teacher.
Steps:
1. Pre students are given time to prepare questions on the passed occupation.
2. The participants sit in a circle.
3. One of the participants is given a skein, and it sets a prepared question (which itself needs to know the
complete answer), hold the thread end, and shifting skein of any student.
4. A student who has received a skein, answers the question (the party who asked him, says the answer),
and passes the baton to the issue further. Members continue to ask and answer them, until they are in the
web.
5. Once all of the questions students will graduate, a student holding a skein, returns to a participant, from
whom he received the question, while asking a question, etc., until the "unwinding" of the coil.
Note: warn students that should be sensitive to each answer, because they do not know who to throw a
coil.
Maximal score 2018-17 points
16-15 points
14-13 points
12 points
19 points
Excellent
Good
Satisfactory
Not satisfactory
bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
4.Analitic part
4.2.1. Case Studies:
1. During a routine inspection at the 10 year old girl found diastolic tremor along the body of the sternum.
Auscultation of the heart and the cleaved amplified II tone and systolic murmur in the second intercostal
space to the left of the sternum. From history: she often suffered colds and the last time he was troubled by
shortness of breath, palpitation on exertion. OBJECTIVE: The girl slightly built, with delicate translucent
skin. Heart enlarged in diameter. Radiographically, the roots of the lungs increased, pulmonary pattern is
reinforced, the expansion of the pulmonary artery and its branches. Heart enlarged in diameter. On the left
contour protrudes II arc. In II oblique projection is determined by the increase of the right heart. CBC
unchanged.
1. Your preliminary diagnosis;
2. Provide the necessary instrument studies to confirm the diagnosis;
3.Gemodinamicheskie change in this condition;
4. Tactics of GPs.
№
1
2
3
Replies
CHD. ASD. Donkey.: NC II A item. (FC II)
ECG, echocardiography, angiocardiography, cardiac catheterization
When underdevelopment WFP resets arterial blood from left to right. With
great relief the right heart and pulmonary circulation are overloaded with excess
blood. Formed pulmonary hypertension develops and the relative lack sometimes
PVS. Over time, the pressure increases and the PP is discharge of blood from right to
20
40
30
4
left (a recurring sharp cyanosis)
consultation heart surgeon
10
2. 12 year old child in the last 2-3 years are concerned fatigue, shortness of breath, palpitation on
exertion. In the history of chronic bronchitis. On-no: Externally does not match his age. Skin pale, moist,
sponginess and dark circles under the eyes. Noted increased carotid pulse. Extended to the left border of the
heart. Auscultation: At the top of the tone I and III enhanced tone, accent II tone of the pulmonary artery.
Top of the left edge of the sternum and the subclavian area auscultated systolic-diastolic ("machine") the
noise is gradually growing by the end of systole. Heart rate and pulse 88 beats. per min., blood pressure
130/60 mm Hg The abdomen was soft painless. On fluoroscopy gr. the cells of the esophagus with contrast:
Pulmonary vascular pattern is reinforced, extended roots. Marked bulging second arc on the left contour of
the heart, the fourth extension of the arc. The expansion of the ascending aorta.
1. Your preliminary diagnosis;
2. Provide the necessary instrument studies to confirm the diagnosis;
3. Basic hemodynamic changes in this condition;
4. Peripheral signs of this disease;
1. 31 year old patient asked the GPs. Complaints: palpitation on exertion, pain in the heart compressing
character, occasionally dizziness with fainting. In the history - rheumatism. On-no: state of moderate
severity. Pale skin, visible pulsation of the neck vessels, positive symptom Landolfi and Musset. Borders of
the heart: the right by the right edge of the sternum to the upper III m / d on the left, left-to 2 cm laterally
from the left mid-clavicular line in the VI intercostal space. Auscultation: I tone at the top and, in II
intercostal space on the right tone II significantly weakened, soft blowing protodiastolic noise that BotkinErb., Noise Flint on top. Pulse 90 beats / min., Fast and high. BP 140/60 mmHg Peripheral edema is not.
Jabs: erit.-3, 0.1012 / L, WBC 10.2 × 109 / L, erythrocyte sedimentation rate of 35 mm / hour, seromucoid75-mmol / l.
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. Survey plan;
4. What noises heard over the large vessels in this pathology.
5. Tactics GP
Answers
Rheumatic fever, infective endocarditis, GB, atherosclerosis, cardiomyopathy
Rheumatism. A / f act II of Art. Breakout rheumatic heart disease. Aortic valve. The
relative failure of the mitral valve.
Donkey: NC II A item. (FC II)
Sialic acid, DPA, CRP, fibrinogen, coagulation, ECG, X-ray gr.kletki, echocardiography
Dual tone Traube, dual noise Dyureze on the femoral artery
Points
15
35
20
20
10
2. A patient 35 years old, went to the doctor complaining of recurrent vertigo, squeezing chest pain,
fatigue. Twice in six months, there was a faint. Earlier than not ill. On-no: pale, amplified, ascending, diffuse
apical impulse in the VI intercostal space 2 cm outwards from the left mid-clavicular line. Rhythmic pulse
small, slow, 57 beats / min. When percussion is determined by the expansion of the left border of the heart. I
loosened the top of the tone, here is a systolic murmur, which is heard over the whole precordial area, the
epicenter of it is in II intercostal space to the right of the sternum, which is also a short auscultated killing
protodiastolic noise, II tone on the base of the heart is weakened. Liver 2 cm, which is sensitive.
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. Survey plan;
4. Tactics GPs.
3. Male 26 years old, complains of headaches, dizziness, pressing pain in the heart during exercise,
weakness, fatigue. At the age of 8 hr after the next exacerbation. tonsillitis there was pain and swelling in the
large joints of the limbs, on which it was treated permanently. After that tonsillectomy performed and for 2
years to receive a monthly bicillin 5 V / m In connection with the move to a different city then the doctors
did not address. OBJECTIVE: The skin is pale. The apical impulse is displaced to the left and down. The left
border of the heart is 3.0 cm to the outside of the left mid-clavicular line, VII intercostal space, the right and
the top is not changed. Auscultation I and II tones weakened at Botkin and II intercostal space on the right is
determined by the rough systolic and diastolic murmurs conducting the jugular fossa and carotid artery.
Pulse 68 beats / min, rhythmic. Blood pressure 140/50 mm Hg. Art. The liver and spleen were not enlarged.
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. Survey plan;
4. Tactics of GPs and treatment.
__________________________________________________________________________________
4. A patient 30 years old, was admitted to the hospital with complaints of shortness of breath, palpitations,
headaches, pain in the contracting of the heart, dizziness, fainting, often, a feeling reinforced pulsation in the
cervical region, increase in body temperature to 38.70 C. With 22 years of notes from time to time increase
blood pressure. He was treated at irregular intervals. On-no: General state of moderate severity. What is
striking pale skin, cyanosis of the lips, acrocyanosis, pulsation vessels of the neck, swinging the head.
Borders of the heart: the left on the mid-axillary line, top and right in the normal range. Auscultation:
diastolic murmur at Botkin and the second right intercostal space, conducting up the neck vessels, II tone of
the aorta is weakened sharply on the top of the tone I weakened and systolic murmur. Pulse high and fast,
blood pressure 140/30 mm Hg 1. List at least 5 diseases for which there are complaints listed above and
auscultatory signs;
2. Your complete a preliminary diagnosis;
3. What noises heard over the femoral artery in this pathology;
4. What changes are observed in the X-ray gr. the cells of the esophagus with contrast in this patient;
5. Tactics GPs.
___________________________________________________________________________________
5. 25 year old young man went to the GP with complaints of pain in the heart palpitations dizziness,
headache, fever and chills, sweating, pain in the large joints and muscles. From history: the above complaints
concerned within one month. Disease connects with a cold. Took home ampicillin, bisseprol for 7 days, with
no effect. OBJECTIVE: overall moderate body temperature is 38.80 C. Skin pale yellowish spots found
Janeway and Osler nodes. Heart borders extended to the left by 2.0 cm Auskultivno heart sounds are
muffled, due to arrhythmic beats, the tone at the top I weakened at Botkin protodiastolic noise. Pulse of 104
beats / min., Fast and high. BP 120/40 mmHg Liver 3 cm UAC: Hemoglobin - 90 g / l, erit.-2 8.1012 / l
leukocytes 12.2 x 109 / L ESR-50 mm / h,
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. List the main laboratory and instrumental studies are needed to confirm the diagnosis;
4. Tactics GPs. Treatment.
6. In 30 year old man in a month after surgery for mitral stenosis was the body temperature is instructing
with chills, pain in the joints and muscles. Within 2 months. treated, the effects were not. Last week there
were pains in the heart, disruption of the heart, cough with mucous and bloody sputum, pain in the right
upper quadrant, swelling, increased blood pressure, headaches, and dizziness. Objectively: general state of
severe body temperature 39.10 C. Ikterichnost skin, wet, revealed multiple bruises and hemorrhagic rash,
clubbing and nails, swelling around the body. In the lower lung congestion wheezing. The boundaries of the
heart increased in diameter. Auskultivno heart sounds are muffled, arrhythmic, at the top I relaxed tone,
systolic-diastolic murmur at Botkin conducting vessels in the neck. Heart rate and heart rate 120 beats / min.
BP 180/90 mmHg Liver 6 cm
8 painful, spleen 4 cm Jabs: Hemoglobin - 86 g / l, erit.-2, 8.1012 / L, WBC 6.2 × 109 / L, erythrocyte
sedimentation rate, 60 mm / hour.
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. List the main laboratory and instrumental studies are needed to confirm the diagnosis;
4. Tactics GPs. Treatment.
____________________________________________________________________________________
7. Male 72 years old, complains of memory loss, recurrent dizziness, weakness, fainting, seizures, with a
sharp turn of the head, difficulty in swallowing solid food, pain and restriction of knee, ankle joints.
Considers himself sick for 2 years. Not been treated with traditional methods. On examination: The patient
increased nutrition, skin pale. Increased area of percussion dullness of the vascular bundle and the left border
of the relative dullness of the heart. Auscultation of heart sounds are muffled, on top of the relaxed tone I, II
strengthened the tone of the aorta, systolic-diastolic murmur with metal shade in II intercostal space on the
right, is carried out on the carotid artery, the jugular and supraclavicular fossa. Heart rate and pulse 80 beats /
min, blood pressure 170/85 mmHg Pain and crunching in the knee and ankle joints. Peripheral edema is not.
1. List at least 5 diseases for which there are complaints listed above and auscultatory signs;
2. Your complete a preliminary diagnosis;
3. Survey plan;
4. Tactics of GPs. Treatment.
_____________________________________________________________________________________
8. Patient 28 years old with a history of articular attack and a systolic murmur at the apex since childhood.
Ill 6 months. ago, when the body temperature has to rise to 39 ˚ C with a fever. Treatment with antibacterial
drugs at usual doses was ineffective. After 2 months, developed a dynamic stroke, there was a sharp pain in
the lumbar region, accompanied by gross hematuria. OBJECTIVE: pale skin, sclera icteric, the end of the
phalanx thickened nails in the form of time running down. Percussion: Increased the left border of the
relative dullness of the heart. Auscultation: systolic murmur at the apex, diastolic murmur at point B. Erb.
Blood pressure 140/60 mm Hg. Dimensions of the liver, see Kurlovu 10/09/11 :: UAC 100 g Hb / l,
erythrocytes, 3, 0 x 1012 / l, L -7.2 x109 / L ESR 65 mm / hr. In urine, moderate proteinuria, hematuria.
1. Your complete a preliminary diagnosis;
2. Survey plan;
3. Describe the main causes of dynamic cerebral blood flow, fever and pain in the lumbar region, enter
the objective signs of the disease;
4. Tactics GPs. Treatment
Maximal ny score
20-19
18-17 points
16-15 points
14-13 points
12 points
excellent
good
satisfactory
Not satisfactory
bad
100% -86%
85% -73%
70-56%
53%-46%
43% and
downward
Tests.
1. Which of the following is not common in primary pulmonary hypertension:
a) Legal Basis ventricular hypertrophy
b) left ventricular hypertrophy
c) atherosclerotic plaques in major pulmonary arteries
d) a weak peripheral pulmonary vasculature
e) right bundle branch block
2. Systolic murmur interventricular defect often be differentiated:
a) with the noise of mitral regurgitation
b) noise pulmonary stenosis
c) noise aortic stenosis
g) with the noise of tricuspid regurgitation
d) with the noise of tricuspid stenosis
3. For sharp pulmonary stenosis is not typical
a) small stature, thin neck
b) a pronounced swelling of the jugular veins
c) an intense systolic murmur and shake
in II intercostal space at the left sternal
g) ECG signs of right ventricular hypertrophy and atrial
e) significant pulmonary venous congestion
3. For sharp pulmonary stenosis is not typical
a) small stature, thin neck
b) a pronounced swelling of the jugular veins
c) an intense systolic murmur and shake
in II intercostal space at the left sternal
g) ECG signs of right ventricular hypertrophy and atrial
e) significant pulmonary venous congestion
4.What of the above does not matter in the occurrence of congenital heart disease:
a) the medicinal effect on the fetus
b) parents' alcoholism
c) increased radioactivity
g) increased the nitrate content in products
e) transferred to the mother destve tonsillitis
5. For cyanotic congenital not typical:
a) polycythemia
b) fingers in a "drumstick"
c) shortness of breath during physical activity
d) an increase in blood pressure
d) the noise of the heart
6. Uncharacteristic trait for tetralogy of Fallot:
a) the interventricular defect
b) dextroposition aortic
c) pulmonary stenosis
g) interatrial defect
d) right ventricular hypertrophy
7. Which of these can be safely, cheaply and quickly confirm th of atrial septal defect:
a) imaging of the heart
b) radionuclide angiography
c) echocardiography with Doppler
g) koronaroarteriografiya
e) phonocardiography
8. Which of the methods can accurately confirm the presence of interventricular defect:
a) electrocardiography
b) X-rays
c) phonocardiography
g) with Doppler echocardiography
e) coronary angiography
9. For physical data interventricular defect complicated by pulmonary hypertension and right to left shunt,
does not include:
a) The minimum systolic murmur (or lack of it)
b) rough systolic murmur and shake at the left sternal
c) a sharp focus on the pitch P of pulmonary artery
d) diastolic murmur at the apex
d) cyanosis
e) "drumsticks"
10. Sign of tetralogy of Fallot
a) shortness of breath and cyanotic attacks
b) anemia
c) diastolic murmur at the apex
d) diastolic murmur in II-III intercostal space
e) II-tone accent on the aorta
11. What are the symptoms of aortic and subaortic stenosis:
a) poststenotic enlargement of the ascending aorta
b) the weakening and splitting II tone of the aorta
c) systolic "cat purring" second left intercostal space, at the edge of the sternum
d) right ventricular hypertrophy
d) hypertrophy of the right atrium
e) systolic "cat purring" second intercostal space on the right, on the edge of the sternum
12. Isolated pulmonary stenosis is characterized by:
a) dizziness, tendency to fainting
b) systolic murmur of the right edge of the sternum
c) the scrapes systolic murmur at the left sternal border
d) expansion of the aorta
e) enlargement of the left ventricle
e) I tone for the pulmonary artery is weakened or does not listen
13. List of disease accompanied by systolic noise between the 2. Reb. on the right:
a) aortic valve stenosis
b) an atrial septal defect
b) aortic atherosclerosis
g) ventricular septal defect
e) coarctation of the aorta
e) failure of the mitral valve
14. List of disease, sopravazhdayuschiesya auscultation systolic murmur in the 2 intercostal space on the
left:
a) ventricular septal defect
b) an atrial septal defect
a) Tetralogy of Fallot
d) aortic valve stenosis
e) aortic atherosclerosis
e) pulmonary stenosis
15. Select the symptoms associated with tetralogy of Fallot, with marked cyanosis:
a) shortness of breath, tachycardia
b) Strengthening of the first tone at the top
c) the X-ray: the heart - in the form of "Dutch slipper"
g) on the ECG - a deviation EOS left
e) left ventricular hypertrophy
e) systolic murmur
16. For congenital heart disease is typical, except
a) The defect after 7 years
b) systolic murmur
c) a birth defect
g) a history of rheumatic fever
d) lagging behind in physical development
17. The components of tetralogy of Fallot, except:
a) an atrial septal defect
b) pulmonary stenosis
c) VSD
g) a shift to the right aortic
e) left ventricular hypertrophy
e) mitral stenosis
18. X-ray signs of ventricular septal defect, except
a) left ventricular hypertrophy
b) right ventricular hypertrophy
c) aortic heart shape
d) moderate hypertrophy of the left atrium
e) the depletion of lung pattern
e) hypertrophy of the right atrium
Tests.
1. For aortic insufficiency is characterized by:
a) "dance carotid"
b) the capillary pulse
a) low diastolic pressure
d) enhanced spilled, mixing the left and down the apex beat
d) a low systolic blood pressure
2. By the ECG signs of compensated aortic stenosis include:
a) gipergrofiya left ventricular systolic overload characteristics
b) hypertrophy of the left atrium
c) right ventricular hypertrophy
d) a shortening of the interval PQ
e) axis deviation to the right
3. The most informative method of assessing the severity of mitral stenosis is:
a) physical examination
b) echocardiography
c) electrocardiography
d) X-ray examination
e) phonocardiography
4. Clinical signs of coarctation of the aorta are not:
a) intense pulse of the upper limbs and weak - on the lower
b) numbness of the lower extremities, intermittent claudication
c) cyanosis of the lower half of the body
d) Raynaud's Syndrome
d) high pressure in the upper limbs
5. For pronounced aortic stenosis is not typical:
a) angina
b) syncope
c) sudden death
g) high arterial hypertension
e) shortness of breath
6. Presystolic gallop rhythm may occur when all of the states, except for:
a) expressed aortic stenosis
b) gipertroficheskoyy cardiomyopathy
c) severe hypertension
d) mitral stenosis complicated by atrial fibrillation
e) aortic stenosis
7. To identify the dilation of the left ventricle has the greatest value:
a) electrocardiography
b) X-ray polypositional
c) imaging
g) echocardiography
e) phonocardiography
8. Female 32 years old ill 2 months, during which disturb increase in body temperature to 39 º C with
chills, shortness of breath on slight exertion, and headaches. She was treated independently antipyretics,
sulfonamides, once was a five-day course of oxacillin.
Objective: body temperature - 38.2 º C, pale skin, petechial exanthema single character on the face and
ladodonyah, pulse - 100 per minute, blood pressure - 140/20 mm Hg,
cerdtsa muted tones, along the left sternal выслушиваветсявысокочастотный diastolic murmur
immediately following II-m tone gepatosplenomegaliya.Chto of the following is most likely the patient:
a) rheumatism, the active phase and mitral stenosis
b) infective endocarditis and aortic insufficiency
c) rheumatism, the active phase and aortic insufficiency
g) rheumatism, the active phase, mitral insufficiency
9. In infective endocarditis process is localized in the cardiovascular system, and the agent gets to the
heart only by hematogenous. Which of the following is not conducive to entering the bloodstream:
a) research and invasive surgery on the heart and blood vessels
b) endoscopy (urogenital, surgical)
c) dental procedures (extraction, deep drilling)
d) Pregnancy and Childbirth
e) permanent venous catheters and frequent intravenous infusions
10. Which of the following is not related to the main clinical syndromes of infective endocarditis:
a) Infection
b) arterial embolism
c) changes of the heart
g) Glomerulonephritis
e) hyperbilirubinemia
11. The most informative laboratory test that confirms the diagnosis of infective endocarditis is:
a) a sharp acceleration of ESR
b) anemia
c) leukocytosis
g), leukopenia
e) the seeding of the pathogen in blood culture
e) changes in the urine
12. Differential diagnosis of infectious endocarditis always begins with a search for the causes of fever.
The cause long raise the temperature more often than not are:
a) TB
b) the neoplasm
c) collagen diseases
d) chronic glomerulonephritis
d) Chronic pyelonephritis
13. The most reliable method to confirm a heart defect
a) echocardiography
b) ECG
c) ventriculography
d) record the pressure in the pulmonary artery
d) X-ray
14. The complaints are typical of patients with aortic stenosis
a) fainting and dizziness
b) fatigue
c) asthma
g) hemoptysis
e) swelling in the legs
15. For aortic stenosis is characterized by
a) rough systolic murmur in the aortic
b) the weakening of the two-tones of the aorta
c) 1-slapping tone at the top
d) relaxation of the 1-ton top
e) systolic murmur at the apex
16. For aortic valve characteristic
a) an increase in pulse pressure *
b) low systolic and diastolic normal
c) reduction of pulse pressure
g) pressure changes without significant
d) high systolic and diastolic blood pressure
17. Sign of aortic insufficiency
a) the shifting boundaries of the heart down and to the left, diastolic murmur at Botkin-Erb
b) the shifting boundaries of the heart up and right
c) atrial hypertrophy, diastolic murmur at the apex
g) waist heart smoothed
d) right ventricular hypertrophy
18. Sign characteristic of the ductus arteriosus
a) machine systolic murmur in the left intercostal space II
b) systolic shake at the top
a) focus on the two-tone pulmonary artery
d) diastolic murmur at the apex
d) Emphasis 2 tone of the aorta
19. Ripple neck arteries characteristic
a) aortic insufficiency
b) lack of mitral
c) atrial septal defect
g) aortic stenosis
d) the open flow artepialnogo
Maximal score 2019
18-17 points
16-15 points
14-13 points
12 points
excellent
good
satisfactory
not satisfactory
bad
100% -86%
85% -73%
70-56%
53%-46%
43% and
downward
 4.2.2.Grafic organizer: Conceptual table
 Conceptual table provides a comparison of the phenomena, concepts, attitudes, and so that in two or
more dimensions.
 Develop systems thinking, the ability to structure. Organize information.Acquainted with the rules of
drawing up a conceptual table. Determine what not compare, distinguish the characteristics that will be a
comparison. Individually or in small groups, build and fill the conceptual table
 Vertical is something that is subject to comparison
 Horizontally - various characteristics that are compared.
and diastolic
diastolic
systolic
Noise in the aorta.
Asso
malfor
fai
Aortic
The group is divided into two small groups, the participants each small group evaluate the work of a small
group of other students. Each correct answer is worth 15 points.
group№
Correct and
Visibility(5)
Announceme
Most
Total
clear answer (5)
nt of
members of
points
regulation
the group
(2,5)
(2,5)
1.
2.
Maximal ny score
20-19
excellent
100% -86%
18-17 points
16-15 points
14-13 points
12 points
good
85%-73%
satisfactory
70-56%
not satisfactory
53%-46%
bad
43% and
downward
4.3.Practical part. The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with acquired aortic valvular disease (isolated and combined,
rheumatic, septic, sclerotic).
2. Interpretation of ECG, echocardiography, radiological findings in the diagnosis of acquired aortic
valvular disease (isolated and combined, rheumatic, septic, sclerotic).
3. Prescription of drugs for angina and myocardial infarction, depending on the stage.Heart murmur and
cardiomegaly. Differential diagnosis of noise while listening to the aorta (rheumatic fever, infective
endocarditis, atherosclerosis), the aorta
stage
indicators /interpretation
not done
Achieved in full
number
Curation of the patient
Complete blood
АLТ, АSТ, LДГ,
СRP
Sugar, seromucoid
cholesterol, triglycerides
coagulation
EKG
0
50
EHO KG
ECG monitoring
differential diagnosis
0
20
Justification diagnosis
0
10
Tactics GPs and treatment assignment
0
10
recommendations
0
10
TOTAL
0
100
Congenital malformations of the heart and great vessels.
stage
indicators /interpretation
not done
Achieved in full
number
Curation of the patient
Complete blood
PSA
acute phase indicators
coagulation
EKG
Аngiografia
differential diagnosis
Justification diagnosis
Tactics GPs and treatment assignment
recommendations
TOTAL
0
0
0
0
0
0
50
20
10
10
10
100
5. Control forms of knowledge, skills and abilities
- Oral
- The decision of situational problems
- Demonstration of practical skills
- CDS
1. The evaluation criteria of the current control
levels of
Rating
Characteristics of the student
estimates
points
Point of presence on the practical session. Complete lack of knowledge
20
and ability to perform a skill - the student is not ready for practical
employment.
The student answers unsatisfactory.
 Students do not know the fundamentals of knowledge and skills, at
least one of the following:
 Do not know the clinical signs of disease with functional noise aorta
 Do not know the clinical manifestations of disease with organic noises
on the aorta
 Do not know the causes of noise in the aorta of the heart
 Do not know the diagnosis of various diseases with the noise of the
not
20 - 54,9
aorta.
satisfactory
• Can analyze data complaints and history of diseases with functional
and organic noises on the aorta
• Not able to assemble a rational history during the Supervision of
patients.
• During Supervision is not able to objectively assess the condition of
patients
• Do not rationally be able to plan a survey of patients in a hovercraft or
a joint venture.
Provide a basic level of knowledge and skills
Satisfactory response of low quality.
55-60,9
The student tries to hold the basic levels of knowledge and skills (see
below), but when replying or performing skills make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but when
61-65,9
not
replying or performing skills make mistakes (subject to certain margin
satisfactory
of error)
55-70,9%
 Satisfactory answer quality.
 The student is wholly owned by the basic levels of knowledge and
skills:
66-70,9
• Know the clinical signs of aortic stenosis, aortic valve .
• Can differentiate between different types of acquired mitral for
subjective, objective, and laboratory and instrumental data
• Able to build a rational history during the Supervision of patients with
acquired heart disease.
• During Supervision able to objectively assess the condition of patients
with heart defects.
• Can interpret the results of laboratory-instrumental metods– может
indicate about presence giperholesterinemi , leikocitosis, raised KFK show
technology to registrations EKG. Capable rationally to form plan of the
examination patients with defects in a hovercraft or a joint venture.
• Able to correctly fill in the patient diary.
Advanced level of knowledge
The student is wholly owned by the basic levels of knowledge and skills
(listed under "66-70,9") + has the following knowledge and skills:
71-75,9
• Know the classification of defects
• Know the tactics of GPs in aortic defects.
good
The student is wholly owned by the basic levels of knowledge and skills
(see above) + knowledge referred to in paragraph "71-75,9", and also
71-85,9%
owns the following knowledge and skills
76-80
• Know the indications and contraindications for surgical treatment.
• Knows the principles of primary, secondary and tertiary prevention.

The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph "71-75,9"
and "76-80", and also owns the following knowledge and skills:
81-85,9
86-90
excellent
91-95
• Principles of management, supervision and monitoring of patients with
defects in a hovercraft or a joint venture.
• Is able to advise you on the boards of non-drug and drug-using skills of
IPC.
• Principles of clinical examination and rehabilitation of patients with
defects in a hovercraft or joint venture
 The student is wholly owned by the basic levels of knowledge and
skills (see above) + knowledge referred to in paragraph "81-85,9", and
also owns the following knowledge and skills:
• Know the indications and contraindications of surgical correction of
aortic heart defects
• Is able to provide reliable information about the evils of the Internet on
the basis of data
The student is wholly owned by the basic levels of knowledge and skills
(see above) + knowledge referred to in paragraph "86-90", and also
owns the following knowledge and skills
• Can be monitored in a hovercraft or a joint venture.
86-100%
96-100
The student is wholly owned by the basic levels of knowledge and skills
(see above) + knowledge referred to in paragraph "91-95", and also
owns the following knowledge and skills:
• to provide scientific data from the literature (articles and Internet)
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle of
"security" for the patient
7. Test Questions
1. Clinic and diagnosis of aortic stenosis.
2. Clinic and diagnosis of aortic valve.
3. Clinic and diagnosis of infectious endocarditis.
4. Diagnostic criteria for infective endocarditis
5. The differential diagnosis of aortic heart defects in rheumatism and atherosclerosis
6. Tactics GPs in aortic defects.
7. Tactics GPs in infective endocarditis.
8. Surgery in infective endocarditis.
Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8.Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа,
2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
Chronological content classes
Duration
time
activity
content
materials
of training
8.30– 9.30
Morning
The report of the doctor on duty
Medical history, 1:00
conference
and duty subordinators on
ECG, overhead
duty.
projector.
9.15-10.00
Clinical audit to
A detailed report on the
45 minutes
prescribe patients.
students' written out sick ..
10.05-10.45
Theoretical
Checking the initial level of
Educational
45 minutes
analysis of the
preparedness of students.
boards folder with
topic
Student survey on employment ECG, tables and
with application of the "handle case studies,
on the middle of the table."
relevant theme of
Students heard ECG, which
employment.
students must analyze, explain
and give an opinion. The
solution case studies on the
topic.
10.45 -11.05. Study of practical Student under the supervision
The patient or
20 minutes
skills.
of a teacher must complete at
volunteer.
least two practical skill.
11.05-11.45
Curation of
Each student is supervised by a
The patient,
40 minutes
patientsIn the
particular patient wards.
stethoscope,
department of
sphygmomanomete
cardiology and
r, medical history
coronary care
(with data of
clinical and
laboratory
findings).
11.45-12.15
break
30 minutes
12.20-13.20
Analysis of casepatients
At the choice of the teacher
conducted a full examination
of the patient on the theme of
employment or patients
preparing for discharge, data
analysis, laboratory and
instrumental studies, the
rationale for the preliminary
and final clinical diagnoses.
Determined by the treatment
plan with the doses of drugs
Sick,
stethoscope, blood
pressure monitor,
medical history
(data of clinical and
laboratory
research).
1:00
Practical session number 12
Theme: "Heart noise and cardiomegaly. Differential diagnosis in congenital heart and great vessels.
Tactics GPs. The principles of clinical supervision, control and rehabilitation in RPP or joint venture.
The principles of prevention. The principles of teaching topics.»
Learning technology
Study time: 6 hours Number of students 8-10
The structure of the training session
1. Training themed office chair
2. training aids
3. Hospital wards.
4. TV, video equipment, computer, overheyt, multimedia
5. Complete sets of tables, guidelines, video;
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis of
congenital heart and great vessels, as well as the principles of management of patients in primary
care, provided the requirements of the "Qualification characteristics of the GP"
Pedagogical objectives:
1.
Learning outcomes:
1.
Consider the diagnosis and
The general practitioner (GP) should know:GPs should be
differential diagnosis of congenital heart
aware of:
and great vessels: ASD, VSD, PDA,
1. The mechanism of congenital malformations of the heart
stenosis of the pulmonary arteries,
and great vessels: ASD, VSD, PDA, stenosis of the
tetralogy of Fallot, coarctation of the aorta pulmonary arteries, tetralogy of Fallot, coarctation of the
aorta.
.2. Demonstrate patients with CHD and
1. The clinical manifestations of heart diseases and major
major vessels
vessels.
3. Discuss the clinical and laboratory data 2. Disease diagnosis: ASD, VSD, PDA, stenosis of the
and instrumental studies in the diagnosis
pulmonary arteries, tetralogy of Fallot, coarctation of the
of congenital heart and great vessels.
aorta.
4. Discuss questions about tactics in the
3. Differential diagnosis of CHD and major vessels.
qualifying characteristics of GPs
4. Tactics GPs.
5. Discuss the principles of treatment
5. The principles of treatment (medication and non(medication and non-medication).
medication) in these diseases.
6. Discuss the principles of management,
6. Principles of follow-up and monitoring of patients in a
supervision and monitoring of patients in
hovercraft or a joint venture.
a hovercraft or a joint venture.
7. The principles of primary, secondary and tertiary
7. Discuss the principles of primary,
prevention in these diseases. GPs should be able to:
secondary and tertiary prevention in these 1. Analyze the data and history of complaints for the
diseases.
diagnosis of CHD and major vessels: ASD, VSD, PDA,
stenosis of the pulmonary arteries, tetralogy of Fallot,
coarctation of the aorta.
2. To be able to diagnose, differentiate congenital heart and
great vessels.
Direct the patient to a special hospital for heart surgeon to
decide on surgery of the vice
2. Choose drugs with proven efficacy
3. Advise on non-drug therapies.
4. To monitor in a hovercraft or joint venture.
Training Methods
Forms of organization of learning
activities
learning tools
Methods and feedback means
Lecture, case studies, tests, demonstration, entertainment
experience, discussion, conversation, brainstorming training
game.
Individual work, group work, team, classroom,
extracurricular.
Training manuals, handouts, a collection of case tasks and
tests, set EKG.Televizor, video equipment, multimedia
Quiz, test, presentation of the results of the learning task,
filling medical history, perform a practical skill "ECG
monitoring, deciphering ECG"
Technology chart classes. "Heart sounds and cardiomegaly. Differential diagnosis in congenital
heart and great vessels. Tactics GPs. The principles of clinical supervision, control and rehabilitation
in RPP or joint venture. The principles of prevention. The principles of teaching topics. »
№
Stages of the practice session
1
Chapeau (justification themes)
2
The discussion on the practical lessons with the use of
new educational technologies (the "round table"), as
well as demonstration material (tables, posters,
rentgenogram, EKG), the definition of the initial level.
3
4
conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the provisions
and recommendations for the job by filling in the
medical history
5
Mastering the practical part of the training under the
guidance of a teacher.
Forms of training
Place
Duration
225
10
The survey, discussion
Classroom skills
40
Discussion
Classroom
10
20
20
6
Interpretation of the survey data of patients,
complaints, inspection, palpation, percussion,
auscultation of patients
Prof. questioning. A
conversation with patients
and filling medical history,
situational
problems.Cardiology,
rheumatology department
clinics
Medical history,
laboratory data situational
problems
7
Discussion of theoretical and practical knowledge of
Oral questioning, tests,
the students, securing the material to determine the discussion, identification of
level of assimilation of knowledge assessment.
practical skills
Cardiology and
rheumatology department
clinics
Oral questioning, tests, discussion, identification
Information, questions for
of practical skillsCardiology and rheumatology
homework.Classroom
department clinics
75
8
2. Motivation
25
25
Patients with congenital heart disease (CHD) are often encountered in the practice of primary care. In this
situation, the force of a general practitioner (GP) is directed to the diagnosis of congenital heart defects. In
the case of CHD GPs have to solve the question of determining the group of patients to be treated in a
hovercraft or a joint venture, or referral to specialized hospitals. These and other conditions are the basis
for the inclusion of this subject in the training of GPs.
3. Intra Communication
Anatomy, histology and cytology with embryology, biology, normal physiology, biochemistry,
pathological anatomy, pathological physiology, topographic anatomy and operative surgery, propaedeutics
internal medicine, radiology and nuclear medicine, physiotherapy, cardiology, endocrinology, faculty
therapy, in-hospital treatment.
4. The content of classes
4.1. The theoretical partIn the theoretical part of the training series covers the following topics: the
differential diagnosis of congenital malformations of the heart and great vessels: ASD, VSD, PDA, stenosis
of the pulmonary arteries, tetralogy of Fallot, coarctation of the aorta
Ventricular septal defect (illness Tolochinova-Roger)
Clinic: complaints of shortness of breath on exertion, fatigue, pain in the heart. Are frequent pneumonia.
Inspection: heart hump, systolic jitter over the area of the heart, increased heart size of percussion to the
right.
Auscultation: pansystolic loud noise with its epicenter in the II-IV intercostal space to the left of the
sternum, the accent II tone of the aircraft. Often joined diastolic murmurs of relative insufficiency pulmonary
valve (Graham Steele), relative tricuspid stenosis, reverse discharge from the right ventricle to the left. PCG:
pansystolic tape-like noise in the IV intercostal space to the left of the sternum, the shape of the noise
depends on the degree of pulmonary hypertension.ECG: combined ventricular hypertrophy.
Violation of atrioventricular conduction. Echocardiography: the study of M-mode one of the clear signs
is the lack of continuity of the interventricular septum. Indirect signs of ventricular septal defect caused by
hemodynamic changes include increasing the LP and the LV cavity. By increasing the pressure in LA there
is dilatation of the prostatic hypertrophy and the front wall of the pancreas. When X-ray has been a dramatic
increase in the pancreas, an increase in left ventricular reduction of the aorta, a moderate increase in the PL.
A reliable diagnosis is in probing the cavities of the heart and angiokardiografii.Subaortic stenosis.
Morphologically in obstructive cardiomyopathy found a dramatic thickening of the interventricular
septum with bulging muscle mass in the left ventricular cavity and narrowing of the outflow tract, atrium
enlarged, exaggerated. Clinic - complaints of shortness of breath, heart attacks toads, fatigue, dizziness with
transient loss of consciousness, palpitations.Examination - the apex beat is displaced to the left, strengthened;
systolic shake at the top and along the left edge of the breast in III-IV intercostal space and corresponds to
the degree of obstruction.Auscultation: I sound normal, it is often preceded by a tone IV, II tone usually split
- the main auscultatory sign of a rough school, the noise on the PCG has a diamond shape, is carried down
into the axilla and on the ground. SS occurs as a result of passage of blood through the narrowed opening and
mitral insufficiency.
Systolic murmur increases with Valsalva maneuver, tachycardia, in a standing position, while taking
nitroglycerin. Noise is reduced by sitting on his haunches, taking β-blockers, the introduction - agonists.ECG
- hypertrophy of the left ventricle with high voltage batteries QRS, depression ST-T, may be atrial
fibrillation. On radiographs - can be left ventricular hypertrophy. Echocardiography - left ventricular
hypertrophy, the ratio of the thickness of the interventricular septum to the left ventricular free wall thickness
at end-diastole 1.3. The second feature - the movement of the front mitral leaflet to meet the interventricular
septum with an even more pronounced tapering of the outflow tract of the left ventricle.
Angiography: reduced left ventricular cavity during systole and takes the shape of an hourglass. The
primary means of therapy - β-blockers, limit physical activity.Atrial septal defect.Clinic: complaints of
shortness of breath on exertion, fatigue, susceptibility to pneumonia, the development of pulmonary
hypertension, anginal pain. Inspection: no characteristic features.
Auscultation: faint systolic murmur in the II-III intercostal space to the left of the sternum, the accent II
tone of the pulmonary artery. In severe pulmonary hypertension there are attacks of shortness of breath and
sharp cyanosis (Eisenmenger syndrome), but from now on surgical correction is not possible.Ltambashe
syndrome is diagnosed based on the symptoms of mitral stenosis, in the later stages of forming
dekompensirovannyydefekt WFP.PCG: oval systolic murmur, with its epicenter in the II-III intercostal space
on the left, increasing the amplitude of the tone II, II split tone. ECG: prostate hypertrophy, right bundle
branch block. On the X-ray - a sharp increase in prostate stem elongation and protrusion of the LA branch of
the left, expand the branches of blood vessels, hypervolemia, then hypertension in the pulmonary circulation,
reduction of the aortic arch.Echocardiography with M-scan: signs RV volume overload caused by
arteriovenous reset: a significant increase in RV cavity, paradoxical movement of the interventricular
septum: During systole, ventricular septal motion parallel to the movement of the rear wall of the left
ventricle or movement during systole smoothed increase excursions anterior leaflet of the tricuspid valve, the
decrease in the amplitude and the speed of the opening of the anterior leaflet MC. In the presence of
pulmonary hypertension symptom of paradoxical movement of the interventricular septum is absent.
The decisive method - cardiac catheterization.Isolated pulmonary stenosisClinic: complaints of severe
weakness, fatigue, dizziness, heaviness in the heart, shortness of breath. Inspection: possible backlog of
physical development, heart hump, reinforced ripple of RV systolic jitter II-III intercostal space to the left of
the sternum, the shift to the right border of cardiac dullness, low heart rate, blood pressure
reduction.Auscultation: a rough school in II-III intercostal space to the left of the sternum, the weakening II
tone on the aircraft. PCG: NL LA (II-III intercostal space on the left), reduced the amplitude of the tone of
the LA II.ECG showed hypertrophy of the PP, RV, right bundle branch block.
On the X-ray - a marked increase in the pancreas that may be forming on the left edge of the contour of
the heart, sharp stem elongation and protrusion of the aircraft; severe narrowing branches of the pulmonary
arteries in the roots, the depletion of lung pattern.Echocardiography: A deepening wave ECHO graphy on the
back of the leaflet LA: the opening of the valves occurs earlier than normal, with the one-dimensional study,
marked narrowing of outflow tract and prostate hypertrophy of the wall of RV RV is not expanded, it is
determined only by dilatation of right heart failure in 2-dimensional ECHO graphy marked bulging folds into
the lumen of the aircraft in the systole phase, sash thickened.Reliable diagnosis is achieved by
angiokardiografii.
On examination: cyanosis, initially with exertion, in the later stages and at rest, the fingers in the form of
"drumsticks" heart hump, expanding the boundaries of the heart to the right.Auscultation: rough systolic
murmur, with its epicenter in II intercostal space to the left of the sternum, the weakening II tone of the
pulmonary artery, until his disappearance.ECG - hypertrophy and right ventricular overload, hypertrophy of
the right atrium.Radiography - mitral heart shape, an increase in the right atrium, right ventricle enlargement,
elongation, and bulging of the left pulmonary artery, pulmonary pattern depletion
.PCG - a rough diamond-shaped systolic murmur, with its epicenter in II intercostal space to the left of
the sternum, lower amplitude II tone.
Catheterization and angiography. Echocardiography in tetralogy of Fallot - a one-dimensional study: the
expansion of the aortic root enlargement of the right heart, the restriction of the right ventricular outflow
tract; dimensional study allows to describe in detail the changes outflow tract, visually examine the aircraft,
its valve, transposition of the aorta to identify, visualize a large ventricular septal defect.
Visualization of the left parasternal approach in cross-section along the short axis of the aorta - the aorta
dekstrapozitsiya like sitting on top of the interventricular septum. LA is normal, but shifted to the right,
infundibular department is visualized in the left section of the parasternal short-axis approach as a restriction
of the right ventricle, which confirms the Doppler study.
Patent ductus arteriosus - cleft birth duct that connects the aorta and the pulmonary artery.
Complaints: shortness of breath, weakness, fatigue, false angina. Inspection: pale skin, systolic jitter, high
pulse pressure. Auscultation: systolic - diastolic murmur ("machine"), with its epicenter in II intercostal
space to the left of the sternum, worse on inspiration, weakens straining. PCG - continuous systolic diastolic murmur in II intercostal space to the left of the sternum with the greatest intensity at the end of
systole and early diastole, increasing II tone of the pulmonary artery.
ECG-LVH. On radiographs - mitral heart shape, an increase in the PL, left ventricular hypertrophy,
increased aortic hypertension - increased RV, elongation, and bulging of the left LA, hypervolemia.Signs of
left ventricular volume overload: an increase in the LV cavity, increased trips septal infarction and left
ventricular posterior wall.
Coarctation of the aorta.The pathological substrate - the narrowing of the aortic isthmus in the field with
obstruction of blood flow through the narrowed area (congenital anomaly).
Clinic: complaints of headache, dizziness, shortness of breath, fatigue of the lower limbs during walking.
Inspection: the difference in pulse vessels of the upper and lower half of the body, pulsating collateral
vessels in the interscapular, axillary areas, and along the intercostal space, increased blood pressure in the
arms and the reduction or complete lack of standing.Auscultation: Secondary school over the top or at the
bottom of the right side of the heart, increasing the amplitude of the tone of the aorta II. ECG-LVH. On
radiographs - increased left ventricular enlargement of the aorta, uzuratsiya lower contours of the rear
sections of ribs (corroded the lower edges of the edges for an X-ray study).
With multiplanar fluoroscopy and tomography in the optimal projection revealed a constriction of the
aorta. Reliable diagnosis - angiocardiography, aortography.Initial diagnostic evaluation of suspected
congenital heart disease must include electrocardiography and x-ray examination of the heart and lungs,
which in most cases can detect a set of lines (echocardiography) and indirect signs of a certain defect. In the
case of an isolated valve lesion differential diagnosis with acquired defect. A more complete diagnostic
examination of the patient, including, if necessary angiokardiografii and sensing chambers of the heart,
cardiac surgery performed in a hospital. Treatment with surgery alone. When surgery is not possible, the
patient is prescribed mode of the limited physical activity, postpones deadlines decompensation blemish, and
upon the occurrence of heart failure is preferably carried out its symptomatic treatment. Some congenital
heart defects do not require special treatment.In cardiac surgery hospital aortography confirmed the
diagnosis and study of the difference in blood pressure in the ascending and descending aorta through its
catheterization.
Treatment consists of excision of the narrowed section of the aorta by replacing it with a prosthesis or the
creation of end-to-end anastomosis or in the creation of a shunt operation. The optimum age for surgery with
a favorable course of vice - 8 - 14 years.
Ventricular septal defect - the diagnosis of ventricular septal defect is set according to the color Doppler
echocardiography, left ventriculography, and cardiac catheterization. Changes in the ECG and Chest x-rays
of the heart and lungs are different for different sizes of the defect and varying degrees of pulmonary
hypertension, diagnosed correctly guess they help only when clear evidence of hypertrophy of both
ventricles and severe hypertension, pulmonary circulation.
Treatment of small defects without pulmonary hypertension is often not required. Surgical treatment is
indicated in patients whose discharge of blood through a defect of more than one third of the pulmonary
blood flow. The operation is preferably carried out at the age of 4 - 12 years if it is not made earlier for
urgent reasons. Small defects are sutured, with major defects produce their patch plasty of autoperikarda or
polymeric materials. Seek recovery in 95% of operated patients. With concomitant aortic valve prosthesis
produce it.The diagnosis of atrial septal defect detection suggest, along with the described symptoms, signs
of severe right ventricular hypertrophy (including According to the echo, and electrocardiography),
radiographic signs of fluid overload defined by the pulmonary circulation (pulmonary arterial enhancement
pattern), and the roots of the characteristic ripple of light .
A significant diagnostic value of color Doppler echocardiography may have. The differential diagnosis is
carried out mostly with primary pulmonary hypertension (pulmonary drawing when it is depleted) and with
mitral stenosis. Unlike the latter, with an atrial septal defect, a significant dilatation of the left atrium is not
observed, in addition, mitral stenosis is reliably avoided zhokardiografiey.
Definitively confirm the diagnosis of atrial catheterization and angiocardiography with the introduction
of contrast in the left atrium.Treatment - The closure of the defect or plastic. Not operated patients live an
average of about 40 years.
9. Open arterial (Botallo) Flow - The diagnosis is confirmed by aortography (see Reset the contrast in
flow) and cardiac catheterization and pulmonary trunk (there is an increase of pressure and oxygen saturation
in the pulmonary trunk), but it is sufficiently reliable to install and without these studies using Doppler
echocardiography ( Registration shunt flow) and x-rays. Last reveals increased lung markings by arterial
bulging arc (extension) of the aorta and pulmonary trunk, their intensified pulse, increased left ventricle.
Treatment consists of ligation of patent ductus arteriosus.
Triad of Fallot - Diagnosis specify in a cardiothoracic hospital cardiac catheterization to measure the
pressure gradient between the right ventricle and the pulmonary trunk and right ventriculography. Treatment
- valvuloplasty, which when combined with the triad of Fallot closing interatrial communication. Valvotomy
is less effective.
Tetralogy of Fallot - the final diagnosis based on defect data angiocardiography and cardiac
catheterization. Treatment may be palliative - the imposition of the aorto-pulmonary anastomoses. The
radical defect correction is to eliminate stenosis and ventricular septal defect closure.
Theoretical survey can be carried out by traditional didactic method using the method of the
"round table".
Purpose: Engage in the discussion of topics of all students while controlling their knowledge.The main
provisions of the technique: Circling the paper starts with the job. Each student writes a one right in his view
of options and forwards to the next participant, who must continue to answer your choice. During the
discussion of incorrect answers crossed out, which is included in your final evaluation at the end of class.
Advantages: Control of knowledge can be made in written and oral form.Example:
1. List the major components of Tetralogy Falo1. Hemodynamic changes in VSD.
2. Clinical and hemodynamic changes in congenital stenosis of the pulmonary artery Usti.
3. List of instrumental studies necessary for the diagnosis of coarctation of the aorta.
Answer: See the theoretical part.The analytical part of the class is desirable to continue with situational
problems.In the practical part in the cardiology department under the supervision of teachers conducting
Supervision sick students so-called educational practice.To prepare thematic bypass 02.01 wigs patients with
congenital heart and great vessels. There must be a sufficient medical history with a minimum of
surveys.Requires special attention from the teacher correctness of the medical records and diaries
subordinators.
Maximum score of 18-17 score
16-15 score
14-13 score
12 points
20-19
excellent
good
Satisfactory
Not satisfactory
bad
100%-86%
85%-73%
70-56%
53%-46%
43% or less
4. Analitical part
4.2.1. Case studies:
1. During a routine inspection in 10 year old girl found diastolic tremor along the body of the sternum.
Auscultation of the heart and amplified split II tone and systolic murmur in the second intercostal space to
the left of the sternum. Of history: she often suffered colds and the last time he was troubled by shortness of
breath, palpitations during exercise. OBJECTIVE: The girl slightly built, with delicate transparent skin
surface. Heart enlarged in diameter. Radiographically enlarged hilar, pulmonary pattern is reinforced,
increasing the pulmonary artery and its branches. Heart enlarged in diameter. Left-loop protrudes II arc. In II
oblique determined by the increase of the right heart. Blood count unchanged.1. Your preliminary diagnosis
2. Specify the necessary instrumental tests to confirm the diagnosis;
3.Gemodinamicheskie change in this condition;
4. Tactics GPs.№ Answers1 CHD. ASD. Osl.: NC II and art. (FC II) 202 ECG, echocardiography,
angiocardiography, cardiac catheterization 403 If underdevelopment WFP resets arterial blood left to right.
With a large discharge pulmonary heart and pulmonary circulation are overloaded with excess blood.
Formed pulmonary hypertension develops relative failure and sometimes pulmonary valve stenosis. Over
time, the pressure increases and the PP is shunt right-to-left (a recurring sharp cyanosis) 304 Consultation
cardio 102. 12 year old child in the last 2-3 years are concerned fatigue, shortness of breath, palpitations
during exercise. A history of chronic bronchitis. On-but: Apparently not match his age. Pale skin, wet,
pastoznost and dark circles under the eyes. Has increased, the carotid pulse. Enlarged left heart border.
Auscultation: On top of the I and III enhanced color tone, accent II tone of the pulmonary artery. Top of the
left edge of the sternum and the infraclavicular region auscultated systolic-diastolic ("machine") the noise
gradually increasing to the end of systole. Heart rate and pulse 88 beats. in min., BP 130/60 mm Hg
Abdomen soft painless. On fluoroscopy gr. cells with contrast esophagus: Pulmonary vascular pattern
strengthened roots extended. Marked bulging of the second arc on the left contour of the heart, the fourth
extension of the arc. Expansion of the ascending aorta.1. Your preliminary diagnosis;2. Specify the
necessary instrumental tests to confirm the diagnosis;3. Basic hemodynamic changes in this condition;4.
Peripheral signs of this disease;
_______________________________________________________________________
3. At 18 years of conscript during the inspection revealed a loud systolic murmur in the III-IV intercostal
space on the left edge of the sternum, the accent II tone of the pulmonary artery. On questioning established
that he is concerned about shortness of breath, palpitations during exercise. Often sick colds. Objectively:
general condition is satisfactory. Dermal net, pale - pink. Above the light vesicular breathing, no wheezing.
Heart rate of 78 beats. in 1 min. Blood pressure 110/70 mm Hg Abdomen soft painless. The liver and spleen
were not palpable. No edema.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Basic hemodynamic changes in this condition;
4. Tactics GPs.
__________________________________________________________________________________
4. A young man of 26 years, complaining of headaches, periodic heartbeat, fatigue, pain in the legs when
walking. Works as a loader. The above complaints were busy for the last 2-year periodically. The patient
noted a well-developed upper body muscles, the leg muscles atrophic. Heart borders shifted left 2 cm of the
left mid-clavicular line, the right and the upper normal. Reinforced cardiac impulse. Heart sounds average
sonority, auscultated rough systolic murmur, with its epicenter in the so Botkin and interscapular region. BP
on hand 180/110 mm Hg Pulse 82 beats / min. rhythmic tension. Liver of the costal margin, swelling in the
legs do not. Ripple stop weakened arteries on both sides.
1. List at least five diseases accompanied with high blood pressure;
2. Your preliminary diagnosis;
3. Specify the necessary instrumental tests to confirm the diagnosis;
4. Tactics GPs. Radical treatment.
________________________________________________________________________________
5. 10 year old girl T last 2 years concerned fatigue, shortness of breath, palpitations during exercise,
sometimes intermittent asthma. Of history: the girl is very weak, sickly from - for that it is lagging behind
their classmates. Objectively, it looks for 7-8 year olds. Pale skin, cyanosis of the lips, blush on his cheek,
under eye dark circles. Small "heart hump", the boundary of the heart extended upwards and to the right.
Auskultatvno: Rough sistolodiastolichesky noise with its epicenter in the II-III intercostal space on the left of
the sternum, popping the first tone and diastolic murmur at the apex. Pulse of 96 bpm. in 1 min., rhythmic.
BP on the arm 100/60 mmHg Liver 2 cm No peripheral edema. X-ray examination: pulmonary pattern
enhanced by arterial significantly increased pulmonary heart and left atrium protrudes II arc.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Basic hemodynamic changes in this condition;
4. Tactics GPs.
_____________________________________________________________________________________
6. 8 year old boy worried about stabbing pains in the heart, palpitations, shortness of breath on exertion,
dizziness. Objectively, the child is not age appropriate. The chest is deformed due to a heart hump. There is a
strong pulse in the heart. Above the light vesicular breathing, no wheezing. Percussion border of the heart:
the right to the right edge of the sternum, upper III m / d on the left, on the left anterior axillary line.
Auscultation: Cardiac average sonority, in the second intercostal space to the right rough systolic murmur
auscultated conducting on the neck vessels, easing II tone of the aorta and I tone at the top. Pulse 90 beats /
min., Rhythmic. BP 110/80 mmHg The abdomen is soft and painless. The liver and spleen were not
palpable. No edema.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. List the major complication of this disease;
4. Tactics GPs.
_______________________________________________________________________________
7. 9 year old boy complained of stabbing pains in the heart area radiating to the left arm, palpitations,
shortness of breath on exertion, headache, dizziness. OBJECTIVE: The general condition Wed gravity. Pale
skin. In the heart of a heart hump. Palpation is determined systolic tremor in the second intercostal space at
the left sternal border. Here auscultatory systolic murmur, conductive to the left edge of the sternum.
Percussion border of the heart: Right + 2 cm from the right edge of the sternum, upper III m / d on the left,
the left 1 cm medially from the left mid-clavicular line. Pulse 88 beats / min., Rhythmic. BP 100/70 mmHg
The abdomen is soft and painless. 2 cm liver, spleen not palpable. No edema.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Tactics GPs and treatment.
________________________________________________________________________________
8. GPs asked to woman complaining that her 9 month old baby poorly developed, choking and turning
blue during breast-feeding and movement, loses consciousness, often sick. OBJECTIVE: The child behind
the physical development, lack of exercise. Pale skin pink, cyanosis of the lips, akratsianoz. When driving
increased cyanosis. There is deformity of the chest, systolic shake in the heart. Auscultation heart sounds are
muffled, at all points in systolic hearing noises of varying intensity. Heart rate 120 times in 1 min. Above the
light weakened vesicular breathing, no wheezing. The abdomen is soft and painless. No edema. In general,
the analysis of blood polycythemia, thrombocytopenia.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Prospective radiographic changes in the patient;
4. Tactics GPs.
_____________________________________________________________________________________
9. B. 10 year old boy in the last 4-6 months. became concerned about fatigue, shortness of breath,
palpitations during exercise, asthma attacks at night. A history of frequent colds. On-but: Apparently not
match his age. Pale skin, wet, pastoznost and dark circles under the eyes, cyanosis of the lips and
acrocyanosis. Has increased, the carotid pulse. Small "heart hump", the boundary of the heart extended
across. Auscultation: At the top of the tone I strengthened emphasis II tone of the pulmonary artery. Top of
the left edge of the sternum and the infraclavicular region auscultated systolic-diastolic murmur, gradually
increasing to the end of systole. Heart rate and pulse 88 beats. in min., BP 120/60 mm Hg Abdomen soft
painless. On fluoroscopy gr. the cells of the esophagus with contrast: enhanced vascular lung markings, roots
extended. Marked bulging of the second arc on the left contour of the heart, the fourth extension of the arc.
Expansion of the ascending aorta.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Basic hemodynamic changes in this condition;
4. Enter the reason for the deterioration of the child.
________________________________________________________________________________
10. On examination, the GP 22 year old female with 12 weeks' gestation revealed a loud systolic murmur
in the III-IV intercostal space on the left edge of the sternum, the accent II tone of the pulmonary artery. On
questioning established that she was concerned dyspnea, palpitation on exertion. As a child, often sick colds.
Objectively: general condition is satisfactory. Dermal net, pale - pink. Above the light vesicular breathing, no
wheezing. Heart rate of 78 beats. in 1 min. Blood pressure 110/70 mm Hg The abdomen is soft and painless.
The liver and spleen were not palpable. No edema.
1. Your preliminary diagnosis;
2. Specify the necessary instrumental tests to confirm the diagnosis;
3. Tactics GPs in this case.
4. List the possible complications in women with this disease.
__________________________________________________________________________________
Tests
1. What of the following is not common in primary pulmonary hypertension:
a) Legal basis ventricular hypertrophy
b) left ventricular hypertrophy
c) atherosclerotic plaques in large pulmonary arteries
d) weak peripheral pulmonary vasculature
e) right bundle branch block
2. Systolic murmur interventricular defect often be distinguished:
a) with the noise of mitral regurgitation
b) with noise pulmonary stenosis
c) with the noise of aortic stenosis
d) with noise tricuspid regurgitatione) with the noise of tricuspid stenosis
d) with noise tricuspid regurgitatione) with the noise of tricuspid stenosis
3. For sharp pulmonary stenosis is not typical
la) small size, thin neck
b) pronounced swelling jugular veins
c) the intensity systolic murmur and shakein II intercostal space at the left sternal
d) ECG signs of right ventricular hypertrophy and atriald) significant pulmonary venous engorgement
4.What of the following is not important in the occurrence of congenital heart disease:
a) drug effects on the fetus
b) parents' alcoholism
c) increased radioactivity
d) increase the nitrate content in products
e) transferred into the mother destve tonsillitis
5. For cyanotic congenital not typical:
a) Polycythemia
b) fingers in a "clubbing"
c) shortness of breath during physical activity
d) increase in blood pressure
d) the noise of the heart
6. Uncharacteristic trait for tetralogy of Fallot
:a) interventricular defect
b) dextroposition aortic
c) pulmonary stenosis
d) interatrial defect
e) right ventricular hypertrophy
7. Which of the following can be safely, cheaply and quickly confirm e of atrial defect:
a) imaging of the heart
b) radionuclide angiography
c) with Doppler echocardiography
d) koronaroarteriografiya
e) phonocardiography
8. Which of the methods can accurately confirm the presence of interventricular defect:
a) electrocardiography
b) X-rays
c) phonocardiography
d) with doppler echocardiography
e) coronary
9. For physical data interventricular defect complicated by pulmonary hypertension and right to
left shunt, does not include:
a) The minimum systolic sound (or lack of it)
b) rough systolic murmur and shake at the left sternal
c) P tone sharp focus on the pulmonary artery
d) diastolic murmur at the apexd) cyanosise) "drumsticks"
10. Sign of tetralogy of Fallot
a) shortness of breath and cyanotic attacks
b) anemia
c) systolic murmur at the apex
d) diastolic murmur in the II-III intercostal spacee) II-tone emphasis on the aorta
11. What are the signs of aortic and subaortic stenosis:
a) poststenotic enlargement of the ascending aorta
b) weakening and splitting II tone of the aorta
c) systolic "cat purring" second intercostal space on the left, at the edge of the sternum
d) right ventricular hypertrophye) hypertrophy of the right atrium
e) systolic "cat purring" second intercostal space on the right, near the edge of the sternum
12. Isolated pulmonary stenosis is characterized by:
a) dizziness, tendency to fainting
b) systolic murmur right edge of sternum
c) scraping systolic murmur along the left edge of the sternumd) expansion of the aorta
d) expansion of the left ventricle
e) I tone in the pulmonary artery is weakened or does not listen
13. List the disease is accompanied by systolic noise between the 2. Reb. on the right:
a) aortic valve stenosis
b) an atrial septal defect
c) aortic atherosclerosis
d) ventricular septal defect
e) coarctation of the aortae) mitral insufficiency
14. List the disease sopravazhdayuschiesya listening systolic murmur in the 2 intercostal space on
the left:
a) ventricular septal defect
b) an atrial septal defect
c) Tetralogy of Fallot
d) aortic valve stenosis
e) aortic atherosclerosise) pulmonary stenosis
15. Select the symptoms of tetralogy of Fallot, with marked cyanosis
:a) shortness of breath, tachycardia
b) strengthening of the first tone at the top
c) the X-ray: the heart - in the form of "Dutch shoe"
d) on the ECG - deviation EOS left
e) left ventricular hypertrophye) systolic murmur
16. For congenital heart disease is typical, except
a) defect after 7 years
b) systolic murmur
c) with the birth defect
d) a history of rheumatic fever
e) delay in physical development
17. Components of tetralogy of Fallot, except:
a) an atrial septal defect
b) pulmonary stenosis
c) ventricular septal defect
d) a shift to the right aortic
e) left ventricular hypertrophy
e) mitral stenosis
18. Roentgen signs of ventricular septal defect, except
a) left ventricular hypertrophy
b) right ventricular hypertrophy
c) aortic heart shape
d) a moderate hypertrophy of the left atrium
e) depletion of lung patterne) hypertrophy of the right atrium
Maximum score of 18-17 score
16-15 score
20-19
excellent
good
satisfactory
100%-86%
85%-73%
70-56%
14-13 score
12 points
not satisfactory
53%-46%
bad
43% or less
4.2.2.Graphic organizer: Conceptual table. Conceptual table provides a comparison of the phenomena,
concepts, attitudes, etc., with the same two or more aspects. Develop systems thinking, the ability to
structure. Organize information.Acquainted with the rules of the conceptual table. Define what is to be
compared, isolated characteristics that will be a comparison. Individually or in mini-groups build and fill the
table conceptual. Vertical is that not compare .Horizontal - different characteristics that are compared.
diastolic and
систолический
diastolic
systolic
noises
Associated
malformations
Aortic valve
insufficiency
Aortic stenosis
The group is divided into two small groups, the participants of each small group evaluate the work
of students of another small group. Each correct answer is worth 15 points.
Group №
Correct and clear
Lucidity (5)
announcement
Active
Total
answer (5)
of regulation
members of
points
(2,5)
the group
(2,5)
1.
2.
Maximal ny score
20-19
excellent
100%-86%
18-17 mark
16-15 mark
14-13 mark
12 mark
good
85%-73%
satisfactory
70-56%
Not satisfactory
53%-46%
bad
43% and less
4.3.Practical part. The list of skills that GPs should possess after completing studies on the subject.
The list of skills that GPs should possess after completing studies on the subject1. Conduct a survey of
patients with congenital heart and great vessels. 2. Interpretation of ECG, echocardiography, X-ray
data for CHD. Heart sounds and cardiomegaly. Congenital heart and great vessels.
№ stage
indicators /interpretation
not done
implemented in full
Supervision of patient
Complete blood count
SRP
acute-phase indicators
coagulation
ECG
EchoCG
0
50
angiography
differential diagnosis
0
20
justification diagnosis
0
10
Tactics GPs and treatment assignment
0
10
recommendations
0
10
TOTAL
0
100
The number and types of control measures to assess student knowledge. Verbally. In writing the
decision of situational problems.Demonstration of skills mastered
5. Control forms of knowledge, skills and abilities- Oral- Decision of situational problemsDemonstration of practical skills
- CDS
6.Criteria of assessment monitoring
levels of
Rating scores
Characteristics of the student's work
estimates
Point of presence on the practical lesson. Complete lack of
knowledge and ability to perform practical skills - the student is
20
not ready for the practical sessions.
Student answers unsatisfactory.Students do not possess the
underlying levels of knowledge and skills, at least one of the
following:
• Do not know the clinical signs of heart diseases and major vessels.
• Do not know the mechanism of the development of birth defects
and major vessels.
not satisfactory
20 - 54,9
• Do not know the diagnosis of CHD and major vessels.
• Do not specify the ECG signs of CHD.
• Not able to build a rational history during supervision of patients.
• During supervision can not objectively evaluate the condition of
patients.
• Not able to rationally plan examination of patients with CHD in a
hovercraft, or joint venture.
Providing basic knowledge and skills
55-60,9
61-65,9
Satisfactory
55-70,9%
66-70,9
Satisfactory answer to poor quality.The student tries to hold the
basic knowledge and skills (see below), but when replying or
performing skills commit serious mistakes.
Moderately satisfactory answer.The student has the basic
knowledge and skills (see below), but when replying or
performing skills mistakes (twin errors)
Satisfactory response quality.The student is fully owned baseline
knowledge and skills:
• Knows the clinical features of ASD, VSD, PDA, pulmonary
stenosis, tetralogy of Fallot, coarctation of the aorta.
• Can differentiate ASD, VSD, PDA, pulmonary stenosis, tetralogy
of Fallot, coarctation of the aorta by the subjective, objective, and
laboratory and instrumental data
• Can specify the ECG signs of ASD, VSD, PDA, pulmonary
stenosis, tetralogy of Fallot, coarctation of the aorta.
• Able to build a rational history during supervision of patients.
• During supervision able to objectively assess the condition of
patients.
• Can interpret the results of laboratory and imaging studies - may
indicate the presence of hypercholesterolemia, leukocytosis,
elevated CPK and ESR.
• Can display technology ECG
• Able to plan a rational examination of patients with ASD, VSD,
PDA, pulmonary stenosis, tetralogy of Fallot, coarctation of the
aorta in a hovercraft or a joint venture.
• Able to correctly fill in the patient diary.
Advanced knowledge
71-75,9
good
71-85,9%
76-80
81-85,9
The student is fully owned baseline knowledge and skills (listed in
"66-70,9") + has the following knowledge and skills:
• Does the mechanism of action of drugs
• Rationally choose drugs with
proven effectiveness.
The student is fully owned baseline knowledge and skills (see
above) + the knowledge referred to in paragraph "71-75,9" and has
the following knowledge and skills:
• Knows the principles of primary, secondary and tertiary
prevention of these diseases.
The student is fully owned baseline knowledge and skills (see
above) + the knowledge referred to in paragraph "71-75,9" and "7680" and has the following knowledge and skills:
• Can send the patient to a special institution for cardiac surgery.
• Principles of management, supervision and monitoring of patients
in a hovercraft or a joint venture.
• Able to hold a consultation on the boards of non-drug and drug
using IPC skills.
• Principles of clinical examination and rehabilitation of patients in
a hovercraft or FP
86-90
The student is fully owned baseline knowledge and skills (see
above) + the knowledge referred to in paragraph "81-85,9" and has
the following knowledge and skills:
• Knows the indications and contraindications of the coronagraph
• Is able to provide reliable information about the evils of the
Internet on the basis of data
91-95

The student is fully owned baseline knowledge and skills
(see above) + the knowledge referred to in paragraph "86-90" and has
the following knowledge and skills:

• Can be monitored in a hovercraft, or joint venture
96-100

The student is fully owned baseline knowledge and skills
(see above) + the knowledge referred to in paragraph "91-95" and has
the following knowledge and skills:
• provide scientific data from the literature (articles and internet)
• Knows the indications and contraindications for stenting and USA
excellent
86-100%
Note: The basic knowledge and skills - a minimum of knowledge that provides a principle of "security"
for the patient.
7. Test questions
1.Clinics and auscultatory findings in ASD, VSD.
2. Clinics and diagnosis of pulmonary artery stenosis.
3. Clinics and diagnosis of tetralogy of Fallot.
4. Clinics and diagnosis of patent ductus arteriosus.
5. Clinics and diagnosis of coarctation of the aorta.
6. Differentiated treatment of CHD.
8. Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1.Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2.Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3.Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4.Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5.Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6.Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
7.Диагностика болезней внутренних органов. Окороков А.Н..2005.
8Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа,
2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
1.
Chronological content of classes
time
8.30–
9.30
9.1510.00
activity
Morning
conference
Clinical audit is
written out sick.
content
The report of the doctor on duty
and duty subordinators on duty
A detailed report of the student
prescription patients.
materials
History, ECG,
overhead.
lesson time
1 hour
45 minute
10.0510.45
Theoretical
analysis of topics
10.45 11.05.
Study skills.
11.0511.45
Supervision of
patientsThe
Department of
Cardiology and
Cardiac
11.4512.15
12.2013.20
break
Analysis of casepatients
Checking the initial level of
preparedness of students using
the "round table" and the decision
of situational problems. Students
are heard case studies on the
topic, they need to analyze and
give an opinion.
Student under the supervision of a
teacher must complete a
minimum of two skills
Each student is in charge of a
particular patient ward.
Case studies,
educational
boards, tables,
corresponding to a
subject class.
40 minute
Patient or
volunteer
20 minute
Sick,
stethoscope, blood
pressure monitor,
medical history
(with data of
clinical and
laboratory
research).
40 minute
30 minute
At the option of the teacher
conducted a full inspection of the
patient on activity or patients who
are preparing to leave the
hospital, data analysis laboratory
and instrumental studies, study
the preliminary and final clinical
diagnoses. Determined by the
treatment plan with the doses of
drugs
Sick,
stethoscope, blood
pressure monitor,
medical history
(data of clinical
and laboratory
research).
1 hour
Practical lesson number 13. Theme: "Heart sounds and cardiomegaly. Differential diagnosis in
different clinical forms of cardiomyopathy (dilated, restrictive, hypertrophic, arrhythmogenic right
ventricular dysplasia). Differential diagnosis between cardiomyopathies, valvular disease, coronary
heart disease, hypertension. Tactics GPs. Principles of follow-up, monitoring and rehabilitation in
RPP or joint venture. Principles of prevention. Principles of teaching topics. "
Education technology
Learning time: 6 hours
1. Training room.
2. Cabinet ECG
The structure of the training session
3. Tutorials, phantoms, models, handouts, a collection of
case tasks and testsTV, video equipment, multimedia
The purpose of the training session:Teach GPs on timely diagnosis and differential diagnosis, selection of
the optimal treatment strategy options for diseases soprvozhdayuschihsya configuration change of heart,
particularly when rzlichnyh forms of cardiomyopathy, as well as principles of management of patients in
primary care, provided the requirements of "Qualification characteristics of a general practitioner"
Pedagogical objectives:
Learning outcomes:
1. Consider diagnosis to configuration
GPs should know:
changes of the heart, particularly in rzlichnyh
1. The mechanism by which changes in the configuration
forms of cardiomyopathy.
of the heart (cardiomyopathy).
2. Patients demonstrate a disease in which
2. Clinical manifestations of diseases associated with
there is a configuration change of heart.
changes in the configuration of the heart (cardiomyopathy).
3. Discuss questions about tactics in the
3. Differential diagnosis of diseases associated with
qualifying characteristics of GPs
changes in the configuration of the heart.
4. Discuss the principles of treatment (non4. Features of physical data of diseases associated with
drug and drug).
changes in the configuration of the heart.
5. Discuss the principles of management,
5. Tactics GPs.
supervision and monitoring of patients in a
hovercraft or a joint venture.Discuss the
principles of primary, secondary and tertiary
prevention for these diseases
training methods
Forms of educational activity
learning Tools
Ways and means of feedback
6. NN principles of treatment (drug and non-drug) for these
diseases.
7. Principles of follow-up and monitoring of patients in a
hovercraft, or joint venture.
8. The principles of primary, secondary and tertiary
prevention in these diseases.
GPs should be able to:
1. Analyze the data of patients with a history of complaints
and to configuration changes of the heart.
2. Diagnose, to differentiate on clinical and ECG various
configuration change of heart.
3. Choose the right medications diseases to configuration
changes of the heart.
4. Choose products with proven efficacy
5. Advise on non-medicated treatments.
6. To monitor the RPP or in joint venture.
method "gallery tour", demonstration, entertainment
experience, discussion, conversation, decision tests and
situational problems
Individual work, group work, team, classroom,
extracurricular.
Distributing educational materials viziualnye materials,
videos, models, graphic organizers, history, tables,
benches.
Quiz, test, presentation of the results of the training task,
filling medical history, perform a practical skill
"professional questioning"
Technology chart classes. "Heart sounds and cardiomegaly. Differential diagnosis in different
clinical forms of cardiomyopathy (dilated, restrictive, hypertrophic, arrhythmogenic right ventricular
dysplasia). Differential diagnosis between cardiomyopathies, valvular disease, coronary heart disease,
hypertension. Tactics GPs. Principles of follow-up, monitoring and rehabilitation in RPP or joint
venture. Principles of prevention. Principles of teaching topics. "
№
Stages of practice session
1
Intro (study subject)
2
Discussion of the topic of practical classes using the new
educational technologies (method of "role-playing game"),
as well as demonstration material (history, tables, posters,
x-ray), the definition of the initial level
3
4
conclusion discussion
Job definition for the practical part - professional questions.
Explanation of the provisions and recommendations for the
job to fill history
5
The development of practical training under the guidance of a
teacher.
Forms of training
Place
Duration
225
10
Survey, discussion
classroom, Chamber
offices
40
discussionIn the wards
offices
Prof. questioning.
Conversation with
patients and filling
medical history, case
studies
10
20
20
6
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients.
Medical history,
laboratory data
situational problems
25
7
Discussion of the theoretical and practical knowledge of the
students, securing material, the level of learning assessment
75
8
Defining output on practical training, evaluation of 100-point
scale, and ad evaluations. Homework the next practice
session (a collection of questions).
Oral examination,
tests, discussion,
identification of
practical skills
Classroom
Information, questions
for homework.
Classroom
25
2. Motivation. In clinical practice, are important diseases associated with changes in the configuration of
the heart, cardiomyopathy. In this situation, the force of a general practitioner (GP) is directed to the
diagnosis of these diseases for medical care and refine locations of this group of patients to be treated in a
hovercraft or a joint venture, or referral to specialized hospitals. These circumstances are the basis for the
inclusion of this subject in the training of GPs.
3. Intra and interdisciplinary communication.Of teaching of the subject is based on the knowledge of
students the basics of anatomy, and the normal and pathological physiology. Acquired during the course will
be used for the passage of medicine, surgery and other clinical disciplines, and with further study of topics
such as heart disease, coronary artery disease and GB. Given that the symptoms of the heart sounds and
cardiomegaly is a symptom of many diseases, GPs have to work with many experts, surgeons, cardiologists.
4. Contents of classes
4.1. The theoretical part . Dilated cardiomyopathy is characterized by dilatation, in violation of the
contractility of the myocardium of the left or both ventricles. Depending on the etiology, it can be familial /
genetic, viral or immune, alcoholic (toxic), idiopathic (caused by unknown factors) or associated with
recognized cardiovascular disease in which the degree of myocardial dysfunction explained enough.
Hypertrophic cardiomyopathy, characterized by hypertrophy of the left or right ventricle, which is usually
asymmetric and involves the interventricular septum. For many patients, the disease is caused by mutations
in genes encoding sarcomeric contractile protein synthesis.Restrictive cardiomyopathy, characterized by
restrictive (limited) content and reduced diastolic volume of either or both ventricles with normal or nearnormal systolic function. Can be idiopathic or associated with other diseases (such as amyloidosis,
endomyocardial disease).Arrhythmogenic right ventricular cardiomyopathy, characterized by progressive
fibro-fatty replacement of right ventricular myocardium, in some cases, left ventricle, usually a family
disease.In outpatient facilities can meet the typical situations, 0 allow suspected hypertrophic
cardiomyopathy.In the initial stage of the disease any patient complaints does not show. The first symptom is
usually the chance discovery of a systolic murmur over the entire surface of the heart, with a maximum at the
top or in the area Botkin. False angina, shortness of breath of a young man showing a history of congenital
heart disease. False angina, shortness of breath in combination with deep negative T waves or accidental
detection of pathological "infarct" ECG with no complaints.In dilated cardiomyopathy, asymptomatic period
of the disease lasts from 1 to 10 years, an average of 3-5 years. At this stage dilated cardiomyopathy lists you
can identify suspected accidental cardiomegaly according to X-ray, ECG, echocardiography in young and
middle-aged, excluding CAD, GB, valvular heart disease clinical manifestation - there were no apparent
cause shortness of breath on exertion, tachycardia, fatigue, sometimes cardialgiae.Differential diagnosis
between the Commission, coronary heart disease and GB held on the following criteria: the complaint, the
patient's age, the beginning of the disease, clinical signs, physical examination findings, laboratory
data.Acquired heart disease (PPP) are most often the result of rheumatic myocardial endokpardita
etirologii.Clinic faculty: There are two groups of symptoms - direct signs caused distortion of the valve
apparatus and indirect signs - caused compensatory hypertrophy dilatation respective chambers of the heart.
In contrast to heart diseases at the ILC in isolation affects the heart muscle, with the development of
cardiomegaly. The reasons are not known and are characterized by rapid development in a short period of
severe heart failure and complex arrhythmias and thromboembolism.The most common cause of CHD is
atherosclerosis of the coronary arteries. For CHD characteristic syndrome is pain attack, paroxysmal pressing
pain in the sternum. In laboratory studies revealed hyperlipidemia.At GB - increase blood pressure is not
associated with primary organic damage to organs and systems. Benign GB is characterized by slow
progression of target organ damage (heart, ERs, retina and kidney). ECG and X-ray revealed signs of left
ventricular hypertrophy. Investigation of the fundus can make certain judgments about the changes of the
brain.The use of "role play"Purpose: To teach students critically evaluate information and identification
completeness of knowledge on the subject.Role-playing game - a method of learning in which participants
act out the situation related to the objectives of lessons.Two participants in your group will agree to
participate in the performance of roles. One will be a medical professional, the other - the patient. Each
participant who is taking part in a role play, due in a few minutes to get acquainted with the situation and
enacted to prepare for the game. Those participants who will watch the game, should also read the
background information to be able to participate in discussions in small groups, subsequent to the role
play.Roles of the participantsHealth professionals: physicians with extensive experience, the therapist. In
cardiology clinic came first and has never worked with the staff at the clinic.Patient: 28 year old woman who
has two children, while prof. examination complained of shortness of breath and palpitations, seen revealed
systolic noisy top, the noise intensity increases with rising sharply. On ECG negative tooth T. doctor sent the
patient to X-ray and echocardiography study for the diagnosis and the development of optimal treatment
strategy.Contents RPG: Role-playing game focuses on the interaction between doctor and patient. The
physician should advise the patient and calm. The patient should continue to be nervous until the doctor will
choose the appropriate words and phrases that will give her the information and comfort her.
Questions for discussion:
1. Communicated the doctor with the patient in a friendly, reassuring manner?
2. Did you approach the doctor scheduled an effect on the patient?
3. What other approaches could be effective?
4. Whether the patient fears justified?
5. How can I avoid this problem?
№ evaluation
excellent
good
satisfactory
Not satisfactory
assimilation in %
100%-86%
85%70-55%
54%-37%
71%
1 The theoretical part
20-17,2
17-14,2
14-11 point
10,8-7,4 m
point
point
point
bad
36% and
below
7,2 point
4.2.1.Patient P., within 2 years of worry shortness of breath, palpitations, with little physical load,
swelling in the legs, pain and heaviness in the region. right upper quadrant, irregular heart work. Regularly
took digoxin, diuretics, aspirin and kordaron scheme. This afternoon, after fiz.nagruzki suddenly appeared
chest pain, shortness of breath, coughing, coughing up blood, dizziness, cold sweats, cyanosis. An
ambulance was called. On ECG - signs of hypertrophy of the left and right ventricular overload of the right
ventricle, complete blockade of PNPG. On echocardiography: a diffuse decrease in myocardial contractility,
a symmetric increase in cavities and an ejection fraction of both ventricles diagnosis. Tactics GPs.
Treatment.
questions
mark
Replies
What kind of disease you
Dilated cardiomyopathy with conduction disturbance. Complete
65
can think of?
blockade of PNPG. OSL: HK IIB Art. PATE
Tactics of GPs and treatment.
hospitalization in the coronary careAnalgesics, thrombolytics,
35
fraxiparine, aspirin, digitalis glycosides, ACE inhibitors, and AB.
Task
A patient aged 68, who suffers from angina for several years, noted the appearance of angina attacks 1-2
times daily walking. One week before admission noticed that the pain became more intense and prolonged.
A few days later the number of strokes on the way to work up to 10-15 severity of attacks has not changed,
they stopped soon after the removal of the load, but sometimes the patient used nitroglycerin. To the doctor
did not address, any antianginal drugs did not accept. On the day of admission on the street developed severe
anginal attack, accompanied by shortness of breath, cough with frothy sputum, fainting, falling blood
pressure to 80/60 mm Hg, the patient is taken to the hospital for "fast." On ECG - ST segment elevation in I,
II, aVL, V1-6. Diagnosis.
Treatment.
questions
mark
Replies
What kind of disease you can
CHD: MI front-septal and apical region, covering the side wall.
60
think of?
acute period. OSL: Reflex cardiogenic shock. pulmonary edema
Tactics of GPs and treatment.
humidified oxygen, narcotic analgesics, nitrates against dopamine
and hormones, diuretics, alcohol / in
40
Task Patient N., 50 years old, complained of headaches in the parietal-occipital region, breathlessness
when walking, asthma alone, irregular region. heart, increasing blood pressure marks over 10 years. at the
time of the inspection there was choking, cough with frothy sputum, pressing chest pain. Blood pressure
245/135 mmHg Serious condition, the skin is pale and moist. Breath of Light weakened, both sides are many
moist rales. Heart borders shifted left 2 cm, a significant focus II tone of the aorta, systolic murmur at the
apex. Rhythmic activity of the heart, dull tones, tachycardia to 140 minutes. The liver performs at 1-2 cm
below the costal arch. No edema. On the ECG rhythm siniusovy signs of LV hypertrophy with
overdrive.Expose detailed clinical diagnosis. Plan evaluation and treatment
questions
mark
Replies
What kind of disease you can
GB II Art. with damage to the heart and brain. OSL: Hypertensive 50
think of?
crisis. Pulmonary edema.
Additional studies.
KLA, OAM, cholesterol, lipids, urea, kriatinin, blood sugar,
25
coagulation, echocardiography, chest X-ray.
Tactics GPs and treatment.
ACE inhibitors, B blockers, aspirin, nitrates, a / c, diuretics,
25
ganglionic, narcotic analgesics
Task
Patient T., 16 years old. Last 2-3 years, complaining of fatigue, body temperature to 38.70 C, dyspnea,
palpitation on exertion. Occasionally fever. On-no: pastoznost, dark circles under the eyes, the skin moist to
the touch, a little "heart hump", the boundary of the heart expanded in diameter, pulse 92 min., Blood
pressure arm 125/50 mmHg standing 130/80 mmHg Rough sistolodiastolichesky noise with its epicenter in
II intercostal space on the left of the sternum, registered in the PCG. ECG signs of hypertrophy 10the left
ventricle. X-ray examination: pulmonary pattern strengthened at the expense of the arterial bed, significantly
increased pulmonary heart and the left atrium, II arc moderately protrudes. Liver 3 cm KLA: leukocytosis
(9h109 / l) with a shift to the segmented. In smears from the throat viridans streptococcus. KLA:
Hemoglobin, 96 g / l, er 3,1 L-11, 0, ESR-50 mm / h In biochem. blood test: hyperproteinemia,
disproteinemia, increased fibrinogen, DPA and thymol test, the PSA-positive. Your diagnosis. Plan survey.
Questions
What kind of disease you
can think of?
Additional studies.
Tactics GPs and treatment.
Answers
CHD. ductus arteriosus. Secondary tank. Endocarditis and / f.
Activity II, an infectious-toxic stage.
Blood cultures 3x, echocardiography, chest X-ray.
Broad-spectrum antibiotics, heparin, detoxification therapy.
scores
50
25
25
Task
The problem patient 57 years taken to hospital with "fast" with complaints of sudden pressing chest pain,
irradiruyuschie in his left hand, fear of death, general weakness. The pain lasted for 3 hours, not stoped
nitroglycerin. On-no: pale skin, his face covered with a cold clammy sweat, cyanosis of the lips. Marble skin
color over light: vesicular breathing, congestion in the lower sonorous rales. Heart: Left granitsya 2 cm
laterally from the mid-clavicular line, the right - on the edge of the sternum, upper - 3 edge tones deaf. Pulse
and heart rate - 120 per minute, filling the small, soft, arrhythmic. BP - 70/40 mm Hg slightly swollen
abdomen, palpation painless. The liver and spleen were not enlarged. t - 36,6 C, on the second day, the
temperature - 38 C. The blood test: er - 4.5 Hb -116 g / l, L-10, 2, ESR - 18 mm / h PTI - 109%, AST - 1.8,
ALT - 0.9 mmol / L, aldolase - 12 U / ml. Urine output is reduced.
On ECG - sinus rhythm, in II, III, aVF leads deep and wide tooth Q, negative T waves and ST interval in
the form of contour lines above the dome. Politopnye extrasystoles. Diagnosis. Tactics GPs. Treatment.
Questions
What kind of disease you can
think of?
Answers
. CHD: AMI back wall with a tooth Q, acute stage, GEN III
class on lawn. OSL: Cardiogenic shock.
scores
60
Tactics GPs and treatment.
Gospiatlizatsiya in coronary care. Nitrates against hormones,
dopamine, heparin, kordaron
40
Task
N., 50 years complains of headaches, pinching pain in the heart radiating to the left arm, shortness of
breath with physical stress, asthma attacks in a horizontal position, disruption of the heart, increase blood
pressure. History of over 10 years is suffering from GB. During the inspection, there were suddenly chest
pain, cough with frothy makrotoy, suffocation. The patient's severe, pale skin, moist, akratsianoz. Above the
light on both sides multiple rales. NPV -28 times a minute. Cor-border amuses left. Auscultation: muted
tones, irregular. HR-140 bpm. in min. BP-245/135 mm Hg Abdomen soft b / w. Liver +1 +2 see no
peripheral edema. ECG to attack: sinus rhythm, left ventricular hypertrophy with overdrive. Politopnye
extrasystoles. KLA unchanged. Full diagnosis. Treatment.
Questions
Answers
scores
What kind of disease you CHD. Progressive exertional angina with jetlag. GEN III cells. on 65
can think of?
the moon. Hypertensive heart disease II Art. with damage to the
heart and brain.
Complication: Hypertensive crisis I type. Pulmonary edema.
Tactics GPs and
nitrate intravenously and orally, ACE inhibitors, kordaron,
35
treatment.
aspirin, diuretics, ganglionic, narcotic analgesics, moist kislarod.
Task
The problem patient 20 years directed the survey to daily bouts of dizziness and presyncope that emerged
six months ago after a cold. t - 38,2 C. Heart tones are muted, arrhythmia, heart rate -60 bpm. In 1 minute.
Blood pressure 120/80 mm Hg In the analysis of blood: er - 4.5 Hb -116 g / l, L-10, 2, ESR - 25 m / h, the
ECG: atrioventricular block II degree. OAM: Spec. Weight 1020, 0.033% protein, leukocytes 3-4/1.
Tentatively diagnosed. Plan Survey. Tactics of GPs.
Questions
Answers
scores
What kind of disease you
Myocarditis infectious etiology with conduction disturbance.
50
can think of?
Atrioventricular block II degree.
Additional studies. survey.
KLA revmoproby, koagulogarmma, ECG, rhythmogram and
25
echocardiography.
Tactics GPs and treatment.
Consulting cardiologist, hospital care
25
Task
Female 32 years old, after a rest in the south noted erythema on the face, joint pain, hair loss, heart rate,
body temperature 390S, pain in the region. heart, swelling in the legs. On-no: pale skin, rash on the cheeks.
Over easy: vesicular breathing, congestion in the lower sonorous rales. Heart: the left border of 2 cm laterally
from the mid-clavicular line, the right - on the edge of the sternum, upper - 3 edge tones deaf. Pulse and heart
rate - 120 per minute, filling the small, soft, rhythmic. BP - 160/120 mm Hg abdomen is soft, painless on
palpation. The liver and spleen were not enlarged. In the analysis of blood: er - Hb 2.8 -96 g / l, L-8, 2, ESR 38 mm / h PTI - 109%, AST - 1.8, ALT - 0.9 mmol / l. Urine output is reduced. OAM: Spec. Weight of
1020, 0.66% protein, leukocytes 3-4/1, waxy cylinders -2-3 / 1.
Your preliminary diagnosis. Research methods. Tactics GPs.
Tests:
What are 3 types of myocardialdistrofias
a) dishormonal
b) alcoholic
c) thyrotoxic
d) coronary
d) allergic
e) after myocardial infarction
List the 4 periods of MI
a) acute
b) secretive
c) Subacute
d) Scarring
e) Initial
e) acute
g) thromboembolic
h) the arrhythmic
List typical variants of MI
a) asthma and abdominal
b) anginal
c) the intestinal variant
d) arrhythmic and cerebral
e) thromboembolic
Which of the following research methods are the most important for the diagnosis of coronary
artery disease in doubtful cases?
a) ECG
b) Central Hemodynamics
c) phonocardiography
d) Echocardiography
e) Veloergometry
For dilated cardiomyopathy is characterized, except:
a) hypertrophy of the interventricular septum
b) dilatation of the heart cavities
c) valvular heart disease
d) thromboembolism
e) refractory heart failure
For congenital heart disease is typical, except
a) defect after 7 years
b) systolic murmur
c) with the birth defect
d) a history of rheumatic fever
e) delay in physical development
Recommendations for patients with hypertension - all except:
a) work at night
b) Normalization of sleep
c) Reduction of overweight
d) Limit consumption of salt
e) participation in sports
For hypertension using all diuretics, except:
a) gipotiazid
b) furosemide
c) veroshpiron
d) mannitol
e) diakarb
Contraindications to ACE inhibitors believe all, except:
a) Pregnancy
b) CRF
c) Dry Cough
d) CHD PICS
d) diabetes with hypertension
Increased blood pressure can cause long-term use of all drugs, except:
a) Ephedrine
b) Erinit
c) SCS
d) Inderal
e) Enalapril
e) dopmin
Contraindications for use of b-blockers, except:
a) hypertension
b) obstructive bronchitis
c) bradycardia
d) partial atrioventricular block
d) CHD angina
Rating
Excellent
Good
Satisfactory Not
Bad
№
satisfactory
1
Assimilation in%
100%-86%
85%-71%
2
Two case studies
50-43 score
42,5- 35,5
score
70-55%
54%-37%
35- 27,5 score
27-18,5
score
36% and
below
18 score
points
4.2.2. Graphic Organizer:
Venn diagram
 used to compare or contrast or matching 2 to 3 dimensions and show them both traits.
 Develop systems thinking, the ability to compare, compare, analyze and synthesis.
Familiar with the construction of a Venn diagram. Individually / in pairs construct a Venn diagram and
fill of disjoint circles (X)
Paired, compare and complement your charts.
The intersection of circles make a list of those features that, in their opinion, are common to information 2
to 3 laps (xx / xxx).
Сommunity
Venn diagram
Nothing
common
Something
common
Much
common
4.3. The practical part
The list of skills that GPs should possess after completing studies on the subject
1. List the principles of GP-inclusive family medicine
2. Take responsibility for ethical issues in the work of GPs
№
Rating
Assimilation in%
Excellent
100%-86%
Good
85%-71%
4
Practical part
15-12,9 score
12,75-10,6
score
Satisfactory
70-55%
Not satisfactory
54%-37%
Bad
36% and
below
10,5-8,25
score
8,1-5,5- score
5,4 score
5. Control forms of knowledge, skills and abilities
• Verbally
• In writing
• The decision of situational problems
• Demonstration of skills mastered
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
Excellent
Good
Satisfactory
Not
№ Rating
satisfactory
Assimilation in%
100%-86%
85%-71%
70-55%
54%-37%
1
The theoretical part
2
Situational tasks
20-17,2
score
50-43 score
3
Test
15-12,9 score
17-14,2
score
42,5- 35,5
score
12,7-10,6
14-11 score
35- 27,5
score
10,5-8,25
10,8-7,4
score
27-18,5
score
8,1-5,5 score
Bad
36% and
below
7,2 score
18 score
points
5,4 score
4
Practical part
15-12,9 score
score
score
12,75-10,6
10,5-8,25
score
score
8,1-5,5score
points
5,4 score
points
6. The evaluation criteria of the current control
Rating lavels
Rating
points
20
not
satisfactory
20 - 54,9
Characteristics of the student's work
Point of presence on the practical lesson. Complete lack of knowledge and
ability to perform practical skills - the student is not ready for the practical
sessions.
Student answers unsatisfactory.
Students do not possess the underlying levels of knowledge and skills, at
least one of the following:
• Do not know the clinical signs of cardiomyopathy
• Do not know the mechanism of the development of cardiomyopathy.
• Do not know the diagnosis of diseases associated with changes in the
configuration of the heart.
• Can not specify a particular physical data of diseases associated with
changes in the configuration of the heart.
• Not able to build a rational history during supervision of patients.
• During supervision can not objectively evaluate the condition of patients.
• Not able to rationally plan examination of patients with cardiomyopathy
in a hovercraft, or joint venture.
Providing basic knowledge and skills
Satisfactory answer to poor quality.
The student tries to hold the basic knowledge and skills (see below), but
55-60,9
when replying or performing skills commit serious mistakes.
Moderately satisfactory answer.
The student has the basic knowledge and skills (see below), but when
61-65,9
replying or performing skills mistakes (twin errors)
Satisfactory response quality.
The student is fully owned baseline knowledge and skills: Know the
clinical signs of disease, accompanied by changes in the configuration of
the heart.
 Can differentiate disease involving changes in the configuration of the
satisfactory
heart to the subjective, objective, and laboratory and instrumental data
55-70,9%
 Can specify the ECG various configuration changes of the heart.
 Able to build a rational history during supervision of patients.
 During supervision able to objectively assess the condition of patients.
66-70,9
 Can interpret the results of laboratory and imaging studies - may
indicate the presence of hypercholesterolemia, leukocytosis, elevated CPK
and ESR.
 Can display technology ECG
 Able to plan a rational examination of patients with changes in the
configuration of the heart in a hovercraft, or joint venture.

Able to correctly fill in the patient diary.
Advanced knowledge
The student is fully owned baseline knowledge and skills (listed in "6670,9") + has the following knowledge and skills:
71-75,9
• Does the mechanism of action of drugs
• Rationally choose drugs with proven effectiveness.
good
71-85,9%
76-80
81-85,9
86-90
91-95
The student is fully owned baseline knowledge and skills (see above) + the
knowledge referred to in paragraph "71-75,9" and has the following
knowledge and skills:
• Knows the principles of primary, secondary and tertiary prevention of
these diseases.
The student is fully owned baseline knowledge and skills (see above) + the
knowledge referred to in paragraph "71-75,9" and "76-80" and has the
following knowledge and skills:
• Principles of management, supervision and monitoring of patients in a
hovercraft or a joint venture.
• Able to hold a consultation on the boards of non-drug and drug using IPC
skills.
• Principles of clinical examination and rehabilitation of patients in a
hovercraft or SP
The student is wholly owned by basic levels of knowledge and skills
(see above) + knowledge referred to in paragraph (81-85,9», and also owns
the following knowledge and skills:
Is able to provide reliable information about the vices on the basis of the
Internet данных.
The student is wholly owned by basic levels of knowledge and skills (see
above) + knowledge referred to in paragraph (86-90», and also owns the
following knowledge and skills:
 Can conduct the monitoring in the conditions of the RPP or FP.
Excellent
86-100%
96-100
The student is wholly owned by basic levels of knowledge and skills (see
above) + knowledge referred to in paragraph (91-95», and also owns the
following knowledge and skills:
• Provide scientific data on the basis of literature (articles, and Internet)
Knows indications and contraindications stetting and АКSH
Note: the Basic level of knowledge and skills is a minimum of knowledge that provides the principle
of «security» for the patient.
7. Test questions
1.Name diseases that occur with changes in the configuration of the heart.
2.Classification of cardiomyopathy (WHO).
3.Clinical symptoms and diagnosis of cardiomyopathy.
4.Clinical symptoms and diagnosis of HCM.
5.Principles of treatment of cardiomyopathy.
6.Clinical symptoms and diagnosis RKMP.
7.Tactics of GPs when changing the configuration of the heart.
8. Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1. Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2. Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа,
2009.
3. Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4. Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т.,
2010.
5. Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С.,
2010. Т.
6. Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7. Диагностика болезней внутренних органов. Окороков А.Н..2005.
8. Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
9. Hronological content of classes
lesson
time
1 hour
Time
Activity
Content
Materials
8.30–
9.30
9.1510.00
Morning
conference
Clinical
audit is written
out sick.
Theoretical
analysis of
topics
The report of the doctor on duty and duty
subordinators on duty.
A detailed report of the student
prescription patients.
History, ECG,
overhead.
Checking the initial level of preparedness
of students using the "role-play". Survey
of students on class. Students distributed
ECG that students must analyze, explain
and give an opinion. The decision of
situational problems on the topic.
The student under the supervision of a
teacher must complete a minimum of two
practical skill.
Each student is in charge of patients
determined by the Chamber.
Whiteboard, a
folder with ECG,
tables, and case
studies, relevant
topic classes.
40
minutes
The patient or
volunteer.
20
minutes
Sick, stethoscope,
blood pressure
monitor, medical
history (with
data of clinical
and laboratory
research).
40
minutes
10.0510.45
10.45 11.05.
11.0511.45
11.4512.15
12.2013.20
Elaboration
of practical
skills.
Supervision
of patients
The
Department of
Cardiology and
Cardiac
45
minutes
break
Analysis of
case-patients
At the option of the teacher conducted a
full inspection of the patient on activity
or patients who are preparing to leave the
hospital, data analysis laboratory and
instrumental studies, study the
preliminary and final clinical diagnoses.
Determined by the treatment plan with
the doses of drugs.
Sick, stethoscope,
blood pressure
monitor, medical
history (data of
clinical and
laboratory
research).
30
minutes
1 hour
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
BASED ON SOLVING THE PROBLEMS OF PATIENTS WITH EDEMATOUS-ASCITIC
SYNDROME
Purpose: To teach students to solve the problems of patients with edematous-ascitic syndrome, as
well as the principles of their management in primary health care in the qualifying characteristics of
GPs
Key learning objectives:
• Train students in solving problems associated with swelling and ascites syndrome;
• giving students timely diagnosis when there is a problem associated with swelling and ascites syndrome.
• To teach students to differentiate the disease, accompanied with swelling and ascites syndrome.
• Improve the knowledge, skills, and practical skills in solving problems of patients with edematousascitic syndrome (gathering information, identifying problems and physical examination, as well as the
ability to reasonably prescribe laboratory and instrumental methods of investigation);
• To teach students to reasonably choose the tactics;
• To teach students to exercise reasonable medical and preventive measures and surveillance in a
hovercraft and SP.
During analysis of the problem of patients the key points of assessing students must be:
 Ability to identify the main issues that affect the quality of life of patients.
 Ability to ask support questions rational history.
 The ability to distinguish the presence of risk factors.
 The ability to transfer a disease or condition that may be causing the problem.
 The ability to reasonably conduct physical examination.
 Ability to use sound laboratory and laboratory studies in a hovercraft or OP.
 Ability to identify the need for additional studies outside SVP or OP.
 Based on this information the ability to identify the root cause (diagnosis) of the problem.
 The ability to determine the tactics based on the qualifying characteristics of GPs.
 Ability to provide non-medical advice. Ability to determine medical treatment on the basis of evidencebased medicine
 Ability to identify preventive measures at the primary care level. The ability to define the principles of
clinical examination and rehabilitation of patients in a hovercraft or a joint venture.
What the student needs to know to solve the problems of patients with edematous-ascitic syndrome:
№
The list of knowledge
basic level
The list of diseases that present with swelling and ascites
The student should know at least 10
1
syndrome
of the most common diseases
A list of the most dangerous diseases that present with
The student should know at least five
2
swelling and ascites syndrome
diseases
The list of states that require management in a hovercraft According to the characteristics of the
3
or SP (1 category)
GP qualifying
The list of states that require a specialist consultation or
According to the characteristics of the
4
hospitalization (category 2)
GP qualifying
According to the characteristics of the
5
A list of studies requiring in RPP or FP (3-1 category)
GP qualifying
The list of research areas requiring outside RPP or FP
According to the characteristics of the
6
(3.2-category)
GP qualifying
A student must know features and
Key points (criteria) diagnosis, occurring with
7
symptoms of each disease, and the
edematous-ascitic syndrome
criteria for their diagnosis.
Student should know signs of heart,
8
Symptoms of internal organs
lung, liver, spleen, and kidneys.
The student must list the major
9
Signs of nephrotic syndrome
manifestations
The student must list the major
10
Signs of heart failure
manifestations
The student must list the major
11
signs of ascites
manifestations
12
Symptoms of venous insufficiency
13
Indicators of laboratory and instrumental methods of
investigation
14
treatment policy
15
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and rehabilitation
of patients in a hovercraft or OP (4-category)
The student must list the major
manifestations
The student should know:
- Performance standards and expected
changes in diseases
The student must know the
techniques and principles of treatment
(including non-drug).
Student should know key activities
necessary for the primary, secondary
and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve the problems of patients with edematous-ascitic syndrome:
№
list of skills
basic level
 The student should be able to ask questions of
rational concise questions that really helps to set the
probable diagnosis.
 The student must be able to specifically
identify and assess the patient's complaints.
 The student must be able to analyze medical
1
Ask the patient and his relatives
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics
of their development.
 The student must be able to analyze the history
of life: identification of risk factors, the health of
parents and family members.
The student must be able to identify the managed
2
Identify risk factors
and unmanaged risk factors as on questioning
patient, based on an objective approach
The student must be able to identify features:
3
Calculate the index weight / body
- Underweight
- Increased weight.
Student should be able to hold tonometry with the
4
Measure blood pressure.
incremental principle.
The student must be able to identify:
-fasies nefrotica
-puffiness
5
general inspection
- Liver palms
-gynecomastia
-swelling of the neck veins - cachexia
The student must be able to detect the presence of:
pale- Cyanosis,
6
An inspection of the skin
- Icterus,
-the presence of rash
- seal
- Telangioektazii.
The student should be able to appreciate the
7
examination of the mouth
language.
The student must be able to detect:
Explore the pulse of the carotid, radial and
- The presence or absence of a pulse
8
femoral arteries
The student must be able to evaluate the properties
of the radial artery.
9
Conduct palpation, percussion and
auscultation of breath.
10
Conduct palpation, percussion and
auscultation of heart and vascular system.
11
An inspection, palpation, percussion, belly
12
Conduct percussion and palpation of the
kidneys
13
Conduct auscultation over the renal arteries
14
Inspect the limb
15
To inspect the bones and joints
16
Examine the thyroid gland.
17
Hold ophthalmoscopy
18
Interpret the clinical and biochemical
19
Interpret the X-ray picture of light
20
ECG and decrypt it.
The student must be able to assess:
- A tour of the chest
- Voice trembling
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
- If the heart murmur, be able to identify their
epicenter, and the relation to the phase of the
cardiac activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
-ascites
-flatulence
-spider veins
- Venous collaterals
Student should be able to conduct surface and deep
palpation of the abdomen
The student must be able to identify features: hepatomegaly, splenomegaly.
The student must be able to assess:
- All available structures in the abdomen
The student must be able to detect the presence of:
- Enlarged kidneys
The student must be able to detect the presence of:
-systolic murmur.
The student should see the limbs and body, and to
be able to detect:
- Local or generalized edema. Fingers should be
able to put pressure on the dorsum of the foot and
discover:
- There is a pit or not.
Should pay attention to the condition of the veins of
the lower limb
The student must be able to detect:
- The presence of the articular syndrome
Student should be able to inspect and palpate the
thyroid gland and identify signs of increase, and
depending on the size of the thyroid gland to
distinguish the degree of goiter
Student should be able to hold ophthalmoscopy
with the principle of step and look of the eye, and
to identify features:
- Arteriovenous Perekrestov
The student must be able to identify a shift from the
norm
The student must be able to identify features:
- pneumonia
- pneumothorax
- pleurisy
- Lung cancer and tuberculosis
1. The student must be able to record the ECG
21
Differentiated disease, accompanied with
swelling and ascites syndrome.
22
Give non-medical advice
23
Rational use of medicines in the treatment of
diseases that occur with edematous-ascitic
syndrome.
24
Conduct monitoring and surveillance of
patients
with the incremental principle.
2. Student should be able to decipher the results of
the ECG and identify signs:
- Myocardial ischemia
- MI
- Hypertrophy of the heart
- Arrhythmia
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and
instrumental investigations)
The student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
13. The student should be able to choose products
with proven effectiveness.
14. When choosing drug student should be able to
evaluate:
- Efficiency
- Safety
- Eligibility
- Economy.
The student must list the principles of management
and surveillance of diseases that occur with
edematous-ascitic syndrome.
Practical Exercise № 14
Theme: "Edematous syndrome. Differential diagnosis of acute and chronic heart failure.
Differentiated therapy for heart failure. The tactics of a general practitioner with edema. The
principles of treatment, follow-up, control and rehabilitation in a hovercraft or a joint venture. The
principles of prevention. Definition of disability. Principles of teaching topics. "
Learning Technology
Study time: 6,4 hours
The structure of the training session
Number of students 8-10
1. Training themed office chair.
2. Training aids
3. Hospital wards.
4. TV, video equipment, computer, overhead,
multimedia.
5. Complete sets of tables, guidelines, video;
The goal of lesson: Teach GP timely issues of differential diagnosis, selection of the optimal treatment
strategy option for heart failure due to various diseases, as well as the principles of management of
patients in primary care, provided the requirements of the "Qualification characteristics of the GP"
Pedagogical objectives:
Learning outcomes:
1. GPs familiarize with the list of diseases The general practitioner (GP) should know:
associated with edema and to be treated
GPs should be aware of:
in specialized hospitals.
1. The etiology and pathogenesis of heart failure.
2. Teach GP treatment of heart failure.
2. Classification of heart failure.
3. To teach the tactics of GPs in edema.
3. Clinical manifestations of acute and chronic heart failure.
4. Explain the possible complications of
4. Diagnosis and differential diagnosis of edema syndrome in
the use of diuretics and cardiac
the pathology of the heart, lungs, kidneys, intestines, and
glycosides.
anemia.
5. GPs teach prevention, identification
5. Tactics GPs.
disability in patients with heart failure.
6. The principles of treatment (medication and non-
6. Discuss questions about tactics in the
qualifying characteristics of GPs
7. Discuss the principles of treatment
(medication and non-medication).
8. Discuss the principles of management,
supervision and monitoring of patients in
a hovercraft or joint venture these
diseases.
Training Methods
Forms of organization of learning
activities
Learning Tools
Methods and feedback means
medication) in these diseases.
7. Principles of follow-up and monitoring of patients in a
hovercraft or a joint venture.
8. The principles of primary, secondary and tertiary
prevention in these diseases.
GPs should be able to:
1. Diagnose, differentiated by ECG, clinical acute and
chronic heart failure.
2. Choose the right medications for acute and chronic heart
failure.
3. Choose drugs with proven efficacy
4. Advise on non-drug therapies.
5. To monitor in a hovercraft or a joint venture.
Lecture, case studies, tests, demonstration, entertainment
experience, discussion, conversation, brainstorming training
game.
Individual work, group work, team, classroom,
extracurricular.
Teaching aids, handouts, a collection of case studies and
tests, set EKG.Televizor, video equipment, multimedia.
Quiz, test, presentation of the results of the learning task,
filling medical history, perform a practical skill
Technology chart classes
"Edematous syndrome. Differential diagnosis of acute and chronic heart failure.
Differentiated therapy for heart failure. The tactics of a general practitioner with edema. The
principles of treatment, follow-up, control and rehabilitation in a hovercraft or a joint venture.
The principles of prevention. Definition trudosposobnosti.Principes of teaching the topics. "
№ Stages of the practical session
Forms of training
Duration
225
Place
1
Chapeau (justification themes)
10
2
3
4
5
The discussion on the practical lessons with the
use of new educational technologies, as well as
demonstration material (tables, posters,
radiographs. EKG), the definition of the initial
level.
Conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the
provisions and recommendations for the job by
filling in the medical history
Mastering the practical part of the training under
the guidance of a teacher.
The survey, discussion
40
Classroom skills
Discussion
10
20
Classroom
Prof. questioning. A
conversation with patients
and filling medical history,
situational problems.
Cardiology, rheumatology
department of the clinic
20
6
Interpretation of the survey data of patients,
complaints, inspection, palpation, percussion,
auscultation of patients, as well as research OAM
KLA sputum Office
Medical history,
laboratory data situational
problems
25
7
Discussion of theoretical and practical knowledge
of the students, securing the material to determine
the level of assimilation of knowledge assessment.
Oral questioning, tests,
discussion, identification of
practical skills
75
8
Defining output on practical sessions on a 100point rating system and ad evaluations. Homework
of the next practice session (a collection of
questions).
Cardiology, rheumatology
department of the clinic
Information, questions for
homework.
Classroom
25
2. Motivation
Often, patients with edema seek medical help. General practitioners (GPs) have to solve the question of
diagnosis and prevention of diseases associated with edema, and define a group of patients to be treated in
a hovercraft or a joint venture, or referral to specialized hospitals. These circumstances are the basis for
the inclusion of this subject in the training of GPs.
3. Intra and Interdisciplinary communication
Anatomy, histology and cytology with embryology, biology, normal physiology, biochemistry,
pathological anatomy, pathological physiology, topographic anatomy and operative surgery,
propaedeutics internal medicine, radiology and nuclear medicine, physiotherapy, cardiology,
endocrinology, faculty therapy, in-hospital treatment.
4. The content of classes
4.1. The theoretical part
Theoretical part of the training series covers the following topics: Lack of blood circulation
(NC) - a pathological condition is a failure of the circulatory system to deliver organs and tissues of the
amount of blood necessary for their proper functioning.
Depending on the speed of development are acute NC, which manifests itself in a matter of minutes
and hours, and chronic NK, which is formed during the period of several weeks to several years. In
addition, the isolated heart failure associated with cardiac and vascular insufficiency, in which the fore in
the mechanism of impaired circulation acts predominantly vascular component.
Acute heart failure
Cardiac asthma (CA) and pulmonary edema (AL) paroxysmal form of severe shortness of breath
caused by the bleeding in the lung tissue of serous fluid in the formation of edema - interstitial (in cardiac
asthma) and alveolar, with the foaming protein-rich transudate (pulmonary edema).
The reasons for the SA and OL are the primary acute left ventricular failure (myocardial infarction,
other acute and subacute forms of ischemic heart disease, hypertensive crisis, acute nephritis, acute left
ventricular failure in patients with myocardiopathy, etc.) or acute manifestations of chronic left
ventricular failure (mitral or aortic defect, chronic cardiac aneurysm, and other forms of chronic ischemic
heart disease, etc.).
Symptoms within. 1. Forerunners: gain (appearance) of dyspnea, orthopnea. Choking, coughing, or
just soreness in the chest with a little exertion or when switching to a horizontal position. Usually decreased breath and wheezing scarce below the angle of the blades.
2. Cardiac asthma: asthma with cough, wheezing. Orthopnea, forced rapid breathing. Excitement,
fear of death. Cyanosis, tachycardia, often - increase blood pressure. Auscultation - the weakening of
breath, dry, often-scarce finely wheezing. In severe cases - cold sweat, "gray" cyanosis, jugular veins.
Swelling of the bronchial mucosa may be associated with bronchial obstruction ("mixed asthma").
3. Lung edema: there is a more or less suddenly, either by increasing severity CA. The appearance
at the SA abundant small-and medium vesicular rales extending to the front upper parts of the lungs,
indicating growing OL. The appearance of a frothy, pink sputum usually (admixture of red blood cells) is
a reliable sign of OL. Rattling clearly audible in the distance. For severe AR characterized orthopnea,
cold sweat. Distinguish lightning (death within a few minutes), acute (duration of an attack from 30
minutes to 2-3 hours) and prolonged (up to a day or more) for.
Congestive heart failure
Congestive heart failure (CHF) is formed during the period of several weeks to decades.
Symptoms within different for different forms and stages of heart failure.
Clinical forms: 1. Congestive left ventricular failure is characteristic of mitral defect, for severe coronary
artery disease, particularly in patients with hypertension. Symptoms: shortness of breath, orthopnea,
auscultatory signs of pulmonary congestion (dry wheezing, below the angle of the blades migrating rales),
and radiographic signs, cardiac asthma and pulmonary edema, secondary pulmonary hypertension, and
tachycardia.
2. Left ventricular ejection failure characteristic of the aortic defect, coronary artery disease,
hypertension. Implication: cerebrovascular insufficiency (dizziness, blackouts, fainting), coronary
insufficiency, sfigmograficheskie and echocardiographic signs of low output. In severe cases Cheyne Stokes, alternating pulse (rare), presystolic gallop rhythm (abnormal tone IV), clinical signs of congestive
left ventricular failure. In the terminal stages can join right ventricular failure.
3. Congestive right ventricular failure is characteristic of the mitral and tricuspid blemish,
constrictive pericarditis. Normally attached to congestive left ventricular failure. Symptoms: swelling of
the neck veins, high venous pressure, acrocyanosis, liver enlargement, subikterichnost, edema abdominal and peripheral.
4. Right ventricular failure emission characteristic of pulmonary artery stenosis, pulmonary
hypertension. Radiologically diagnosed mainly (depleted peripheral pulmonary vascular pattern). May
show other signs of this form: shortness of breath with a well-defined threshold level of exercise, right
ventricular hypertrophy - palpation, then the ECG signs of the type "pressure load" (tall R wave and a
decrease of the T wave in the right chest leads). In severe cases, the gray color of the skin.
5. Dystrophic form. Typically, end-stage right heart failure. The options are: a) cachectic b)
swelling and dystrophic with degenerative changes in the skin (thinning, gloss, smoothness of the picture,
sagging), edema - common or limited mobility observed hypoalbuminemia, in the most severe cases hyposarca c) nekorrigiruemoe salt depletion.
Stage of development and the severity of congestive heart failure. Among the numerous features
CH enumerated in the description of a particular stage, it is necessary to allocate a few, each of which is
sufficient to determine the specific stage. For the correct choice of treatment tactics is extremely
important staging HNK. According to the classification, ND Strazhesko and VH Vasilenko, there are
three stages of HNK.
Stage I: The Phantom circulatory failure, manifested by shortness of breath, palpitations, fatigue
only during exercise. At rest, hemodynamics is not broken.
Stage II A: signs of circulatory failure alone expressed moderately, exercise tolerance is reduced,
there are violations in a large or small circle of blood, the severity of their moderate.
Stage II B: severe symptoms of heart failure at rest, severe hemodynamic abnormalities in the large
and in the pulmonary circulation.
Stage III: The dystrophic stage with severe hemodynamic, metabolic, irreversible changes in the
organs and tissues
Classification of heart failure of New York Heart Association (NYHA):
FK
I
II
III
IV
Definition
Patients with heart disease, but not limited to physical
activity
Patients with diseases of the heart, causing a slight
limitation of physical activity
Patients with diseases of the heart, causing a
significant reduction in physical activity
Patients with heart disease who perform even minimal
physical activity causes discomfort
Terminology
Asymptomatic left ventricular
dysfunction
Easy heart failure
Heart failure of moderate severity
Severe heart failure
In chronic heart failure, edema develops slowly, symmetrically localized predominantly in the feet
and legs. In bedridden patients swellings appear on the back, in the sacrum. The material is cold to the
touch, cyanotic, its flexibility is reduced. Cardiac edema is moderately dense, leave a hole when pressed
with your finger, move with changes in body position. The development of edema is usually preceded by
a more or less prolonged period of breathlessness. Often, swelling of the skin and subcutaneous tissue is
accompanied by ascites, hydrothorax (predominantly right-sided). Typically, there are other
manifestations of heart failure - swollen neck veins, enlarged liver. In the study of the heart are
determined by immediate signs of damage (resizing, the presence of arrhythmias, heart murmurs, etc.).
Cardiac edema may be the same composition of urine, but urine often reflects the so-called
"congestive kidney." In this case, the urine can be proteinuria, typically less than one ppm, an adequate
proportion, moderate changes in the precipitate.
Treatment of cardiac asthma and pulmonary edema.
Therapeutic measures in the interstitial and alveolar forms of pulmonary edema in cardiac patients
are very similar: they are primarily focused on the basic mechanism of edema with a decrease in venous
return to the heart, afterload reduction with an increase in propulsive function of the left ventricle and a
decrease in increased hydrostatic pressure in the vessels of the pulmonary . When alveolar pulmonary
edema added activities aimed at the destruction of the foam, as well as more vigorous correction of
secondary disorders. Treatment - an emergency at the time of the precursors (possible death). Indications
for hospitalization can occur at the stage of precursors and after removal from the attack of the SA.
Excretion of OL is held in place by a specialized cardiac intensive care ambulance. After removal from
the AL hospitalization carried out by the same team (the threat of recurrence AL).
The sequence of therapeutic interventions is largely determined by their availability, the time it will
take to implement them. The patient should make sure that the doctor takes seriously his complaints and
state acts decisively and with confidence.
Treatment program:
1. Normalization of emotional status, eliminating giperkateholaminemii and hyperventilation
2. The decrease in preload (venous return of blood to the heart): Sick seat (with your pants down).
3. The unloading of the pulmonary circulation with diuretics
4. Reducing the pressure in small and large circulation
5. Oxygen therapy.
6. The destruction of the foam in the alveoli th.
7. Increased myocardial contractility:
If pulmonary edema develops in the presence of paroxysmal arrhythmias (flicker, flutter,
ventricular tachycardia), it is recommended urgent cardioversion.
With the development of pulmonary edema, cardiogenic shock against the use dobutamine. It is a
biological precursor of norepinephrine stimulates alpha and to a lesser extent beta-adrenoceptors,
dopamine receptors specific increases cardiac output, blood pressure increases. It has a unique feature: in
addition to providing a powerful inotropic effect of dilating effect on the blood vessels of kidneys, heart,
brain, intestines and improves blood circulation. The drug is administered intravenously at 50 mg in 250
ml of isotonic sodium chloride solution. Enter drip on 175 mcg / min, gradually increasing the dose to
300 mg / min. Side effects: extrasystoles, tachycardia, angina pectoris. Furthermore, use of
phosphodiesterase inhibitors that enhance systole and extending peripheral vessels. These include
amrinon - used intravenously (bolus) at a dose of 0.5 mg / kg, followed by infusion at a rate of 5-10 mcg /
kg / min to continue to enter the persistent increase in blood pressure. The maximum daily dose amrinona
10 mg / kg.
Treatment is carried out under the constant (every 1-2 minutes) control of systolic blood pressure,
which should not be reduced by more than one third of the original or below 100-110 mm Hg. Art.
Special care is required with concomitant use of drugs, as well as in the elderly and high blood pressure
history. With a sharp decrease in systolic blood pressure are necessary emergency measures (to lower his
head, put your feet up, start the introduction mezatona with the pre-arranged backup system for drip
infusion). At low blood pressure maximum value in the treatment of AL has a long (1-2 inherently more)
large doses (up to 1.5 g / day), prednisolone Unlikely cases ventilator pressurized.
Treatment of edema in chronic heart failure
In view of the pathogenesis of edema at the NC can offer the following treatment program:
1. Treatment of the underlying disease, which led to the HNK, can significantly reduce its
appearance, improve the efficiency of therapeutic interventions.
2. A rational therapeutic regimen: in stage I - respect the work and rest, moderate exercise (but not
a sport!). In the more severe stages of physical activity should be limited, periodically or permanently
assigned bed, polupostelny mode.
3. Clinical nutrition: Diet for HNK number assigned to tables 10 and 10a, preferably - rich in fruit,
cottage cheese and sour cream. With tendency to fluid retention and hypertension shows a moderate
restriction of salt. With massive edema can be assigned to a short-term strict salt-free diet. Long-term
(more than 1-2 weeks), the use of diet number 10, especially when combined with salureticheskih therapy
can lead to a dangerous depletion of salt. Effective fasting days, during which used monotonous, easily
digestible, poor sodium chloride food (rice, cottage cheese, apple and rice and so on holidays).
Drug therapy
Drug therapy is not the same in different forms, manifestations and stages of the origin of HF. It should
be against the limitation of physical activity. In CHF adequate medical therapy should be permanent unjustified cancellation of its often leads to decompensation.
1. Gain decreased myocardial contractility. For this purpose, cardiac glycosides (SG) and
neglikozidnye inotropes.
Indication for cardiac glycosides:
• CHF II-IV PC with a low emission by reducing myocardial function in combination with atrial
tachyarrhythmia-treatment is carried out by oral SG;
• CHF II-IV FC in sinus rhythm and left ventricular ejection fraction less than 30-35% if
auscultated III tone heart and cardiothoracic ratio greater than 0.55;
• Supraventricular tachyarrhythmias (flicker and flutter, paroxysmal supraventricular tachycardia),
regardless of the presence or absence of NC-usual in this case being treated with intravenous injections of
SG.
SG contraindicated in obstructive hypertrophic cardiomyopathy, severe hypo-and hyperkalemia,
hypercalcemia, atrioventricular block, syndrome, WPW, sick sinus syndrome, ventricular arrhythmia,
frequent, steam rooms, and in the rhythm of politopnye allodromy, as well as ventricular tachycardia.
With reduced elimination of cardiac glycosides (renal failure, aged) they reduce the maintenance dose is
2-3 times as possible corresponds with the view in serum creatinine or blood glycoside.
Nonglikozide inotropic agents have a more pronounced than that of the SG, the positive inotropic
effect.
Apply two groups nonglikozid inotropic agents:
• stimulators (agonists) β-adrenergic receptors (dopamine, dobutamine, ibopamine, prenalterol,
xamoterol)
• phosphodiesterase inhibitors (amrinone, milrinone, enoximone, piroksimon, fenoksimon,
pitobenzan, adibenzan).
Β-adrenergic stimulants. - The most commonly used drugs include:
Dopamine (dopamine, dopamine) - 40 mg of the drug is dissolved in 200 ml of 5% glucose solution
or isotonic sodium chloride solution and injected / drip at a rate of 2.4 mcg / kg / min. At this speed the
introduction of improved myocardial contractility without increasing heart rate and renal blood flow,
increases the sensitivity of the renal tubules to diuretics.
Dobutamine - increases myocardial contractility due to the selective stimulation of β1-adrenergic
receptors. Dobutamine prescribe short courses to improve cardiac output in patients with severe heart
failure in the absence of hypotension. The drug release in vials with 20 ml of a sterile solution, 1 ml of
which contains 12.5 mg of dobutamine. Contents of the vial are dissolved in 500 ml of 5% glucose
solution and administered at 2.5 mg / kg / min.
Elimination of edema syndrome diuretics. Diuretics are shown not only in edema, liver
enlargement, explicit congestion in the lungs, but also in the hidden fluid retention, one sign of which is
the reduction of dyspnea in response to a test giving diuretics. Prescribed in the lowest effective dose,
usually during treatment with cardiac glycosides when indicated. Massive diuretic therapy is started in a
bed rest. Regimen and work out individually correcting during treatment. A more effective treatment is
usually interrupted when the drug is administered 2-3 times a week or less short (2-4 days) intervals.
Increase the dose and frequency of use of a drug should be preferred alternate (shift) or the combined use
of diuretics with different mechanisms of action and the effect of the acid-base status. With the advent of
refractory to diuretics may be useful time (5 - 7 days), and their attempt to gain cancellation
spironolactone. In most cases, diuretics are more effective if they are taken on an empty stomach, the
patient for 4-6 hours and stays in bed when the day of admission is assigned unloading diet. About the
effectiveness of therapy, in addition to increasing the daily urine, swelling of convergence and reduce
body weight, indicating dyspnea and, in part, reducing the size of the liver. In severe abdominal swelling
(hydrothorax, hydropericardium, massive ascites) evacuation of the liquid may be mechanical (puncture).
The major complications of diuretic therapy include hypokalemia, hyponatremia, hypocalcemia (loop
diuretics), hypochloremic alkalosis, dehydration and hypovolemia, sometimes with the formation and
progression of phlebothrombosis.
Reduction of preload and afterload on the left ventricle.In the treatment of peripheral
vasodilators HNK accepted. These agents enhance venous or arterial vessels, or both simultaneously,
which reduces the pre-and afterload and facilitate the work of the heart. Peripheral vasodilators
administered in more severe cases, the lack of effectiveness of cardiac glycosides and diuretics alone or in
conjunction with preparations of these groups.
Venous vasodilators - expanding veins and reduce preload.
Mostly venous dilators - nitropreparatov (nitrosorbid 0.01 g, 0.04 g Olikard, monosan 0.04 g, 10.0
mL Isoketum, etc.) in high doses reduce ventricular filling pressure ("preload"), and are effective in
congestive failure. Molsidamin (korvaton, sidnofarm) - a drug from the group sidnoaminov by
pharmacological action similar to nitrates. Available in tablets of 0.002 g and 1 ml ampoules of 0.2%
solution for / in the introduction. Arterial vasodilators expand arteries and arterioles, reducing the total
peripheral resistance, thus facilitating the left ventricular afterload and reduce myocardial oxygen
demand. Apressin (Hydralazine) 0,025 g per tablet prescribed 2-3 tablets 3-4 times daily minoxidil-0, 005
g of 1 tablet 1-2 times a day for the control of arterial pressure. Tropafen, phentolamine available in
tablets of 0.025 g (150-200 mg in 4 divided doses) in 1 ml ampoules of 2% solution is introduced into /
drip at a dose of 10 ml of a 1% solution (200 mg) in 200 ml of isotonic sodium chloride at a rate of 5-7
drops per minute under the control of arterial pressure.
Calcium antagonist fenigidin (nifedipine korinfar) tablets of 0.01 g administered to reduce the
afterload at hypertensive heart failure and they may be useful at moderate heart failure in patients with
aortic or mitral insufficiency.
Mixed Vasodilators simultaneously cause dilation of the veins and arteries, reducing the post, and
the preload on the heart. Sodium nitroprusside (Naniprus, niprid) - used / drip, available in capsules
containing 0.025 and 0.05 g. Prazosin (MINIPRESS, pratsiol) designate from 2 to 10 mg / day (0.5-1 mg
first dose, treatment short course). Co-application of venules and arterioles, dilators indicated in severe,
refractory cardiac glycosides and diuretics with CH significant dilation of the left ventricle as well as
hypertensive heart failure. ACE inhibitors are currently the only group of drugs could improve life
expectancy of patients with HNK II-III functional classes that justifies the more widely used in clinical
practice, in combination with a diuretic or cardiac glycoside. ACE inhibitors reduce the formation of
angiotensin II and causes marked dilation of the arteries and veins. And there is no tachycardia in
response to systemic vasodilation. Reduction in pre-and afterload reduces its systolic and diastolic
function. Reduction of increased sympathetic nervous system activity. In the pathogenesis of HNK
important role played by the activation of sympathetic nervous system, which not only promotes
vasoconstriction, but also the development of arrhythmias, worsening the prognosis for life, and
significantly increases myocardial oxygen demand. In this regard, in recent years, began to discuss the
possibility of applying for the treatment of HNK β-adrenergic blockers. But this view is not widely
understood. β-blockers are not a means of monotherapy and should only be used in combination with
diuretics, ACE inhibitors, and, if necessary, cardiac glycosides. With the progression of heart failure
should be abolished. Metoprolol (speksikor) - initial daily dose 6,25-12,5 mg, with a gradual increase in
its 1-2 times a week to 100-150 mg. Propranolol - a daily dose of 40-60 mg, -60 mg oxprenolol.
Anticoagulant and antiplatelet therapy. Anticoagulant therapy is prescribed and antiagrigantnaya for
the prevention and treatment of thromboembolic events, which may be complicated HNK with atrial
fibrillation during treatment with diuretics. Acetylsalicylic acid (Clopidogrel) 50-320 mg / day,
dipyridamole (chimes), 0,025 tablets, 0.05, and 0.075 g, optimal antiplatelet dose is 400 mg per day (4
doses). Warfarin (vitamin K antagonist), - the maintenance dose of 2-10 mg / day orally. Since the effect
of the drug does not develop immediately, it is first coupled with heparin 5000 units subcutaneously twice
a day 4. Tiklopiridin of 0.25 g 1-2 times a day. When using these groups of drugs to control the
svertқvaemosti blood coagulation. Prevention of heart failure is reduced to the prevention and treatment
of the underlying disease, career counseling and job placement. Systematic adequately treated heart
failure prevention and vigorous treatment of intercurrent illness prevents (inhibits) the progression of
heart failure. Ability to work in stage I saved hard physical labor is contraindicated, in II A stage work
capacity is limited or lost, in the II B - lost in stage III patients need constant home care. Theoretical
survey can be carried out by traditional didactic method using the method of "tour of the gallery."
Theoretical survey can be carried out by traditional didactic method using the method of
"snowballs."
Objective: The involvement in the educational process of all students while controlling their
knowledge of the topic under discussion.
Basic methods position: Group divided into 2-3 smaller subgroups which discuss the same problem or
situation to set the highest number of correct answers. Each correct answer is recorded as a credit to this
group as "snowballs." The group which received the greatest number of points, put a higher valuation.
Advantages: Competitive principle activates the thinking process and revitalizes knowledge. This
method teaches students the rapidity of thought, allows the teacher to objectively assess the depth of the
development of the studied material.
Example:
1. Classification of the Tax Code.
2. List the major clinical and hemodynamic changes in the Tax Code, depending on the stage.
3. List the main groups of drugs of proven efficacy, used for the treatment of NK.
4. Clinical and hemodynamic signs of acute left ventricular failure.
Answers: see the theoretical part
UnsatisfactoryThe analytical part of the class is advisable to continue using case studies.
In the practical part in the cardiology department is conducted under the supervision of a teacher-student
curation of patient so-called educational practice.
For topical bypass preparing 1-2 patients with edema. This requires a sufficient history minimum surveys.
The maximum
score 20-19
18-17 points
16-15 points
14-13 points
12 points
Excellent
Good
Satisfactory
Not satisfactory
Bad
100%-86%
85%-73%
70-56%
53%-46%
43% and less
4. The analytical part
4.2.1. Case Studies:
1. 55 year old woman in 5 years suffer from hypertension. During the increase in blood pressure takes
Adelphanum, enalopril. The last week of episodes increased blood pressure increased, and was
accompanied by attacks of breathlessness and suffocation. History of hereditary burdened. Diet is not in
compliance. It prefers dense and salty foods. Objectively, the patient increased supply. Skin is clean,
flushing of the face. Above the simple release, vesicular breathing, no wheezing. Heart sounds, rhythmic,
accent II tone of the aorta. Pulse - 80 beats. 1 min, rhythmic. BP 190/110 mm Hg Abdominal palpation
soft and painless.
There is not peripheral edema
1. Your complete a preliminary diagnosis;
2. Plan Survey;
3. The tactics of the GP;
4. Prehospital Emergency medication (specify the name and dose of drugs).
№
1
2
3
4
Answers
GB II Art. Stage III AH. The risk is very high. Donkey: Hypertensive crisis I type. The attacks
of cardiac asthma
KLA, , sugar, urea, creatinine, enzymes, lipids, ECG, echocardiography, X-ray gr. cells,
ultrasound of the liver and kidneys
Hospitalization in the coronary care unit
Capoten 25-50 mg, 10 mg korinfar, clonidine 0,015-0,3 mg, 20-40 mg furotsemid
2. Patient N., 58 years old, complains of headaches in the parietal-occipital, shortness of breath when
walking, asthma attacks at night, interruptions in obl.serdtsa. Increased blood pressure celebrates more
than 10 years. During the inspection there was choking, cough with frothy sputum, pressing pain in the
chest. Blood pressure 245/135 mmHg A serious condition, the skin is pale, moist, cyanosis of the lips,
akratsianoz. Breathing easier over the weakened mass moist rales on both sides. The boundaries of the
heart shifted to the left by 2 cm heart sounds are muffled, rhythmic, accent II tone of the aorta and the
pulmonary artery. Heart rate of 140 bpm. per min. The liver and spleen were not palpable. No edema.
1. List at least four diseases accompanying symptoms listed above;
2. Your detailed preliminary diagnosis;
3. Plan Survey;
4. Tactics GPs. Prehospital Emergency medication (specify the name and dose of drugs).
__________________________________________________________________
3. Patient Yu, 66 years old, retired, suffering from coronary heart disease and hypertension for 8 years. In
2000 he suffered a heart attack. After heavy physical exertion appeared strong choking. After about 15
minutes, was caused by a car "emergency" and was examined by a doctor. Objectively: the condition is
grave, pale, cyanosis of the lips, acrocyanosis. Position - orthopnea. In the lower lung on the background
of several weakened vesicular breathing moist rales are heard. The left border of the heart in the anterior
axillary line. Auscultation: cardiac deaf, systolic murmur at the apex, the accent II tone of the aorta. Pulse
- 120 in 1 minute, rhythmic. Blood pressure 160/100 mm. Hg Abdominal palpation soft and painless.
Peripheral edema is not. The ECG: sinus rhythm. Scarring in front of the septal area. In leads II, III, aVF
ST segment amused the dome top and merged with a positive T-wave, and I, aVL ST leads down to mix.
1. List at least four diseases accompanying symptoms listed above;
2. Your detailed preliminary diagnosis;
3. Plan Survey;
4. Tactics emergency physician. Prehospital Emergency medication (specify the name and dose of drugs).
__________________________________________________________________
3. Man 41 years old, complains of recurrent vertigo, headaches, squeezing pain in the heart area
radiating to the left arm, odқshka, pain, knee joint pain, general weakness, memory loss, pain and
heaviness in the right upper quadrant. On examination: pale skin, cyanosis of the lips. Above mild
with bottoms in the lower fine moist rales. RR 24 times in one minute. Auscultation of the heart on
the top of I-tone on tone weakened aorta II, rough systolic murmur at Botkin and II intercostal space
on the right, is carried out on the carotid artery and the jugular and supraclavicular fossa. Systolic
murmur at the apex and base of the xiphoid process. Pulse small and slow, 66 beats / min, blood
pressure 120/90 mmHg Liver + 4 +6 cm medium density painful. The spleen is not enlarged.
Symptom fluctuation positive. On the lower leg edema. UAC: 110 g Hb / l, leukocytes 11.5 x 109 / L
ESR 25 mm / hr. OAM: Share of 1020, a protein 0,033 ‰, 0-1/1 red blood cells, white blood cells 4-6 / 1
1. Your complete a preliminary diagnosis;
2. Recommended examination;
3. List at least three diseases in which I auscultated weakening tone at the top;
4. Tactics GPs and treatment guidelines.
__________________________________________________________________
5. 60 year-old patient for 10 years, suffering from coronary artery disease and GB. Not treated regularly.
In 2003, suffered a myocardial infarction. The last days of increased heart pain radiating to the left arm,
decreased urine output, shortness of breath and swelling appeared. Objective: The general condition is
serious. Above mild with bottoms in the lower fine moist rales. Heart sounds, rhythmic, systolic murmur
at the apex. Heart rate and heart rate 96 beats min 1. AD-160/100 mm Hg Liver + 3.4 cm and spleen were
not palpable. Hard swelling in the leg. The ECG: Electrical rejected axis to the left. In leads II, III, and
aVF wide and deep tooth Q, ST and T on the contours slightly negative. In the V1-3 deep S, and the V5-6
high R, ST lower contours, T is negative.
1. Your complete a preliminary diagnosis;
2. Plan Survey;
3. How many classes of shares in accordance with the Tax NYNA classification and diagnostic criteria
for each class;
4. Tactics GPs and treatment guidelines.
__________________________________________________________________
6. Patient 70 years there has been at home for congestive heart failure due to myocardial infarction. He is
constantly taking digoxin (2 tab. Daily) gipotiatiazid daily and furosemide 2 times a week, nitrosorbid (4
tab.v day). His wife complains that he became irritable, angry, sometimes it does not recognize. In
addition he has diarrhea, severe weakness and nausea. Objective: The general condition of moderate
severity. Above the light in the lower fine moist rales. Heart sounds, arrhythmic, accent II tone of the
aorta, systolic murmur at the apex. HR-110, pulse 96 beats 1 minute. AD-180/100 mm Hg Liver + 3.4 cm
and spleen were not palpable. On the lower leg edema and trophic skin changes.
1. Your complete a preliminary diagnosis;
2. Identify the reasons for the appearance of the above complaints;
3. Plan Survey;
4. Tactics GPs and treatment.
__________________________________________________________________
7. Patient U. 58 years for 5 years suffer from coronary heart disease and hypertension. The last 2 years
dyspnoea, dry cough at night, swelling in the legs. Prescribed by a doctor regularly takes diuretics in a
day, nitrosorbid 1 tab 3 times a day and enalopril in increased blood pressure. The last days of increased
shortness of breath, palpitations, swelling of the legs appeared. On that began to take
furosemidezhednevno, sometimes 2 times a day. Yesterday, after a large meal at night there was a strong
pain in my right ankle and first metatarsophalangeal joint of the foot. The next morning he went to a
general practitioner. OBJECTIVE: Over the light in the lower divisions is not ringing fine moist rales.
Heart sounds are muffled, the accent II tone of the aorta. Heart rate and heart rate 90 beats / min.
rhythmic, blood pressure 150/900 mmHg Liver 2 cm swelling in the lower leg.
1. Your complete a preliminary diagnosis;
2. Enter at least 4 most necessary surveys to clarify the causes of arthritis;
3. The tactics of the GP;
4. Treatment.
8. A 52 year old patient to a GP with complaints of cough with muco-purulent sputum, shortness of
breath, edema, decreased urine output, general weakness, poor appetite. History of over 16 years of
suffering bronchiectasis, not treated regularly. The above complaints emerged in the last 4 months. Onno: swelling of the face, lower back and extremities, cyanosis of the lips. NPV 24 in 1min., Body
temperature 37.20 C. Percussion over the light box sound in the lower regions of blunting pulmonary
sound. Auscultation against a weakened vesicular breathing scattered dry, wheezing, crackles in the lower
divisions is not ringing rales. Heart sounds, rhythmic, heart rate 84 bpm. 1 min. BP 120/70 mmHg The
liver was not palpable. With th tapotement negative on both sides. OAM: Share of 1015, protein 12.5 g /
day; 3-5/1 red blood cells, white blood cells 5-6/1. KLA: Hb 90 g / L, red blood cells 3.3, ESR 65 mm /
hour.
1. Your complete a preliminary diagnosis;
2. Plan Survey;
3. Why is such a massive proteinuria;
4. Tactics of GPs and treatment guidelines.
9. Patient T. 40 years old, complains of weakness, palpitations, shortness of breath on exertion, weight
loss, swelling of the entire body, unstable chair with a tendency to diarrhea. From history became clear
that the patient has the last 2 years was observed periodic fever, diarrhea 5-6 times a day, sometimes
blood-streaked stool. During this time, lost 12 lbs. Patient notes abdominal pain and this pain is getting
worse in the act of defecation. X-ray examination of the intestine marked narrowing of the small intestine
in its terminal portion, mosaic pattern with small filling defects. UAC: Hemoglobin 90 g / l 11,5 * 109
leucocytes / liter -38 ESR mm / hour. The potassium content in serum - 3.4 mmol / l. Koprotsitogramma:
steatorrhea, red blood cells, mucus.
1. Your complete a preliminary diagnosis;
2. Plan Survey;
3. What caused the development of edema syndrome in this case;
4. Tactics of GPs and treatment guidelines.
Tests
1. When cardiac glycoside intoxication is advisable not to use:
a) phenytoin
b) lidocaine
c) potassium salt
g) unitiol
d) calcium chloride
2. Which of these can not be the cause of heart failure due to primary (direct) myocardial damage:
a) Coronary artery disease
b) dilated cardiomyopathy
c) myocarditis
d) vitamin deficiency
d) the mitral stenosis
3.Do not a cause, provoking the emergence of heart failure or increases the size of the clinical
manifestations:
a) the occurrence of arrhythmias
b) accession infection
c) a significant increase in blood pressure
d) anemia
e) pulmonary embolism
e) chronic hepatitis
4. The most informative method of detecting signs of heart failure are:
a) electrocardiography
b) chest X-ray
c) phonocardiography
d) radionuclide cardiography
e) velloergometriya
5. In assessing the type or severity of heart failure is the least reliable indicator:
a) chest pain
b) cyanosis
c) bloating
g) hemoptysis
e) discomfort in the right upper quadrant
d) receiving β blockers
6. Heart failure can occur with high cardiac output:
a) in thyrotoxicosis
b) with hypertrophic cardiomyopathy without outflow tract obstruction
c) in dilated cardiomyopathy
g) with arteriovenous fistulas
e) heart failure developed a diffuse myocarditis
7. The risk of DVT increases:
a) Congestive heart failure
b) obesity
c) malignancies
g) exercise
d) the use of various clouds fruit
e) the use of various clouds vegetables
8. The causes of heart failure due to volume overload of the heart can byt:
a) aortic insufficiency
b) mitral regurgitation
c) anemia
g) myocardial
e) coarctation of the aorta
9. For heart failure because of the difficulty of diastolic filling of the heart can lead to:
a) acute myocardial iifarkt
b) restrictive cardiomyopathy
c) pericardial effusion
d) "crustacean" heart
e) ventricular septal defect
e) an atrial septal defect
10. Sprovotsirovat heart failure due to fluid retention or reduction of myocardial contractility can:
a) β-blockers
b) steroids
c) non-steroidal anti-inflammatory agents
d) furosemide
d) cytotoxic agents, anthracyclines
e) cardiac glycosides
g) veroshpiron
h) eufillin
11. For left ventricular failure the most specific:
a) orthopnoea
b) dyspnea
c) asthma attacks at night (paroxysmal nocturnal dyspnea)
g) Cheyne - Stokes
d) crackles with both sides in the lower lung
e) The number of breath erezhenie
12. Improved heart function in heart failure results in:
a) increased myocardial contractility
b) relief of cardiac output
c) reduction of the heart load
g) the number of heart contractions uvelechenie
e) the number of heart contractions umenschenie
g) increase in pulmonary hypertension
The maximum
score 20-19
18-17 points
16-15 points
14-13 points
12 points
Excellent
Good
Satisfactory
Not satisfactory
Bad
100%-86%
85%-73%
70-56%
53%-46%
43% and less
4.2.2. Graphic Organizer: Conceptual table
• Conceptual table provides a comparison of the phenomena, concepts, attitudes, and so that in two or
more dimensions.
• Develop systems thinking, the ability to structure. Organize information.
Acquainted with the rules of drawing up a conceptual table. Determine what not compare, distinguish the
characteristics that will be a comparison.
Individually or in small groups, build and fill the conceptual table
• Vertical is something that is subject to comparison
• Horizontally - various characteristics that are compared.
HSN
cardiac asthma
pulmonary edema
heart failure
The role of the GP
inhibitors
АПФаортального
клапана
diuretics
The group is divided into two small groups, the participants each small group evaluate the work of
a small group of other students. Each correct answer is worth 15 points.
Group
Correct and clear
Visibility
Announceme The activity
Total
№
answer (5)
(5)
nt of the rules of the group
points
(2.5)
members
(2,5)
1.
2.
The maximum
score 20-19
18-17 points
16-15 points
14-13 points
12 points
Excellent
Good
Satisfactory
Not satisfactory
Bad
100%-86%
85%-73%
70-56%
53%-46%
43% and less
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with congenital malformations of the heart and great vessels.
2. Interpretation of ECG, echocardiography, X-ray data in CHD.
Heart murmur and cardiomegaly.
Congenital malformations of the heart and great vessels.
Stage #
indicators /
interpretation
Curation of the patient
Completed Blood test
PSA
Acute phase indicators
Coagulation
ECG
Echocardiography
Angiography
Differential diagnosis
Justification diagnosis
GPs tactics and treatment assignment
Recommendations
TOTAL
not done
Fully Achieved
0
50
0
0
0
0
0
20
10
10
10
100
The number and types of control measures to assess student knowledge
• Verbally
• In writing
• The decision of situational problems
• Demonstration of practical skills mastered
5. Control forms of knowledge, skills and abilities
- Verbal
- The decision of situational problems
- Demonstration of practical skills
- CDS
6. The evaluation criteria of the current control
Levels of
estimates
Rating
points
20
Characteristics of the student
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not ready
for practical employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and skills,
at least one of the following:



Not
satisfactory
20 - 54,9




• Do not know the clinical manifestations of acute and chronic
heart failure.
• Do not know the etiology and pathogenesis of heart failure.
• Do not know the diagnosis of diseases associated with heart
failure.
• Can not specify a particular physical findings of diseases
associated with heart failure.
• Not able to assemble a rational history during the Supervision
of patients.
• During Supervision is not able to objectively assess the
condition of patients.
• Not able to rationally make a plan of examination of patients
with heart failure in a hovercraft or a joint venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and
55-60,9
skills (see below), but when replying or performing skills make
serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but
61-65,9
when replying or performing skills make mistakes (subject to
certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of knowledge
and skills:
Satisfactory
55-70,9%
66-70,9
 • Know the clinical signs of diseases associated with acute and
chronic heart failure.
 • Can differentiate disease, heart failure accompanied by
subjective and objective laboratory and instrumental data
 • Can specify the ECG and clinical acute and chronic failure.
 • Able to build a rational history during the Supervision of
patients.
 • During Supervision able to objectively assess the condition of
patients.
 • Can interpret the results of laboratory and instrumental methods
of research - may indicate the presence of hypercholesterolemia,
leukocytosis, elevated CPK and ESR.
 • Can show the technique of ECG recording
 • Able to efficiently make a plan of examination of patients with
a change in the configuration of the heart in a hovercraft or a joint
venture.
 • Able to correctly fill in the patient diary.
Advanced level of knowledge
71-75,9
Good
The student is wholly owned by the basic levels of knowledge
and skills (listed under "66-70,9") + has the following
knowledge and skills:
• Knows the mechanism of action of drugs
• Rationally choose drugs with proven efficacy.
71-85,9%
76-80
81-85,9
86-90
The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph
"71-75,9", and also owns the following knowledge and skills:
• Knows the principles of primary, secondary and tertiary
prevention of these diseases.
The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph
"71-75,9" and "76-80", and also owns the following
knowledge and skills:
• Principles of management, supervision and monitoring of
patients in a hovercraft or a joint venture.
• Is able to advise you on the boards of non-drug and drugusing skills of IPC.
• Principles of clinical examination and rehabilitation of
patients in a hovercraft or joint venture
The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph
"81-85,9", and also owns the following knowledge and skills:
• Is able to provide reliable information about the evils of
the Internet on the basis of the data.
91-95
The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph
"86-90", and also owns the following knowledge and skills:
• Can be monitored in a hovercraft or a joint venture.
96-100
The student is wholly owned by the basic levels of knowledge
and skills (see above) + knowledge referred to in paragraph
"91-95", and also owns the following knowledge and skills:
• To provide scientific data from the literature (articles
and Internet)
• Know the indications and contraindications of stenting
and bypass surgery
Excellent
86-100%
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
7. Test Questions
1. 1. Aetiopathogenesis NC.
2. Differential diagnosis of AHF and CHF.
3. The clinical picture of CHF.
4. Classification of the Tax Code.
5. The clinical picture of the Tax Code, depending on the stage.
6. Decompensated heart lung.
7. Characteristics of ß-blockers.
8. Description ACE inhibitors.
9. Characteristics of diuretics.
10. The tactics of the GP at HNK.
Main Readings
1.Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2.Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3. Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1. Умумий амалиёт врачлар учун маърузалар туплами, Гадаев А.Г., Т., 2012
2. Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3. Справочник врача общей практики. Дж. Мёрта. М.: Практика, 1998.
4. Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5. Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г.,Ахмедов Х.С., 2010. Т.
6. Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
7. Диагностика болезней внутренних органов. Окороков А.Н..2005.
8. Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
Internet resources:
www.medlook.ru, www.medbok.ru, www.medicum.ru, www.medtext.ru,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
1. Chronological content classes
Time
Activity
Content
Materials
8.30–
9.30
Morning
conference
The report of the doctor on duty and
duty subordinators on duty.
Medical history,
ECG, overhead
projector.
9.1510.00
10.0510.45
Clinical audit to
prescribe patients.
Theoretical
analysis of the
topic
10.45 11.05.
Study of practical
skills.
11.0511.45
Curation of
patients
In the department
of cardiology and
coronary care
A detailed report on the students'
prescription patients.
Checking the initial level of
preparedness of students using the
"snowball" and the decision of the
situational problem. Students heard
the case studies, ECG,
echocardiography on the subject,
they have to analyze and give an
opinion.
Student under the supervision of a
teacher must complete at least two
practical skill.
Each student is supervised by a
particular patient wards.
11.4512.15
12.2013.20
Break time
Analysis of casepatients
Duration of
of training
1 hour
45 minutes
Situational tasks,
folders, ECG,
echocardiography,
educational boards,
tables, corresponding
to a subject class.
40 minutes
The patient or
volunteer.
20 minutes
The patient,
stethoscope,
sphygmomanometer,
medical history (with
data of clinical and
laboratory findings).
40 minutes
30 minutes
At the choice of the teacher
conducted a full examination of the
patient on the theme of employment
or patients preparing for discharge,
data analysis, laboratory and
instrumental studies, the rationale for
the preliminary and final clinical
diagnoses. Determined by the
treatment plan with the doses of
drugs.
The patient,
stethoscope,
sphygmomanometer,
medical history (data
of clinical and
laboratory findings).
1 hour