Download Ministry of Public Health Republic of Uzbekistan Center for

Ministry of Public Health
Republic of Uzbekistan
Center for Development of Medical Education
Tashkent Medical Academy
"The implementation of case technology in studying the
faculty therapy on the theme
"MITRAL VALVULAR DISEASES"
Tashkent 2012
Ministry of Public Health
Republic of Uzbekistan
Center for Development of Medical Education
Tashkent Medical Academy
“Approved”
Head of the Chief Department of science
and educational institutions of MPH RUz
Professor Sh.E. Atahanov
___________________________
“____” ________________ 2012
№ of the report
"The implementation of case technology in studying the
faculty therapy on the theme
"MITRAL VALVULAR DISEASES"
(Training manual for the practical lessons on Faculty Therapy
for the 4th year students of general medicine faculty, for 3rd
year students of medical-prophylaxis faculty and for teachers of
medical universities)
Tashkent 2012
Authors:
Nazarova K.H. – department of faculty and hospital therapy of the faculty
of general medicine and internal diseases for medical
prophylaxis faculty, associate professor.
Berdieva D.U. – department of faculty and hospital therapy of the faculty
of general medicine and internal diseases for medical
prophylaxis faculty, assistant.
Reviewers:
Zakirhodzhaev Sh.Y. – Head of the Department of Propaedeutics of
Internal Medicine, Hematology, VPT and professional
diseases, Professor
Fozilov A.V. – Department of GPs TIAME, Professor, Doctor of Medical
Science
The teaching and methodological guide is examined and confirmed at the session
of ТМА CMC (report № _____ “_____” _____ 2012).
Chairman of the CMC, professor
M.Sh.Karimov
The teaching and methodological guide is confirmed on the Scientific Council of
ТМА and is recommended to publication (report № _____ “_____” _____ 2012).
The scientific secretary,
doctor of medical science, professor
Salomova F.I.
Theme: Mitral Valvular Diseases
1. The study venue and equipment
- The department of cardiology, cardiorheumatology and general treatment, department of laboratory and
instrumental diagnostics, training classrooms.
- Blood tests, serologic tests, clinical and biochemical tests, immunological studies, acute phase tests, Xray analysis, ECG, PCG, EchoCS, teaching-controlling tests, case patients, distributed material.
- TV-Video, overhead, multimedia, charts, slides, information and computer software.
2. Duration of the lesson
Time for interpretation of the yielded theme - 270 minutes
3. The study purpose:
To teach students the etiology, pathogenesis, clinical symptomatology, laboratory
and instrumental diagnostics, rational therapy, prevention of complications,
rehabilitation.
The purpose of training is to acquire and consolidate a theoretical knowledge:
The educational goal - to help a doctor to meet the interests and relevant international standards of the
profession, to create a sense of responsibility and raise an interest in expanding their knowledge, forming
the deontological level of education, to formulate clarity, responsibility and caution in the implementation
of practical work.
The development goal – to help students in individual thinking and discussion, development of critical
thinking in students (both clinical and hygienic).
.
Briefing
1. Determination of mitral valvular diseases (MVD).
2. Etiology of MVD.
3. Pathogenesis of MVD.
4. Classification of MVD.
5. Hemodynamics of MVD.
6. Clinical picture of MVD: subjective data, general examination, palpation, percussion and auscultation
data, conclusions by laboratory and instrumental methods of studies.
7. Differential diagnosis of MVD.
8. The basic principles of MVD treatment.
9. The progress and prognosis of MVD.
The student should know:
- Etiology of MVD;
- Pathogenesis of MVD;
- Classification of MVD;
- Hemodynamics of MVD;
- Methods of MVD diagnostics;
- Basic principles of treatment.
The student should be able to:
- Collect anamnesis, patient’s complaints, to conduct a general examination, palpation, percussion and
auscultation;
- Make a plan of patient examination;
- Interpret the laboratory data;
- Interpret the X-ray data;
- To substantiate the clinical diagnosis step-by-step;
- Write a prescription for drugs and explain their mechanism of action and side effects.
4. Motivation
At present, the study of mitral valvular diseases has an enormous importance, it can lead patients to
life-threatening complications.
5. Interdisciplinary and internal disciplinary communication.
Interdisciplinary communication:
Integrate with the following items:
I. Vertically:
1.Normal anatomy;
2.Normal physiology;
3.Histology;
4.Pathological anatomy;
5.Pathological physiology;
6. Propaedeutics of internal diseases;
II. Horizontally
1. Ray diagnostics
6. The lesson contents.
The theoretical part
Mitral stenosis - the most common rheumatic heart disease is caused by long lasting
rheumatic endocarditis. The disease is usually formed at a young age and more frequently (80%)
in women. Rarely the narrowing of mitral orifice may occur at carcinoid syndrome, mitral
valvular disease, rheumatoid arthritis, in 13% of cases are valve degenerative changes.
Classification
According to the severity stage there may be classified the slight mitral stenosis (maximal
gradient pressure is 7-11 mm Hg, the opening square >2 cm2), moderate (maximal gradient
pressure is 12-20 mm Hg, the opening square is 2-1 cm2), significant (maximum gradient
pressure is 20 mm Hg, the opening square <1 cm2).
Pathological anatomy
The cause of the heart defect is calcification and thickening the heart’s valve cusps, the fibrous
annulus, chordae and papillary muscles are also involved into pathological process. The
narrowing of the opening occurs in the beginning due to gluing the edges of the valves with the
formation of commissures, with future extension to the middle of the hole, gradually narrowing
it. Thereby, there are fibrotic changes of valvular structure, it sclerotizes, and the annulus is
losing its elasticity. Long-term existence of the defect leads to the calcification of the valve.
Pathological physiology
The "critical area" when hemodynamic disturbances become noticeable is 1-1.5 cm2. The
resistance to blood flow created by the narrowed mitral orifice (a "first barrier"), operates the
compensatory mechanisms to ensure adequate performance of the heart. Due to the increasing
gradient pressure between the left atrium and left ventricle (LV) the left atrial pressure
compensatory increases, atrial myocardium hypertrophies, its cavity expands. When pressure in
the left atrium is above a certain level there is a reflex contraction of small pulmonary (lung)
arterioles (LA) on the precapillary level (a "second barrier") – the Kitaev’s reflex that protects
the lung capillary net overflow with blood. High pressure in the LA (up to 80 mm Hg and
above) leads to compensatory hypertrophy, and then the dilation of the right ventricle (RV), the
diastolic pressure increases, this would lead to the right ventricular failure and the relatively
insufficiency of the tricuspid valve.
The clinical picture
Depends on the stage of the disease, a condition of compensation of blood circulation. Failure is
usually does not appear clinically if the area of mitral orifice is more than 1,5 cm2. When there is
a compensatory hyperfunction of the left atrium patients usually do not complaint, and even can
carry significant physical activities. When the pressure in the pulmonary circulation increases
there are complaints to a breathlessness and palpitations during physical activities occur. With a
sharp increase in pressure in the capillaries the heart asthmatic attacks occur, with a dry or with a
small amount of mucous cough, often mixed with blood (hemoptysis). At high pulmonary
hypertension the patients note weakness and fatigue. At significant stenosis and the increase of
the symptoms of pulmonary hypertension there is a typical facies mitralis observed: “Mitral"
blush on the cheeks against the pale skin, cyanosis of the lips, nose and ears.
While examination the heart area at the lower part of sternum is often protruded and pulsates as a
result of the formation of the "cardiac hump" due to amplified beats of the RV onto the frontal
chest wall. At the apex of the heart or less laterally there are defined diastolic thrill – a "cat
purring."
Auscultatory the mitral stenosis is diagnosed on the basis of the characteristic melodic tones of
the heart (the “quail” rhythm) – enforced (clapping) I tone at the apex of the heart and an
opening tone (click) of mitral valve, which appears in 0,08-0,11 seconds after II tone.
A typical diastolic noise is noted, which may occur in different periods of diastole.
Protodiastolic noise ratio is low, rumbling (the equivalent of palpation is a "cat purring"), of
varying duration, its intensity gradually decreases. Presystolic noise has usually a short, rough,
scraping and growing timbre, ending with clapping I tone.
Diagnostics
The ECG with the progression of disease emerge signs of left atrial overload (P mitrale),
hypertrophy of RV: increased amplitude of the QRS complex waves in conjunction with a
modified final part of the ventricular complex (flattening, inversion of T wave, ST segment
depression) in appropriate leads. Often there are the cardiac arrhythmias noted (atrial fibrillation,
atrial flutter).
The X-Ray analysis determines the increase of the left atrium and right ventricle, mitral valve
calcification, pulmonary vascular redistribution of blood flow to the upper sections of the lung,
the expansion of the LA.
EchoCG and doppler echocardiography are the main methods of assessing the severity of defect
and morphological changes in the valve (thickening, fibrosis, calcification, impaired movement
of cusps), functional parameters (gradient pressure, pressure in the LA, the presence and severity
of concomitant mitral regurgitation, LV and RV function), the size of the left atrium and mitral
orifice area calculation. In echocardiography (at M-mode) there are the unidirectional (Ushaped) forward movement of front and rear mitral valve cusps, slowing down the speed of the
early diastolic shut of the frontal cover of mitral valve (up to 1 cm/s), reducing the amplitude of
the mitral valve opening, an increase of left atrium space (anteroposterior dimension can grow up
to 70 mm);
Transesophageal echocardiography is performed to exclude left atrial thrombosis before the
commissurotomy or after an episode of embolism. In patients with moderate or severe mitral
stenosis the stress echocardiography can be performed, which allows to objectively evaluate the
functional ability of the heart and the value of transmitral gradient at rest and during exercises,
and often reveal pulmonary hypertension during exercising. The values of transmitral gradient at
a load of 20 mm Hg or more and the maximum systolic pressure in RV of 60 mm Hg and more is
an evidence of the presence of hemodynamically significant mitral stenosis. With patients who
are unable to perform exercise tests, they use an echocardiography, performed with dobutamine.
Average transmitral gradient above 18 mm Hg at peak of dobutamine infusion can identify
patients with risk for cardiovascular complications. Catheterization of heart cavities plays a
supporting role in the diagnosis and is held in the case when the clinical data contradict the
results of clinical echocardiography. Complete hemodynamic and angiographic study in mitral
stenosis involves catheterization of right and left heart to determine the pressure in all four of its
chambers, particularly important is a measurement of diastolic mitral valve gradient. Coronary
angiography is performed in older patients with risk factors for coronary heart disease.
Course
The course of the process is determined by the degree of severity of stenosis, presence of
pulmonary hypertension and the condition of RV myocardial contractility. Mitral stenosis in
most patients is steadily progressing, the rate of the mitral orifice area decrease is 0,09-0,32
cm2/year. After appearing the symptoms of cardiac decompensation (CD) within the period of 5
years, 50% of patients die.
There are 5 stages of mitral stenosis.
Stage 1 - the full compensation. Hemodynamic disturbances caused by insignificant narrowing of
the mitral orifice (its area is 2-2.5 cm2), left atrial pressure increased to 10-15 mm Hg. Clinical
manifestations are minimal: there are no complaints, work ability is not limited. The ECG signs
of overload of the left atrium (P mitrale), the X-Ray determined a slight increase in left atrial and
LA’s diameter. Surgical treatment is not indicated.
Stage 2- pulmonary congestion. It is characterized by narrowing of the mitral orifice down to
1.5-2 cm2, left atrial pressure is increased up to 20-30 mm Hg. Clinical symptoms include
breathlessness during exercise, signs of pulmonary hypertension with the frequent development
of complications, ability to work is limited, and there is no decompensation at right ventricle.
There are typical auscultatory signs of mitral stenosis, and the accent of II tone above LA
determined. ECG – P-mitrale, signs of RV hypertrophy. On echocardiography - a single-way Ushaped movement of the mitral valve cusps. On X-ray - increases of the left atrium, LA,
intensification of the lung pattern, congestion in the lungs. Disorder of blood circulation
corresponds to the 1st stage of HF (heart failure). Recommendations for surgical treatment are
relative.
Stage 3 - right ventricular failure. Mitral orifice area is 1-1.5 cm2. It is characterized by a
persistent hypertension in the pulmonary circulation with the formation of a "second barrier",
with increased RV’s load and development of its failure. Sclerosis of the pulmonary vessels,
reducing pulmonary blood flow leads to a decrease or disappearance of cardiac asthma attacks
and pulmonary edema. Dystrophic changes in parenchymatous organs expressed moderately.
Clinical symptoms include severe shortness of breath, pale skin, cyanosis, exercise intolerance,
signs of right ventricular decompensation, increased venous pressure, enlargement of the liver, a
significant expansion of the right heart. The ECG is expressed mitral P wave, signs of RV
hypertrophy, atrial fibrillation can be determined. At X-Ray - a marked increase in LA, left
atrium, right ventricle and enlargement of the right atrium. Surgery treatment is absolutely
recommended.
Stage 4 - dystrophy. Mitral orifice area is less than 1 cm2. It is characterized by severe disorders
of a blood circulation in large and small circles. Venous pressure increases, there is blood
congestion in the liver, in blood vessels of the lower extremities, edemas are noted. At
echocardiography there is a significant increase of the heart sizes due to atria and RV, a relative
valve failure is determined, also the calcification of mitral valve and thrombosis of the left
atrium are noted. At X-Ray - a further increase of a cardiac shadow, intensification of lung
pattern, expansion of the lungs’ roots. Drug treatment gives insufficient and short term effect.
The operation may be recommended, but that prolongs life for a short time.
Stage 5 - terminal. This clinically complies with the III stage of the heart failure (HF). It is
characterized by strong disorders of blood circulation with irreversible degenerative changes of
the internal organs (liver, kidney), ascites, atrophy of the muscular system. At ECG - significant
degenerative changes in the myocardium, various cardiac arrhythmias. At X-Ray a
cardiomegaly, high standing of the diaphragm, marked congestion in the lungs, often effusion in
the pleural area are determined. Drug treatment is ineffective. Surgical treatment is not indicated
already.
Treatment
Drug therapy is aimed at treatment and prevention of complications. It is necessary to use
prophylactic antibiotics before dental and other interventions to reduce the risk of infective
endocarditis. Young patients with acute rheumatic fever in their anamnesis are at a high risk of
relapse, so according to this prophylactic antibiotics are to be used by them regularly until
adulthood age.
The use of diuretics or long-acting organic nitrates gives a chance to reduce temporarily the
severity of dyspnea. β-blockers or blockers of calcium channels that reduce the heart rate, can
significantly improve exercise tolerance due to increase of diastole duration and LV filling time.
An indication for the use of anticoagulants is an atrial fibrillation, in patients with sinus rhythm
there are indicated in cases of large left atrium (> 50 mm), presence of spontaneous echo contrast
during transesophageal echocardiography, presence of thromboembolism at anamneses and
thrombus in the left atrium.
Prior to electrical cardioversion if the duration of atrial fibrillation was ≥ 48 hours,
anticoagulation should be used for 3-4 weeks before and 4 weeks after cardioversion.
Conducting cardioversion prior to surgery is not indicated in patients with severe mitral stenosis,
because it does not restore sinus rhythm for a long period. Mitral stenosis can be most
successfully corrected by surgical methods (valvuloplasty or valve endoprosthesis).
Mitral commissurotomy is performed in patients with severe mitral stenosis with symptoms that
limit physical activity and reduce the ability to work.
Percutaneous mitral commissurotomy is shown for patients with an area of orifice <1.5 cm2:
• patients with symptoms and optimal clinical characteristics;
• patients with symptoms and with the presence of contraindications or high risk surgery;
• as an initial intervention in patients with symptoms at unfavorable anatomical condition of the
valve, but with optimal clinical characteristics;
• in asymptomatic patients with optimal clinical characteristics and a high risk of
thromboembolic complications or hemodynamic decompensation (thromboembolism, the
presence of spontaneous contrast in left atrium, the recently carried out or paroxysmal atrial
fibrillation, systolic blood pressure at rest in LA> 50 mm Hg, the need for extracardiac surgery,
pregnancy planning).
Cons for percutaneous mitral commissurotomy are:
• mitral orifice area >1.5 cm2;
• a blood clot in the left atrium;
• moderate and severe mitral regurgitation;
• heavy or bicomissurotal calcification;
• severe concomitant aortic valve or severe combined stenosis and tricuspid valve failure;
• concomitant coronary artery disease requiring CABG.
Improving the condition of patients after mitral commissurotomy occurs in 70-89% of cases. The
ineffectiveness of intervention is usually due to late referral to a surgeon, marked morphological
changes of the heart and other internal organs.
If there are contraindications for percutaneous mitral commissurotomy the only alternative
method of treatment is a full surgery.
MITRAL INSUFFICIENCY
Etiology
Reducing the prevalence of rheumatic fever and the increase in life expectancy in industrialized
countries have changed the cause of this defect, and therefore in Europe today rheumatic fever
(14%) is dominated by degenerative mitral regurgitation (61%). Other causes of defect are
infective endocarditis, systematic diseases of connecting tissues (mitral valvular disease,
systemic sclerosis), coronary artery disease.
Classification
According to the severity level, the mitral regurgitation can be divided to initial (the volume of
regurgitation <30 ml for the reduction, the fraction of regurgitation <30%, the effective area of
the holes regurgitation <0.20 cm2), moderate (the volume of regurgitation is 30-59 ml for the
reduction, the fraction of regurgitation is 30-49 %, the effective area of the holes regurgitation is
0,20-0,39 cm2), severe (the volume of regurgitation is ≥ 60 ml for the reduction, the fraction of
regurgitation ≥ 50%, the effective area of the holes regurgitation ≥ 0,40 cm2).
Morbid anatomy
As a result of the pathological process the boundary defects would be formed, twisting the edges
of the cusps, and not letting the valves to close during the systole of LV. The shortening and
soldering the chords lead to limit the mobility of the valves (usually the rear). For mitral
regurgitation due to infective endocarditis is characterized boundary usuration of the spectral
cusps or their central perforation. A separation of chords is often revealed, and the boundaries of
the gap can be fresh or calcified vegetations.
Pathological physiology
Hemodynamic disorders in mitral insufficiency caused by the return of blood from the left
ventricle into the left atrium, which causes volume overload of the left atrium and left ventricle,
which depends on the amount of regurgitation. Disease is compensated by a powerful left
ventricular for a while, further the dilatation of the left atrium will progress, and it begins to
function as a cavity with low resistance. Over time, because of not fully yet defined causes the
LV progressively expands, a diastolic pressure increases and a fraction of ejection reduces (FE).
Wedge pressure in the pulmonary capillaries increases and pulmonary hypertension and RV
dysfunction progress. With the decompensation of the last, a relative dysfunction of tricuspid
valve develops and signs of right atrium failure appears. Long-term blood circulation disorders
lead to persistent changes in the lungs, liver, kidneys and other organs.
The clinical picture
In the compensation phase the defect can be detected incidentally during a medical examination.
With decreasing the contractile function of the left ventricle and increasing the pressure in small
circle of the blood circulation, breathlessness and palpitation occurs during physical exercises.
With increasing stagnation in the small circle (the capillaries) and with a growth of right heart
failure symptoms edemas in the legs and pain in the right upper quadrant appears, there may be
attacks of cardiac asthma and breath shortness at rest. Patients are often concerned about the
aching, pressing, stabbing pain in the heart, not always associated with physical activity.
When significant regurgitation, to the left of the sternum there is a heart hump, which is
determined by the strong and diffused apical impulse, localized in the fifth intercostals space,
outwards from the medioclavicular line.
Auscultatory the weakening or absence of the I heart tone, often split II tone over the LA is
determined, the deaf III tone is defined at the apex of the heart. The accent of II tone on LA is
usually expressed moderately and occurs when there is a stagnation develops in small circle of
blood circulation. The systolic murmur is the most characteristic, which is well heard at the apex
of the heart, held to the left axilla and along the left chest border, it’s intensity varies widely and
usually due to the severity of valvular defect. The timbre of a noise is different - soft, blowing or
rough, which can be combined with palpable systolic tremble at the top. Systolic murmur can
take a part or all of the systole (i.e. pansistolic noise).
Diagnostics
The ECG in severe mitral valve insufficiency notes the signs of hypertrophy of the left atrium
and left ventricle in the form of increased amplitude of the QRS complex waves, often in
conjunction with a modified final part of the ventricular complex (flattening, inversion of T
wave, reducing the segment ST) in the corresponding leads. With the development of pulmonary
hypertension, there are signs of hypertrophy of the right ventricle and right atrium. Atrial
fibrillation can be detected in 30-35% of patients. X-ray in the anteroposterior projection
visualizes the heart increased in size, more to the left, there is no waist due to a significant
increase in the left atrium, which may reach giant proportions, and be added to the right contour
of the heart as an additional shade.
Echocardiography is a fundamentally important study and should include an assessment of the
mechanisms of defect, the morphology of the valve and its function, the severity of mitral
regurgitation, LV and RV function. LV may be of normal size or dilated depending on the
severity and duration of mitral regurgitation, left atrium is dilated especially significantly in the
presence of atrial fibrillation.
The Doppler echocardiography can estimate the severity of mitral regurgitation. A direct sign of
blemish - a turbulent systolic blood flow in the left atrium, which correlates with the severity of
regurgitation. The severity of mitral regurgitation assessed by a semi quantitative method based
on the size (length, area) or by regurgitant flow method with the quantitative calculation of the
volume and regurgitant fraction and effective regurgitant orifice area.
The echocardiographic criteria of severe organic mitral regurgitation have been developed.
Specific features include the followings:
• the size of the vena contracta ≥ 0,7 cm with large central area of the flow of mitral
regurgitation> 40% of the left atrium or the parietal stream of any size, circulating in the left
atrium;
• a broad convergence of flow (radius ≥ 0,9 cm)
• systolic reverse current in the pulmonary veins;
• abnormal mobility of the mitral valve or papillary muscle rupture.
Additional signs of severe mitral regurgitation include the followings:
• Intensive triangular flow of mitral insufficiency at Doppler echocardiography with a constant
wave.
• prevalence of E peak of a transmitral flow (E > 1.2 m/s);
• increasing the size of the left atrium and left ventricle (especially while the normal function of
the LV).
Quantitative criteria for severe mitral regurgitation include the magnitude of regurgitation ≥ 60
ml per contraction, regurgitation fraction ≥ 50%, the effective area of the holes regurgitation ≥
0,40 cm2. Transesophageal echocardiography performed prior to surgery to determine the exact
nature of the damage to the valve, as well as the intraoperative assessment of the need for
additional correction. In the case of lack of informativeness of transthoracic echocardiography
specify the diameter of the left atrium and left ventricle, ejection fraction, systolic blood pressure
in the LA, the severity of mitral regurgitation.
Stress echocardiography is used to assess the functional significance of mitral regurgitation,
especially in asymptomatic patients, as well as to detect latent LV dysfunction.
Catheterization of heart cavities defines high blood pressure in LA. On the curve the pulmonary
capillary pressure characteristic pattern is visible as the form of increased wave V of more than
15 mm Hg with the rapid and steep decline thereafter. During ventriculography it can be seen as
a contrast agent in the left ventricular systole filling the cavity of the left atrium. The intensity of
staining the latter depends on the degree of mitral valve insufficiency.
Course
There are five stages of the mitral insufficiency course:
Stage I - compensation. It is characterized by minimal regurgitation of blood through the mitral
orifice, hemodynamic disturbances are practically absent. Clinically can be detected a slight
systolic murmur at the apex of the heart, a slight enlargement of the left atrium. According to
echocardiography a slight regurgitation at the mitral valve can be revealed. Surgical treatment is
not indicated.
Stage II - subcompensation. The reverse flow of blood into the left atrium increases,
hemodynamic dysfunction leads to its dilatation and left ventricular hypertrophy (LVH), which
effectively compensates the hemodynamic instability.
Physical activity is limited slightly, shortness of breath occur only when a significant physical
exertion. There is moderate-intensity systolic murmur at the apex of the heart. The ECG
electrical axis deviation to the left, in some cases - signs of overload of the left heart. There are
increase and strengthening the pulse of the left heart visible on X-ray. At echocardiography moderate regurgitation of the mitral valve. Surgical treatment is not indicated.
Stage III - right ventricular decompensation occurs at a significant regurgitation of blood into the
left atrium. Periodically decompensation of cardiac activity occurs, controlled by drug therapy.
There is a shortness of breath during exertion. A rough systolic murmur at the apex of the heart,
radiating to the axillary region can be auscultated.
The ECG reveals LVH signs. X-ray visualizes a significant enlargement of the left heart
chambers, increasing their pulsation - a symptom of "yoke". There is a severe mitral valve
regurgitation echocardiography. Surgical treatment is recommended.
Stage IV - dystrophy is characterized by the appearance of right heart failure. On examination,
there is a growing apical impulse, pulsation of the veins on the neck. Auscultation, except for a
rough systolic murmur mitral regurgitation often reveals various noises due to the dilatation of
the fibrous ring and tricuspid valve insufficiency. On ECG - LVH signs or both ventricles
hypertrophy, atrial fibrillation, extrasystolic arrhythmia. On X-ray - a significant expansion of
the heart, blood stasis in the pulmonary circulation. Kidneys and liver dysfunction. Work
capacity is lost. Surgical treatment is recommended.
Stage V - terminal, clinically consistent with the stage III of heart failure. Dystrophic stage of
circulatory disorders with severe irreversible changes of the internal organs (liver, kidney),
ascites. Surgical treatment is not carried out. Predictors of poor prognosis are the clinical
symptoms, age, presence of atrial fibrillation, severe degree of mitral regurgitation, dilatation of
the left atrium and left ventricle, low ejection fraction, the progression of pulmonary
hypertension.
Treatment
The prophylactic antibiotics should be administered to all the patients prior to dental or other
surgical interventions to reduce the risk of infective endocarditis. Fundamental is the treatment
of the underlying disease in patients with coronary heart disease or infective endocarditis. The
indications for the use of anticoagulants is a permanent or paroxysmal atrial fibrillation. In
patients with sinus rhythm, their administration is indicated in the case of anamnestic
thromboembolic episodes or the presence of thrombus in the left atrium, as well as during the
first 3 months after surgical restoration of the valve (the INR index should be maintained in the
range of 2.0-3.0)
There is currently no evidence of the efficacy of vasodilators, including ATE (angiotensintransforming enzyme) inhibitors in patients without evidence of heart failure, so their use in
these patients is not recommended. On the other hand, if you have heart failure, ATE inhibitors
are shown in the case of significant mitral regurgitation and severe clinical symptoms with
contraindications to surgery or in the presence of residual symptoms after surgical treatment,
usually as a result of impaired left ventricular function.
Developing heart failure is managed by conventional methods, according to indications diuretics
are prescribed, β-adrenoceptor blockers and spironolactone. Current and modern direction in the
therapy of heart failure is the use of drugs with a direct inotropic effect and a cytoprotective
effect and a direct metabolic effect on the cellular level. Understanding that a violation of the
metabolism of cardiomyocytes plays an important role in the mechanism of electrophysiological,
hemodynamic disorders, predetermined the development of a new direction of MVD therapy myocardial cytoprotection. In this direction, promising is a new generation of
cardiocytoprotectors - Corvitin (water-soluble form of Quercetin) - an inhibitor of several
oxidase enzymes, mainly lipoxygenase, a powerful antioxidant that promotes increased levels of
nitric oxide, which has antiremodeling, antiarrhythmic, membrane stabilizing properties,
improves the contractile and electrophysiological properties of myocardium. 0.5 g of Corvitin is
administered intravenously diluted in 50 ml 0.9% sodium chloride solution, 1 time a day for 10
days followed by oral administration at a dose of 2 g in granules (quercetin), 2 times a day for 20
days. The main objectives of the surgical operation are: decrease severity of clinical symptoms,
preservation of LV function, prevent / reduce the severity of pulmonary hypertension and RV
dysfunction, maintenance and/or restoration of the sinus rhythm.
Indications for reconstructive surgery are the failures without rough changes in valves, chords,
papillary muscles and in the absence of valves calcification. The valve reconstruction at patients
with severe mitral insufficiency is the best surgical approach. The best results in patients with EF
more than 60% and the value of the finite-size systolic size less than 45 mm before the operation.
In cases of inability to restore the valve, its replacement with mechanical or biological prosthesis
is preferable with preservation of the natural mitral valve apparatus.
Mitral valve replacement in most patients provides extended life and rehabilitation in the
postoperative period. There is no consensus with regard to the surgical treatment of
asymptomatic patients, because there are no randomized studies on this issue.
In separate groups of asymptomatic patients with severe mitral insufficiency surgical treatment is
indicated when there is an evidence of LV dysfunction (ejection fraction value of less than 60%
and / or finite-size systolic over 45 mm) in patients with atrial fibrillation and preserved LV
function, with preserved LV function and pulmonary hypertension.
New pedagogic technologies applied on lesson.
CASE
Solving the problem of in-time diagnostics of MVD
and a choice of their rational therapy
The pedagogical summary
Subject: “Faculty therapy” and “Internal diseases”
Theme: “Mitral valvular diseases diagnostics and treatment”
The purpose of the yielded case: broadening and dilating of knowledge of the causes of
development of MVD. Development of ability of an assessment and the analysis of a situation
of managing patients with MVD. Skills of drawing up of diagnostic algorithm and a choice of
tactics of treatment in the conditions of a hospital.
Scheduled educational effects – by results of operation with a case students get skills:
 Assessment and the analysis of common state of patients with MVD
 Choice of the correct diagnostic algorithm of patients with MVD.
 Choice of treatment tactics in the conditions of a hospital.
For the successful solution of the yielded case the student should know:
• Hemodynamics and clinic of MVD.
• To perform differential diagnostics
• To number the diagnostic methods, to compound and prove the plan of examination in
the hospital conditions.
• To compound and prove a treatment planning
The yielded case reflects a real situation in the hospital conditions.
Case references:
1.
2.
3.
4.
5.
6.
7.
History of the disease
Internal diseases (cardiovascular system) G.E. Roytberg, A.V. Strutynsky, 2007.
Clinical cardiology / edited by E.I. Chazov
Guidelines for cardiology / edited by VN Kovalenko, 2008
Internal diseases Martynov A.I., Muhin N.A., Moiseev A.S., М, medicine, 2004
Internal diseases Martynov A.I., Muhin N.A., М. – 2008.
http://.www.med-site.narod.ru/index.htm
The description, diagnostics, treatment of diseases. Pharmaceutics, anatomy.
8. http:// www.recipe.ru
Medicine: information resources, databases.
9. http:// www.vh.org
10. http:// www.meddean.luc.edu
The encyclopaedia of examination of the patient with set of an illustration, the short
description of diseases and testing.
11. http://embbs.com
Case histories, training, the atlas on an electrocardiogram, etc.
12. WWW.TMA.uz.
The case performance according to typological signs
The yielded case corresponds to the room, subject genres. It is volumic and structured. It is a
case-question.
On the didactic purposes the case is training, boosting thinking in a real situation in the
hospital conditions.
The case can be used on disciplines: therapy, cardiology, urgent conditions.
I CASE
«MVD diagnostics and treatment»
Introduction
Mitral valvular diseases - are the diseases, which are based on morphological and functional
disorders of the valve apparatus (valve leaflets, annulus, chordae, papillary muscles), developed
as a result of acute or chronic disease and injury in violation of the valvular function and causing
changes in intracardiac hemodynamics.
Mitral insufficiency is characterized by incomplete closure of the cusps and is the result of their
shrinkage, contraction, perforation, or expansion of the fibrous valve ring, deformation or
detachment of the chords and papillary muscles. In some cases, the valve failure is caused by
dysfunction of the valve apparatus, including papillary muscles.
Stenosis (narrowing) of valve orifices is caused predominantly by fusion of the valve cusps.
More than a half of all the acquired heart diseases is accounted for the mitral valve failure. The
main cause of stenosis of the mitral orifice in the adult population remains the rheumatic fever,
note that two thirds of patients with rheumatic mitral stenosis are women. Besides, 50% of them
have no indications to the attacks of rheumatic fever in the past, because of increased latent
course of rheumatic fever.
The high prevalence, the involvement of the working age population, the difficulty of timely
diagnosis of the disease justify the need for further study of the disease and knowledge of the
rational management methods.
The purpose of this case study is the development of the students’ (i.e. case users) abilities of
the study analysis of the supervising situation of patients with mitral valvular disease of the
heart. Skills and choosing tactics, diagnosis, providing a rational therapy in the hospital
environment.
The solution of the prospective case will allow students to reach following educational effects:
 To educe abilities of an assessment and the analysis of common state of patients with
MVD
 To fulfil a choice ability of the correct diagnostic algorithm of patients with MVD.
 To fulfil a choice ability of treatment tactics in stationary conditions
The live situation:
The Cardiorheumatology Department received woman, 37 years with complaints of shortness of
breath, palpitations, heart pain, coughing up with blood.
From the history of the disease: suffering from rheumatic fever in childhood. In 14 years,
diagnosed with a heart disease. All those years felt satisfactory. In the spring recovering from a
sore throat had become concerned about the noted complaints.
From the history of life:
- Suffered illnesses - frequent colds.
- Menstruating at age 12, sexual activity from 22 years, pregnancy - 4, deliveries - 3.
- Allergies to medications and foods are not observed.
- Family / social history: married, housewife. No bad habits.
Epid. anamnesis:
- Contact with infectious patients absent.
- Blood products not received.
- Injection therapy - denies.
Physical examination: The general condition of moderate severity. Consciousness is clear,
condition - forced orthopnea. Skin and mucous membranes pale in color, acrocyanosis - facies
mitralis. In the lungs - wet nonresonant, fine rales. On palpation of the heart - diastolic "cat
purring". Percussion - the boundaries of the heart expanded to the right and upward. Muffled
heart tones, irregular, flapping tone I at the apex and tone of the heart mitral valve opening (the
rhythm of quail), diastolic murmur. Abdomen soft, painless. The liver and spleen not enlarged.
Pulse -126 bpm, arrhythmic. HR -130 bpm. AP -100/70 mm Hg. Diuresis regular.
Surveys conducted in the hospital, showed
- CBA: HB -108 g/l, white blood cells - 4.8, ESR 10 mm/h
- Urinalysis: protein - ABC. Eritrocytes - 1-2/1, Leukocytes - 4-6/1
- Blood biochemistry: total blood protein - 68g / l, bilirubin -20 mmol / L, ALaT - 0,4 and ASaT0,2 (normal)
Questions and tasks
1. What additional methods should be performed for diagnosis?
2. In your opinion, which pathologies need to perform a differential diagnosis with?
3. What is your diagnosis, justify it.
4. Make a plan of treatment.
The assignment: On the basis of the state analysis of patients condition it is necessary to make
the preliminary diagnosis, to perform necessary methods of diagnostics, to accept the wellfounded treatment plan.
II. Methodical indications for students
2.1 Issue: Diagnostics and treatment of patients with MVD in the stationery conditions
2.2. Subissue
1. The habitus analysis
2. The analysis of the anamnesis morbi and anamnesis vitae of the patient
3. The examination analysis
4. Choice of necessary methods of diagnostics
5. The analysis of the received effects of examinations and performing the differential
diagnostics
6. Choice of treatment tactics.
2.3. Algorithm of the solution
1. The habitus analysis includes the following examination
- Examination of skin and visible mucous
- Face, body, extremities.
2. The anamnesis analysis
- The underwent diseases
- The family-social anamnesis
- Duration of disease
3. The examination analysis
- Pulse, arterial pressure.
- Palpation, Percussion, Auscultation of heart and lungs
- Abdominal palpation
4. A choice of necessary methods of diagnostics
- CBA, CUA
- B/C of blood
Coagulogram
Acute phase samples
ECG
Echocardiography
Chest x-ray
Ultrasound of the abdominal cavity
5. To correlate the received results and to carry out differential diagnostics with:
- Mitral valve prolapse
- Congenital heart disease
- Aortic valvular disease.
6. A choice of treatment tactics
- The use of drug therapy
- The use of surgical treatment
The instruction to independent work on
the analysis and the solution of a practical situation
Sheet of the situational analysis
Work stages
1. Acquaintance with
case
2. Acquaintance with
the given situation
3. Revealing,
formulation and a
substantiation of a
key issue and
subissues
4. Diagnostics of the
situation analysis
5. A choice and a
substantiation of
methods and problem
resolution means
6. Development and
resolution of a
problem situation
Recommendations and advises
Firstly make acquaintance with a case
While reading, do not try to analyze a situation at once
Read the information once again, mark the paragraphs which have
seemed important to you.
Try to characterize a situation. Mark what is important, and what is less.
Problem:
Diagnostics and treatment of patients with MVD
At the situation analysis answer following questions:
Make definition, enumerate the causes and the hemodynamics
development of MVD.
Enumerate the diagnostic methods of MVD using the patient example.
What methods of diagnostics are necessary for diagnosis statement?
Compound and prove the examination plan.
Formulate the clinical diagnosis and prove it.
What nosologies are necessary to eliminate during the differential
diagnostics?
Define the treatment tactics
Enumerate the possible means of solution of the yielded problem in the
presented situation
State the diagnosis, choose the treatment tactics
The rating table of individual work with a case
Participants
Rating criteria and indexes
The analysis
of a current
situation
max 1,0
Problem
substantiation
max 0,5
Choice of
methods and
problem
resolution
max 0,5
1.
2.
№
* 2,0 – 2,5 points – “excellent”, 1,5 – 2,0 points – “good",
1,0 – 1,5 points – “satisfactory",
Less than 1,0 points – “unsatisfactory"
Detailed
development
of standards
on solution
realisation
max 0,5
Common
mark
(max 2,5) *
Rating system of the group problem resolution.
Each group receives two estimate points. It can donate them at once all to one candidate solution
or part it by two (1:1; 0,5:1,5; etc.), not including the own solution rating.
All received points on each candidate solution are summarized. The solution which has achieved
the greatest quantity of points wins. In disputable cases it is possible to take voting.
The rating table of the group problem resolution, mark
Group
The alternative candidates of the problem solution
1
2
3
1.
2.
№
Total
№
Rating of presentation of the offered solution
Group
Completeness and
clearness of
presentation
(1 – 20)
Obviousnes
s of the
presentation
(1 – 20)
Mass
activity of
group
participant
s (1 – 20)
Originality
of
presented
solutions
(1 – 20)
Recption ability
to the legislative
norms
(1 – 20)
Total sum
of
achieved
points
(max 100)
1.
2.
№
III. THE CASE CANDIDATE SOLUTION VARIANT BY
THE TEACHER-CASEOLOGIST
1. The symptoms listed above in the case indicate that the patient acquired a heart disease,
namely, rheumatic mitral stenosis. The patient must carry the following survey: acute phase
samples, blood clotting time, coagulogram - to detect changes in blood coagulation, ECG - to
detect a hypertrophy of the heart, arrhythmias and conduction EchoCS - to detect lesions of
endo- and myocardium of the heart, Doppler - to identify abnormal flow in the heart, chest x-ray
- to identify the configuration of the heart and signs of congestion in the lungs, abdominal
ultrasound - to detect congestion in the liver, heart surgeon consultation.
2. There are many diseases similar to mitral valvular disease of the heart:
- Mitral valve prolapse
- Congenital heart disease
- Aortic valvular diseases.
3. In this patient revealed the following symptoms: position - orthopnea, facies mitralis. In the
lung - wet non-resonant, fine rales. On palpation of heart - diastolic "cat purring." Percussion the expanded boundaries of the heart to the right and upward. Auscultation - slapping tone I at
the apex and tone of the mitral valve opening (the rhythm of quail), diastolic murmur at the
pulmonary artery tone with II tone accent, pulse -126 beats / min, arrhythmic. HR-130 bpm. AP100/70 mm Hg. ECG - signs of hypertrophy of the left atrium and atrial fibrillation. Chest X-ray
- an enlargement of the left atrium and right ventricle, signs of pulmonary hypertension. On
echocardiography - a one-way U-shaped motion of the mitral valve cusps, area of the mitral
orifice - 1.9 cm2. Signs of dilatation and hypertrophy of the left atrium and right ventricle.
Doppler echocardiography: a turbulent flow.
The diagnosis wording: Chronic rheumatic heart disease. Mitral heart failure (stenosis of the
mitral orifice stage II). Complications: Atrial fibrillation.CCI (chronic cardiac insufficiency) IIA.
4. Medical therapy: hypothyasidum 50mg/day, digoxin 0.25 mg/day, metoprolol 50mg/day,
warfarin 2.5 mg /day. Secondary prophylactics - extencillin 2.4 million MU i/m 1 time per 3
weeks. Recommended: cardiologist’s consulting.
IV CASE – TECHNOLOGY OF TRAINING AT THE SEMINAR
4.1 Model of technology of training
Theme
Duration – 90 minutes
Diagnostics and MVD treatment
Quantity of the trained: 10 persons
Seminar on extension and broadening of
The shape of educational lesson
knowledge, working out the abilities of tactics of
conducting patients with MVD
 Introduction to the educational lesson
 Actualisation of knowledge
 Working with a case in minigroups
 Presentations of results
The seminar plan
 Discussion, assessment and choice of the
best variant of strategy
 The inference. An assessment of activity
of groups and students, degrees of goal
achievement of educational lesson
The purpose of educational lesson: an extension and broadening the knowledge of the causes of
development of MVD. Development of rating ability and the situation analysis of criteria at the
real patients management with MVD. Skills of composing the diagnostic algorithm and a choice
of treatment tactics in the hospital conditions.
Effects of educational activity:
Tasks of the teacher:
 Estimate and analyze a situation and
 To set and broad the knowledge by
common state of patients with MVD
rating and analysis of the common
 Choose algorithm of activities for
state of patients with MVD
diagnosis statement.
 To develop a choice ability of the
 Educe skill of self-maintained decision
correct algorithm of activities for
making at conducting patients with
diagnosis statement.
MVD in the hospital conditions.
 To develop skills on rendering the
 Develop algorithm of treatment for the
rational therapy
patients with MVD
Training methods
Tutorials
Form of study
Training requirements
Monitoring and assessment
Cases-stages, discussion, practical method
Case, methodical indications
Individual, face-to-face, operation in groups
Audience with a hardware, adapted for operation
in groups
Observation, blitz-poll, presentation, rating
The procedure sheet of the educational lesson based on a case.
Stage and the
operation
content
Activity
Teacher
Students
Preparational
stage
Explains appointment of a case-stages and its
influence on development of professional
knowledge. Distributes the case materials and
acquaints with a situation analysis algorithm (see
Methodical indications for students).
Yields the assignment of self-maintained to carry
out the analysis and bring the results in the «Sheet
of the situation analysis»
I stage.
Introduction to
educational
lesson
(10 mins)
1.1. Terms the lesson theme, plan, its purpose, tasks Listen
and scheduled effect of educational activity.
Write down the conforming
1.2. Acquaints with the lesson regimen and criterias records
of results rating (see indications for students)
II stage
basic
(60 mins)
III Summarizing
the lesson, the
analysis and
rating
20 mins
2.1. Proves the statement of a problem and a
situation choice – the urgency. Makes quiz on
purpose to activate knowledge trained on a theme:
1. Comprise the MVD definition.
2. Enumerate the causes of occurrence and the
mechanism of disease development?
3. Enumerate the course variants of MVD
4. Enumerate the diagnostic criterias of MVD
5. The methods of diagnostics applied to statement
of the diagnosis
6. For which nosologies is it necessary to perform
differential diagnostics
7. Tactics of management and treatment of patients
with MVD
2.2. Divides students into bunches. Reminds the
content and case problems. Acquaints (reminds)
with operation rules in groups and discussion rules.
2.3. Yields the assignment, improves correctness of
perception of the assignment:
2.4. Co-ordinates, advises, refers educational
activity.
Estimates effects of individual operation: Sheets of
the situation analysis.
2.5. Will organise presentations following the
results of the done operation under the case
solution, discussion.
The organizer of discussion: asks questions,
replicas, reminds a theoretical stuff
2.6. An organizer - algorithm of activities in the
present state of affairs (cascade, lotus)
2.7. Reports the own candidate solution of a case
3.1. Extends results of educational activity, declares
results of individual and teamwork.
Analyzes and rates the group, notes the pro and con
moments.
3.2. Emphasises the value of a case-stage and its
influence on development of the future expert
Listen
Independent study the case
content and fill individually the
sheet of the situation analysis.
Answer questions, discuss, ask
defining questions.
Are divided into groups
Discuss, perform the joint
analysis of an individual
problem, spot the major aspects
of situation, the basic problems
and means of their solution,
design the solution results
Represent candidates solution of
a problem of 10-15 mins
Questions after the presentation
terminal, choose an optimum
variant
Develop uniform system,
discussion
Listen.
Can spend a self-rating and
inter-rating
Express their opinion
7. A quality monitoring of practical skills and theoretical knowledge.
1. Professional inquiry and examination of the patients with mitral valvular disease.
The purpose:
- Reception of the information necessary for diagnostics;
- An assessment of disease probability;
- Definition of other sources of the information (relatives, other doctors, etc.);
- An establishment of confidential mutual relations with the patient;
- An assessment of the face of the patient and its attitude to disease (an intrinsic pattern of
disease);
- To estimate a state of consciousness and the mental status of the patient, its standing, a habit
view, a state of integuments and separate body areas.
Indications: poll recommended for all patients who are in consciousness; examination is
performed to all the patients.
Equipment: well lighted boxes, physician offices, incandescent lamps.
Performance requirements: no strange persons, confidential situation.
Carried out stages (steps):
№
Action
Was not
executed
1
2
3
4
5
6
7
8
9
10
Inquiry of passport data
Assembly of complaints
Assembly of the anamnesis morbi
Assembly of the anamnesis vitae
The epidemiological, allergic anamnesis
Objective examination of the patient
Will compound the examination plan
The correct statement of the diagnosis
Differential diagnostics
Compound of a treatment plan
Total
0
0
0
0
0
0
0
0
0
0
0
Completely and
correctly
executed
5
15
20
15
5
5
5
5
20
5
100
2. Drawing up the dietary references and the treatment program.
The purpose: Treatment of disease and remission achievement
Was not
№ Action
executed
(0 points)
1 Studying the performance of medical tables
0
The correct choice of a dietary table according to
2
0
the diagnosis
3 Assessment of full value of a diet
0
According to the diagnosis, severity of disease and
4
0
a stage appointment of the basic therapy
According to the diagnosis, severity of disease and
5
0
a stage appointment of symptomatic therapy
6 Preventive actions
0
0
Total
Completely and
correctly executed
10
10
20
20
20
20
100
Tests
1. The main etiological factors of the mitral heart disease:
A. Rheumatism *
B. bacterial endocarditis *
C. rheumatoid arthritis *
D. CHD
E. Atherosclerosis
2. Objective data from the heart with mitral valve insufficiency:
A. an increase in the border of the heart to the left and upward *
B. I weakening tone at the top, strengthening II tone on the pulmonary artery *
C. I systolic murmur at the apex *
D. diastolic murmur at the apex
E. II increased tone in the aorta
3. The main objective data from the heart with mitral valve stenosis:
A mitral Butterfly *
B. Mitral nanism *
C. facial hyperemia
D. pale skin
E. cyanosis around the lips *
4. The main changes of the heart with mitral stenosis:
A heart hump *
B. an increase in the border of the heart to the right and upward *
C. I diastolic murmur at the apex of the heart *
D. an increase in the border of the heart to the left and upward
E. II increased tone in the aorta
5. The main complaint with mitral stenosis:
A shortness of breath *
B. heart *
C. hemoptysis *
D. pain in the lumbar region
E. pain in the left upper quadrant
6. What are the percussion changes in mitral stenosis:
A. an increase in the border of the heart upward *
B. an increase in right heart border *
C. an increase in the left heart border
D. an increase in the border of the heart downward
E. shifting apex beat downward
7. Auscultatory data in mitral stenosis:
A. I increased tone at the apex *
B. II increased tone in the pulmonary artery *
C I diastolic murmur at the apex of the heart *
D. systolic murmur at the apex
E. systolic murmur over the aorta
8. ECG in mitral stenosis:
A hypertrophy of the left atrium *
B. right ventricular hypertrophy *
C. atrial fibrillation *
D. Left ventricular hypertrophy
E. right ventricular hypertrophy and left atrial
9. The main complication of mitral stenosis:
A pulmonary hemorrhage *
B. thromboembolism *
C. atrial fibrillation *
D. Hypertension
E. Renal Failure
10. Radiographic changes in mitral stenosis:
A bulging waistline of the heart *
B. mitral configuration of the heart *
C. narrowing of the posterior mediastinum *
D. waist of the heart expressed
E. enlargement of the left ventricle
11. Types of the mitral stenosis treatment:
A conservative *
B. Operational *
C. nitroglycerin
D. Beta-blocker
E. cardiac glycosides
8. Measure of an assessment of monitoring
The level of student knowledge
Progress in % and
the score
Evaluation
A student on the major issues and themes for students' independent work::
Summarizes and makes decisions
creative thinking
independent analysis
Performs into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 7-10 sources and the Internet.
96-100
5
A student on the major issues and themes on the SIW:
creative thinking
independently analyzes
Performs into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 4-6 sources and the Internet.
91-95
5
A student on the major issues and themes on the SIW:
86-90
5
independently analyzes
Performs into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 3-5 sources and the Internet.
A student on the major issues and themes on the SIW:
Performs into practice
Shows high activity, a creative approach to the conduct of interactive games
Correctly solves the case studies with full justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 3-5 sources and the Internet.
81-85
4
A student on the major issues and themes on the SIW:
Shows high activity during the interactive games
Correctly solve situational problems, but the justification for an incomplete
answer
Understands the subject matter
Knows, says confident
Has a faithful representation
Prepares modern visual aids or abstracts using the recent literature data of 1-2
sources.
76-80
4
A student on the major issues and themes on the SIW:
Correctly solve situational problems, but the justification for an incomplete
answer
Understands the subject matter
Knows, says confident
Has faithful representations or
A student on the major issues and themes on the SIW:
71-75
Mistakes in solving situational problems
Knows, says uncertainly
Has a faithful representation of some issues topic
Prepares informative modern visual aids or abstracts of high quality using data
from the recent literature of 7-10 sources and the Internet.
Prepares modern visual aids or abstracts of high quality using data from the recent
literature of 4-6 sources and the Internet.
4
A student on the major issues and themes on the SIW:
Understands the subject matter
Correctly solve situational problems, but can not justify a response
Knows, says confident
Has a faithful representation of some issues topic
66-70
3
A student on the major issues and themes on SIW:
Mistakes in solving situational problems
Knows, says uncertainly
Has a faithful representation of some issues topic
61-65
3
A student on the major issues and themes on SIW:
Knows, says uncertainly
Has a partial view
55-60
3
A student on the major issues and themes on SIW:
Less then 55
2
Has not determined opinion
Does not know anything
9. A chronological card of lesson.
Duration
(minutes)
270
№
Stages of practical lesson
1.
Opening address of the teacher (theme
substantiation).
2.
Discussion of a theme of practical lesson, checkout
of basic knowledge of students with use of new
pedagogical technologies, a demonstration stuff
(slides, audio - videocassettes, X-ray patterns, ECG
etc.).
3.
Discussion end.
20
4.
Allocation of assignments to students for
performance of a practical part of lesson. Instructing
and the explanatory under the demands shown to
practical assignments. Self-maintained curation.
30
Development by means of the teacher of a practical
part of lesson.
Interpreting of laboratory-instrumental methods of
examinations differential diagnostics, treatment and
preventive maintenance scheduling.
Lesson shapes
10
Poll, explanatories.
60
Case study
90
6.
Discussion of theoretical and practical knowledge of
students, their reinforcement and assessment of
activity of bunch in respect of achievement of an
object in view of lesson.
Oral poll, the test,
discussion, checkout of
effects of practical
operation.
40
7.
The inference of the teacher on the transited lesson,
an assessment of activity of each student and the
announcement of effects. Working out of
assignments for preparation for following lesson (the
receiving tank of questions).
Questions for selfmaintained operation.
20
5.
10. Questions for the control of knowledge
1. Etiology and pathogenesis of mitral valvular diseases (MVD).
2. The clinical picture of MVD.
3. Diagnosis of MVD.
4. Classification of the MVD.
5. Differential diagnosis of MVD
6. Treatment of MVD.
11. The recommended references
The basic:
1 Internal diseases (cardiovascular system) G.E. Roytberg, A.V. Strutynsky, 2007.
2 Clinical cardiology / edited by E.I. Chazov
3 Guidelines for cardiology / edited by VN Kovalenko, 2008
4 Internal diseases Martynov A.I., Muhin N.A., Moiseev A.S., М, medicine, 2004
5 Internal diseases Martynov A.I., Muhin N.A., М. – 2008.
The additional:
1. Diagnostics of the internal diseases / A.N. Okorokov, Moscow 2005
2. Treatment of the internal diseases / A.N. Okorokov, Moscow 2005
3. http://.www.med-site.narod.ru/index.htm
The description, diagnostics, treatment of diseases. Pharmaceutics, anatomy.
4. http:// www.recipe.ru
Medicine: information resources, databases.
5. http:// www.vh.org
6. http:// www.meddean.luc.edu
The encyclopaedia of examination of the patient with set of an illustration, the short
description of diseasees, testing.
7. http://embbs.com
Case histories, training, the atlas on an electrocardiogram, etc.
8. WWW.TMA.uz.