Download for vi th course students of medical and pedagogical faculty

THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
THE DEPARTMENT OF INTERNAL DISEASES № 3
OF MEDICAL AND PEDAGOGICAL FACULTY
WORKER PROGRAM
ON THE SUBJECT OF «INTERNAL DISEASES» FOR VI TH COURSE
STUDENTS OF MEDICAL AND PEDAGOGICAL FACULTY
TASHKENT-2016
1
THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
THE DEPARTMENT OF INTERNAL DISEASES № 3
OF MEDICAL AND PEDAGOGICAL FACULTY
Study-methodical
department is
Registered№______________
«_____» ____________2016 year
«APPROVED»
Vice Rector on Academic Affairs,
TMA, Professor O.R. Teshaev
_________________
«_____» ________2016year
THE STUDY WORKER PROGRAM ON THE SUBJECTOF INTERNAL
DISEASES
Sphere
of
knowledge:
Sphere of
education:
the
1 100000 – Humanitarian sphere
5 500000– Public health and social security
1110000P Pedagogy
510000 - P Public health
DDirection edication:555510100- MMedical business
5 5111000 - V Professional training
business)
Tashkent - 2016
2
(5510100-medical
The Worker program subject is designed on base of the standard program and
curriculum
Compiled by:
1. Akhmedov Kh.S. - Head of the department of internal diseases № 3 of
TMA, Associate Professor.
2. Gadaev A.G.- Professor of the department of internal diseases № 3 of TMA
of TMA, PhD, d.m.s.
3. Salaeva M.S. - Head teacher Associate Professor of the department of internal
diseases № 3 of TMA
Reviewers:
1. Karimov. M.Sh– Тashkent medical academy,head of the “Рropadeuitics internal
diseases, hematology, DT professional disease d.m.s. professor.
2. Hamroev A.А. –Тashkent medical academy,head of the gp’s training with
endocrinology faculty of medical education, d.m.s. professor.
Working curriculum of the subject discussed at a meeting of Childhood Illness ___
June 2016 protocol number _____ and recommended for discussion at a meeting of
the faculty council
Head of the department:
Akhmedov Kh.S.
Working curriculum of the subject discussed at a meeting of the faculty council and
is recommended for use (____ June 2016 Protocol № ___)
Chairman of the faculty council
Xamraev A.A.
Аgreed:
Head of training and methodological
of TMA
Rakhimov B.B.
3
1. Introduction
The daily activities of a general practitioner takes the main place treatment and medical
examination of internal diseases. In this regard, the curriculum of general practitioners included a
section "Internal Medicine". In this workshop curriculum wide coverage of etiology and
pathogenesis of the most common diseases of adulthood, the main clinical symptoms, their
diagnosis, differential diagnostic aspects, provision of necessary medical care, as well as the
basics of prevention and rehabilitation.The program is designed to develop the theoretical and
practical skills in the discipline "Internal Medicine" for students of 6th year medical-pedagogical
faculty. The program clearly reflects the goals and objectives of training, mandatory
requirements for a practical and self-knowledge, abilities and skills, taking into account the use
of modern technology and literature, methods of control assessment.
1.1 Goals and objectives of the subject
The purpose of studyTeach students at syndrome addressing patients and principles of conduct in
terms of primary health care to provide medical care, including prevention, early diagnosis,
differential diagnosis and tactics of the Vedaof patients with diseases of internal organs,
provided the requirements of "Qualification characteristics of the general practitioner (GP)"
physician-graduate specialty "Medicine".
Learningobjectives
• To teach students timely and early detection of diseases on the basis of the syndromic
approach.• To teach students to differentiate the disease, accompanied by a specific
syndrome.
• Improve the knowledge, abilities and skills (gathering information, identifying problems and
physical examination, as well as the ability to reasonably prescribe laboratory and
instrumental methods of research, counseling skills);
• To teach students to choose reasonably tactics.
• To teach
students the implementation of targeted therapeutic and preventive measures.
• To teach students the principles of follow-up and monitoring in a rural health units (AEP) or
family clinic
1.2 Requirements for the skills of students in subjectsI. Must know:1. The basis of the principles
and philosophy of family medicine.2. Principles of Counseling3. A list of diseases which
occur with a specific syndrome.4. A list of the most dangerous diseases which occur with a
specific syndrome.5. The list of conditions required to keep under the SVP or SP (according
to the characteristics of the GP qualifying).6. A list of the states that require a specialist
consultation or hospitalization (according to the characteristics of the GP qualifying).7. A list
of the necessary studies, requiring under SVP or SP (according to the characteristics of the GP
qualifying).8. The main clinical manifestations of the most common diseases.9. Highlights
(test) diagnosis of diseases that occur with a certain syndrome.10. The symptoms of internal
organ involvement.11. The methods and principles of treatment (including non-drug) diseases
based on evidence-based medicine.12. The principles of primary, secondary and tertiary
prevention in a hovercraft or a joint venture.13. Principles of reference (including, after
consulting a specialist, and hospital discharge) of follow-up and rehabilitation in a hovercraft
or a joint venture.II. Should be able to:1. Comply with medical ethics and deontology.2.
Select the basic problem, which affected the quality of life of patients.3. Carry out a clinical
examination of the patient, including medical history (ask the patient and his relatives to ask
subsidiary questions of rational history, to identify risk factors), examination of systems and
organs.4. On the basis of history and physical examination to establish a preliminary
diagnosis.5. Assign a meaningful examination.6. To interpret the clinical and biochemical
analyzes, and the results of instrumental studies (ECG, X-ray images, picfluometriya)7.
differentiate between the disease (clinical logic of the decision).8. To establish a definitive
diagnosis.9. Decide on the administration of the consultation, additional medical examination
and hospitalization.10. Assign a rational therapy (non-drug and drug advice).11. To provide
4
prehospital care in case of emergency.12. To monitor and follow-up of patients in a hovercraft
or a joint venture.13. Address the issue of disability (temporary and permanent). Making
medical records.14. To carry out rehabilitation and directed to the spa treatment.15. To
consider in the context of the patient's family.16. To carry out preventive, health, sanitation
and hygiene activities in the MRA, or conditions in the joint venture.17. Implement nursing
and socially disadvantaged groups.
III. Must have skills:1. Independently of patients receiving2. Counseling3. inspection,
palpation, percussion and auscultation of systems and organs4. Identify the leading
syndrome5. Identification of risk factors6. Drawing up the required inspection plan
7.Techniques
8. Techniques picphuometria9. Tonometria10. The choice of drugs with proven efficacy11.
Monitoring the effectiveness of the treatment12. Monitoring of the state13. Providing
health care to pregnant women with extragenital pathology.14. Promoting healthy lifestyles
(work with risk groups and the population).15. The process of rehabilitation and medical
examination.16. The implementation of preventive measures.
1.3 Contact subject with other subjects provided in the curriculum and its place in the health
care system
This course is closely related to the following items, provided the curriculum: 1. Human
anatomy, histology with embryology and cytology, biology, normal physiology, biochemistry,
pathological anatomy, pathological physiology, topographical anatomy and operative surgery,
propaedeutics internal medicine, tuberculosis, cancer, radiology and medical radiology,
physiotherapy, endocrinology, faculty therapy, hospital therapy, orthopedics.The daily activities
of a general practitioner principal place of treatment and take medical examination disease
adulthood.
1.4. Modern information and pedagogical technologies in the study of the subject
The provisions related to the process of teaching and governing the quality of education:
teaching at a high scientific and pedagogical level, the reading problem lectures,
organizationeducational process in the form of questions and answers, the use of advanced
educational technologies and multimedia, to the students to put the problems that will make them
clinically think, demands, individual work with the students accustom students to free
communication, involvement of scientific research.
When planning the course "Internal Medicine", the following conceptual approach:
educational process. In turn, the planning of the educational process must take into account not
only the identity of the individual learner, but also the specifics of his future profession.
Systems approach. Educational technology must contain all the features of the system: the
logic of the process, the relationship of all its parts, integrity
Proactive approach. Does the educational process aimed at the formation of personality,
activation and activity intensisification learner in the learning process to take into account all the
skills and abilities of the student, revelation his initiative
The dialogic approach. This approach means the need of creation of educational relations. As a
result, it enhances the ability of the individual self activation and self-realization
The organization of educational process on the basis of cooperation. It does the need for
democracy, equality, the formation of the content of teaching and the student and draw attention
to the need to implement cooperation in the evaluation of the results.
Problem learning. The method of presenting educational content due to problems helps to
activate the activity of the student. This results in an independent activity of student
The use of modern methods and techniques of information transmission - the introduction
of new information and computer technologies in educational process.
Methods and techniques of teaching.
5
Lectures, problem-based learning, case studies, pinbord paradox and design method, practical
work.
The forms of organization of educational process: dialogue, cooperation and mutual learning
frontal, gr
Learning Tools: In addition to traditional forms of learning (tutorial, lecture texts), the computer
and information technology.
Methods of communication: direct mutual dialogue based on immediate feedback from
students.
Methods and means of feedback: observation, quiz, diagnosis of learning based on analysis of
the current, intermediate and final control.
Methods and tools for management: planning training sessions based on the history card,
synergy teacher and the student to achieve the goals supplied, control not only the classroom but
also outside the classroom work
Monitoring and evaluation: planned control of learning outcomes within each class and all. At
the end of the cycle to assess the level of knowledge of students.
In the process of studying the subject "Internal Medicine" will be applied training and checking
computer programs, handouts on topics classes.
Distribution sessions on topics and hours on the subject of "Internal Medicine"
in areas 5510100 - medical business, 5111000 - vocational education (5510100-Medicine)
№
Theme workshop
1
Basics of family medicine. GP 10
functions. Features of work.
Medical records. Involving the
public. doctor and patient rights.
Ethics and deontology in the GP.
The
use
of
information
technology to improve the
administration of patients
Appendix 1
The Art of Communication. 10
Factors contributing to the
conversation.
Difficulties
in
communication.
Interpersonal
communication. Practical advice.
The agreement on the health of
the patient Appendix 2
2
Practica The name of the Lectures
lly
lecture
occu
patio
n
Basics of family medicine.
Independ
ent
educat
ion
6
Basics of
Medicine
Family 2
2
6
Thedifferental
2
diagnosis
of
hypertension.
Differentiated
therapy
and
emergency
care.
Primary
and
secondary
prevention
2
6
3
4
5
6
7
8
Prevention in the GP. Types of
prevention. Promotion of healthy
lifestyles. The impact on risk
factors. Impact on the main
causes
of
morbidity
and
mortality. Promoting mental
status.
Environmental
and
occupational factors.
Psycho-social model of health
effects. Appendix 3
Differential diagnosis in the
practice of GPs. A presumptive
diagnosis. Diagnostic errors.
Mental disorders and simulation.
Integration
psychosomatic
problems with clinical practice
Appendix 4
Nutrition
and
obesity.
Nutritional requirements and
assessment of diet. Vitamins and
lack of control and excess
minerals. Lack and surplus
supply. Enteral nutritional therapy
and parentarlnaya
Appendix 5
Clinical genetics. Family history.
Genetic examination. The ethical
and social aspects. Genetics
rasprostronennyh diseases in
primary care.
10
6
The
differential 2
diagnosis of chest
pain. Peculiarities
of
myocardial
infarction.
2
10
6
Differentialdiagnosi 2
s of noise in the
heart. Tactics GPs
2
10
6
Differential
2
diagnosis
of
broncho-obstructive
syndrome.
Emergency
treatment
2
10
6
Differential
2
diagnosis of jaundice
and hepatomegaly
2
Cough with sputum. Diseases 10
that occur cough. The most
dangerous diseases that occur
with
coughing.
Differential
diagnosis in the equity and
segmental lesions of the lung.
Lobar pneumonia, infiltrative
pulmonary
tuberculosis,
pulmonary
infarction.
Community-acquired pneumonia
and nosocomial. Tactics GPs.
Cough with sputum. Differential 10
diagnosis of lung lesions in the
round.
Focal
pneumonia,
tuberculoma, abscess of lungs,
lung tumors, lung echinococcus.
Pneumonia of different etiology
(bacterial, viral, mycoplasma).
Differential diagnosis in diffuse
disseminatsii. Tactics GPs.
Pulmonology
6
Differntial diagnosis 2
for dysphagia and
dyspepsia
6
Differential
2
diagnosis
of
proteinuria,
abnormal
urinary
sediment.
Tactics
GP
7
2
2
9
10
11
12
13
14
15
Chest pain associated with lung
disease. Differential diagnosis of
pleural effusion and dry. Types of
exudative pleurisy. The principles
of follow-up, monitoring and
rehabilitation in a hovercraft or a
joint venture.
Bronchial
obstruction
syndrome. Differential diagnosis
of diseases occurring with
bronchial obstruction (asthma,
COPD, lung tumors). Tactics
GPs.
Shortness of breath, choking.
Differential diagnosis of diseases
occurring
with
bronchial
obstruction (asthma, COPD, lung
tumors). Tactics GPs.
Shortness of breath, choking.
Differential diagnosis of dyspnea
in heart and lung disease.
Circulatory failure and pulmonary
insufficiently
10
6
Differential
2
diagnosis in the
articular syndrome.
Individual approach
to treatment
2
10
6
Differential
2
diagnosis
of
edematous-ascitic
syndrome. Tactics
GPs
2
9
6
3
9
6
3
Arrhythmias.
Differential 9
diagnosis migration pacemaker,
sick sinus syndrome, arrhythmia,
as well as sinus tachycardia,
bradycardia, sinus arrhythmia,
extrasystoles Forms. Tactics GPs.
Arrhythmias.
Differential 9
diagnosis flicker, flutter or
fibrillation
(permanent
and
paroxysmal),
paroxysmal
tachycardia syndrome, premature
ventricular. Tactics GPs.
Arrhythmias.
Differential 9
diagnosis of blockades: sinoatrial,
intraatrial,
atrioventrikulyarnoyvnutrizheludo
chkovyh. Morgani- syndrome
Adams-Stokes.
Routine
and
emergency treatment at the
blockade. Tactics GPs..
Cardiology
6
6
3
3
6
8
16
17
18
19
20
21
Hypertension.
Differential
diagnosis of hypertensive disease
with renal hypertension. Risk
factors, stage of hypertension,
renal
types
of
arterial
hypertension (parenchymal and
renovascular). The syndrome of
malignant hypertension. Tactics
GPs
Hypertension.
Differential
diagnosis of hypertensive disease
with endocrine hypertension.
Types of endocrinehypertension
(pheochromocytoma
syndrome
Kona
Itsenko-Kushenga,
thyrotoxicosis)
Differential
diagnosis of hypertensive crises.
Tactics GPs
Hypertension.
Differential
diagnosis of hypertensive crises..
Principles of treatment, clinical
supervision,
control
and
rehabilitation in a hovercraft or a
joint venture. Tactics GPs
Obesity and hypertension.
Abdominal obesity. (Metabolic
sind rum). Identifying the
problem. WHO age-related
diagnostic factors in adults.
Visceral adipotsitoz and free fatty
acids. Classification. Menezhment
and farmokote-stitution treatment
Appendix 7
Pain in the heart. Differential
diagnosis of pain in coronary
artery disease stable angina different functional classes (FC IIV). Indications for surgical
treatment. Tactics GP.
Pain in the heart. Differential
diagnosis of pain in ischemic
heart disease unstable angina
pectoris
(new-onset
angina,
progressive angina, spontaneous
angina, and postoperative early
post-infarction angina). Acute
coronary syndrome. Indications
for surgical treatment. Tactics
GP.
9
6
3
9
6
3
9
6
3
8
6
2
8
6
2
8
6
2
9
22
23
24
25
26
27
The pain in the heart.
Differential diagnosis of pain in
angina and myocardial infarction.
Differential
diagnosis
of
complications of myocardial
infarction. Tactics GP.
The pain in the heart.
Differential diagnosis of pain in
angina and myocardial infarction.
Differential
diagnosis
of
complications of myocardial
infarction, cardiogenic shock,
types, severity, pulmonary edema,
arrhythmias,
conduction
disturbances, myocardial rupture,
nonbacterial
thrombotic
endocarditis,
Dressler's
syndrome. The tactics of the
general practitioner.
The pain in the heart.
Differential
diagnosis
of
miocarditis
and
miocardidistrophy.
thromboembolism,
cardiac
aneurysm, The tactics of the
general practitioner.
Heart
murmur
and
cardiomegaly.
Differential
diagnosis of the presence of noise
on the top of the heart and aorta.
Evaluation of functional and
organic heart murmurs. Tactics
GPs.
Heart
murmur
and
cardiomegaly.
Differential
diagnosis of the presence of noise
on the top of the heart and aorta.
Mitral
insufficiency,
mitral
stenosis holes, mitral valve
prolapse, acquired defect of the
aortic valve. Tactics GPs.
Heart
murmur
and
cardiomegaly.
Differential
diagnosis of different clinical
forms of cardiomyopathy (dilated,
restrictive,
hypertrophic,
arrhythmogenic right ventricular
dysplasia). Differential diagnosis
between
cardiomyopathies,
valvular heart disease, coronary
artery disease, hypertension.
Tactics GPs.
8
6
2
8
6
2
8
6
2
8
6
2
8
6
2
8
6
2
10
28
29
30
31
32
33
34
35
36
37
38
6
Heart
murmur
and 8
cardiomegaly. The differential
diagnosis of acute and chronic
heart
failure.
Differentiated
therapy for heart failure. Tactics
GP
Gastroenterology
Dysphagia. Differential diagnosis 8
6
of esophagitis, reflux esophagitis,
dysphagia in scleroderma and
esophageal tumors. Tactics GPs
Abdominal pain. Differential 8
6
diagnosis of gastritis and peptic
ulcer disease (gastric and 12
duodenal ulcer). Tactics GPs.
Abdominal pain. Differential 8
6
diagnosis of gastritis and peptic
ulcer disease (gastric and 12
duodenal ulcer). Tactics GPs.
Abdominal pain. Differential 8
6
diagnosis of ulcerative colitis and
Crohn's disease. The tactics of the
general practitioner.
Hepatomegaly.
Differential 8
6
diagnosis of active and chronic
hepatitis Tactics GPs.
Hepatomegaly.
Differential 8
6
diagnosis of chronic hepatitis and
cirrhosis. Tactics GPs.
Jaundice. Differential diagnosis 8
6
of cholelithiasis with biliarypancreatic tumor area (cancer of
the liver, gallbladder, pancreas).
Tactics GPs.
Rheumatology
Articular Syndrome. Diseases 8
6
that
occur
with
articular
syndrome. The most dangerous
diseases that occur with articular
syndrome. Differential diagnosis
of rheumatism and rheumatoid
arthritis. Tactics GPs. Tactics
GPs.
6
Differential
diagnosis
of 8
seronegative spondyloarthritis
(reactive arthritis, ankylosing
spondylitis, psoriatic arthritis).
Tactics GPs
Articular Syndrome.
8
6
Differential diagnosis of SLE,
SSc, dermatomiositis. The tactics
of the general practitione
11
2
2
2
2
2
2
2
2
2
2
2
39
40
41
42
43
44
6
Differential
diagnosis
of 8
hemorrhagic
vasculitis,
nonspecific aortoarteritis and
periarteritis nodosa. The tactics of
the
general
practitioner,
nonspecific aortoarteritis and
periarteritis nodosa. The tactics of
the general practitioner
Nephrology
6
Changes
in
the
urinary 8
sediment. GP tactics when
proteinury and altered urinary
sediment. Differential diagnosis
of immuno and inflammatory
diseases of the kidneys (acute and
chronic
glomerulonephritis,
interstitial nephritis. The tactics
of the GP.
6
Changes
in
the
urinary 8
sediment. Differential diagnosis
of
nephropathy
(pregnant,
diabetic, drug). The tactics of the
GP.
6
Changes
in
the
urinary 8
sediment Differential diagnosis
of the different stages of chronic
renal failure. The tactics of the
GP.
Edematous
syndrome. 8
6
Differential diagnosis of edema of
various etiologies local - allergic,
cardiovascular,
inflammatory;
General
circulatory
insufficiency, renal, endocrine.
The tactics of the GP.
Geriatrics
Geriatrics. Problems of the age 8
6
norm. Functional and organic
changes in aging . Laws of the
aging process . The mechanism of
development
of
age-related
changes . Physiology and hygiene
of the elderly nutrition.
Feeding habits and rational
pharmacotherapy
in
elderly
patients
Appendix 8
12
2
2
2
2
2
2
45
46
47
48
Geriatrics. Engine mode and
occupational health . Features of
diet and motor mode in the
elderly. Clinical manifestations of
osteoporosis
and
fracture
prevention and treatment
Geriatrics.
The
clinical
manifestations of atherosclerosis
and dinamicheskoenablyu - denie
. Emphysema in the elderly. Age nyeizmeneniya predisposing to
the
development
of
atherosclerosis and emphysema
Geriatrics. Problems with older
diseases gastrointestinal tract. Age
-WIDE change - believing
predisposition to diseases of the
gastrointestinal tract
Geriatrics. Problems with older
diseases, urinary -inflammatory
system. Age-related changes that
predispose to disease - urinary inflammatory system
Total
8
6
2
8
6
2
8
6
2
8
6
2
412
288
20
104
EDICATIONAL CONTECT
2.1 Lecture
1. "FUNDAMENT OF FAMILY MEDICINE"
Auguste Rodin once said: "In my youth I considered separately nose, lips and expressions. I
was ignorant, we would have to watch everything in general. "
In recent years, total medical practice activities attracts more and more the attention of
Governments of many countries as an economical and effective way to of rendering primary
health care, allowing to in time to to suspect illness and begin treatment.
Place a general practitioner in the health care system is unique - it is directly communicating
with the patient and his family, taking responsibility for the health of the observed, provides
treatment and prevention, involving the latest achievements of medical science, is
coordinating the efforts of all health services.
Background of general practice in Uzbekistan:
• founder of general practice is the United Kingdom.
• In 1948 it was created National Health System, providing a comprehensive free medical care
to the entire population of the UK.
• In the late 70-ies of the last the century medics in the countries of Western Europe and USA
have realized, that the amplification specialization of postpones medical assistance on the
specific needs ofthe population, increases the costs the health system at the realization of
these the needs of.
List of medical care provided by different health units in England:
• Assistance provided by general practitioners on an outpatient basis - 90% of patients.
• Assistance provided in hospitals - 9-10% of patients.
• Assistance provided in specialized centers - 1% of patients.
• Given the current situation, in 1978 adopted the Alma-Ata Declaration, which put primary
health care at the forefront of health policy, removing general practice role.
13
PHC is an integral part of the national health care system and at the same time acts as a major
component of overall social and economic development of society
• The reason fewer family doctors, rural health units.
Primary health care is the first step in the contact between individuals, family, community,
people and the national health system, health care as close as possible to the place of
residence and work in forming the first element of the continuing health care process.
Today in the Republic there are more than 3,100 rural health units. Rural health units may
be:Type 1 - up to 1500 people;Type 2 - up to 3,500 people;Type 3 - up to 6,000 people;Type
4 - up to 10 000 people and more of the population servedDOCTOR OF GENERAL
PRACTICES- Family doctor - a specialist attached to provide quality primary health care
to the population, regardless of gender, age, nationality, race, religion, social status, and type
of disease.Literature:O: 1,2,3,4,5;D: 1,2,3,7,8,10,11,12.
2. "DIFFERENTIAL DIAGNOSIS OF HYPERTENSION. DIFFERENTIATED THERAPY
AND EMERGENCY. PRIMARY AND SECONDARY PREVENTION "
Hypertension (HT) is one of the major risk factors for stroke, myocardial infarction, and heart and
kidney failure. The prevalence of hypertension is 20-40% of the adult population in many
industrialized countries in the world, and among the elderly, its frequency is greater than 50%.
Currently, there is no doubt the need for long-term, essentially lifelong drug therapy of
hypertension. By reducing blood pressure (BP) by only 13/6 mm Hg. Art. the risk of stroke is
reduced by an average of 40%, and myocardial infarction - 16%.
Hypertensive heart disease (GB) or essential arterial hypertensy - a disease at which the is
observed increase of arterial pressure not connected with a primary organic lesion of organ of
and systems. A very common disease is most common in the elderly.There are: optimal blood
pressure <120/80 mm Hg. Art., normal blood pressure <120-129 / 80-84 mm Hg. Art., high,
normal blood pressure 130-139 / 85-89 mm Hg. Art. The diagnosis of hypertension is placed
upon detection of blood pressure above 140/90 mm Hg, at least twice during repeated visits to
the doctorClassification of hypertension in stages (WHO, 1996)Stage 1: At this stage there are
no objective evidence of target organ damage. The only manifestation of the disease - a
syndrome of hypertension.
Stage 2: At least one sign of organ damage:
• LV hypertrophy
•
proteinury7 30-300mg / day. creatininemia 115-133mkmol / l (for men and 107-124 mmol / L
for women
• generalized or focal narrowing of the retinal arteriy
•
atherosclerotic vascular lesions
3 stage of: At this stage are detected, in addition to syndrome of arterial hypertension and signs of
lesions of bodies-targets, associated clinical conditions: angina pectoris, MI, CH, TNMK,
stroke, encephalopathy, dementia, chronic renal failure, changes in the fundus (hemorrhage,
swelling papilla disk ZN , exudation, atrophy)
To date, there are three degrees of hypertension:Grade 1 of AH: 140-159 / 90-99 mm Hg.
Art.Degree2 of AH: 160-179 / 100-109 mm.rt.st.Grade 3 of AH : more than 180/110 mm Hg.
Art.
Isolated SAH:> 140 <90 mm HgIn the presence of hypertension in the patient, except for its degree
of improvement, as assessed risk.In determining the level of risk is taken into account: gender,
age, numbers of cholesterol in the blood, obesity, presence of hypertensive disease in relatives,
smoking, sedentary lifestyle, target organ damage.Literature:O: 1,2,3,4,5,6;D:
1,2,3,4,5,6,7,8,9,10,11,12.
3 THE DIFFERENTIAL DIAGNOSIS OF CHEST PAIN. COURCE FEATURES
MIOCARDIAL INFARCTION
Coronary heart disease (CHD) - a disease of the myocardium caused by acute or chronic
discrepancybetween myocardial oxygen demand and the real coronary blood supply to the heart
muscle, which is reflected in the development of myocardial areas of ischemia, ischemic injury,
14
necrosis and scarring fields and accompanied by a breach of systolic and / or diastolic heart
function. IBS is one of the most common diseases of the cardiovascular system in all
economically developed countries. According to the prospective study, IBS affects about 5-8%
of men aged 20 to 44 and 18-24,5% - aged 45 to 69 years. The prevalence of coronary heart
disease in women and somewhat less in the older age group usually does not exceed 13-15%.
Risk factors for coronary artery disease.
I should also mention about the significance in the formation of coronary heart disease risk factors
(RF), the identical risk factors of atherosclerosis. Recall that one of the most important of them
are:
1. The non-modifiable (modifiable) risk factors: age over 50-60 years; sex (male); family history.
2. modifiable (changeable): dyslipidem (elevated blood cholesterol, triglyceride and atherogenic
lipoproteins and / or reduction of antiatherogenic HDL);
Arterial hypertension (AH); smoking; obesity; carbohydrate metabolism disorders
(hyperglycemia,
diabetes
mellitus);
physical
ipoor
nutrition;hyperhomocysteinemy,andothers.Now it is proved that the greatest prognostic value of
coronary artery disease risk factors are such as dyslipidemy, hypertension, smoking, obesity and
diabetes.Literature:
O1,2,3,4,5,6;D: 1,2,3,4,5,6,7,8,9,10,11,12.
4 NOISE DIFFERENTIAL DIAGNOSIS OF HEART. TACTICS GP
Determination of heart murmurs is important differential diagnostic value, as their presence
often confirms the presence of heart disease or other organic heart disease.Heart defects (vitia
cordis) are morphological changes in valvular heart disease, leading to disruption of its
function and hemodynamics, as well as congenital malformations of the heart and major
blood vessels.
Birth defects are formed during fetal development and in most cases are diagnosed in
childhood. Congenital heart disease is often associated with other developmental defects.
FUNCTIONAL (INORGANIC, INNOCENT, RANDOM) NOISE. There are many causes
and mechanisms of formation of noise in each case. Usually, functional noises heard over the
apex of the heart, at or above Botkina pulmonary artery. They are found in almost every
second child, and almost a third of young adults.
ACQUIRED HEART DISEASES. Mitral stenosis (narrowing of the left atrioventricular
opening, stenosis mltralis, stenosis ostii atrioventricularis sinistra). In humans, the area of the
left atrioventricular opening is in the range of 4-6 cm2.
Under compensation patients no complaints. As the progression of vice appear shortness of
breath on exertion and then at rest, cough, occasionally hemoptysis, palpitations, weakness,
fatigue. Rarely arise nojushchie or stitching pains in the field of heart, not connected with of
physical load. Arrythmia, usually serves a harbinger of atrial fibrillation. Meets Athos
(symptom Ortner) due to increased pressure in the left atrium recurrent nerve.
In the process of inspection can be detected cyanosis of the lips, nose, p important diagnostic
sign of mitral stenosis –diastolic murmur at the apex of the heart, usually with presystolic
3. The fight against consanguineous marriages
4. Careful observation and study of women who had contact with the rubella virus or have
comorbidities that could lead to the development of congenital heart
disease.Secondaryprevention1.Profilaktic unfavorable development of heart disease: the
timely establishment of vice, ensuring proper care and determine the best method of
correction of the defect (surgical at UPU)Tertiary prevention
1.Operativnye intervention (acquired heart defects)2.Prevention complications of congenital
heart disease (bacterial endocarditis)Literature:O:1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,125
5 DIFFERENCIAL DIAGNOSIS OF BRONCHIAL OBSTRUCTION. EMERGENCY
TREATMENT
15
Anemia - a condition characterized by a decrease in red blood cell count below 3,5.10 / L or
decrease in the level of hemoglobin per unit volume of the blood below 110 g / L for infants and
120 g / l -for older children.The disease occurs in violation of iron metabolism that is in the body
of the child is done very vigorously. The main reason is the depletion of iron stores in the time
when the need for it increases blood volume and red cell mass exceed the dietary and absorption.
Term infants is the total amount of iron in the body about 240 mg, 75% of which is accounted
for by hemoglobin. Neonatal iron stores are exhausted in 3-4 months in preterm infants and 5-6 in term. Sideropeny, especially a long-term, violates not only the formation of hemoglobin and
myoglobin, as well as a number of tissue enzymes containing iron, which provide the transport
of oxygen and electrons, the destruction of peroxide compounds, redox processes in cells, as well
as the absorption of iron. The smallest value of a latent iron deficiency - long sideropsipya in
which there is no reduction in hemoglobin levels of peripheral blood.Preventive maintenance of
Lies in the treatment of anemia of pregnant, prevention the prematurely; rational feeding of
children
of
all
ages,
the
treatment
of
diseases
associated
with
impairedintestinaдabsorptioLiterature:A:1,2,3,4,5,6;D: 1,2,3,4,5,6,7,8,9,10,11,12.
6DIFFERENTIAL DIAGNOSIS OF HEPATOMEGALY AND JAUNDISE. TACTICS
GENERAL PRACTITIONERS
It is not an independent disease, and drew the attention of a symptom of many diseases with a
complex pathogenesis. Icteric staining of the skin and sclera are the result of the accumulation of
bilirubin in the blood serum and its subsequent deposition in the subcutaneous tissues. She
recognized the yellow coloration of plasma, skin and mucous membranes. Typically jaundice can
not be detected as long as the content of total serum bilirubin will not exceed 51.3 mmol \ l.
Distinguish several kinds of jaundices. Hemolytic (the suprarenal) - excessive destruction of
of erythrocytes and increased production of bilirubinHepatic jaundice - violations of of catching of
by cells liver of bilirubin and binding of his with glucuronic acid. Subhepatic - there is an
impediment to the release of bilirubin in the bile in the intestines and reabsorption of bilirubin in the
blood.
Hereditary
microspherocytosis - an inherited disease, with extravascular hemolysis - in cells of the
reticuloendothelial system Anemia moderate, but during crises hemoglobin of 20-25 g / l.
Hereditary stomatsitoz characterized by defects of erythrocyte membranes. Anemia (hemoglobin
level 70-90 g / L crisis is 30-50 g / l during it), jaundice due to unbound bilirubin. The most
common among chronic liver disease is a chronic hepatitis. It is characterized by enlargement of the
liver, pain, or a feeling of heaviness in the right upper quadrant. In 95% of patients noted an
increase in the liver. Etiology and pathogenesis of jaundice. Currently, the causes of jaundice
studied well enough. A large group of diseases of the biliary system and pancreas accompanied by
the development of mechanical neprohodi-Mosty bile ducts, manifesting the appearance of the
patienticteric coloration of the skin and sclera, which led to the erroneousthe unification of all these
diseases is one that came into clinicalcal practice called "jaundice". The differential diagnosis
should be carried out with allowance for the data. Most often with different forms of jaundice or
hemolytic or parenchymal jaundice. Differential diagnosis with hepatomegaly. When diagnosing
diseases manifested an increase in the liver, it should be remembered that the edge of the right lobe
of the liver can be taken as a neoplasm of the gallbladder, colon, right kidney; in addition, it is
necessary to distinguish hepatoptoz hepatomegaly.
To differentiate the true increase in the liver by these states allows palpation of the liver in different
positions and ultrasound.
Literature:O1,2,3,4,5,6D1,2,3,4,5,6,7,8,9,10,11,12.
7THE DIFFERENTIAL DIAGNOSIS OFDYSPHAGIA AND DYSPEPSYA. TACTICS GPS.
Dysphagia - difficulty swallowing. Odynophagia - painful swallowing. The sensation of a lump
in the throat - constant feeling of something in the posterior part of the pharynx, extending in
swallowing, the type of functional neurological condition.Classification of dysphagiaAccording
16
to the etiology: a) functional; B) organicPathogenesis: A) spastic (occurs when funkts.izm.)B)
Paradoxically (difficulty.gulp liquid food)By Location: A) buccopharyngeal (in diseases of the
oral cavity)B) esophagealAdrift: A) Permanent; B) Temporary (transient)Causes of
dysphagiaFunctionality: Mental, Hysterical, Anxiety Depression Post-stroke dysphagia,
Botulism, cardiospasm, hiatal herniaOrganic: The tumors of the esophagus, Achalasia
esophagus, peptic narrowing of the esophagus, esophageal foreign bodies, gastritis esophagitis,
esophageal Compression outside, thyroid tumors, tumors of the larynx, diffuse goiter, aortic
aneurysm, acute thyroiditis. GERD as an independent nosological form received official
recognition at the Congress in Genval (Belgium, 1997). In the same year at the VI United
Gastroenterology Week (Birmingham, 1997) sounded the postulate "of the twentieth century - a
century of peptic ulcer disease, and the twenty-first century - a century of GERD."The esophagus
is a complication of GERD or barreta.Eto DGERB - replacement of squamous epithelium of the
lower esophagus columnar epithelium.Cancer stomach.V 99% of cases - the stratum cell
carcinoma; 1% - adenocartsenoma (lower esophagus). Sprout into adjacent organs and spreads to
the lymphatic system. Forecast: usually diagnosed late, when complete resection is not possible
and the prognosis is bad.
System sklerodermiya.disease characterized by fibrosis of the skin, blood vessels and internal
organs, immune disorders, thickening and scarring of connective tissue changes. SSD comes in
two types: local and diffuse. The forecast is better when only the skin lesion. If it affects the
lungs and kidneys prognosis is badDyspepsia - are symptoms associated with dysfunction of the
upper gastrointestinal tract: retrosternal or epigastric pain, feeling of fullness, bloating,
heartburn, nausea and vomiting. More than 40% of adults suffer indigestion in your life. Causes:
gastroesophageal reflux (15-25%), peptic ulcer (15-25%), gastric cancer (2%). 60% for nonulcer dyspepsia include, functional forms.Literature:O:1,2,3,4,5,6;D:, 2,3,4,5,6,7,8,9,10,11,12.
8. THE DIFFERNTIAL DIAGNOSIS OF PROTENURIA AND URINARY SEDIMENT
PATHALOGY TACTICS GP
To date, a number of diseases are accompanied by changes in urine sediment. In particular focus
on diseases that occur with abnormal urinary sediment and proteinuriaOne of the diseases that
occur severe proteinuria is a multiple myeloma which is characterized by the following
symptoms:accompanied by abnormal production of immunoglobulins of one clone, causing
obstruction of the tubulethis disease, proteinuria can be up to 20 g / day;Valdestrema
Macroglobulinemia - a disease in which synthesized and accumulates in the blood pathological
IgM. There is damage to the kidneys, but rarely (frequency of proteinuria 15 -20%), the most
characteristic of other clinical signs: hepatosplenomegaly, hemorrhagic syndrome; a sharp
increase in erythrocyte sedimentation rate; isolated increase in the fraction IgM, sometimes there
osteoparoz.
Intravascular hemolysis -perelivanie incompatible blood; hemolytic effects of poisons and
toxins; pharmaceutical, immunological and traumatic injuries of red blood cells.
Glomerular
proteinuria (0.1-20 g / day) - is caused by lesions of the basal membrane. The protein fraction is
represented by albumin, transferrin, β- micro globulin, globulin. Glomerular proteinuria
observed: acute and chronic glomerulonephritis; amyloidosis; diabetic glomerulosclerosis.
Glomerulonephritis occur very often in connection with which they dwell more podrobno.V
practice physician glomerulonephritis (nephritis) do not occur as often as, for example, coronary
heart disease, rheumatic diseases and chronic non-specific lung disease.
Treatment. To suppress the activity app Glucocorticoids (GC) having immunosuppression nym
and anti-inflammatory effect, for several decades remained the main means of pathogenetic
therapy of nephritis.
Literature:O: 1,2,3,4,5,6;D:: 1,2,3,4,5,6,7,8,9,10,11,12.
9THE DIFFERNTIAL DIAGNOSIS OF ARTICULAR SYNDROME
17
Articular Syndrome - almost universal manifestation of rheumatic diseases; its differential
diagnosis is the basis of determining nosology, and thus justifies the choice of therapeutic
approach. In advanced stages of the disease when there is organic changes of organs and tissues,
the diagnostic problem is greatly simplified. Serious analysis is required in the opening part of
the show exclusively arthralgia.A survey of patients who complain of arthralgias, is to identify
exactly what the structure of the musculoskeletal system are the source of pain or dysfunction.
Joints consist of the surfaces of the articular cartilage, bones, ligaments, and synovium. On
physical examination, the joints need to be taken into account three parameters: pain
(sensitivity), swelling, mobility. For synovitis characterized by tenderness (sensitivity) all over
the joint. If the pain is localized only in a particular area (point) of the joint, one should think
about the local, local because of its appearance, such as bursitis, tenosynovitis or fracture.
During the radiographic examination should be remembered that:
1) non-specific and often osteoporosis is a consequence of immobility associated with pain;
2) narrowing of joint space indicates loss of cartilage;
3) The new bone proliferation indicate osteosclerosis, are a sign of lack of osteophytes and
synovitis;
4) soft tissue swelling is best diagnosed by physical examination.
The most informative laboratory test in rheumatoid arthritis is a latex test aimed at identifying
rheumatoid factor. Diagnostics in rheumatology, as in any other clinical disciplines, based on the
analysis of the whole complex of clinical, laboratory and instrumental data.
Thus, taking into account all a lot of articular syndrome, it should be noted which family doctor
practice primary contact with patient , careful history, complaints, aiming physical examination
are of particular importance that the correct interpretation is difficult pereotsenit.I obtained at the
initial stage will allow the diagnostic data retrieval in the future adequately choose diagnostic
and treatment schemes for each exactly patient succeed therapy.
Literature:O: 1,2,3,4,5,6;D: 1,2,3,4,5,6,7,8,9,10,11,12.
10THE DIFFERENTIAL DIAGNOSIS AND TREATMENT OF EDEMATOUS
SYNDROME
Edematous syndrome - excessive accumulation of fluid in body tissues and serous cavities,
shown an increase in tissue and changing capacity serous cavities, changes in physical properties
and dysfunction swollen organs and tissues.
edematous syndrome - excessive accumulation of fluid in body tissues and serous cavities, shown
an increase in tissue and changing capacity serous cavities, changes in physical properties and
dysfunction swollen organs and tissues.
On palpation there is a doughy consistency of the skin, after pressing a finger on it is a pit. If,
after pressing a finger on the edematous skin is left fossa, the swelling can be attributed to false.
There are local edema (localized) associated with fluid retention in the limited area of the body
tissue or organ, and total (generalized) - manifestation of positive water balance of the body as a
whole. To include generalized edema edema in heart failure, liver cirrhosis, nephrotic and
nephritic, dropsy pregnant kaheksicheskie and idiopathic, and as a result of chronic loss of body
potassium in the abuse of laxatives. Promote edemas or accelerate their development are:
finilbutazon derivatives pirozolona, mineralocorticoids, androgens, estrogens, drugs licorice
root.Heart failure - a pathological condition in which cardiac output does not match the needs of
the body due to the reduction of the pumping function of the heart. hypooncotic swelling can
occur when hypoproteinemy (less than 50 g / l). This is of particular importance albumin
deficiency (less than 25 g / l), has a much greater osmotic activity than globulins.
Swelling caused by hypoalbuminemia in liver disease can manifest itself in the advanced stages
of severe liver disease (chronic hepatitis, cirrhosis) in patients with severe liver function
violation albuminsynthesizing. The most common liver diseases is dominated by ascitic
syndrome (often in combination with right hydrothorax).
In the treatment of edematous syndrome is necessary to comply with the following ps
1. Treatment of the underlying disease.2. The rational order of treatment: Creating optimal for
18
patients with physical and psychological environment at home and at work.3. Clinical nutrition:
diet - full quickly digestible, rich in protein, vitamins, potassium. At high fluid retention and
hypertension
limited amount
of
salt
and
water.Literature:A:
1,2,3,4,5,6;D:
1,2,3,4,5,6,7,8,9,10,11,12.
Calendar -TOPICALLY plan lecture materials in internal medicine
THE NAME OF THE LECTURES
1
Fundamentals of family medicine
2
Differential diagnosis arterial hypertensia. The differentiated therapy and
emergency aid. Primary and prevention
3
Differential diagnosis of pains in a thorax. Features of a course of a
myocardial infarction
4
Differential diagnosis of noise in heart tactics GP
5
The differential diagnosis at a bronchus obstruction syndrome Urgent
therapy
6
The differential diagnosis at jaundices and the hepatomegaly tactics GP
7
Differential diagnostics at dysphagies and dyspepsias Tactics GP
8
Differential diagnostics at proteinurias, pathological uric a deposit Tactics
GP
9
Differential diagnosis at an articulate syndrome individual approach to
tratnent
10
Differential diagnostics edematous ascites syndrome, tactics GP
value
HOURS
2
2
2
2
2
2
2
2
2
2
20
2.2. RECOMMENDED CASE STUDIES
Students VI course1. "Fundamentals of Family Medicine. Features GP. Features of work.
Medical records. Visiting patients at home. Involving the public. Rights physician and the
patient. Ethics and deontology in the GP. Principles of teaching about "(6 hours)
Family medicine - a medical specialty that provides primary health care to the entire population,
a full, comprehensive, high-quality, long-lasting, affordable and economical in nature. This
specialty is wider than the simple combination of pediatrics, gynecology and therapy. This
individual, one of a kind specialty built on specific, the basic principles that distinguish it from
other medical specialties. Like other professions, the academic discipline that studies at the
university and as medical science is constantly evolving, with its research institutions.
The
activities of a general practitioner in the 80-90% consists of preventive work. Promoting healthy
lifestyles and responsible attitude of people towards their health, identification and elimination of
risk factors for various diseases, early diagnosis and timely treatment, prevention of
complications, provision of social assistance to the disabled and home, all this contributes to the
improvement of public health.
Teach SPM implementation of
preventive measures, immunization and promote healthy lifestyles among the population.
Learning objectives: To familiarize GPs with views of prevention. Teach GP propaganda healthy
lifestyle among the population, food hygiene and living conditions. Teach GP practices for
preventive check-ups and screening. Train carrying out immunization activities in the
community. Expected results: the use of methods of active primary, secondary and tertiary
prevention will improve health indicators, to stabilize and reduce the incidence of losses of
permanent disability, reduce mortality and improve the quality and duration of life of healthy and
sick, that will help to increase the overall life expectancy of the population and reduce economic
losses.GPs should be aware of: Forms of prevention in GPs. On the principles of healthy
lifestyles, and their use in educating the public and patients. How to conduct a conversation in
Mahalla and prepare topics of lectures. How to create brochures, lectures and reviews in the
media. Immunization, screening principles and methods of its implementation.GPs should be
able to: make brochures, lectures and notes in the media on the topics: alcoholism, drug
19
addiction, smoking, tuberculosis, viral hepatitis, AIDS, contraception. To prepare a healthy diet
pyramid, mapping and evaluate the results of the screening, immunization plan population. GPs
should do: carry out preventive check-ups to improve the health of the population, population
screening for the most common diseases.
conduct interviews and lectures in local communities (schools, mahallas), to carry out
immunization activities.Conducting business game: ClusterLiterature: O: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
2. Work with the family. Features of work. The psychological climate in the family. Problems
of religious rites. Advising family. The principles of teaching subjects (6 hours)
Monitoring and treatment throughout life - the essence of general practice. The doctor knows the
patient and his family, the conditions of work and leisure. Caring, responsible and
knowledgeable doctor - a reliable support of the patient and his family. Sadly, families do not
always perceive the general practitioner as an advisor, do not realize that they can turn to him
with questions not only of a medical nature, so the doctor himself tactfully to offer themselves as
such. Especially relevant is during counseling couples are going to marry, pregnancy, under the
supervision of the growth of children and adolescents, women of childbearing age, pregnant
women, well, especially the elderly.
Communication during this period establishes a new relationship between doctor and patient,
facilitates the further work with the family.
Teach GP - work with different groups of people - children, adolescents, women (women of
childbearing age, pregnant women), men, the elderly, workers and industries of agriculture,
social and unprotected people, difficult patients dying patients; address the issues of
rehabilitation and medical examination, to prepare documents for the examination of disability.
Learning Objectives: learn to work with different groups of people: children, adolescents,
women (women of childbearing age, pregnant women), men, the elderly. Learn how to work
with employees of industries and agriculture. Learn to work socially unprotected people. Learn
how to work with difficult patients dying .Spends issues of rehabilitation and medical
examination. Know how to prepare documents to the examination of disability. Expected results:
Implementation of this lesson provides an opportunity to work with different groups of people:
children, adolescents, women (women of childbearing age, pregnant women), men, the elderly.
Be able to work with the employees of industries and agriculture, socially unprotected people
with difficult patients dying patients, rehabilitation and medical examination, to prepare
documents for the examination of disability.
GPs should know: to be able to work
with different groups of people: children, adolescents, women (women of childbearing age,
pregnant women), men, the elderly. Be able to work with the employees of industries and
agriculture. Be able to work socially unprotected people. Be able to work with difficult patients
dying patients.
Conducting business game: clusterLiterature:O : 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
3. The art of communication. Factors contributing to the dialogue. Difficulties in
communication. Interpersonal communication. Practical advice. Advising. Types of
consultations. The principles of counseling. Responsibility for the health of the patient. The
principles of teaching subjects (6 hours)
The Art of Communication. Interpersonal communication (IPC).The professionalism of the doctor
is determined not only by how well he knows the etiology and pathogenesis of diseases, methods
of diagnosis and treatment, but also its ability to advise, ie communicate, teach, advise. The
ability to communicate a doctor determines his relationship with the patient, only won the trust
of the patient, you can collect detailed history, to explain what is required in the treatment
process.
Communication - is the exchange of information between people.Interpersonal communication
and face to face communication is the most basic and probably the most effective way to share
20
information, opinions or feelings with the other person or people. Interpersonal communication
is a direct and momentary process. This increases the importance of the use of carefully designed
materials and thus improves itself. Interpersonal communication is an important issue,
contributing to a change in behavior or adoption of a new practice of communication. IPC is
used in all areas of health care relies on communicating directly with people. For this reason,
good skills IPC can contribute to the success of the implementation of programs of primary
health care.
FEEDBACK - the process by which you can evaluate whether you understand the patients, ask
them how they feel, and what they could improve. They can also use the feedback to tell you
how you cope with their responsibilities. Difficulties in communication. Dissatisfaction with the
doctor more often than not due to his errors in diagnosis and treatment, and poor ability to
communicate with patients and their relatives. Medical consultation - an important part of the
therapeutic process, especially in psychiatry, rehabilitation and long-term monitoring.
Counseling is a correct opinion or behavior of another person as a result of conversation doctor
patient.
Skills consultation
What aspects of counseling you need to pay attention to the training of students:-The importance of
certain goals consultations
- Inherent reverse process between the teacher and students during the skills training consultations.Psychological counseling component is fundamental and requires consideration of feelings, the
psychological state of the patient and the doctor.
- The learning process may entail a change of attitude to the work of the student.It is important to
know
that
in
the
course
of
consultations
formed
the
doctor-patient
relationship.Conductingbusinessgamecluster
Literature:
O: 1,2,3,4,5,6; D1,2,3,4,5,6,7,8,9,10,11,12.
4. "Prevention in the GP. Types of prevention. Promoting a healthy lifestyle. Food hygiene
and living conditions. Prophylactic examinations, screening. Prevention of infectious and
noninfectious diseases. Immunization. Programs and activities. (6 hours)
The activities of general practitioners is focused not only on treatment, but primarily on disease
prevention. This means that during each meeting, the physician should try to change the attitude
of the healthy population as well as to the health of the patient, to bring his desire to actively
participate in the treatment of this disease and prevent the emergence of new ones. Preventive
work is a major part of the work, or the core of the family doctor. Studies conducted in
developed countries proved that 85% of humanity's office visits a family doctor at least once a
year, an average of five visits per person. When patients come to the anxieties and symptoms of
the disease to talk to the doctor, they are more receptive to advice on how to protect the health
and therefore better.
The family
doctor is the key person in the process of improving the health and disease prevention in the
public and in particular, on the individual level. The purpose of work in both areas is to give a
person the opportunity to be healthy and stay healthy, improve the quality of life, prevent
disease, reduce mortality and disability and thereby to prolong his life.Prevention - a set of
measures aimed at maintaining and promoting health and disease prevention, promotion of
healthy lifestyles is the responsible attitude of people towards their health.
Types of prevention.
Primary prevention - it measures aimed at maximum preservation of health, identification and
elimination of risk factors (including: untethered - age, gender, heredity, can not be changed, but
they pay attention to families at risk and help to identify the controllable risk factors - smoking,
"nosvoy" , alcohol, sedentary lifestyle, obesity, poor diet, etc.) of various diseases among the
healthy population. This includes advice on healthy lifestyles, including advice on nutrition, the
fight against bad habits, regular physical exercise. Primary prevention also means Sanitation:
21
clean water, toilets, fighting flies, hand washing, health education (.bulletin, leaflets and
lectures).
Secondary prevention - is the early diagnosis
and timely treatment of disease. These include screening, prophylactic examinations, the use of
questionnaires. We know that the tumor diseases are more common in the elderly, such as breast
cancer (breast). For early detection of changes in breast self-examination family doctors
recommend all women with breast 25 years and mammography in women with risk factors,
ranging from 40 years 1 every 2 years.Tertiary prevention - is the treatment of the disease, for
the prevention of complications. For example, all patients with hypertension and diabetes we
prescribe aspirin as a preventive doses for the prevention of stroke and myocardial infarction.
Counseling patients about lifestyle changes under the scope of the general practitioner. The
family doctor should be able and willing to discuss with the patient strategy of lifestyle changes
and encourage him to start to change.A healthy lifestyle (HLS) in the narrower sense includes
the biological optimum conditions for feeding, nutrition, maturation, aging and functioning in
accordance with the physiological age and sex characteristics of a person. The fight for healthy
lifestyle requires a deep knowledge of preventive measures by family doctors, and their
systematic use of propaganda among the population. Among adults, tobacco and alcohol are the
main causes of premature death. Quitting smoking is not easy, but even a short consultation of
the family doctor on this subject can give good results. Passive smoking is associated with many
diseases, for example, among children cases of sudden death, respiratory diseases, asthma, lung
cancer, adult lung and heart disease.Nutrition and physical activity play an important role in the
prevention of cardiovascular disease, but to the same extent and in the preservation of the quality
of life and reduce overall morbidity. A balanced diet and moderate exercise lasting up to 30
minutes 3-5 times a week are required to provide health at any age. GP can offer advice on
healthy eating, and if the patient worried about the problem of excess weight, the doctor can
recommend the suitable nutrition program.Thus, the family doctor has the skills counseling for
lifestyle changes such as quitting smoking, giving up alcohol, food with health benefits, the
movement for all, etc. In contrast to the experts of other structures with a GP has a unique
opportunity to influence the way of life of patients as a long, continuous and comprehensive
monitoring of the patient and his family makes it possible to identify risk factors, control over
the conduct of preventive and therapeutic measures.Screening - a process for identifying patients
with a broad survey of the population. Prevention of infectious and noninfectious diseases.
The basis of the planning of preventive measures is the analysis of the structure of morbidity and
mortality. Over time, these indicators are changing: in the past, the main causes of morbidity and
mortality are infectious diseases - tuberculosis, syphilis, diphtheria, smallpox, today they were
replaced by atherosclerosis, cancer and HIV infection.
Immunization. According to the recommendations of the National Board of Health and Medical
Research, all children are immunized against diphtheria, tetanus, pertussis, polio,
measles,mumpsandrubella.Adults every 10 years revaccinated against diphtheria and tetanus. All
women of childbearing age determine the antibody titer to rubella virus.
Td for adults (16, 26, 46) contains an adult dose of tetanus toxoid and reduced dose of diphtheria
toxoid
Conducting business problem-based learning games
Literature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
5. The impact on the risk factors. Health education. Impact on the main causes of morbidity
and mortality. Strengthening the mental status. Environmental and occupational factors.
Education of patients, "school". (6 hours)
A healthy lifestyle (HLS) in the narrower sense includes the biological optimum conditions
for feeding, nutrition, maturation, aging and functioning in accordance with the physiological
age and sex characteristics of a person. The fight for healthy lifestyle requires a deep knowledge
of preventive measures by family doctors, and their systematic use of propaganda among the
population.For example, for the prevention and early detection of cardiovascular disease, family
medicine focuses on leading healthy lifestyles. Smoking, lack of exercise, excessive intake of fat
22
and obesity increase the risk of cardiovascular disease is not only at risk, but also all people.
Each risk factor alone affects the risk, but a combination of two or three factors greatly increases
the possibility of the disease. Improving lifestyles, including smoking restrictions is the most
effective means of reducing the incidence of heart disease.Among adults, tobacco and alcohol
are the main causes of premature death. Quitting smoking is not easy, but even a short
consultation of the family doctor on this subject can give good results. Passive smoking is
associated with many diseases, for example, among children cases of sudden death, respiratory
diseases, asthma, lung cancer, adult lung and heart disease.Thus, the family doctor has the skills
counseling for lifestyle changes such as quitting smoking, giving up alcohol, food with health
benefits, the movement for all, etc. In contrast to the experts of other structures with a GP has a
unique opportunity to influence the way of life of patients as a long, continuous and
comprehensive monitoring of the patient and his family makes it possible to identify risk factors,
control over the conduct of preventive and therapeutic measures.
Promotion of healthy
lifestyles. GPs can provide training HLS. With the help of interviews with a population of
Mahalla, teahouses, schools, sports halls, etc .; with the distribution of leaflets, visual aids,
backyard rounds, with the involvement of activists of neighbourhood, respected people, lectures
and notes in the media about the problems of common communicable and non-communicable
diseases (alcoholism, drug addiction, smoking, tuberculosis, viral hepatitis, contraception, AIDS,
flu).Ideally, a balanced diet should be an integral part of everyday life since childhood, and it
should be followed for life. Many of the factors that increase the risk of cardiovascular disease
can be prevented or influence them through a healthy diet and increasing physical activity.
Conducting business game case technoliogyLiterature: O: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
6 "Arrhythmias. Differential diagnosis migration pacemaker, sick sinus syndrome,
arrhythmia, as well as sinus tachycardia, bradycardia, sinus arrhythmia, extrasystoles
Forms. Tactics GPs. Indications for referral to a specialist or hospitalization in specialized
department. Principles of treatment, clinical supervision, control and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching about "- 6.0
hours.
Cardiac arrhythmias - any heart rhythm is not regular normal sinus rhythm frequency and
conduction disturbances electric pulse on various parts of the conduction system of the heart.Sinus
tachycardia - increased heart rate from 90 to 150-180 per minute while maintaining the proper sinus
rhythm. It is caused by an increase in automaticity main pacemaker CA site. Sinus bradycardia is a
decrease in heart rate up to 59-40 per minute while maintaining the proper sinus rhythm. It is caused
by a decrease in the SA node automaticity. Often the main cause of sinus bradycardia is to increase
the vagal tone. Sinus arrhythmia is called the wrong sinus rhythm, characterized by periods of
gradual change in frequency and deceleration rate. Migration of pacemaker - this arrhythmia, which
is characterized by gradually from cycle to cycle, moving the source of rhythm from the SA node to
AV - connection. Sick sinus syndrome (SSS) - reduction or cessation of function of sinus node
automaticity.
The clinical picture. In the first option, patients may not
complain or say periodically weakness, dizziness, or irregular heart fading. Objectively, you can
identify bradycardia, irregular heart rhythm due to the loss of some of its systoles or having early
contractions.For the second (bradyarrhythmias) variant of the syndrome characterized by severe
bradycardia, which may be persistent or transient and is often accompanied by signs of the disorder
in cerebral blood flow in the form of instantaneous blackouts, semiconscious state, "swallowing"
words, paresis, etc. Furthermore, in this embodiment, there may be symptoms of dyspnea CH,
asthmatic attacks, edema, and hypotension.
If bradycardia-tachycardia syndrome on the background of increased frequency of seizures
observed bradycardia rhythm (paroxysmal tachycardia or atrial fibrillation). After arresting appear
episodes of paroxysmal tachycardia bradycardia.
Beats
is
premature excitation of the heart or its parts arising in ectopic foci under the influence of a
23
pathological impulse. ECG signs of atrial beats: the extraordinary appearance of premature P wave
followed by a complex QRS; deformation or change in the polarity of P wave beats; the presence of
unmodified like ekstasistoles complex QRS, similar in shape to the usual normal sinus QRST
complexes of origin; the presence of atrial beats after an incomplete compensatory pause. PVCs premature ventricular excitation and contraction due to heterotopic focus of automatism in the
myocardium of one of them. The mechanism of ventricular arrhythmia mechanisms are re-entri and
after depolarization ectopic foci in the branches of the bundle of His and the Purkinje fibers. ECG
signs of ventricular ekstrastoly: premature extraordinary appearance on the ECG altered ventricular
QRS complex without previous P wave; significant expansion and deformation extrasystolic
complex QRS; the location of the RS-T segment and T wave beats discordantly to the QRS; left
ventricular arrythmia in the main prong of the QRS complex in I and V5-V6 leads pointing down,
and III and in leads V1-V2 up.
Diagnosis of arrhythmias. History and
physical examination. Holter - ECG recording to tape using portable monitors. This method allows
us to study the frequency distribution and the nature of the heart rhythm disturbances in health and
disease, arrhythmias trace the connection with physical activity, sleep-wake period with daily
physical and emotional stress, to evaluate the efficacy of antiarrhythmic therapy. Exercise test.
Psychoemotional samples play a special role in identifying arrhythmias. Vagal tests are used to
determine and clarify the nature of arrhythmias. "Vagal" sample - are mechanical methods of
stimulation of the vagus nerve. Of these, the most common are the Valsalva maneuver and carotid
sinus.
Medication samples. Sometimes, to clarify the pathogenesis and clinical manifestations of some
medications used arrhythmias sample using atropine, aymalina and other drugs.Conducting
business game case technology
Literature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
7. "Aritmii.Differential diagnosis flicker, atrial flutter or fibrillation (permanent and
paroxysmal), paroxysmal tachycardia syndrome, premature ventricular. Tactics GPs.
Indications for referral to a specialist or hospitalization in specialized department.
Principles of treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching about "(6 hours)
Cardiac arrhythmias - any heart rhythm is not regular normal sinus rhythm frequency and
conduction disturbances electric pulse on various parts of the conduction system of the
heart.Syndromes of premature ventricular abbreviated named after the authors who described:
Wolff-Parkinson-White (WPW), Lown-Genonga-Levine (LGL), Clerc-Levy Kritesko. The
phenomena and syndromes ventricular pre-excitation due to inherent characteristics of the
conduction system of the heart, in particular the operation of additional ways of momentum.
There are 5 kinds of additional ways: bundles of Kent, James Brehenmaine fibers Maheyma,
Maheyma and Leva.Paroxysmal tachycardia - a sudden beginning and ending as suddenly attack
more frequent heart rate to 140-250 per minute while retaining most of the regular rhythm.
Paroxysmal tachycardia, as well as the beats, divided into supraventricular and ventricular.
Supraventricular or supraventricular, paroxysmal tachycardia includes several types of
tachycardia, in which the pacemaker is located above the branching bundle branch block. There
are sinoatrialnuyu, atrial and supraventricular tachycardia atriventrikulyarnuyu.
Ventricular paroxysmal tachycardia. Etiology. Observed most frequently in patients with
myocardial infarction. Often this arrhythmia observed in patients with postinfarction
cardiosclerosis, especially with an aneurysm of the heart. Ventricular paroxysmal tachycardia
may occur in patients with diffuse myocarditis, rheumatic and congenital heart disease,
cardiomyopathies. The reasons it may serve intoxication cardiac glycosides, toxic myocardial
injury, the use of sympathomimetic amines.
Atrial flutter - a
significant acceleration of the atrial contraction (up to 200-400 per minute.) When you save the
correct regular rhythm. ECG signs of atrial fibrillation: the presence of up to 200-400 m in the
regular alike atrial waves F, having a characteristic sawtooth (abduction II, III, avf, V1,
V2).Blink (fibrillation) of the atria or atrial fibrillation - rhythm disturbance, in which throughout
24
the cardiac cycle occurs frequently (from 350 to 700 min.) Disorderly, chaotic excitation and
contraction of individual groups of muscle fibers of the atria, each of which is actually now the
kind of ectopic hearth impulses. Ventricular flutter - frequent (200-300 min.) The rhythmic
ventricular due to steady circular motion momentum localized in the ventricles. Ventricular
flutter, usually goes to flicker (fibrillation) of the ventricles, in which notes chaotic, irregular
excitation and contraction of individual muscle fibers of the ventricles with a frequency of 250500 per minute.
Treatment WPW syndrome. Persons with masked
phenomena excitation ventricular therapy is not needed. Relief of paroxysmal supraventricular
tachycardia patients should start with mechanical methods of stimulation of the vagus nerve. If
these methods are ineffective, then appointed ATP ajmaline. The drugs of choice are
amiodarone, flecainide. Supraventricular paroxysmal tachycardia
Reflex Methods:1) Valsalva maneuver - holding your breath with straining at the height of
inspiration for 5-10 seconds;
2) sample Iermaka-Hering - massage of the carotid sinus.3) Sample-Aschner Danini pressing the thumb on both eyes for about 1-3 minutes. At intervals4) the reproduction of the gag
reflex – effectively5) diving reflex - dive face in cold water with breath for 10-30
seconds.Medication:1) verapamil is administered at 10 mg (or 4 ml of 2.5% solution) undiluted,
or 10 mg of verapamil (finoptin) 10 ml of sodium chloride 0.9% solution in / in the slow
jet;Conducting business game case technology\
Literature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
8"Arrhythmias. Differential diagnosis of blockades: sinoatrial, intraatrial,
atrioventricular intraventricular. Morgani- syndrome Adams-Stokes. Routine and
emergency treatment at the blockade. Indications for cardioversion, pacing. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching about "(6 hours)
Heart block - a deceleration or complete cessation of the pulse of any department of the
conduction system of the heart.
Etiologiya.Revmocardit, myocarditis, atherosclerotic cardiosclerosis, acute myocardial mikarda,
intoxication cardiac glycosides, novokainamidom, aftermiocardial cardio, mitral valvular heart
disease, cardiomyopathy, myocardial dystrophy, the application of anti-arrhythmic drugs,
coronary heart disease, congenital abnormality.
Depending on the place where the infringement occurred conductivity distinguished:
sinoatrialnuyu, intraatrial, atrioventricular, intraventricular blocks.
Sinoatrial block - violation of the electrical impulse from the sinus node to the atria.Clinic:
During pause cardiac patients experience dizziness, noise in my head, possible loss of
consciousness. At this time, I do not listen heart sounds and pulse is not detected. ECG: 1)
periodic loss of individual cardiac cycles (P wave and QRST). 2) an increase in the pauses
between the PP and RR (2, rezhe- 3-4 times).
Intraatrial blockade - a violation of conduction of the electrical impulse of atrial prvodyaschey
system. ECG: 1) an increase in the duration of the P wave 0,11sek more. 2) cleavage of P
waveAtrioventricular block I degree AV block ECG: lengthening of the interval P-Q 0,20sek
more. II degree AV block 1) Itip (Mobitz type I) - a progressive lengthening of the interval P-Q,
followed by loss of gastric complex (periods Samoilova-Wenckebach). 2) II type (Mobitz type
II) - P-Q interval remains constant, but some ventricular complexes fall. 3) III type (Mobitz type
III) - a high degree of blockade, which is characterized by a certain sotnoshenie between P wave
and complex QRS (2: 1, 3: 1). AV block III degree (complete). At the level of the AV node
completely stops the conduction of impulses.
Frederick's syndrome - a combination of complete AV block with atrial flutter or fibrillation.
ECG: P wave instead of the recorded wave flutter (F) or flicker (f) of the atria. Broadening and
deformed complexes QRS. The rhythm of the right ventricle, 30-50 per minute
25
.Bundle-Gisa- violation of supraventricular impulses (sinus or ectopic) by a bundle branch block.
Clinically manifested splitting or split heart sounds. Diagnostics with ECG: left bundle branch
block, complete (bifastsikulyarnaya): 1. Levocardiogram 2. Expansion of the QRS complex
more 0,12sek. 3. in leads I, V5-V6 R wave wide, jagged, split, Q wave is absent. 4.
otvedeniyahv1-V2-wide, deep teeth S. 5. ST-segment and T wave directed discordantly relative
to the main prong of the complex QRS
Blockade perdney branch of the left bundle branch block. Sharp axis deviation to the left RI> R
II> R III, S III> R III, S II> R II, S avf> R avf, R avr> Q (S) avf 2. QRS complex is not
broadened and broadened imperceptible- to 0,11sek. 3.In the leads V5-V6 recorded pronounced
tooth S. 4. The leads V1-V2 sometimes a notch on an upward knee teeth and small tooth r
recorded in lead V1. 5. In leads V5-V6 sometimes disappears tooth Q.
Treatment blockades. Sinoatrial block in the absence of clinical symptoms, which suggests sick
sinus syndrome (SSS), does not require treatment. In some cases, there may be employed drugs
decrease parasympathetic effects on the myocardium (atropine) or drugs from the group of
sympathomimetics (ephedrine, isopropyl noradrenaline several preparations). Intraatrial and
interatrial block. Conduction abnormalities at the level of the atria and bundle branch block
require no special treatment.
The therapy of the underlying disease, abolish drugs that led to violations of the
conductivity.Conducting business game: cluster
Literature: A: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
9"Hypertension. Differential diagnosis of hypertensive disease with renal hypertension. Risk
factors, stage of hypertension, renal types of arterial hypertension (parenchymal and
renovascular). The syndrome of malignant hypertension. Tactics GPs. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a joint venture.
Principles of teaching topics. " (6 hours)
At the present time, the term "hypertension" decided to unite all the pathological conditions that
occur with a persistent increase in blood pressure (BP). AG is a symptom of many diseases and
the main and often the only symptom of essential hypertension (EH).
The main criterion for the diagnosis of hypertension is blood pressure that exceeds the value
characteristic of the age group.
Diagnostic criteria for hypertension for persons over 18 years:
-sistolic blood pressure> 140 mm Hg
-diastolic> 90 mm Hg
Epidemiological studies have expanded our understanding of the role of factors in the formation
of hypertension. In connection with the collection of this history in patients with the general
practitioner has to follow the recommendations of the WHO (1992) and pay particular attention
to the following risk factors:
hereditary history on hypertension and cardiovascular disease (CVD);- A violation of lipid
metabolism in the patient and his parents;- The presence of diabetes in the patient and his
parents;- Smoking;- Feeding habits;- Obesity;- The degree of physical activity;- The identity of
the patient and his entourage;- A profession;- social status.
One of the major risk factors for hypertension is hereditarya burdened. For example, if one
parent is sick AG, the probability of a child is 25% if both parents are sick, the risk increases to
50%.GB begins gradually, and often first detected during random measurement of blood
pressure or diagnostic examination. At the heart of this form of hypertension is the primary
degradation (neurosis) high vesselcontrol centers with subsequent inclusion of neurohormonal
and renal mechanisms. In the initial stages of the disease, these changes are functional, but the
progression of hypertension they are joined by organic damage the kidneys, heart, central
nervous system and other organs.Symptoms indicating the defeat of -aim:
26
- The brain and eyes: headache, dizziness, blurred vision, transient ischemic attack, sensory and
motor disorders;
-Heart: palpitations, chest pain, shortness of breath;
-Kidney: thirst, polyuria, noctury, hematury;
Symptomatic hypertension - This term refers to a group of cardiovascular and endocrine
diseases, kidney diseases, central nervous system and a number of other pathological conditions
in which secondary hypertension caused by one or another organic process, or defect, is
becoming a major feature of the disease, and the primary defect ( often disposable) not only
affects the body or local blood circulation, but also to destabilize the systemic hemodynamics,
with consequences in many respects similar to those of GB. Clinical and laboratory evidence of
renal parenchymal hypertension:
- An indication of a history of pyelonephritis, glomerulonephritis, nephropathy pregnant, kidney
disease and others;
Characteristic changes in urine sediment, laboratory data, instrumental and morphological
studies indicating the presence of primary renal disease;
- Positive hypotensive effect of specific treatment of renal disease;
Clinical and laboratory evidence of renal artery stenosis:- The young age of the patient at a
congenital disease, senile - in atherosclerotic lesions of the renal artery;
- Fever;
-Leukocytosis, increased erythrocyte sedimentation rate, hypergammaglobulinemia;- Malignant
course;- Stable nature of the increase in blood pressure (diastolic primuschestvnno);- Systolic
murmur, sometimes with diastolic component of the area of origin of the renal artery.The
syndrome of malignant hypertension. Syndrome of malignant hypertension (SZG), according to
the WHO, called rapidly progressive hypertension, morphologically characterized by necrotizing
arteritis with fibrinous changes and clinically -high blood pressure, cerebral hemorrhage, and
often, but not always, papilledema and progressive uremia. SZG declares itself a constant
headache (often occipital) and visual impairment up to amaurosis.
Conducting
business
game
case
technologyLiterature:
O
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
10"Hypertension. Differential diagnosis of hypertensive disease with endocrine hypertension.
Types of endocrine hypertension (pheochromocytoma syndrome Kona Itsenko-Kushenga,
thyrotoxicosis) Differential diagnosis of hypertensive crises. Tactics GPs. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching about "(6:00)
Symptomatic hypertension - This term refers to a group of cardiovascular and endocrine
diseases, kidney diseases, central nervous system and a number of other pathological conditions
in which secondary hypertension caused by one or another organic process, or defect, is
becoming a major feature of the disease, and the primary defect ( often disposable) not only
affects the body or local blood circulation, but also to destabilize the systemic hemodynamics,
with consequences in many respects similar to those in the EG. SAG peculiarity is that the
increase in blood pressure in these conditions is one of the main manifestations of the disease
process and can often be normalized when it is radical therapy.There are a number of grounds on
which it can be assumed that there SAG:-Age <40 years;- Ineffectiveness of antihypertensive
therapy;- Malignant or progressive nature of hypertension;- Good tolerance of hypertension, the
small number of complaints;- Volatility is BP primushestvennoe increase in diastolic blood
pressure.Troubling history:- Nephropathy, cystitis, edema, renal colic."Extracurricular"
violations:- Muscle weakness, vascular noise, paroxysmal increase in blood pressure;- A
paradoxical reaction to some drugs.Clinical and laboratory features of the syndrome of
Cushing Cushing's syndrome occurs 3-4 times more frequently in women than in men and 8090% of cases with malignant hypertension passing. In 1/3 of the patients it is caused by a
primary adenoma (or carcinoma), the adrenal cortex. High levels of cortisol in the blood as a
27
result of the feedback results in suppression of ACTH production by the pituitary
gland.Tireotaccicosis- meets everywhere. Most often the disease occurs between the ages of 20
to 50 years old, more frequently in women than in men. Reasons: diffuse toxic goiter, toxic
thyroid adenoma (SHZH), subacute granulomatous thyroiditis (thyroiditis Kerwin), tireoiditnyh
flow of hormones from the outside.Treatment for feochromocytoma. Treatment is done by
surgery and involves the removal of the tumor together with the remnants of adrenal tissue.
Treatment of primary hyperaldosteronism. Surgical treatment.Conducting business game:
clusterLiterature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
11"Hypertension. Differential diagnosis of hypertensive crises. Tactics GPs. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching about
Hypertensive crises. Hypertensive crisis (GC) is a sharp, usually a significant increase in blood
pressure with a pronounced worsening symtomatic diseases involving the brain
(encephalopathy), heart (left ventricular failure, angina, arrhythmia), renal (disorders of water
metabolism –saline, proteinuria, hematuria, azotemia) syndromes and require immediate
adequate medical therapy, taking into account the pathogenesis of its various f
The
clinical picture of GK type I (neurovegetative form - hyperkinetic type) is characterized by a
sudden onset of headache, dizziness, excitation, "grid" or "fog" in front of the eyes, sweating,
cooling the hands and feet, dry mouth, palpitations, feelings of incompleteness of breath,
palpitations copious urination. There may be pain in the heart up to the angina attack. The facial
skin, neck and chest covered with red spots, then. Auscultation of heart sounds loud accent II
tone of the aorta. There principally increase in systolic blood pressure with a high pulse
amplitude. The ECG may be a decrease in segment ST, T wave flattening in the urine after the
crisis revealed mild proteinuria, hyaline cylinders, single modified erythrocytes. Complications
are rare. HA Type I develops most often in the early stages of EG, usually lasts for 2-3 hours,
relatively quickly docked.
GC type II (water and salt, swollen shape with hypokinetic syndrome) develops gradually takes a
long time (from 3 to 4 hours to 4 to 5 days). In its clinical picture is dominated by cerebral
symptoms associated encephalopathy: headache, heaviness in the head, drowsiness, weakness,
dizziness, and transient visual and hearing impairment, tinnitus, nausea, vomiting, and
disorientation. Can an observer squeezing pain in the heart, shortness of breath, attacks of
breathlessness. Urine output is lowered. Face the patient pale, puffy, swollen veins, the fingers
thickened. Identified transitorily paresthesia, hemiparesis, the state of stupor, confusion. Face
hyperemic, cyanotic. Increase of systolic and diastolic blood pressure may occur simultaneously
or with a predominance of the latter. Pulse pressure is reduced. Pulse or slow down, or
unchanged, at least, speeded up. ECG - reducing the interval ST, T wave biphasic or negative. In
the urine after a crisis appear proteinuria, modified erythrocytes, hyaline cylinders. Not
infrequently complications such as stroke, myocardial infarction or acute left ventricular
failure.It should be emphasized that in some patients a sharp increase in blood pressure with the
development of GC occurs in response to the deterioration of the cerebral, coronary, renal blood
flow or pulmonary hypoxia. After the elimination of these syndromes, blood pressure stabilizes.
Keep in mind that over-intensive antihypertensive therapy
.Conducting
business
game
case
technologyLiterature:
A:
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
12"Pain in the heart. Differential diagnosis of pain at CHD stable angina - different functional
classes (FC I-IV). Acute coronary syndrome. Indications for surgical treatment. Tactics GP
for angina. Clinical examination, primary and secondary prevention of CHD. Principles of
teaching about "(6:00)
Angina -one of the clinical forms of ischemic heart disease, manifested paroxysmal pain arising
feeling or discomfort in the area of the heart caused by myocardial ischemia (but without the
28
development of its necrosis), which is associated with a decrease in blood flow and an increase
in myocardial oxygen demand.
Characteristics of pain in stenocardi:
It has the nature of an attack, t. E. has a distinct time of occurrence and termination, remission;
occurs under certain conditions:
• pain occurs during physical (accelerating movement during uphill, with a sharp headwind walking
after a meal or with a heavy load), or emotional stress, cold or after a meal, and disappears at rest
(in minutes) or after taking nitroglycerin
• The pain of angina pectoris are usually oppressive, localized behind the sternum, radiating to
the arm, jaw, neck, back, often accompanied by shortness of breath.
• Outside the attack physical examination little information.
For IFK include individuals who have stable angina attacks are rare, only caused excessive
physical exertion. IIFK - slight limitation of ordinary physical activity. Angina attacks occur
when walking on level ground at a distance of more than 500 m, with a rise of more than 1 floor.
FC III pronounced the usual limitation of physical activity. Seizures occur when walking at a
normal pace on level ground at a distance of 100-500 meters, with the rise in the 1st floor. FC IV
- Angina occurs when small physical activities, walking on level ground at a distance of less than
100 m. It is characteristic of attacks alone, as well as among sleep due as well as bouts of angina,
myocardial metabolic demands increase.
ECG at rest. During an attack of angina marked segment depression ST, T waves are negative or
sharp and high. Sometimes there is no ECG changes. In the diagnosis of silent myocardial
ischemia significantly helps Holter ECG monitoring.
Stress ECG tests. In CHD stress ECG tests are positive in 75% of patients. These samples were
carried out as for diagnosing coronary artery disease, and for prognosis, determining indications
for coronary angiography. The negative result of the load ECG samples can not be regarded as
absolutely reliable proof that no coronary atherosclerosis, but the outlook is thus in any case, a
favorable, even if the sample false negative. General and biochemical blood tests. Myocardial
infarction of the destroyed cardiomyocytes into the systemic circulation comes intracellular
enzymes. Diagnostic significance: 1 and troponin T, creatine kinase, in particular MVA-isomer,
AST LDH, especially LDH-1
Echocardiography to detect violations of contractility of ischemic myocardium. Informativeness,
even in the early stages of myocardial infarction, even when no ECG changes and improve
enzymes.
Treatment in the interictal period: rare angina (FC 1) - nitrates (nitrosorbid 10 - 20 mg per dose) in
anticipation of heavy loads. Angina FC 11 requires continuous use (years!) Beta-adrenergic
receptors (propranolol, obzidan et al.); Dose them individually (10 to 40 - 60 mg per one dose), it
is highly desirable reception 4 rather than three times a day (at present there sustained release
formulations), and the last time within 3 - 4 hours before bedtime ; while the heart rate should be
reduced to 60 - 70 in 1 min (not being counted on an electrocardiogram, taken alone, but only in
the active state of the patient!). Nitrates (nitromazin, Trinitrolong etc.) Should be used
systematically, and to stop the attacks (stabilization of current) - just before the load (tour of the
city, emotional stress, and so on. P. Nitrosorbid take 10 mg of 4 - 6 times a day; ointment
Nitrolime applied to the skin every 4 - 6 hours (effective 4 - 5 hours), including just before
bedtime.
Conducting
business
game
case
technologyLiterature:
O:
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
13Topic: "Pain in the heart. Differential diagnosis of pain in ischemic heart disease unstable
angina pectoris (new-onset angina, progressive angina, spontaneous angina, and postoperative
early post-infarction angina). Acute coronary syndrome. Indications for surgical treatment.
Tactics GP for angina. Clinical examination, primary and secondary prevention of CHD.
Principles of teaching about "(6:00)
29
Angina -one of the clinical forms of ischemic heart disease, manifested paroxysmal pain arising
feeling or discomfort in the area of the heart caused by myocardial ischemia (but without the
development of its necrosis), which is associated with a decrease in blood flow and an increase
in myocardial oxygen demand.
Atypical symptoms of angina (equivalent angina): localization of pain is not in the chest, but
only in areas of irradiation, seizures, muscle weakness left arm and numbness IV - V finger of
the left hand, attacks of shortness of breath on exertion, even without signs of heart failure,
cough when walking fast , bouts of arrhythmia at an altitude of physical activity, heart attacks of
asthma.The basis of any stage of diagnosis of angina is properly constructed and carefully
conducted inquiry of the patient. In case of doubt, carry out exercise tests (bicycle stress test) to
detect hidden existing coronary insufficiency. Tactics diagnosis determines the following flow
diagram to address key issues: whether the nature of the coronary pain, whether there are signs
of angina before infarction not due if the present aggravation of coronary artery disease for the
influence of extracardiac (related) diseases? Only a convincing reasoned negative answer to the
first three questions gives the right to search for other causes of pain: the detection of other
diseases of the patient as the source of his pain can not exclude the presence of a simultaneous
and stroke as a manifestation of coronary artery disease.
ECG at rest. During an attack of angina marked segment depression ST, T waves are negative or
sharp and high. Sometimes there is no ECG changes. In the diagnosis of silent myocardial
ischemia significantly helps Holter ECG monitoring.Stress ECG tests. In CHD stress ECG tests
are positive in 75% of patients. These samples were carried out as for diagnosing coronary artery
disease, and for prognosis, determining indications for coronary angiography. The negative
result of the load ECG samples can not be regarded as absolutely reliable proof that no coronary
atherosclerosis, but the outlook is thus in any case, a favorable, even if the sample false negative.
General and biochemical blood tests. Myocardial infarction of the destroyed cardiomyocytes into
the systemic circulation comes intracellular enzymes. Diagnostic significance: 1 and troponin T,
creatine kinase, in particular MVA-isomer, AST LDH, especially LDH-1
Echocardiography to detect violations of contractility of ischemic myocardium. Informativeness,
even in the early stages of myocardial infarction, even when no ECG changes and improve
enzymes.
Emergency measures in a fit stenokardii.Nitroglitserin, 300-600 mcg under the tongue. Aspirin
150 mg orally one time a day.
When pain - nitroglycerin (sublingual tablets or metered aerosol). In some cases - blockers,
nitrates in the form of ointments or patches
Conducting
business
game
case
technologyLiterature:
O:
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
14"The pain in the heart. Differential diagnosis of pain in angina and myocardial infarction.
Differential diagnosis of complications of myocardial infarction, cardiogenic shock, types,
severity, pulmonary edema, arrhythmias, conduction disturbances, thromboembolism,
cardiac aneurysm, myocardial rupture, nonbacterial thrombotic endocarditis, Dressler's
syndrome. The tactics of the general practitioner. Prehospital care in myocardial infarction.
The principles of follow-up, monitoring and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching topics. " (6 hours)
Myocardial infarction (MI) - ischemic myocardial necrosis due to acute coronary flow mismatch
needs infarction. The prevailing age - older than 40 years.Clinically isolated 5 times of the MI:
1. prodromal period, lasting from a few hours, days to one month, may be missing. Clinical
symptoms corresponds to a progressive, unstable angina;
2. The acute period- from occurrence of sharp myocardial ischemia before signs of necrosis
(from 30 minutes to 2 hours). The beginning of myocardial infarction was defined as an attack
of intense and prolonged (more than 30 minutes, often many hours) retrosternal "dagger" pain
30
(anginal state) is not stopped by repeated doses of nitroglycerin; compressive pain, Expander
nature radiates to the left arm, wrist, jaw, ear, teeth, under the left shoulder blade.
Rarely in the picture dominates asthma attack or pain centers in the epigastric region (asthmatic
and gastralgic forms of acute infarction attack) is accompanied by a sense of fear and
excitement. Inspection- pale skin, visible mucous membranes may acrocyanosis. Pulse =
possible bradycardia, alternating with standard-setting or tachycardia, arrhythmia. BP initially
rise and then moderately decreased;
Acute period -formation necrosis and miomalyatsii (2-14 days). Clinic: pain disappears, there
are hypertension (often considerable), which disappears after decrease in pain and does not
require the use of antihypertensive drugs; increased heart rate (not always); increase in body
temperature (from 2-3 days); hyperleukocytosis, alternated persistent elevated erythrocyte
sedimentation rate; serum - transient increase glycemia azotemia, fibrinogen, the activity of
enzymes - creatine kinase myocardial isoenzyme and its (within the first 48 hours), ACAT
(within 72 hours), LDH and its isoenzyme LDG1 (within 5 days);
4. Subacute period- end of the initial processes of the organization scar tissue granulation
zameshenie necrotic (4-8 weeks from the beginning of the disease). Pain syndrome is not
available, recovering the rhythm and conduction of the heart, reduces the appearance of
rezarbtsionno- postipenno necrotic syndrome;
5. Postinfarction period- an increase in the density of the scar and the maximum myocardial
adaptation to the new conditions of operation (3-6 months from the beginning of a heart attack).
At congenial no specific clinical manifestations. Laboratory findings are normal.
ECG pathological tooth Q, transient changes in T-wave and ST-segment dynamics which gives an
indication of old infarction.
1.IsheMIC stage is associated with the formation of ischemic focus, over the lesion increases the
amplitude of the T wave, it becomes high, pointed (subendocardial ischemia).
2.
damage: In areas of subendocardial ischemia develops subendocardial damage, which is
manifested by mixing ST interval from top to bottom contour. Damage and transmural
ischemia quickly spread to subepicardial zone, ST interval dome mixed up, the T wave is
reduced and directly merges with the interval ST
3.sharp stage is associated with the formation of necrosis in the center of the lesion. ECG
signs: t disappearance of tooth R (transmural myocardial infarction), a dome-shaped rise of ST
interval of the contour lines, the negative T wave
4.Podostraya stage: Zone no damage, ST-interval contour lines (if the interval ST is not
lowered to the contour lines more than 3 weeks, can be suspected aneurysm), T wave initially
negative symmetrical gradually then decreases, it becomes izoelektrichnym or weakly
positive.5.Rubtsovaya stage is characterized by the disappearance of the ECG - signs of
ischemia, but persistent preservation scarring, T wave is positive.
Conducting business problem-based learning gamesLiterature: O: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
15"Heart murmur and cardiomegaly. Differential diagnosis of the presence of noise on the
top of the heart and aorta. Evaluation of functional (myocardial, anemic, with changes in the
blood, fever) and organic (mitral insufficiency, mitral stenosis holes, mitral valve prolapse,
acquired defect of the aortic valve) heart murmurs. Tactics GPs. Principles of teaching topics.
" (6 hours)
Cardiomegaly significant increase in the size and weight of the heart. Increases may be one,
several or all of the chambers of the heart. The size and configuration of the heart depends on the
sex, age and other person. Therefore, the term "cardiomegaly" is to some extent relative
ponyatiem.Neredko general practitioner faced with conditions and diseases accompanied by an
increase in heart size. Therefore, to determine their causes, assess the severity and prognosis, as
well as select the correct medical tactics of such a patient is extremely important.
Many diseases and conditions can lead to an increase in heart size.
31
Myocarditis - inflammation of the heart muscle diseases of various etiologies.
Diagnosis miokardite Foundation on the presence of clinical symptoms of heart disease and the
results of additional research methods.
1. Peripheral symptoms include pallor, cyanosis of lips, feveк.
2Symptoms defeat of the cardiovascular system:
• pain symptoms (prolonged dull, stabbing pain in my heart with 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 and (or) systolic murmur, voiceless heart tones,
lowering blood pressure, disturbance frequency and cardiac rhythm;• Signs of cardiovascular
disease or on left ventricular type (s) of right ventricular type (shortness of breath, swelling of
ST-segment changes and tooth T;
echocardiography and radiography of the heart - increase in the size of the heart;
Anemia - a condition characterized by a decrease in the content hemoglobin per unit volume of
blood. Anemia can be an independent disease, and a manifestation or complication of other
diseases (syndromes). The causes and mechanisms of development are different.Mitral valve
insufficiency.
Etiology: rheumatic fever, bacterial endocarditic, atherosclerosis, systemic connective tissue
diseases.
Clinic: Under no compensation claims.
Decompensate - shortness of breath, palpitations, irregular and pain in the heart, in the
development of pulmonary congestion - cough, hemoptysis, attacks of cardiac asthma, swelling
in the legs, acrocyanosis, increased painful liver, swelling of the neck veins. On examination:
facies mitralis; "Heart hump" (parkas if a child), the displacement of the left apical impulse reinforced spilled. At a percussion: the increase in the relative dullness of the heart to the left and
upward. Auscultator: weakening of I tint on top (before his absence) often auscultated at the
apex III tone, accent and break down of II tone of the pulmonary artery systolic murmur at the
top of the soft blowing or the rough with the musical tinge, depending on the severity of valve
defect is carried out axilla; If the front - left edge of the breast.
ECG - LV hypertrophy and LP, left bundle branch block. PCG - reducing the amplitude of I tint
over the top, III tone occupies the entire systole, school associated with the I tone
decreasing.Echocardiography - discordant movement front and rear wing, signs of fibrosis and
calcification. Increasing the speed of the front wing, the signs of fibrosis.
Stenos is of the mitral orifice - narrowing of the left ateroventricular holes (normally 4-6 cm2, the
"critical area" -1-1,5 cm2).
Etiology: rheumatism, diseases Lyutembashe component. Under compensation patients complaint
may be missing if decompensation appear dry cough, hemoptysis, palpitations, disruption of the
heart, swelling in the legs, stabbing pain 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 due to the
right ventricle, the lack of apical impulse, diastolic tremor.
Radiographic study: mitral configuration of the heart with contrasting side view of the
esophagus, esophageal displacement along the arc of small radius, taper arc
LV.Echocardiography - unidirectional movement of the front and back flaps of the mitral
diastolic forward, reducing the rate of early diastolic opening the front flap, reducing the range of
motion front wing, the left ventricle is not expanded, well lotsiruetsja right ventricle hypertrophy
LP, stagnation in the pulmonary circulation. The method allows to determine the degree of
stenosis and the presence of fibrosis and calcification of the leaflets.Mitral valve prolapse vybuhanie, protrusion or reversing one or both of the valves MK into the cavity of the left
atrium.
ECG may be determined by flattening, or two-humped, and negative T waves in leads II, III, rarely
in V5- V6 and tall T waves in V1- V2. Additional PCG research and echocardiography.Tactics
32
GPs. Treatment own faults can only be surgical. To clarify the indications for this treatment need
timely consultation of a specialist heart surgeon. Conservative therapy is to prevent relapse and
treatment of the main process and complications, treatment and prevention of heart failure, and
cardiac arrhythmias. Of great importance are the timely and adequate vocational guidance and
placement of the patient. Drug therapy is ineffective. In the later stages - nitrates, calcium
antagonists. Perhaps surgery (commissurotomy, implantation of an artificial valve).
Aortic stenosis. Etiology: rheumatic fever, bacterial endocarditis, atherosclerosis, congenital
aortic stenosis. Pathological substrate: the fusion and compaction of the leaflets and the
deposition of calcium in them.
Auscultatory: rough school of the aorta at the point Botkin with carrying on the carotid arteries,
interscapular region, the jugular fossa, better auscultated in a horizontal position on the exhale.
Weakening I tone at the top, the weakening or disappearance of II tone over aortoy.ECGsyndrome, left ventricular hypertrophy and left ventricular overload.EhoCG- thickening of the
aortic valve with multiple echo in them, reducing the differences in systolic cusps during systole,
the detection of left ventricular hypertrophy and the posterior wall of the left ventricle enddiastolic cavity size is normal for a long time.Aortic insufficiency - a pathological condition in
which the semilunar valves do not close completely and during diastole, the reverse flow of
blood from the aorta into the left ventricle.The combination of aortic insufficiency and aortic
stenosis. Rheumatic aortic heart disease often is a combination of aortic stenosis and aortic
insufficiency. This combination of auscultation determined systolic and diastolic murmurs at
Botkin and in II intercostal space on the right.Rheumatism: frequent combination with mitral and
aortic stenosis.Bacterial endocarditis: the appearance of other signs of endocarditis.When
echocardiography existence of another blemish to the development of aortic insufficiency.
Syphilis: the formation of defect after 10 -25 years after infection, and other manifestations of
syphilis, a positive Wassermann reaction.
Also, a differential diagnosis of diseases such as congenital aortic valve Bivalve, ankylosing
spondylitis, Reiter's syndrome, SLE, SSc, chest trauma, aortic atherosclerosis, aortic aneurysm,
Marfan syndrome, nonspecific aortoarteriit.
Conducting business game: cluster
Literature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
16"heart murmur and cardiomegaly. Differential diagnosis in congenital heart and great
vessels. Tactics GPs. The principles of follow-up, monitoring and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching about "(6:00)
Ventricular septal defect (illness Tolochinova- Roger). Clinic: complaints of shortness of breath
on exertion, fatigue, pain in the heart. There are frequent pneumonia. Inspection: cardiac hump,
systolic tremor of the heart, the expansion of percussion heart size to the right.ECG combined
ventricular hypertrophy. Violation of atrioventricular conduction. Echocardiography: in a study
in M mode, one of the clear signs is the lack of continuity of the IVS. When X-ray has been a
sharp increase in the RV, increased LV, reduction of the aorta, a moderate increase in the PL. A
reliable diagnosis is in probing the cavities of the heart and angiocardiography.
Subaortic stenosis. Morphologically in obstructive cardiomyopathy found abrupt thickening
of IVS with the protrusion of the muscle mass in the cavity of the left ventricle and outflow tract
narrowing, atrium enlarged, exaggerated. Inspection - apical impulse is displaced to the left,
strengthened; systolic jitter at the top and along the left side of the chest in the III-IV intercostal
space and corresponds to the degree of obstruction.
Auscultation: I tone
normal, it is often preceded by a tone IV, II tone usually split - the main auscultatory sign of a
rough school on PCG noise has a diamond shape, is held down in the armpits and on the
ground. NL arises as a result of the passage of blood through the narrowed opening, and mitral
regurgitation. Systolic murmur increases with Valsalva maneuver, tachycardia, in a standing
position, while taking nitroglycerin. Noise is reduced in the position squatting reception βblockers, administration - agonists.
33
ECG - LV hypertrophy high the Voltage QRS, depression ST-T, may be atrial fibrillation. On
radiographs - possible LV hypertrophy. Echocardiography - left ventricular hypertrophy,
interventricular septum thickness ratio of the thickness of the free wall of the left ventricular
end-diastolic 1.3. The second feature - the movement of the front mitral leaflet for a meeting
with IVS even more pronounced narrowing of the outflow tract of the left ventricle.
Atrial septal defect. Clinic: complaints of shortness of breath on exertion, fatigue,
susceptibility to pneumonia, the development of pulmonary hypertension, anginal pain.
Auscultation: a soft systolic murmur in the II -III intercostal space left of the sternum, the accent
II tone of the pulmonary artery. In severe pulmonary hypertension, there are attacks of
breathlessness and sudden cyanosis (Eisenmenger syndrome), but from that point on surgical
correction becomes impossible.
Ltambashe syndrome is diagnosed based on the symptoms of mitral stenosis, in the late stages
formed dekompentation effect WFP.
Isolatedpulmonary stenosis.
Auscultatory: rough school in II-III intercostal space left of the sternum, easing II tone on the
aircraft. PCG: NL LA (II-III intercostal space left) decrease in the amplitude II tone of the
aircraft.
ECG
hypertrophy PP, RV, right bundle branch block. On the X-ray - a marked increase in the
prostate, which can be a way to the left edge of the contour of the heart; rapid elongation and
bulging trunk LA; marked narrowing of the pulmonary artery branches in the area of the roots;
depletion of lung pattern. Accurate diagnosis is achieved by angiocardiography.Tetralogy of
Fallot - a congenital heart defect characterized by a combination of the interventricular septum,
pulmonary artery stenosis, right ventricular hypertrophy. Complaints: shortness of breath,
increasing a load until he lost consciousness. On examination: cyanosis, at the beginning of a
load 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.
Auscultatory: rough systolic murmur, with its epicenter in II intercostal space left of the
sternum, easing II ton of the pulmonary artery, right up to his disappearance.Electrocardiogram
- a hypertrophy and right ventricular overload, hypertrophy of the right atrium.
Ductus arteriosus - cleft birth
duct that connects the aorta and pulmonary artery. Complaints: shortness of breath, weakness,
fatigue, kardialgiya. Inspection: pale skin, systolic jitter, a large pulse pressure. Auscultation:
systolic - diastolic murmur ("machine"), with its epicenter in II intercostal space left of the
sternum, worse on inspiration, weakened straining. ECG LV hypertrophy. On radiographs mitral heart shape, increasing the LP, left ventricular hypertrophy, enlargement of the aorta;
hypertension - an enlarged prostate, elongation and bulging of the left LA, hypervolemia.
Coarctation of the aorta. Clinic: complaints of headache, dizziness, shortness of
breath, fatigue of the lower limbs while walking. Inspection: the difference in the pulsation of
blood vessels of the upper and lower half of the body, pulsating collateral vessels in the
interscapular, axillary areas and along the intercostal spaces, increased blood pressure in the
arms and the reduction or complete lack of standing.Auscultation: NL over the top or the bottom
of the heart to the right, increasing the amplitude of the II tone of the aorta. ECG LV
hypertrophy. On radiographs - increase in left ventricular enlargement of the aorta, the lower
circuits uzurations rear sections of ribs (corroded lower edges of the ribs at the x-ray study).
When multiplanar fluoroscopy and optimal projection tomography revealed aortic constriction.
Accurate diagnosis - angiocardiography, aortography.
Ventricular septal defect - diagnosis of ventricular septal defect is set according to color
Doppler echocardiography, left ventriculography and cardiac catheterization. ECG changes and
the data of X-ray studies of the heart and lungs are different for different sizes of the defect and
the varying degrees of pulmonary hypertension; correctly guess the diagnosis they help only
when clear evidence of hypertrophy of both ventricles and severe hypertension, pulmonary
circulation. Treatment of small defects bezlegochnoy hypertension is often not required.
34
Surgical treatment is indicated in patients whose discharge of blood through a defect of more
than 1/3 of the volume of pulmonary blood flow.
Atrial
septal
defect is detected at diagnosis suggests, along with the described symptoms, signs of severe
right ventricular hypertrophy (in tonnes. C. According to the echo and electrocardiography),
radiographic signs of fluid overload defined pulmonary circulation (gain arteriapnogo lung
pattern) and the characteristic ripple roots of the lungs . Coarctation of the aorta - the cardiac
surgery in the hospital confirmed the diagnosis of aortography and study the difference in blood
pressure in the ascending and descending aorta by its catheterization. Treatment consists of
excision of the narrowed area of the aorta with a graft or replacing it with the creation of end to
end anastomosis or in the creation of a shunt operation. The optimal age for operation with a
favorable course blemish - 8 - 14 years. Outdoor arteriosus (Botallo) flow - Diagnosis
absolutely confirmed aortografivy (visible relief the contrast through the channel), and cardiac
catheterization and pulmonary trunk (marked increase in pressure, and oxygen saturation in the
pulmonary trunk), but it is quite reliably established without these studies using Doppler
echocardiography ( Check shunt flow) and X-ray examination. Treatment consists of ligation of
patent ductus arteriyTrilogy of Fallot - clarify the diagnosis in cardiac surgery hospital cardiac
catheterization with measurement of the pressure gradient between the right ventricle and the
pulmonary trunk and right ventriculography. Treatment - valvuloplasty that when the triad of
Fallot combined with the closure of interatrial communication. Valvulotomy less effective.
Tetralogy of Fallot - the final diagnosis is based on the defect data angiocardiography and
cardiac catheterization. The treatment can be palliative - the imposition aortolegochnyh
anastomoses. Radical correction of the defect is to eliminate the stenosis and closure of
ventricular septal defect.Conducting business problem-based learning gamesLiterature: A:
1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
17"heart murmur and cardiomegaly. Differential diagnosis of different clinical forms of
cardiomyopathy (dilated, restrictive, hypertrophic, arrhythmogenic right ventricular
dysplasia). Differential diagnosis between cardiomyopathies, valvular heart disease, coronary
artery disease, hypertension. Tactics GPs. The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about "(6:00)
Cardiomyopathy - a disease of unknown etiology infarction are characterized by cardiomegaly,
progressive heart failure The classification of cardiomyopathies1. Dilated2. Hypertrophic: a)
obstructive; b) obstructive.3. Restrictive: a) without the obliteration; b) with
obliteration Dilated cardiomyopathy is characterized by a sharp expansion of the heart
chambers with little reduction of their hypertrophy of myocardial contractility.Clinical
symptoms: 1 Severe circulatory insufficiency on left ventricular type (dyspnea, cyanosis,
orthopnea, attacks of cardiac asthma and pulmonary edema) of right ventricular type
(akratsianoz, pain in the liver, its increase, ascites, edema, jugular vein) or total. 2.
Cardiomegaly, deafness thanes heart, gallop rhythm, systolic murmur, relative mitral and
tricuspid insufficiency.
Severe cardiac arrhythmias (atrial fibrillation, paroxysmal tachycardia, arrythmia, blockades)
..Tromboembolicheskie syndrome (pulmonary thromboembolism, splenic, cerebral arteries).
Diognostic criteria
1.Progresiruyuschaya circulatory failure, lecheniyu
.2.Kardiomegaliya resistant to the presence of a relative lack of clamshell and tricuspid valves.
3.Tromboembolicheskie syndrome, dysrhythmia, conduction.
Hypertrophic cardiomyopathy (HCM) - genetically caused disease characterized by
hypertrophy of the CMC and the violation of the spatial orentatsii, the development of
myocardial fibrosis, dysplastic lesions intramuralnyhvenechnyh arteries, leading to disruption,
coupled intracardiac hemodynamics, reduce the ability of the left ventricle diastolic relative
koranary failure and rhythm and conduction disturbances.There are also obstructive and
35
obstructive forms of whitening.HCM can be asymptomatic for a long time, and often the first
manifestation of the disease is sudden death. Symptoms occur usually at the age of 25-35
years.In the study of the pulse can be detected a weak systolic filling the radial artery.
Auscultatory at the top and at Botkin often auscultated variability (due to the dynamic nature of
the obstruction) systolic murmur. Very rarely can be determined mezosistolic click.
Identification of distinct ECG signs of LVH in young people in the absence of hypertension
and valvular data is not rare considered the first symptoms found in patients with
HCM.Restrictive cardiomyopathy - infiltrative type can also be the cause of cardiomegaly, but
the heart is usually increased slightly. The disease is characterized by increased hardness of one
or both ventricles due fibrosis of the myocardium or endocardium, and in severe cases obliteration of the cavity. The pericardium is not changed. Before the diagnosis of restrictive
cardiomyopathy, constrictive pericarditis should be excluded. To detect thickening and
calcification of the pericardium is performed computed tomography or magnetic resonance
imaging.By restrictive cardiomyopathy include endomyocardial fibrosis and Loeffler
endocarditis parietal fibroplastic. These two diseases are now treated as one disease, often
accompanied by eosinophilia.
Aortic stenosis. Pathogenesis: The obstruction to blood flow from the left ventricle leads to
early LV hypertrophy. Clinic: When decompensation complaints of dizziness, fainting, angina.
By reducing the LV contractility - attacks of cardiac asthma. Inspection: pale skin and mucous
membranes, lifts the apical impulse shifted to the left and down. Systolic jitter in the second
intercostal space to the right of the sternum, behind the sternum, increased cardiac impulse,
increasing its size is, a mixture of down and left. Small slowly rising pulse, blood pressure
reduction (especially sistoldichesky) and pulse pressure.
Auscultatory:
rough
school of the aorta at the point Botkin with carrying on the carotid arteries, interscapular region,
the jugular fossa, better auscultated in a horizontal position on the exhale. Weakening I tone at
the top, the weakening or disappearance of II tone of the aorta.Aortic insufficiency - a
pathological condition in which the semilunar valves do not close completely and during
diastole, the reverse flow of blood from the aorta into the left ventricle.Auscultatory: diastolic
murmur in II intercostal space to the right of the sternum, or at the point Botkin. School relative
aortic stenosis is listened to the right of the sternum I weakening tone at the top and the
weakening of II tone of the aorta. You can identify presystolic noise Flint. Auscultation of the
femoral artery is heard double Traube tone, with compression of the artery - a double noise
Vinogradova - Duroziez. Pulse, quickly rising and falling, high pulse pressure, diastolic
pressure.
ECG LV hypertrophy, deep Q wave in
left chest leads, and left ventricular overload LP.Mitral valve insufficienc
Decompensated - shortness of breath, palpitations, irregular and pain in the heart, in the
development of pulmonary congestion - cough, hemoptysis, attacks of cardiac asthma, swelling
in the legs, acrocyanosis, increased painful liver, swelling of the neck veins. On examination:
facies mitralis; "Heart hump" (parkas if a child), the displacement of the left apical impulse reinforced spilled. Auscultatory: weakening of I tint on top (before his absence) often
auscultated at the apex III tone, accent and break down of II tone of the pulmonary artery
systolic murmur at the top of the soft blowing or the rough with the musical tinge, depending on
the severity of valve defect is carried out axilla; If the front - left edge of the breast.ECG - LV
hypertrophy and LP, left bundle branch block. PCG - reducing the amplitude of I tint over the
top, III tone occupies the entire systole, school associated with the I tone decreasing.
Echocardiography - discordant movement front and rear wing, signs of fibrosis and
calcification. Increasing the speed of the front wing, the signs of fibrosis.Stenosis of the mitral
orifice - narrowing of the left ateroventrikulyarnogo holes (normally 4-6 cm2, the "critical area"
-1-1,5 cm2).
When decompensation appear dry cough, hemoptysis, palpitations, bereboi of the heart,
swelling in the legs, stabbing pain in the heart, in severe decompensation - pain and tyazhestv
36
with the right upper quadrant, ascites. On examination - "facies mitralis", acrocyanosis, children
poor physical development, infantilism, "heart hump", epigastric pulsation due to the right
ventricle, the lack of apical impulse, diastolic tremor.
Percussion: borders of heart and raised up to the right; auscultation: I flapping tone over the top of
the heart, a click of mitral valve opening, accent II tone of the LA preprotodiastolichesky sound
over the top. Electrocardiogram - a hypertrophy of the prostate and the LP.
Conducting
business
game
case
technologi
Literature: O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
18"Edematous syndrome. The differential diagnosis of acute and chronic heart failure.
Differentiated therapy for heart failure. Tactics GP When edema. Principles of treatment,
clinical supervision, control and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Determination earning capacity.Printsipy teaching about "(6:00)
Circulatory failure (NC) - a pathological condition is failure of the circulatory system to deliver
organs and tissues of the amount of blood required for their normal functioning.Acute heart
failure. Cardiac asthma (CA) and pulmonary edema (AL) -paroksizmal form of severe shortness
of breath due to the bleeding of the lung tissue of serous fluid with the formation of edema interstitial (in cardiac asthma) and alveolar, with foaming protein-rich transudate (if pulmonary
edema).The reasons for the SA and AR 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 and others.) Or acute
manifestations of chronic left ventricular failure (mitral or aortic defect, chronic aneurysm of the
heart and other chronic forms of coronary artery disease, and others.).
Congestive heart failure.
Chronic heart failure (CHF) is formed during a period of several weeks to decades.Clinical
forms:
1. Congestive left ventricular failure is characteristic of mitral defect to severe forms of
coronary artery disease, particularly in patients with hypertension.
2. Left ventricular ejection failure is typical for aortic defect, coronary artery disease,
hypertension. Manifestations: cerebrovascular insufficiency (dizziness, blackouts, fainting),
coronary insufficiency, sfigmograficheskie and echocardiographic signs of low output. In severe
cases, possible Cheyne - Stokes pulse of alternating (rarely) presystolic gallop rhythm
(abnormal tone IV), clinical manifestations of congestive left ventricular failure. In the terminal
stage can join right ventricular failure.
3. Congestive right heart failure is characteristic of mitral and tricuspid blemish constrictive
pericarditis. Usually attached to congestive left ventricular failure.
4.
Right ventricular ejection failure characteristic of stenosis of the pulmonary artery, pulmonary
hypertension. Diagnosed mainly radiographically (depleted peripheral pulmonary vasculature
pattern).
5. Dystrophic form. Typically, end-stage right heart failure. Options: a) cachectic; b) edematous
-distrophic with degenerative changes of the skin (thinning, gloss, smoothness drawing laxity),
edema - common or limited mobility, there is hypoalbuminemia, in the most severe cases anasarca; c) nekorrigiruemoe salt depletion.Stages of development and severity of congestive
heart failure. Of the many signs of heart failure, enumerated in the description of one stage or
another, you must select a few, each of which is sufficient to determine the specific
stage.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 directed at the underlying mechanism of edema with
a decrease in venous return to the heart afterload reduction with an increase in propulsive left
ventricular function and reduction of high hydrostatic pressure in the vessels of the small circle .
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 stage of
37
precursors of (possibly fatal). Indications for hospitalization may arise at the stage of the
precursors, and after removal of the SA attack. Withdrawal of the OL is held in place by a
specialized cardiac resuscitation ambulance. After removal from the AL hospitalization carried
out by the same team (the threat of recurrence of herpes zoster).
The sequence of therapeutic interventions is largely determined by their availability, the time it
takes to implement them.
The patient should make sure that the doctor takes seriously his complaints and of acts
decisively and with confidence.
Treatment program:
1. Normalization of emotional status, eliminating giperkateholaminemii and hyperventilation.2.
Reduce preload (venous return blood to the heart): Sick seat (with your pants down).
Nitroglycerin 1- 1.5 mg (2-3 tablets or 5-10 drops) under the tongue every 5-10 minutes under
the control of blood pressure before noticeable improvement (wheezing become less abundant,
and cease to be auscultated at the mouth of the patient, subjective relief) or to reduce BP.3.
Discharge of the pulmonary circulation by using diuretics: In order to reduce congestion in the
lungs and providing a powerful venodilitation effect occurs within 5-8 minutes, intravenously
administered furosemide.
4. Reduce the pressure in the small and large circulation: In some cases (lack of sodium
nitroprusside, nitroglycerin, high blood pressure) to reduce the pressure in the small and large
circulation ganglioblokatory used, short-acting particularly effective when the cause of
pulmonary edema is an increase in blood pressure. Oxygen is carried out in order to improve the
blood oxygen satiety.
Assigned oxygen inhalation through the nasal cannula (at 8 L / min) or mask (at the rate of 5-6 l
/ min) at a concentration sufficient to maintain arterial blood pO2 greater than 60 mm mp. Art.
(through the vapor alcohol).
5. The destruction of foam in alveoli: oxygen inhalation passed
through 700 alcohol; intravenous administration of 10 ml of 960 ethanol with 15 ml of 5%
solution glkozy; 2- inhalation of 3 ml of 10% alcohol solution antifomsilana for 10-15 minutes;
After pre-sedation patients significantly better tolerated inhalation defoamer. 6.Povyshenie
myocardial contractility: Cardiac glycosides are recommended for severe tachycardia, atrial
tachyarrhythmia. Apply strophanthin dose of 0.5-0.75 ml of 0.05% solution, digoxin dose of
0.5-0.75 ml of 0.025% solution by slow intravenous injection of isotonic sodium chloride
solution or 5% glucose solution.
Conducting business game: cluster
Literature:O: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
19"Cough with sputum. Diseases that occur cough. The most dangerous diseases that occur
with coughing. Differential diagnosis in the equity and segmental lesions of the lung. Lobar
pneumonia, infiltrative pulmonary tuberculosis, pulmonary infarction. Community-acquired
pneumonia and nosocomial. Tactics GPs. The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Defining disability.
Principles of teaching about "(6:00).
Cough is the most frequent symptoms of cardiopulmonary diseases. It is a resounding jerking
forced expiration, resulting in the tracheobronchial tree detergent of mucus and foreign bodies.
Coughing occurs when inflammation, mechanical, chemical and thermal stimulation of cough
receptors.
Pneumonia
various etiology (including pathogens of acute pneumonia should first identify pneumococci of
all types, as well as streptococci - and staphylococci, gram-negative bacteria - E. coli, bacillus
Pfeiffer, Proteus, Pseudomonas aeruginosa) - widely used in the hospital, causing nosocomial
pneumonia, Gram-negative bacilli Legionella, in the water, Klebsiella (pneumonia
Friedlander), viral pneumonia (influenza, adenovirus, cytomegalovirus), viral and bacterial
pneumonia, mycoplasma, Pneumocystis {in patients with severe impairment of cellular
immunity, especially AIDS, pneumonia caused by fungi, rickettsia , chlamydia, etc.). It is
38
necessary to emphasize the increasing trend of atypical pathogens: Chlamydia, Legionella,
Mycoplasma.
Basic principles of treatment of acute pneumonia. The choice of antibiotics is directly related
with the establishment of the type of pathogen and its sensitivity specification.I.
pneumococcus. Until 1970, the ideal treatment for penicillin was considered. Soon, however, it
was isolated pneumococcus strains resistant to penicillin and cephalosporin by an
overwhelming majority.
The main mechanism of resistance to beta-lactam antibiotics - bacteria develop betalactamases, beta-lactam-destroying ring.
In this connection, in recent years, it becomes widely used inhibitor of beta-lactamases sulbactam and clavulanic acid. They come in combination with ampicillin and amoxicillin. The
combination of ampicillin with sulbactam - unazin, 1.5-3 g per day for 3-4 hours. The
combination of clavulanic acid amokitsillinom - amoxiclav.
Second-line drugs - cephalosporins. First generation: cefazolin (kefzol) 4-6 g; cephalexin per os
1-2 grams per day. These drugs are highly active against staphylococci, streptococci,
Escherichia coli, Klebsiella; destroyed the majority of beta-lactamase.The second generation:
cefaclor (tseklor) - 750 mg 2 times a day; cefuroxime (ziinat) - 500 mg 2 times a day. These
drugs are also highly active against Haemophilus influenzae, more resistant to beta-lactamase.
Third generation: сlaforan - 3-6 grams per day; dardum (tsefaperazon) - 2-4 grams per day 2
times intravenously; fortum - 3 g per day for 3 doses, only parenterally; Rocephin (ceftriaxone)
- 1-2 grams per day (one dose) intravenously or intramuscularly.The preparation of the third
generation + sulbactam: sulperadon (tsefaperazen) - 2-4 grams per day in 2 divided doses
intravenously or intramuscularly.
Formulations of the third series - macrolides: erythromycin - 200 mg 2-3 times daily by
intravenous injection (to 1 g per day), per os 250-500 mg four times a day; roxithromycin
(rulid) - 150 mg 2 times a day; clarithromycin - 250 - 500 mg 2 times a day.
Klebsiella (Friedlander bacillus): aminoglycosides in combination with chloramphenicol or
tetracycline (doksatsiklina hydrochloride), prolonged scheme - the first day of 200 mg (100 mg
2 times a day), and then 100 mg 1 time a day for 5-10 days.
Chlamydia, Legionella, Mycoplasma: macrolides (erythromycin, rulid, clarithromycin),
tetracyclines (doksatsiklina hydrochloride).
Anaerobic: penicillin, lincomycin (500 mg 3-4 times a day intravenously to 600 mg per day in
250 ml of physiological saline solution 2-3 times a day).
Fluoroquinolones. Drugs in this group could be related to antibiotics. Along with
cephalosporins are widely used in the treatment of bacterial infections. Fluoroquinolones have
an advantage over many antibiotics: well into the cells, are active against gram positive and
gram negative, anaerobic bacteria, they are susceptible Haemophilus influenzae, Streptococcus,
Staphylococcus. Used clinically: ciprofloxacin (tsiprolet, tsiprobay) 250-500 mg 2 times a day
for 7-10 days, 200 mg intravenously 2 times a day for 1-2 weeks; ofloxacin (tarevid) 200-400
mg 2 times a day (more active against Staphylococcus aureus). Fungi: amphotericin B (daily
dose - 250 U / kg intravenously every other day or 2 times a week for 4-8 weeks) .Virusnye interferon.
Tactics GP in acute pneumonia - hospitalization.
Infiltrative pulmonary tuberculosis combines different in character inflammatory reaction process
represented a hotbed of perifocal inflammation larger than 10 mm in diameter, are prone to
sharp flow and rapid progression. It is characterized by the development of inflammation
around fresh or exacerbate old encapsulated focus, remaining after the treatment of TB scars.
Pulmonary infarction - complications of the underlying disease or a manifestation of the latter, if
the patient has in the recent past had surgery or trauma, with thromboembolic one of the
branches of the pulmonary artery embolism is more common in patients with hypertension,
myocardial infarction, thrombophlebitis, with heart defects, with atrial fibrillation with longterm oral contraceptives. X-ray method allows detection of myocardial light shade and a
39
reduction in one of the segments, often back-basal. Pulmonary infarction more often localized
in the lower lobes. Radiographic symptom-triangular shadow vertex facing the root, oval or
round shape.
The diagnosis is difficult because the symptoms are similar to symptoms of lobar pneumonia,
myocardial infarction. In contrast, lobar pneumonia flank pain in myocardial light appears
before the chills and fever, and coughing up blood - after it. When you take into account the
differential diagnosis of ECG data.
Conducting
business
game
case
technologyLiterature:
O:
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
20. "cough with sputum. Differential diagnosis of lung lesions in the round. Focal pneumonia,
tuberculoma, abscess of lungs, lung tumors, lung echinococcus. Pneumonia of different
etiology (bacterial, viral, mycoplasma). Differential diagnosis in diffuse disseminatsii.focal
pneumonia, hematogenic-disseminated form of pulmonary tuberculosis, pneumoconiosis,
cancer metastases. Tactics GPs. The principles of follow-up, monitoring and rehabilitation
in a hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching about
"(6:00).
Cough is the most frequent symptoms of cardiopulmonary diseases. It is a resounding jerking
forced expiration, resulting in the tracheobronchial tree detergent of mucus and foreign bodies.
Coughing occurs when inflammation, mechanical, chemical and thermal stimulation of cough
receptors.Diagnostics. If we keep in mind the above-mentioned causes coughing, then answer the
following general questions: whether acute or chronic cough and whether it is productive, t. E. Is
accompanied by sputum, can significantly limit the number of possible diagnoses. These medical
history, physical examination, chest X-ray results, funktsionaalnyh research lungs and sputum to
help set specific cause coughing. Acute cough can occur during viral infection, such as
traheobronhite or pneumonia or bacterial infection - at bronchopneumonia.
When pneumococcal pneumonia sputum has a rusty color; pneumonia caused by Klebsiella, it
resembles currant jelly. Gram stain and culture of sputum, obtained by deep staining can identify
bacterial, mycoplasma gribkovvuyu or nature of the disease. Sputum cytology to diagnose lung
neoplasm. Pneumonia various etiology (including pathogens of acute pneumonia should first
identify pneumococci of all types, as well as streptococci - and staphylococci, gram-negative
bacteria - E. coli, bacillus Pfeiffer, Proteus, Pseudomonas aeruginosa) - widely used in the
hospital, causing nosocomial pneumonia, Gram-negative bacilli Legionella, in the water,
Klebsiella (pneumonia Friedlander), viral pneumonia (influenza, adenovirus, cytomegalovirus),
viral and bacterial pneumonia, mycoplasma, Pneumocystis {in patients with severe impairment
of cellular immunity, especially AIDS, pneumonia caused by fungi, rickettsia , chlamydia, etc.).
It is necessary to emphasize the increasing trend of atypical pathogens: Chlamydia, Legionella,
Mycoplasma.
Lung abscess - non-specific inflammation of the lung tissue, accompanied by melting it in the form
of a limited focus and the formation of one or more of the necrotic cavities. Clinic. Before the
breakthrough of pus in the bronchus: high fever, chills, heavy sweats, dry cough with chest pain
on the affected side, with light percussion - intensive shortening the sound of the lesion,
auscultation - respiration weakened a touch of hard, sometimes bronchial. After the breakthrough
in the bronchus: cough with release of large amounts of sputum (100-500 ml), purulent, often
fetid. If you have poor drainage body temperature remains high, chills, sweats, cough, poor
separation of foul-smelling sputum, shortness of breath, symptoms of intoxication, loss of
appetite, clubbing as "drumsticks" and nails in the form of "time windows". X-rays until the
break of an abscess in the bronchus - infiltration of the lung tissue, most segments II, VI, X right
lung, bronchus, after a breakthrough in horizontal illumination level of the liquid. Considerable
difficulties arise in the differential. tuberculoma diagnosis with cancer and peripheral lung
lesions parasitic. Note that if the lung cancer patients there are indications of frequent
exacerbations of chronic bronchitis, the patients with tuberculoma - ported on dry or pleural
effusion, contact with TB patients. Dyspnea in patients with Tuberculomas absent, whereas in
40
patients with cancer patient distressing symptom. Valuable diagnostic X-ray data give (inside
dense calcified tuberculoma inclusion, and the shadow of the tumor homogeneous or multi-node)
and cytology and detection in sputum Office.
When lung echinococcus patient often complains of weakness, shortness of breath, cough, chest
pain, coughing up blood. Helps X-ray examination: the detection of intensive round shade
without changes in the surrounding lung tissue and "track" to the root of the lung.
Conducting business problem-based learning gamesLiterature: A: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
21. "The chest pain associated with lung disease. Differential diagnosis of pleural effusion and
dry. Types of exudative pleurisy. The principles of follow-up, monitoring and rehabilitation
in a hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching about
"(6:00).
Dry pleurisy. Clinical symptoms: chest pain, worse when breathing, coughing; when
diaphragmatic pleurisy pain radiates in the upper abdomen or along the phrenic nerve - in the
neck; general weakness; low-grade fever of the body; at the apical pleurisy - tenderness trapezius
and pectoralis major (Sternberg and Pottenger symptoms); respiratory restriction of mobility of
the lungs; auscultation - pleural rub. Laboratory data. 1. Jabs: increased erythrocyte
sedimentation rate, leukocytosis small. 2. LHC: increased content of fibrin seromucoid, sialic
acids. X-ray examination of the lungs, "isolated" dry pleurisy is not recognized, but can be
installed signs of underlying disease (pneumonia, tuberculosis, tumors, etc.).
Pleural effusion. Clinical symptoms: general weakness, shortness of breath, high fever with
chills (empyema), sweating, loss of appetite; lag corresponding half of the chest when breathing
and smoothness of intercostal spaces; when mediastinal encysted pleurisy - dysphagia, swelling
of the face, neck, hoarseness; percussion - a massive dull sound; auscultation - no breathing;
tachycardia; muted tones of the heart.
Laboratory data. OAK 1: improving the content of sialic acid, fibrin, seromucoid, α2- and γglobulins. 3. Investigation of pleural fluid: protein content greater than 3%, the relative density
of more than 1,018; LDH content of more than 1.6 mmol (lh); Rivalta positive test; Neutrophils
predominate in the sediment; straw-yellow color, with empyema - pus. Instrumental research. Xray examination: intense darkening with an oblique upper limit mixing of the mediastinum to the
opposite side. Ultrasonography: fluid in the pleura. Differential diagnosis of different types of
exudative pleurisy based on their clinical and laboratory features. Parapneumonic pleurisy is
usually masked by symptoms of acute pneumonia and are characterized by a small effusion.
When expressed pain syndrome at the beginning of pneumonia should be carried out persistent
search pleurisy. Tuberculous pleurisy occurs at a relatively young age, a history of contact with
TB patients, characterized by intoxication and moderate temperature reaction, positive tuberculin
skin test, the prevalence of pleural effusion cells. Pleurisy when pulmonary infarction have
hemorrhagic exudate in small quantities, which is often seen. Carcinomatous pleurisy
accompanied by pain, massive hemorrhagic exudation, leading to respiratory and circulatory
disorders to the presence of atypical cells in the sediment. When the blockade metastatic thoracic
duct chylous effusion can be. After receiving the turbid fluid or pus typical seeded them on
culture media to determine the etiology. When an obscure diagnosis recommended a thorough
X-ray after the evacuation of the fluid, and plevroskopiya plevrobiopsiya.
Conducting business game case technology
Literature: A: 1,2,3,4,5,6; D: 1,2,3,4,5,6,7,8,9,10,11,12.
22. "Bronchoobstructive syndrome. Differential diagnosis of diseases occurring with
bronchial obstruction (asthma, COPD, lung tumors). Tactics GPs. Indications for referral
to a specialist or hospitalization in specialized department. Principles of treatment, clinical
supervision, control and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about "(6:00).
41
Bronchial obstruction - syndrome caused by bronchial obstruction, leading role in the genesis of
which occupies a bronchospasm. The immediate cause of seizures is unusually high bronchial
reactivity to endogenous and exogenous stimuli.
Chronic obstructive pulmonary disease (COPD) - a term that has duplicate content.
First, COPD - is a collective term that brings together a group of chronic diseases of the respiratory
system characterized by progressive irreversible airflow obstruction and the increase of chronic
respiratory failure. This group includes chronic obstructive bronchitis (COB), emphysema (EL).
Secondly, as an independent disease COPD (nosological form) is the ultimate stage of
progressive course of COB, EL, ie the stage at which the disease progresses as a result lost a
reversible component of bronchial obstruction and disease, leading to COPD, lose their
individuality. Such an attitude to the problem corresponds to the International Classification of
Diseases 10th Revision (ICD-10), it is highlighted under the heading J.44.8 chronic obstructive
bronchitis with no further elaboration, which is part of the revised COPD.Thus, patients with
COPD have a minimum of 2 main features, distinguishes them from HP - diffuse lesions of the
respiratory system and progressive respiratory insufficiency by obstructive type.
Externally and internally the etiological
factors of COPD (risk factors) depending on the share value. The main risk factor (in 80-70% of
cases) COPD - smoking. Smokers have the highest mortality rates, they will develop irreversible
obstructive changes in respiratory function and all of the known symptoms of COPD. It is
believed that reflects the demographics of COPD prevalence of smoking. The most frequently
(70%) cause of COPD is the COB, about 1% of EL (due to lack of a1- antitrypsin), the
remaining percentages fall to severe asthma. Isolation COB in a separate nosological form is of
fundamental importance from the standpoint of early diagnosis and treatment at the stage Save
the reversible component of bronchial obstruction, ie, when the disease has not yet lost its
individuality and the real possibility of inhibition of disease progression by influencing the
reversible component of bronchial obstruction.
The first signs, with which patients typically seek medical attention, a cough and shortness of
breath, wheezing sometimes accompanied with sputum. These symptoms are most pronounced
in the morning. The earliest symptom to appear 40-50 years of life, is a cough. By this time in
the cold season starts occur episodes of respiratory infection, do not associate the beginning in
one disease. Shortness of breath, perceived at first during exercise, there is an average of 10
years after the occurrence of cough.
Thus, the development and progression of COPD occurs under conditions of risk factors,
characterized by a slow gradual onset. The first (the earliest) sign of COPD is a cough. Other
features are joined later on as the disease progresses, with a gradual acceleration of the
progression of the disease.
Physical examination in patients with COPD is not enough to establish the diagnosis of the
disease, it only gives guidance for the future direction of the diagnostic studies using
instrumental and laboratory methods. Conventionally, all diagnostic methods can be divided into
mandatory minimum methods used in all patients (general analysis of blood, urine, sputum, chest
X-rays, a study of respiratory function (ERF), ECG), and additional methods used for special
indications.
For everyday clinical work with patients COB addition to general clinical tests recommended
ERF study (FEV 1, forced vital capacity or VC), a test with bronchodilators (b2-agonists and
anticholinergic), chest X-ray. The rest of the research methods recommended for special
indications, depending on the severity of the disease and the nature of its progression.In
everyday practice, the patients applied COB tests with bronchodilators (b-agonists and / or
anticholinergic), which to some extent the ability to characterize the rapid regression of
bronchial obstruction, in other words, the "reversible" component of obstruction. The increase in
FEV1 during the test by more than 15% from baseline values conventionally accepted
characterized as a reversible obstruction.
1. Quitting smoking and limiting the influence of external risk factors.
42
2. Patient education.
3. bronchodilator therapy.4. Mukoregulyatornaya therapy.5. anti-infective therapy.6. Correction of
respiratory failure.7. Occupational therapy.In forming the strategy and tactics of treatment of
patients with COPD, it is essential to allocate 2 regimens: non-acute treatment (maintenance
therapy) and treatment of COPD exacerbations.
Conducting
business
game
case
technologyLiterature:
A:
1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
23. "Shortness of breath, choking. Differential diagnosis of diseases occurring with bronchial
obstruction (asthma, COPD, lung tumors). Tactics GPs. Indications for referral to a
specialist or hospitalization in specialized department. Principles of treatment, clinical
supervision, control and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about "(6 hours).
Bronhospastick syndrome - a syndrome caused by bronchial obstruction, leading role in the
genesis of which occupies a bronchospasm. The immediate cause of seizures is unusually high
bronchial reactivity to endogenous and exogenous stimuli.
Clinic attack in infectious-dependent asthma (hut) is divided into 2 types:
1. A prolonged shortness of breath - from a few hours to several days, accompanied by a nearly
constant cough with branch mucopurulent sputum.
2. Similar to the classic asthma, but less clear beginning and end, slowly stoped bronchodilators.
Outside attack the lungs auscultated dry and moist rales.
Dishormonal pathogenic variant asthma primarily involves change in the adrenal glucocorticoid
activity, hormonal activity of the ovaries in women. Clinical signs, immediately showing
glucocorticoid insufficiency, no. On the possible infringement of hormonal ovarian function is
judged by the changes of asthma in different phases of the menstrual cycle, during pregnancy
and the postpartum period. Indications of increased frequency of asthma attacks during the
premenstrual period, subsidence or exacerbation during pregnancy and after birth allows to
suspect the participation of hormonal ovarian function in the pathogenesis of asthma.
In addition, asthma attacks in asthma can occur under the influence of not only specific, but
non-specific stimuli - emotions, inhaling cold air, changes in barometric pressure, humidity,
etc.Insufficiency of the left ventricle, which is the cause of congestion, pulmonary edema can
mimic asthma. In addition to shortness of breath, which carry a pronounced inspiratory
character, it must be remembered that in cardiac asthma history there is evidence of heart
disease, its dimensions increased, lung auscultation - stagnation in the basal rales, auscultation
heart-gallop, with vices - noise ECG changes, increase of body weight in a short time. Trial
therapy (diuretics, cardiac glikozity or bronchodilators) confirm the correctness of the diagnosis.
The presence or absence of eosinophilia is a valuable diagnostic for exceptions bronialnoy
asthma.Etiological treatment of asthma involves the implementation of measures such as the
removal of the cause of significant environmental allergens and irritating agents at work and at
home, if necessary, rational employment, sanitation foci of infection, cessation of neuropsychological trauma, using for this therapy.
The main task of the pathogenetic treatment - restoration of bronchial patency. For this purpose,
appointed agents, relieves bronchial obstruction main elements: bronchospasm, swelling of the
bronchial mucosa, dyscrinia and warning their development.
Circulatory failure (NC) - a pathological condition is failure of the circulatory system to deliver
organs and tissues of the amount of blood required for their normal functioning.
Depending on the speed of development are acute NK, which is shown in minutes and hours, and
chronic NK, which is formed during a period of several weeks to several years. In addition,
isolated heart failure associated with cardiac and vascular insufficiency, in which the fore in the
mechanism of circulatory disorders acts mainly vascular component.
Clinically, heart failure manifests a number of characteristic symptoms: shortness of breath,
orthopnea, cardiac asthma, nocturia, peripheral edema and enlargement of the liver, sometimes
43
ascites, anorexia, wheezing over the lungs, enlargement of the heart, atrial gallop, a third heart
sound, jugular veins, anasarca, ascites.
Treatment of the underlying disease, which led to the HNK, can significantly reduce its
manifestation, to increase the effectiveness of therapeutic measures. Rational treatment
regimen.Clinical nutrition. When NK appointed tables number 10 or 10a. restriction of salt and
water. meals should be 5-6 times a day (with the use of a small amount of food intake); food
should be easily digestible, fortified, calorie diet 1900-2500 kcal per day. Strengthening reduced
myocardial contractility is conducted through the application of cardiac glycosides and nonglycoside inotropic agents.
-adrenergic receptors, peripheral vasodilators, angiotensin
receptor antagonists II, anti-arrhythmic drugs.
Drug-free treatment of patients with HNS. Among the non-drug therapies in the HNS often use
isolated ultrafiltration of blood.
Intraaortic balloon kontripulsatsiya used in clinical practice as a method for temporary
mechanical support of the pumping function of the left ventricle. kontripulsatsiyu balloon is most
often used in acute heart failure. however, this method is also used in patients with NC. It is
indicated for patients with end-stage heart failure, which is preparing for a heart transplant and
surgery, to maintain heart function after transplantation, patients in the development of
ventricular arrhythmias refractory to medical therapy.
Surgical treatment of chronic heart failure. Heart transplantation is the only effective treatment
for most patients with end-stage heart failure. In many cases, heart transplantation can not only
extend the life of the patient, but also partially and sometimes fully restore disabled patients.
Conducting business game case technologyLiterature:
A: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
24. "Shortness of breath, choking. Differential diagnosis of dyspnea in heart and lung disease.
Circulatory failure and pulmonary insufficiently.Printsipy teaching about "(6:00).
Bronchial obstruction - syndrome caused by bronchial obstruction, leading role in the genesis
of which occupies a bronchospasm. The immediate cause of seizures is unusually high bronchial
reactivity to endogenous and exogenous stimuli.
Clinic attack in infectious-dependent asthma (hut) is divided into 2 types:
1.Prolongirovannoe difficulty breathing - from a few hours to several days, accompanied by a
nearly constant cough with branch mucopurulent sputum.2.Pohozhie of classic asthma, but less
clear beginning and end, slowly stoped bronchodilators. Outside attack the lungs auscultated dry
and moist rales.
Dishormonal pathogenic variant asthma primarily involves change in the adrenal glucocorticoid
activity, hormonal activity of the ovaries in women. Clinical signs, immediately showing
glucocorticoid insufficiency, no. On the possible infringement of hormonal ovarian function is
judged by the changes of asthma in different phases of the menstrual cycle, during pregnancy
and the postpartum period.
Insufficiency of the left ventricle, which is the cause of congestion, pulmonary edema can mimic
asthma. In addition to shortness of breath, which carry a pronounced inspiratory character, it
must be remembered that in cardiac asthma history there is evidence of heart disease, its
dimensions increased, lung auscultation - stagnation in the basal rales, auscultation heart-gallop,
with vices - noise ECG changes, increase of body weight in a short time. Trial therapy (diuretics,
cardiac glikozity or bronchodilators) confirm the correctness of the diagnosis. The presence or
absence of eosinophilia is a valuable diagnostic for exceptions bronialnoy asthma.
The main task of the pathogenetic treatment - restoration of bronchial patency. For this purpose,
appointed agents, relieves bronchial obstruction main elements: bronchospasm, swelling of the
bronchial mucosa, dyscrinia and warning their development.
Circulatory failure (NC) - a pathological condition is failure of the circulatory system to deliver
organs and tissues of the amount of blood required for their normal functioning.
44
Depending on the speed of development are acute NK, which is shown in minutes and hours, and
chronic NK, which is formed during a period of several weeks to several years. Clinically, heart
failure manifests a number of characteristic symptoms: shortness of breath, orthopnea, cardiac
asthma, nocturia, peripheral edema and enlargement of the liver, sometimes ascites, anorexia,
wheezing over the lungs, enlargement of the heart, atrial gallop, a third heart sound, jugular
veins, anasarca, ascites.
Treatment of the underlying disease, which led to the HNK, can significantly reduce its
manifestation, to increase the effectiveness of therapeutic measures. Rational treatment
regimen.Clinical nutrition. When NK appointed tables number 10 or 10a. restriction of salt and
water. meals should be 5-6 times a day (with the use of a small amount of food intake); food
should be easily digestible, fortified, calorie diet 1900-2500 kcal per day. Strengthening reduced
myocardial contractility is conducted through the application of cardiac glycosides and nonglycoside inotropic agents.
-adrenergic receptors, peripheral vasodilators, angiotensin
receptor antagonists II, anti-arrhythmic drugs.
Drug-free treatment of patients with HNS. Among the non-drug therapies in the HNS often use
isolated ultrafiltration of blood.
Intraaortic balloon kontripulsatsiya used in clinical practice as a method for temporary
mechanical support of the pumping function of the left ventricle. kontripulsatsiyu balloon is most
often used in acute heart failure. however, this method is also used in patients with NC. It is
indicated for patients with end-stage heart failure, which is preparing for a heart transplant and
surgery, to maintain heart function after transplantation, patients in the development of
ventricular arrhythmias refractory to medical therapy.
Surgical treatment of chronic heart failure. Heart transplantation is the only effective treatment
for most patients with end-stage heart failure. In many cases, heart transplantation can not only
extend the life of the patient, but also partially and sometimes fully restore disabled patients.
Conducting business game case technologyLiterature:
A: 1,2,3,4,5,6;
D:
1,2,3,4,5,6,7,8,9,10,11,12.
25. Problem-oriented training on "Cough with phlegm", "shortness of breath, choking"
(6:00).
26. "Dysphagia. Differential diagnosis of esophagitis, reflux esophagitis, dysphagia in
scleroderma and esophageal tumors. Tactics GPs. Principles of treatment, clinical
supervision, control and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about "(6:00).
The main symptom of functional and organic diseases of the esophagus is dysphagia, which
develops as a result of a violation by one of the three phases of swallowing - the mouth, which is
a free act; pharyngeal, depending on the swallowing reflex involving muscles of the pharynx,
larynx; esophageal (low), ie, Related cross esophagus in its middle and bottom thirds.Esophageal
dyskinesia - functional disorders manifest violation of its peristalsis. There are primary
esophageal spasm, which is a consequence of the regulation of cortical disorders of the
esophagus, and esophageal spasm secondary - arising in diseases such as esophagitis, peptic
ulcer, etc. or in cases involving the general convulsive syndrome. Clinical manifestations are
dysphagia, esophageal spasm and chest pain, in some cases resembling coronary. Psychogenic
dysphagia observed in hysterical neurosis, most common in women aged 20-40 years. Dysphagia
may be a manifestation of anxiety neurosis syndrome (anxiety). The objective manifestations of
the disease, along with dysphagia include increase in the tone of skeletal muscles, psychogenic
headache, tremor, muscle twitching, tremors, anxiety, fatigue.Dysphagia can be observed in stem
stroke which, along with paresis of extremities, often observed swallowing disorders, cerebellar
symptoms (severe dizziness), nystagmus, hypotonia or atony, chanted or dizartrichnaya
speech.All these symptoms are manifestations of the syndrome of lateral medulla oblongata at
the stem stroke.
45
When botulism, dysphagia occurs in connection with the use of poor quality canned foods.
Therefore, constant vigilance is required when a physician infectious choking on the background
color, the presence of paresis and other symptoms of the disease, in which the prognosis depends
on timely diagnosis.
When cardiospasm (synonyms: achalasia, hiatospazm, megaezofagus, idiopathic expansion of
the esophagus) violation of the act of swallowing became the leading symptom of the clinical
course of the disease. The disease affects equally to both men and women is more common
between the ages of 20 to 40 years. The main symptoms are dysphagia, regurgitation, and chest
pain. Chest pain manifests itself in the form of painful crises, often occurring at night. If
achalasia esophageal regurgitation observed a large amount of mass accumulated in the
esophagus (saliva, mucus, food residues), which occurs when the body is tilted, the overflow of
the esophagus. Regurgitation is possible at night (a symptom of "wet pillow"). Complications of
the disease include: recurrent pneumonia and chronic bronchitis, as a result of the aspiration of
the masses to belch, as well as chronic esophagitis, esophageal diverticula. The diagnosis is
confirmed by X-ray and endoscopic examination of the esophagus.
Especially need to stop for hiatal hernia, not infrequently accompanied by esophagitis.
Distinguish the gastroesophageal axial hernias (sliding) and paraezofagalnogo type. To their
occurrence can cause Barrett's esophagus - congenital or acquired pathology with shortening of
the esophagus. Esophagitis - inflammation of the esophagus. Esophagitis There are acute,
subacute and chronic. Acute esophagitis caused by irritation of the esophagus hot food and liquid
chemicals can be observed in acute infectious diseases (scarlet fever, diphtheria, septicemia, and
others.). Tumors of the esophagus. Benign tumors of the esophagus are rare. Because malignant
tumors of the esophagus is most common cancer which affects mainly men (women get 3 times
less) over the age of 40 years. The main symptom is dysphagia, most often the first manifestation
of the disease. Sometimes occurrence of dysphagia is 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. The defeat of the esophagus in systemic
sclerosis is accompanied by a number of patients in violation of passage of food through the
esophagus and pain, the need to drink water, dry food. When X-ray observed dysmotility in the
distal esophagus and cardia failure, regurgitation of food into the esophagus, particularly in the
position of a patient lying down, reflux esophagitis. Half of 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. Strictures and stenosis of the esophagus, also accompanied by symptoms
of dysphagia. Dysphagia severity of symptoms depends on the degree of stenosis of uncertain
discomfort behind the breastbone to the complete inability to take food and water. The causes of
dysphagia are diverticula of the esophagus. With larger diverticulum it can accumulate a
significant amount of food, whereby diverticulum compresses the esophagus and makes it
difficult to pass through it first solid food, and then the liquid. Some time after a meal can be a
spontaneous regurgitation of undigested food and mucous fluid from the sac diverticulum.
Dysphagia sideropenic - observed with a deficiency of iron in the body, usually associated with
gastric Achille and iron deficiency anemia. Manifested dysphagia, with time becoming a
constant and is accompanied by unpleasant sensations in the course of the esophagus. On
examination revealed trophic changes of the skin, hair, nails, pale skin and mucous membranes,
atrophic glossitis, pharyngitis, and others. Symptoms of anemia. If endoscopy is determined
atrophic gastritis and esophagitis. In some cases, the initial segment of the esophagus detected
thin connective tissue membrane. When X-ray is usually no change is detected. Treatment: iron
prescribers further - B vitamins
Dysphagia can be observed in the displacement or compression of the esophagus due to
hyperplasia of the thyroid gland, tumors or abscesses of the mediastinum, pericarditis, aortic
aneurysm, and pleural effusion. Dysphagia can be observed in the presence of foreign bodies in
the esophagus.
46
Conducting business problem-based learning gamesLiterature: A: 1,2,3,4,5,6; D:
1,2,3,4,5,6,7,8,9,10,11,12.
27. "Abdominal pain. Differential diagnosis of gastritis and peptic ulcer disease (gastric and
12 duodenal ulcer). Tactics GPs. Indications for referral to a specialist or hospitalization in
specialized department. Principles of treatment, clinical supervision, control and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about "(6:00).
Teach GPs differential diagnosis and selection of optimal alternative treatment strategy for
chronic gastritis and gastric ulcer and 12 duodenal ulcers, as well as the principles of
management of patients in a primary health care provided by the requirements of "Qualification
characteristics of the general practitioner."
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, and pancreas; liver disease, biliary tract and pancreatic cancer; inflammatory
gastrointestinal disease gastritis, giardiasis, Crohn's disease; irritable bowel syndrome; options
for coronary heart disease; alcohol consumption; side effects of drugs and intoxication.During
prolonged and severe dyspepsia to establish its cause is carried out following laboratory and
instrumental studies: complete blood count, fecal occult blood analysis of gastric juice, if
necessary, histamine test, exercise ECG - tests, abdominal ultrasound, X-rays of the
gastrointestinal tract and gall bubble EFGDS with mucosal biopsy, retrograde
holetsistopankreatografiya, esophageal manometer, tumor marker, carcinoembryonic antigen
embriogenalny with suspected colon cancer, A-fetoprotein - with suspected liver
cancer.Treatment of peptic ulcer disease should be carried out in 2 stagesThe first stage involves
lifestyle changes and proper nutrition.
Magnesium oxide (deadburned magnesia) 0.5-1.0 g 3-4 times a day within 1-2 hours after eating 34 weeks 2) Almagel, Maalox, and others fosfolyugel. 1 Dis. spoon 4 times a day within 1-2 hours
after meals and at night for 3-4 weeks 3) Vikalin, vikapro (rhetorician) in particulate form on 2
tab. 3 times a day after meals for 3-4 weeks. At the first stage of treatment with medication of H2
blockers for 8 weeks. With the ineffectiveness of the treatment is carried out 2 stage drug
therapy. 1) Blocker H + -K + -ATPase inhibitor omeprazole -20 mg (1 capsule) into 1 time per
day in the morning for 4-8 weeks. 2) cytoprotector: a) Sukralfat- 1 g orally four times a day for 1
hour before meals and at bedtime b) Mizoprostal- 200 mg orally 4 times a day (prostaglandin E);
c) Substrate bismuth (De Nol) - 240 mg (2 tablets) into 2 times a day (chewed), is effective in resharpening against Helicobacter pylori. In the treatment of gastric ulcer and 12 duodenal ulcer in
the treatment applied antibiotics (oksatsilin, tetracycline, ampicillin, furazolidone, Trichopolum
in high therapeutic doses) for 1-2 weeks.
Widely used physiotherapy treatment: electrophoresis with novocaine, paraffin, ozokerite as
applique on the epigastric region, therapeutic baths, circular shower, and others.The second stage
involves the surgical treatment of gastric ulcer and 12 duodenal ulcer, which is shown:1) the
ineffectiveness of medical treatment for 1 year;
2) When complications: a) Bleeding - not amenable to conservative therapy (ice pack on the
epigastric region, aminocaproic acid / O and inside Almagelum, cimetidine inside / m and / in,
zhelatinol in / etc.) ; b) perforation; c) pyloric stenosis; d) worsening of ulcers after surgical
treatment.
Relative indications for surgery are recurrent stomach bleeding, ulcers penetration, intense pain and
ulcer diameter greater than 2 cm, the ulcer does not heal within four months, and
others.Treatment of acute uncomplicated gastric ulcer and 12 duodenal ulcer is carried out by the
general practitioner in the outpatient setting. Recurrent, complicated forms of the disease require
hospital treatment.
47
Conducting business problem-based
1,2,3,4,5,6,7,8,9,10,11.
learning
gamesLiterature:
A:
D
1,2,3,4:
28. "Abdominal pain. Differential diagnosis of gastritis and peptic ulcer disease (gastric and
12 duodenal ulcer). Tactics GPs. Indications for referral to a specialist or hospitalization in
specialized department. Principles of treatment, clinical supervision, control and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about "(6:00).
Teach GPs differential diagnosis and selection of optimal alternative treatment strategy for chronic
gastritis and gastric ulcer and 12 duodenal ulcers, as well as the principles of management of
patients in a primary health care provided by the requirements of "Qualification characteristics of
the general practitioner."
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, and pancreas; liver disease, biliary tract and pancreatic cancer; inflammatory
gastrointestinal disease gastritis, giardiasis, Crohn's disease; irritable bowel syndrome; options
for coronary heart disease; alcohol consumption; side effects of drugs and intoxication.During
prolonged and severe dyspepsia to establish its cause is carried out following laboratory and
instrumental studies: complete blood count, fecal occult blood analysis of gastric juice, if
necessary, histamine test, exercise ECG - tests, abdominal ultrasound, X-rays of the
gastrointestinal tract and gall bubble EFGDS with mucosal biopsy, retrograde
holetsistopankreatografiya, esophageal manometer, tumor marker, carcinoembryonic antigen
embriohenal with suspected colon cancer, A-fetoprotein - with suspected liver cancer.
Treatment of peptic ulcer disease should be carried out in 2 stagesThe first stage involves
lifestyle changes and proper nutrition.2 stage drug therapy. The second stage involves the
surgical treatment of gastric ulcer and 12 duodenal ulcer, which isineffectiveness of medical
treatment for 1 year;2) When complications: a) Bleeding - not amenable to conservative therapy
(ice pack on the epigastric region, aminocaproic acid / O and inside Almagelum, cimetidine
inside / m and / in, zhelatinol in / etc.) ; b) perforation; c) pyloric stenosis; d) worsening of ulcers
after surgical treatment. Relative indications for surgery are recurrent stomach bleeding, ulcers
penetration, intense pain and ulcer diameter greater than 2 cm, the ulcer does not heal within four
months, and others.
Treatment of acute uncomplicated gastric ulcer and 12 duodenal ulcer is carried out by the
general practitioner in the outpatient setting. Recurrent, complicated forms of the disease require
hospital treatment.
Conducting business problem-based learning gamesLiterature: A: 1,2,3,4; D:
1,2,3,4,5,6,7,8,9,10,11.
29. "Abdominal pain. Differential diagnosis of ulcerative colitis and Crohn's disease. The
tactics of the general practitioner. The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about "(6:00).
Inflammatory bowel disease - a common name two diseases - ulcerative colitis (UC) and Crohn's
disease. The incidence of ulcerative colitis is 25-50 persons per 100 thousand population,
Crohn's disease - 5-15. As UC and Crohn's disease are usually prone to periodic, recurrent
course. In the active phase or exacerbation observed inflammation and all related symptoms in
remission symptoms subside or disappear completely.
Ulcerative colitis. The disease usually begins in people aged 15 to 40 years. Affects only the
colon, the disease often begins with a lesion of the rectum. Clinic: patients complain of diarrhea
mixed with blood, sometimes mixed with pus and mucus, fever, weakness, weight loss, mild
abdominal pain. When barium enema revealed the disappearance haustration, stiff gut; when
48
sigmoidoscopy - swelling, redness, bleeding on the surface of the mucosal erosions and ulcers
exhibit covered with mucus and pus.
Crohn's disease begins in those aged 20-40 years. Clinic: Patients often complain of cramping
pain in the navel and the right iliac region. Concerned about diarrhea mixed with blood and
mucus in the stool, as well as fever, weight loss, weakness. Can form cracks, rectal fistula,
abscess iliorektalny. The defeat is often limited. In 30% of patients are affected only the distal
rectum, 25% - the entire colon.
If colonoscopy reveals that looks slimy "cobblestones". Treatment of an exacerbation of Crohn's
disease is preferably carried out in a hospital; in mild to stool frequency 3-4 times a day, you can
restrict outpatient treatment. Recommended diet prescribed 5-amino salicylic acid (sulfasalazine,
oksalazin, mesalazine), corticosteroids, topically, orally, parenterally. In severe cases, in
advanced lesions, fluid and electrolyte disturbances hospitalization is required. With the
ineffectiveness of drug therapy is recommended surgical treatment.
Tactics GPs. Patients with inflammatory bowel diseases are treated on an outpatient basis under
the supervision of a gastroenterologist, with severe diseases with decompensation requiring
hospitalization in the gastroenterological department.
Clinical examination of patients provides a general practitioner, patients are examined two times
a year, 1 per year, consults a gastroenterologist, proctologist and held gastroenterological
examination (EFGDS, ultrasound of the abdomen, the study of the secretory function of the
stomach, the state of the protein, lipid, carbohydrate and mineral metabolism, koprotsitogramma,
liver function, if necessary, sigmoidoscopy and colonoscopy). In remission appointed: clinical
nutrition, correction of intestinal microbial composition, enzyme therapy, drugs that normalize
motor function of the intestine, herbal medicine, physiotherapy, multivitamin components.
The treatment program for chronic colitis: etiological treatment, clinical nutrition, recovery
eubiosis bowel, use of anti-inflammatory drugs are not absorbed; normalization of motor
function of the intestine and passage of intestinal contents; herbal medicine, the treatment of the
expressed allergic reactions, psychopathology; physiotherapy, exercise therapy, massage; topical
treatment of proctosigmoiditis; detoxification and correction of metabolic disorders; spa
treatments; spa treatment.
Conducting business case stage of the game.Literature: A: 1,2,3. D: 1,2,3,4,5,6,7,8.
30. "hepatomegaly. Differential diagnosis of chronic hepatitis and cirrhosis. Tactics GPs.
Indications for referral to a specialist or hospitalization in specialized department.
Principles of treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching about "(6:00).
Teach GP diagnosis and differential diagnosis, carrying out the optimal variant of treatment tactics
in hepatomegaly caused by various diseases, as well as the principles of management of patients
in a primary health care provided by the requirements of "Qualification characteristics of general
practitioner"
Cirrhosis (from the French kirros - red) - diffuse process characterized by fibrosis and liver
architectonics reorganization, leading to the formation of structurally abnormal nodes.The
International Committee of Gastroenterology recommended for use in clinical hepatology liver
cirrhosis following classification:
Classification of liver cirrhosis (Los Andzhelec, 1994).
According to the etiology: viral, alcoholic, autoimmune, metabolic, alfaantitripsin, holestogenny
(primary, secondary), cryptogenic.
In morphology: portal, Postnecrotic, postgepatitny, laennekovsky, metabolic, biliary, CKD, SKDAs
compensation: compensated, subcompensated, decompensated-xed.Diagnosis of liver cirrhosis
as chronic hepatitis is to identify the main clinical and biochemical syndrome and the use of the
above instrumental methods. Please note that hepatomegaly is more typical of biliary cirrhosis
and in these cases prevails cholestatic syndrome (hyperbilirubinemia, increased alkaline
phosphatase in the blood, jaundice, itching, xanthelasma etc.). When portal cirrhosis
49
hepatomegaly observed in the initial stages of the disease, followed by a decrease in its size and
appearance of splenomegaly. Dominated by other signs of portal hypertension (telangiectasia,
varicose veins, splenomegaly, ascites, etc.)., Jaundice may be absent.
Conducting business case stage of the game.Literature: A: 1,2,3. D: 1,2,3,4,5,6,7,8,9.
31. "Jaundice. Differential diagnosis of cholelithiasis with biliary-pancreatic tumor area
(cancer of the liver, gallbladder, pancreas). Tactics GPs. The principles of follow-up,
monitoring and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about "(6:00).
The predominant symptom - jaundice, which is often preceded by itching. Jaundice develops early
and gradually increases, it is accompanied by Ahola stool, steatorrhea, signs of deficiency of vit
A, D, K Blood: leukocytosis with a shift vlvo, increased erythrocyte sedimentation rate,
deterioration in liver function tests. The liver is enlarged, sealed, often has an uneven surface.
Diagnosis: retrograde cholangiography. Treatment: restoration of patency of the bile ducts is
performed surgically.
Neoplasms of the liver. Liver tumors can be benign or malignant, cells derived from liver or
metastatic.
1) primary hepatocellular carcinoma - characterized by fever of unknown etiology, anemia, weight
loss, increased levels of transaminases, alkaline phosphatase. The history can be moved earlier
viral hepatitis B. Diagnosis is difficult. An important symptom - lasting pain (discomfort) in the
right upper quadrant, and rapid weight loss. Assist in Diagnosing ultrasound, radioisotope
scanning and computed tomography of the upper abdomen. The definitive diagnosis is by liver
biopsy. Treatment: combination therapy, including radical surgery and subsequent
chemotherapy.
2) Metastatic liver disease. Up to 90% of malignant liver tumors are metastatic. Metastases occur
when ovarian adenocarcinoma, pancreatic tumors, tumors of the gastrointestinal tract, small cell
lung cancer. Diagnosis: malignant epithelial tumors of the li
fetoprotein and carcinoembryonic antigen presence of the latter suggests metastatic disease of
-fetoprotein - a primary liver cancer.Diseases that lead to
cholestatic jaundice:
1. Gallstone disease: common bile duct stone, stone hepatic duct, cystic duct stone.
2. Inflammatory diseases: acute and chronic cholecystitis, cholangitis, acute pancreatitis, chronic
pa3. Malignant tumors: liver cancer, gallbladder cancer, bile duct cancer, cancer of the major
duodenal papilla, pancreatic cancer, lymphoma.
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 edematous
compression of the pancreatic head. There are the following forms of the disease: yellownesspain, jaundice, pancreatic, yellowness-holetsistitnaya, icteric-painless, yellowness-septic.
Diagnosis is based on the characteristic triad of symptoms: pain in the right upper quadrant,
quickly developing fever, jaundice, fever with shaking chills. What matters is palpable
gallbladder, leukocytosis in peripheral blood. The diagnosis is confirmed by ultrasound and
retrograde holetsistografii.
Treatment: attack relieves atropine, platifillina, papaverine, no-spa, dibasol, aminophylline,
dipyrone administered antibiotics. Repeated attacks - surgery.
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
examination of treatment.
Conducting business case stage of the game.Literature: A: 1,2,3. D: 1,2,3,4,5,6,7,8,9.
32. Problem-oriented learning on "Abdominal pain", "Dysphagia" and "Jaundice".
50
33. "Articular Syndrome. Diseases that occur with articular syndrome. The most dangerous
diseases that occur with articular syndrome. Differential diagnosis of rheumatism and
rheumatoid arthritis. Tactics GPs. Tactics GPs. Indications for referral to a specialist or
hospitalization in specialized department. Principles of treatment, clinical supervision,
control and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about "(6.0 hours).
Articular Syndrome - a characteristic symptom is manifested by pain in the joints, their deformation
and defiguratsiey, restriction of movements in the joints, changes in tendon and ligaments of the
joints surrounding muscles. The pathogenesis of articular syndrome are inflammatory or
degenerative changes in the joints and peridesmic apparatus, in mild cases, the syndrome occurs
only arthralgia.Rheumatoid arthritis. The reference torque in the diagnosis of rheumatoid arthritis
are transferred connection with streptococcal infection (1-2 weeks); polyarthritis with damage to
large and medium-sized joints, the volatile nature of the defeat of the joints, lasting hours, days,
weeks, with the absence of residual effects in them, otherwise the development of inflammation
in the joints after 3 - 5 days, sometimes even without treatment; the simultaneous development
of carditis; chorea; annular erythema; subcutaneous rheumatic nodules; good effect of
antirheumatic therapy; For small diagnostic criteria include fever, increased erythrocyte
sedimentation rate, acute phase indicators titer antistreptolysin O.The general practitioner should
keep in mind that in recent rheumatism became celebrated cases of chronic persistent flow from
the 2-3 defeat of joints and even a joint with the presence of proliferative changes resembling
rheumatoid arthritis. Unlike the latter, it is the absence of morning stiffness, symmetry of the
process, the lack of rheumatoid factor in the blood. Acute inflammation of the joints, and
suggests the possibility of a so-called palindromic rheumatism obscure nature, distinguishing
feature is the repeated attacks of arthritis at irregular intervals, more frequently in men middleaged and elderly. This usually affects one or more joints (most often the knee, then the wrist, or
the small joints of the hands).Rheumatoid arthritis. It is a chronic systemic autoimmune
inflammatory disease of the connective tissues, mainly affecting the joints of the type of erosivedestructive progressive polyarthritis.The general practitioner should ask in detail the patient and
pay attention when inspecting it at the following diagnostic criteria: morning stiffness in the
joints, joint swelling lasting more than one and a half months, the bilateral symmetrical defeat
joints of the hands ("fin walrus"), the rapid development of atrophy of the regional muscles, the
presence of painless motile rheumatoid nodules, visceral (pleurisy, gastritis, liver enlargement,
myocarditis, pericarditis, renal amyloidosis, polyserositis, etc.), an increase of alpha-1 and 2 and
gamma-globulin levels, the presence of rheumatoid factor in the serum or synovial membrane
(reaction Voleri Rose, latex-test), elevation of C-reactive protein, decrease in the number of Tlymphocytes, T-suppressor function disimmunoglobulinemiya expressed as cell count in the
synovial fluid; biopsy: histological changes of the synovium (synovial proliferation, lymphoid
and plasma cells, hypertrophy, necrosis).
In 10% of cases there is joint-visceral form of the disease, characterized by aggressive, rapidly
progressive course, almost constant activity. In this embodiment, the disease is usually a general
practitioner is forced to send the patient to the hospital due to unsuccessful outpatient treatment
and the severity of the condition.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11.
34. "The differential diagnosis of seronegative spondyloarthritis (reactive arthritis, ankylosing
spondylitis, psoriatic arthritis). Tactics GPs. Indications for referral to a specialist or
hospitalization in specialized department. Principles of treatment, clinical supervision,
control and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about "(6:00).
Reactive arthritis are "sterile" inflammatory arthritis occurring in close temporal (1-1.5 months) due
to any particular infection. For all reactive arthritis characterized by acute onset, clinical
51
manifestations and bright in most cases complete regression of. It is necessary to consider the
following types of reactive arthritis.
Yersinia arthritis caused Xersinia enterxolitika, more often in women. Articular syndrome that
develops in 1-3 weeks, preceded intestinal symptoms such as short-term diarrhea, cholecystitis,
appendicular colic, pain in the right iliac fossa. Typically asymmetrical joint disease of the lower
extremities in the process may involve the acromioclavicular and sternoclavicular joints, the
joints of the first fingers and toes, reveals unilateral sacroiliitis, tendovaginitis, bursitis, fever,
extra-articular manifestations (episcleritis, conjunctivitis, iritis, myocarditis). In the blood - high
leukocytosis and ESR, the detection of antibodies to Yersinia.
Dysenteric salmonellёzny arthritis and differ little from Yersinia reactive arthritis. There are 2 3weeks of disease. A characteristic feature of arthritis - severe pain intensity. Diagnosis of
reactive arthritis enterogenous established on the basis of clinical data, history of connection
with the intestinal infection, the detection of the pathogen in the feces, positive serological
reactions.
Syndrome (disease) Reytera.- combined lesion of urogenital organs, joints and eyes, paced
simultaneously or sequentially. More common in young men. Pathogen Chlamydia trahomatis,
infection is transmitted sexually and asexually, found intracellularly in the epithelium of the
urethra, conjunctiva and synovial cell cytoplasm. In stage 2 of the disease begins
immunopathological damage joints and eyes. Characteristically asymmetric lesion of large joints
of the lower extremities. Clinical disease occur urethritis, cystitis, prostatitis, conjunctivitis,
arthritis. Inherent "as staircase type" joint damage ("bottom-up"), pain worse at night and in the
morning, the skin over them hyperemia, exudate appears. The joints predominate exudative
manifestations may occur ulcerative stomatitis, glossitis, Balanta, keratoderma, nail infections;
blood - leukocytosis, increased ESR antigen HLA - B - 27.
Ankylosing spondylitis. Ankylosing spondylitis (ankylosing spondylitis) - a chronic
inflammatory joint disease ankylosing axial skeleton (intervertebral, vertebrates, sacroiliac),
referring to the group of seronegative spondiloartrtov. More common in men aged 20 - 40 years.
In 90 - 95% of people with a disease associated antigen HLA - B -27.
Psoriatic arthritis. Diagnostic criteria are: the defeat of the distal interphalangeal joints of the
hands (fingers can purchase "allantoid" form); the defeat of the first joint thumb; early loss of the
big toe; heel pain; the presence of psoriatic plaques, nail infections; psoriasis in the immediate
family; the absence of rheumatoid factor; radiological manifestations: osteolytic process
raznoosevym offset bone periosteal overlay, no overarticulation osteporoz; clinical and
radiological signs of sacroiliitis; radiological evidence of paravertebral calcification; Diagnosis is
valid with the presence of three criteria, one of which must be: the presence of psoriatic plaque
psoriasis nail involvement or in the immediate family, or osteolytic process raznoosevym offset
bones.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11.
35. "The differential diagnosis of seronegative spondyloarthritis (reactive arthritis, ankylosing
spondylitis, psoriatic arthritis). Tactics GPs. Indications for referral to a specialist or
hospitalization in specialized department. Principles of treatment, clinical supervision,
control and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about "(6:00).
On a practical lesson in the theoretical part series covers the following subjects: the
characteristics of the articular syndrome in reactive, psoriatic arthritis, ankylosing
spondylitisReactive arthritis are "sterile" inflammatory arthritis occurring in close temporal (11.5 months) due to any particular infection. For all reactive arthritis characterized by acute onset,
clinical manifestations and bright in most cases complete regression of. It is necessary to
consider the following types of reactive arthritis.Yersinia arthritis caused Xersinia enterxolitika,
more often in women. Articular syndrome that develops in 1-3 weeks, preceded intestinal
52
symptoms such as short-term diarrhea, cholecystitis, appendicular colic, pain in the right iliac
fossa. Typically asymmetrical joint disease of the lower extremities in the process may involve
the acromioclavicular and sternoclavicular joints, the joints of the first fingers and toes, reveals
unilateral sacroiliitis, tendovaginitis, bursitis, fever, extra-articular manifestations (episcleritis,
conjunctivitis, iritis, myocarditis). In the blood - high leukocytosis and ESR, the detection of
antibodies to Yersinia.
Dysenteric salmonellёzny arthritis and differ little from Yersinia reactive arthritis. There are 2 - 3
weeks of disease. A characteristic feature of arthritis - severe pain intensity. Diagnosis of
reactive arthritis enterogenous established on the basis of clinical data, history of connection
with the intestinal infection, the detection of the pathogen in the feces, positive serological
reactions.Syndrome (disease) Reytera.- combined lesion of urogenital organs, joints and eyes,
paced simultaneously or sequentially. More common in young men. Pathogen Chlamydia
trahomatis, infection is transmitted sexually and asexually, found intracellularly in the epithelium
of the urethra, conjunctiva and synovial cell cytoplasm. In stage 2 of the disease begins
immunopathological damage joints and eyes. Characteristically asymmetric lesion of large joints
of the lower extremities. Clinical disease occur urethritis, cystitis, prostatitis, conjunctivitis,
arthritis. Inherent "lestnitseobrazny type" joint damage ("bottom-up"), pain worse at night and in
the morning, the skin over them hyperemia, exudate appears. The joints predominate exudative
manifestations may occur ulcerative stomatitis, glossitis, Balanta, keratoderma, nail infections;
blood - leukocytosis, increased ESR antigen HLA - B - 27.
Ankylosing spondylitis. Ankylosing spondylitis (ankylosing spondylitis) - a chronic
inflammatory joint disease ankylosing axial skeleton (intervertebral, vertebrates, sacroiliac),
referring to the group of seronegative spondiloartrtov. More common in men aged 20 - 40 years.
In 90 - 95% of people with a disease associated antigen HLA - B -27.Psoriatic arthritis.
Diagnostic criteria are: the defeat of the distal interphalangeal joints of the hands (fingers can
purchase "sosiskoobraznuyu" form); the defeat of the first joint thumb; early loss of the big toe;
heel pain; the presence of psoriatic plaques, nail infections; psoriasis in the immediate family;
the absence of rheumatoid factor; radiological manifestations: osteolytic process raznoosevym
offset bone periosteal overlay, no okolosustavnogo osteporoza; clinical and radiological signs of
sacroiliitis; radiological evidence of paravertebral calcification; Diagnosis is valid with the
presence of three criteria, one of which must be: the presence of psoriatic plaque psoriasis nail
involvement or in the immediate family, or osteolytic process raznoosevym offset bones.
Conducting business problem-based learning games.Literature: O: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11.
36. "Articular Syndrome. Differential diagnosis of SLE, SSc. Tactics GPs. The principles of
follow-up, monitoring and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about "(6:00).
On a general practitioner has an important responsibility in the primary treatment of patients with
early DBST in terms of their diagnosis, as by promptly started pathogenetic therapy depends on
the further course, the occurrence of various complications and prognosis of patients living with
this serious disease. The defeat of the joints can be observed in SLE. Articular Syndrome thus
may flow type polyarth- like revmatoid or arthritis.
Articular syndrome in SSc proceeds as polyarthralgia or polyarthritis. The defeat of the joints
combined with Raynaud's syndrome, characteristic skin lesions of the esophagus and other
internal organs. Arthritis at DM are rare. Most are marked polyarthralgia not intensive. The
clinical picture is dominated by skin-muscle syndrome.
The diagnosis of SLE is composed of a set of clinical and laboratory data. In a typical SLE with
damage to the skin, the presence of LE-cells or antibodies to native DNA, high titers of
antinuclear factor diagnosis presents no problems. American Associations for Rheumatology has
established 11 criteria: 1.Eritema butterflies in the area - 57%. 2. discoid lupus pockets -18%.
3.Fotosensibilization -43%. 4. ulcer in the oral cavity or nasal -27%. 5.nonerozive arthritis 87%. 6. Pleurisy - 52% or pericarditis7.Long-lasting proteinury - 52% or cylinders in the urine 53
36%. 8. Seizures or psychosis - 12- 13%. 9.Gemoliticheskaya anemia or leukopenia, or
thrombocytopenia - 18% - 46% - 21% respectively. 10.LE-cells - 73% or DNA-antibodies 67%, Sm antibodies - 31%. False positive test for syphilis - 15%. 11. Antinuklear antibodies 99%The treatment program in SLE: the regime, diet, hormonal immunodepressants, hormonal
immunodepressants, immunotherapy, intensive care, aminohinolinovogo compounds, NSAIDs,
anticoagulants and antiplatelet agents, efferent therapy, the treatment of lupus nephritis.Systemic
sclerosis (SSc) - progressive polysyndrome disease with characteristic changes in the skin,
musculoskeletal system, internal organs (lungs, heart, digestive tract, kidneys) and common
vasospastic disorders by type of Raynaud's syndrome, which are based on the substitution of
connective tissue with a predominance of fibrosis and vascular pathology in the form of
obliterative endarteritis.
Diagnostic signs of systemic scleroderma. Major peripheral: scleroderma skin lesions, Raynaud's
syndrome, joint and muscle syndrome (contractures), osteolysis of cardio macrofocal,
scleroderma defeat of the digestive the terminal phalanges, calcification. Visceral: basal fibrosis,
tract, acute scleroderma nephropathy. Laboratory data: antinuclear antibodies (anti - SCR-70 and
antitsentromernye antibodies).
Medical program at MIC: 1. Treatment of anti-fibrotic agents. 2.NPVS. 3.Immunodepressantnye
funds. 4.Gipotenzivnye and improving microcirculation means. 5.Lokalnaya therapy, massage,
exercise therapy. 6.Efferentnaya therapy. 7.Simptomaticheskoe treatment of lesions of the
digestive system. 8. Spa treatment.
Application antifibrotic agents (D-penicillamine, colchicine, diutsifona, enzyme preparations,
dimethyl sulfoxide) is a basic therapy. Tactics GP at DBST: when first diagnosed DBST
hospitalization to confirm the diagnosis and choice of treatment, further medical examination
and outpatient treatment.
Conducting business problem-based learning games.Literature: O: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11.
37. Differential diagnosis of hemorrhagic vasculitis, nonspecific aortoarteritis and
periarteritis nodosa. The tactics of the general practitioner. The principles of follow-up,
monitoring and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
The principles of teaching subjects (6 hours).
On a practical lesson in the theoretical part series discusses the following topics: general
characteristics for CB, the list of diseases related to them, diagnosis and differential diagnosis,
tactics GP at ST.
At the heart of SW are common necrotic-inflammatory changes in the blood vessels. They may be
primary, in which the inflammatory vascular changes are the basis of clinical and anatomical
manifestations of the disease in all its stages, and secondary as part DBST rheumatoid
arthritis.Hemorrhagic vasculitis (Henoch's disease). Communication with the disease of viral and
bacterial infection, vaccination, medicines, food and other allergies, etc. Have often hives and
other allergic rashes, the presence of painless periods, the heat from the very onset of the disease,
increasing the factor Willy-Brandt plasma 1.5-3 times, superfibrination increase alpha2 and
gammaglobulins.
Tactics GP at the first detection of the disease requiring hospitalization to confirm the diagnosis,
reduction of inflammatory activity and selection of basic therapy. In the future, follow-up and
outpatient treatment.
DBST - a disease characterized by systemic immunological lesion of connective tissue and its
derivatives. The former name of this group of diseases, "collagen". It brings together a number of
entities that are characterized by: common pathogenesis (immune and autoimmune mechanisms
of development), systemic failure of the connective tissue and blood vessels autoimmune origin
due to the deposition of immune complexes (changing the basic substance of the connective
tissue, fibrinoid necrosis, disruption of fibrous structures, vasculitis, lymphoid and plasmocytic
54
infiltrates) polymorphism of the clinical picture and the progressive nature of the currents, the
positive effect of corticosteroids, NSAIDs, cytostatics, no Monoetiological factor.
Non-specific aortoarteriit (Takayasu's disease) - a systemic disease characterized by inflammation
of the aorta and its branches extending from the development of a partial or total obliteration of
them; can affect other parts of the aorta. The etiology is unclear. The leading role belongs to the
pathogenesis of immune disorders with the development of chronic inflammation of the wall of
immune affected vessels. Ill mostly young women.
Symptoms within. Gradually growing signs of circulatory disorders in the areas affected vessels.
The main symptom - lack of pulse on one or both hands, at least - in the carotid, subclavian,
temporal arteritis. Patients complain of pain and paresthesias in extremities, aggravated by
exertion, weakness in the arms, often dizzy spells with loss of consciousness. Ophthalmoscopy
detect changes in retinal vessels (narrowing, arteriovenous anastomoses education and others.).
Treatment. Applied average doses of glucocorticoids (prednisone 20 - 30 mg / day) during the
exacerbation within 1.5 - 2 months, with a gradual decrease to a maintenance dose. Displaying
aminohinolinovogo systematic use of drugs (0.25 g hingamin or Plaquenil 0.2 1 g once a day). It
is widely used vasodilators and disaggregants. Perhaps prosthetics affected arteries.
Periarteritis nodosa. The possibility of having a history of exogenous antigenic stimuli (viruses,
bacteria, drugs, poisons, serums, vaccines etc.). more common in men, weight loss, fever,
systemic failure (kidney, lung, heart, etc.), identification of nodules along the vessels, the
biopsies of nodules, it is necessary to consider the possibility of a true acute abdomen (necrosis,
ulcer with peritonitis, bleeding). The most important method of diagnosis is biopsy periarteritis,
allowing to establish a typical necrotizing arteritis. Foreign researchers believe the most valuable
biopsy of the kidney as a result of the biopsy fails to differentiate the different types of vasculitis.
So, Wegener's granulomatosis is characterized by glomerulonephritis with crescents formation
for hemorrhagic vasculitis - necrotizing glomerulitis. To verify the version used
immunomorfologicheskie vasculitis and electron microscopic studies. Skin biopsy gives the
maximum frequency of positive results, it can have an important reference value for the
diagnosis, but not be definitively verifier, since estimates are available for only small vessels.
Treatment of polyarteritis nodosa: 1. Immunosuppressive. 2. extracorporeal therapy. 3. antiplatelet
agents and anticoagulants. 4. NSAIDs and aminohinolinovogo connection. 5. Angioprotectors. 6.
symptomatic treatment.
Conducting business problem-based learning games.Literature: O: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11.
38. Problem-oriented training on "Articular Syndrome."
39. "Changes in urinary sediment. Differential diagnosis of immuno and inflammatory
diseases of the kidneys (acute and chronic glomerulonephritis, interstitial nephritis. The
principles of follow-up, monitoring and rehabilitation in a hovercraft or a joint venture.
The principles of prevention. The principles of teaching about "(6:00).
On a practical lesson in the theoretical part series includes: acute and chronic glomerulonephritis
and interstitial nephritis, diagnosis and differential diagnosis of these diseases.Acute poststreptococcal glomerulonephritis develops within 10-12 days after tonsillitis, pharyngitis. In the
urine, along with varying degrees of proteinuria may appear red blood cells and cylinders. From
extrarenal symptoms are the most important edema, hypertension, oliguria.
Chronic glomerulonephritis occurs with several clinical syndromes: an isolated urinary
syndrome, hypertension, nephrotic syndrome and combinations thereof. Chronic
glomerulonephritis with isolated urinary syndrome is characterized by a subclinical course,
change in urine more frequently detected in the clinical examination. This extrarenal symptoms
are absent in the urine -proteinuriya no more than 1-2 g / day, microscopic hematuria, a small
cylindruria.
For chronic glomerulonephritis with hypertensive syndrome characterized by hypertension,
proteinuria is not high, microscopic hematuria. It is more common in young adults. Clinical
manifestations: intense headaches, dizziness, decreased vision, pain in the heart, palpitations,
55
shortness of breath. On the ECG signs of left ventricular hypertrophy. Chronic
glomerulonephritis can be complicated by left ventricular failure (cardiac asthma, pulmonary
edema). Chronic glomerulonephritis with nephrotic syndrome is characterized by a high degree
of proteinuria to nephrotic syndrome, and edema.
Interstitial nephritis - Acute or chronic abacterial, non-destructive inflammation of interstitial
kidney tissue with subsequent involvement in the process of all of the nephron.Acute interstitial
nephritis. Clinic: 2-3 days after injection of penicillin, receiving sulfonamides, analgesics,
NSAIDs and other medications, pain in the lumbar region, headache, weakness, drowsiness,
nausea, loss of appetite, sweating, increased body temperature and blood pressure, reduced urine
output may the development of acute renal failure, usually reversible. Laboratory data. KLA: a
small leukocytosis with a mild shift to the left, eosinophilia, increased ESR. LHC: increased
content α2- and β- globulin, creatinine, urea. OA urine: proteinuria, microscopic hematuria,
leukocyturia, small cylindruria, reduction in the density of urine.
Chronic interstitial nephritis. Clinic. Dull pain in the lumbar region, weakness, fatigue, thirst,
polyuria, increased blood pressure. Laboratory data. KLA: signs of anemia, increased
erythrocyte sedimentation rate. OA urine: polyuria with low density of urine, proteinuria,
microscopic hematuria, a small leukocyturia. TANK: elevated levels of creatinine and urea.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
40. "Changes in urinary sediment. Differential diagnosis of nephropathy (pregnant, diabetic,
drug) Indications for referral to a specialist or hospitalization in specialized department.
Principles of treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching about "(6:00).
Diabetic nephropathy (principally as diabetic glomerulosclerosis) occurs in diabetes mellitus type I
and II, is characterized, in addition to proteinuria, polyneuropathy, micro - and macroangiopathy.
Thrombosis of the renal vein, patients complain of intense pain in the lumbar region, along with
proteinuria have revealed red blood cell (to the extent of gross hematuria), oliguria, anuria with
the development of ARF.
Nephropathy pregnant usually develops in the preceding dropsy pregnant. To detect nephropathy
in every pregnant systematically investigate the presence of protein in the urine, measure the
blood pressure (BP) and control body weight by weighing. For pregnant nephropathy is
characterized by a triad of symptoms: swelling; increased blood pressure; the presence of protein
in urine. Sometimes pronounced than three, and one or two of these symptoms.
Nephropathy is dangerous for women's health and fetal development, fetal death is possible.
Nephropathy pregnant or late toxicosis of pregnancy - a disease that occurs in women with
healthy kidneys, as a rule, in the III trimester of pregnancy and passing afterwards. This is called
primary nephropathy. It is manifested by proteinuria, edema and hypertension, and may be both
mono- and polisimptomny options toxicity. Among the causes of maternal and perinatal infant
mortality nephropathy pregnant women is relatively high proportion. The frequency of
nephropathy pregnant, according to different authors, varies within 2,2-15,0%.
The most frequent and important manifestation of nephropathy is pregnant hypertensive syndrome.
If a woman in the second half of pregnancy blood pressure greater than 130/85 mm Hg. Art. or
increases to 20-30 mm Hg. Art. compared to the original, you should suspect nephropathy.
Changes in retinal vessels is not always observed. In most cases, they are similar to those that
occur in hypertension - a spasm of the arterioles (hypertensive angiopathy), papilledema,
hemorrhages and foci of degeneration.
The second is the frequency of occurrence of edematous syndrome. Initially, minor swelling and
objectively them difficult to identify. Therefore, mandatory weekly weigh-pregnant woman.
Increased body weight more than 600 g per week indicates pathological fluid retention. First
edema appear on the legs, then spread to the hips, lower back, abdomen, breasts, at least on the
face. Abdominal swelling are rare. Urine output is usually reduced, and with significant swelling,
especially rapidly developing countries, there may be a pronounced oliguria.
56
Proteinuria, reaching 1-6 g / l, and sometimes 40 g / l or more, combined with microscopic
haematuria and cylindruria - the third important clinical and laboratory signs of nephropathy
pregnant. More significant hematuria may indicate a combination of nephropathy
glomerulonephritis.
Medicinal kidney damage are common, have different reasons and often remain undiagnosed. Less
known only 30 years ago, they now occupy an important place in the practice of physicians,
nephrologists and other specialists.
The dosage is necessary to assume the cause in each case of renal failure - both acute and chronic,
regardless of its nature - glomerular, vascular or tubular. The same drug can cause different
variants of kidney damage, such as pre-renal (hemodynamic), acute renal failure (ARF), acute
tubular necrosis (IPOs) or chronic progressive interstitial nephritis. From a practical standpoint
drugs kidney damage conveniently subdivided into acute and chronic. It is also important to
allocate a leading clinical syndrome - it is necessary for differential diagnosis and detection of
drug etiology nephropathy. Medicinal kidney damage manifested acute renal failure; chronic
renal failure (CRF); proteinuria or nephrotic syndrome; tubular disorders; obstruction of the
urinary tract, obstructive uropathy. Acute kidney damage drugs can be functional (transient,
reversible) and organic (with the development of structural changes).
Hemodynamic disorders range from a slight reduction in renal blood flow and glomerular filtration
rate up to severe cases of acute renal failure with IPOs - more likely to occur when taking
NSAIDs, at least - dipyrone and aspirin. Acute renal failure may occur at different times of
treatment - from several hours to several months. Approximately 1/3 of these patients required
hemodialysis, 28% of which kidney function is not restored.
Among the drugs that lead to acute renal failure and IPOs, in the first place are the antibiotics ampicillin, cephalosporins, amphotericin. But most other IPOs aminoglycoside antibiotics cause.
Renal disease develops almost 10% of patients treated with aminoglycosides (the most toxic
gentamicin, kanamycin, tobramycin, streptomycin low nephrotoxicity). Aminoglycosides
excreted by the kidneys unchanged, their nephrotoxicity associated with direct cell
tubulotoksicheskim action. Increased risk of nephrotoxicity in patients with chronic kidney
disease (particularly - with reduced function), high fever, fluid and electrolyte disturbances
(hypovolemia, lack K) in the elderly. Nephrotoxicity of aminoglycosides is compounded when
combined with loop diuretics, cephalosporins, vancomycin, amphotericin B, calcium antagonists,
contrast media (RCC).
Treatment of patients with AN provides for full discontinuation of analgesics and NSAIDs. Only
in case of emergency, you can assign paracetamol, which has the lowest nephrotoxicity.
Requires high fluid intake (at least 2 liters per day). Showing correction of metabolic acidosis
and electrolyte abnormalities, early treatment of metabolic disorders of Ca and P.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
41. "The tactics of the GP when proteinuria and altered urinary sediment. Differential
diagnosis of the different stages of chronic renal failure. Treatment according to steps.
Indications for hemodialysis. . The principles of follow-up, monitoring and rehabilitation in
a hovercraft or a joint venture. Principles of prophylaxis "(6 hours).
CRF - a pathological symptom due to a sharp decrease in the number and function of nephrons,
which leads to a violation of the excretory and endocrine function of the kidneys, all kinds of
frustration metabolic activity of organs and systems, acid-base balance. The most common
causes of CKD -hronichesky glomerulonephritis, chronic pyelonephritis, nephritis in systemic
diseases, hereditary nephritis, polycystic kidney disease, nefroangioskleroz, diabetic
glomerulosclerosis, renal amyloidosis, and urological diseases (bilateral or single kidney). There
are 4 stages of the clinical course of chronic renal failure (Lopatkin NA, IN Kuczynski, 1973.):
Latent; compensated; of intermittent; terminal.
57
Latent stage - no complaints, urine output within the normal hemoglobin of more than 100, the
sample Zimnitsky normal, blood urea to 8.8 mmol / L, creatinine of blood to 0.18 mmol / L,
glomerular filtration of 45-60 ml / min. , urine osmolality 450-500 mosmol / l, blood electrolytes
within normal limits, metabolic acidosis offline.
Compensated stage - complaints dyspepsia, dry mouth, fatigue; diuresis - easy polyuria, 85-100
hemoglobin, blood urea 8,8-10 mg / dL, blood creatinine 0,2-0,28 mmol / l, glomerular filtration
30-40 ml / min., urine osmolality to 400 mOsm / l rarely hyponatremia, metabolic acidosis
lacking.Of intermittent stage - complaints of weakness, headaches, insomnia, thirst, nausea;
marked polyuria, hemoglobin 65-85, gipoizostenuriya, blood urea of 10-19 mmol / l, creatinine
of 0.3-0.6 mmol / l, glomerular filtration 20-30 ml / min., urine osmolality less than 250 mOsm /
l, often hyponatremia, hypocalcemia, mild metabolic acidosis.
End-stage consists of 4 periods:
I - water-excretory kidney function is preserved. Clearance is reduced to 10-15 ml / min, azotemia 71-107mmol / l with a tendency to increase. Acidosis moderate water-electrolyte imbalance
there.
II A - oligo-or anuria, fluid retention, diselektrolitemiya, hyperasotemia, acidosis. Reversible
changes in the cardiovascular system and other organs. Arterial hypertension. NC IIA.II B - the
same data, but more severe heart failure with blood circulation in small and large circles.
III - severe uremia, hyperasotemia (285 mmol / l and above), diselektrolitemiya, decompensated
acidosis. Decompensated heart failure, seizures, cardiac asthma, anasarca, severe degeneration of
the liver and other internal organs.
Treatment of chronic renal failure is inseparable from the treatment of kidney disease, which led to
kidney failure. The stage is not accompanied by impaired renal processes, conduct etiological
and pathogenetic therapy that can heal the sick and prevent the development of renal failure or
lead to remission and a slower disease course. At the stage of renal processes pathogenetic
therapy does not lose value, but increases the role of symptomatic therapies (antihypertensive
agents, antibacterial agents, restriction of protein in the daily diet - no more than 1 g per 1 kg of
body weight, a spa treatment, etc.). Therapeutic measures are mainly aimed at the restoration of
homeostasis, reduction of azotemia and reducing the symptoms of uremia.
The protein content in the daily diet depends on the degree of renal dysfunction. When glomerular
filtration rate below 50 ml / min, and blood creatinine level above 0.02 g / l is expedient to
reduce the amount of protein consumed 30-40 g / day, while the glomerular filtration below 20
ml / min is assigned a diet having a protein content of not more than 20 -24 g / day. The diet
should be high-calorie (about 3000 kcal), and contain essential amino acids (potato-egg diet
without meat and fish). The food is prepared with a limited (2-3 g) amount of salt and
hypertension patients with a high - no salt. By reducing diuresis shown furosemide (Lasix) doses
(up to 1 g / day) providing polyuria. To reduce blood pressure using conventional
antihypertensive drugs (see. Hypertensive heart disease), in conjunction with
furosemide.Hemodialysis can be shown an exacerbation of renal failure and after the
improvement of the patient can be back more or less to spend long conservative therapy. Good
effect in CRF give repeated courses of plasmapheresis.
In the terminal phase, if conservative treatment has no effect, and if there are no contraindications,
the patient is transferred to the treatment of regular (2-3 times a week) hemodialysis.Forecast.
Hemodialysis and kidney transplant patients with CRF change destiny, can extend their lives and
achieve recovery for years. Selection of patients for these therapies performed by specialists
hemodialysis centers and organ transplantation.
Conducting business problem-based learning games.Literature: O: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
42. "edematous syndrome. Differential diagnosis of edema of various etiologies local - allergic,
cardiovascular, inflammatory; General - circulatory insufficiency, renal, endocrine,
hungry.Printsipy teaching about "(6:00).
58
On a practical lesson in the theoretical part series discusses the following topics: Classification of
edema: I General edema: 1.zabolevaniya heart; 2.diseanes of kidney; 3.diseanes of liver;
4.edema gipoproteinemic; 5.idiopatic swelling.
Local oteki.A II. venous edema: 1.ostry deep vein thrombosis; 2.hronicheskaya venous
insufficiency; 3.venoznaya obstruction; B. lymph edema: swelling of lymph 1.idiopaticheskie: a)
congenital idiopathic lymphedema; b) early lymph edema. 2.vospalitelnye lymph edema;
3.obstruktivnye lymph oteki.V. body swelling. G. other types of edema: swelling
1.ortostaticheskie; 2.arterio-venous edema; 3.oteki after vascular surgery; 4. The swelling caused
by lesions of the musculoskeletal system: a) muscle pathology; b) an inflammation of the tendon
sheath; c) fracture of the metatarsals; d) Baker's cyst; 5.reflektornaya sympathetic dystrophy.III
Swelling caused by medication. a) hormones. b) antihypertensive drugs. c) anti-inflammatory
drugs. r) other drugs.Recall only that for kidney swelling occur so-called nephrotic syndrome. In
the primary nephrotic syndrome pathogenesis of edema caused by kidney disease, including
glomerulonephritis leading role. Secondary nephrotic syndrome is a consequence of many
diseases in which the kidneys are involved in the pathological process of secondary
(amyloidosis, nephropathy pregnant, tuberculosis, syphilis, DBST, vasculitis, poisoning by salts
of heavy metals, hypernephroma and more) for it, in addition to edema, characterized by massive
proteinuria, hyperproteinemia, hyperlipidemia, hypercoagulable often.
When edema caused by bowel disease, a history there are indications of diseases associated with
impaired digestive and absorptive function of his diarrhea, leading to gipoproteinemicheskim
states. The same genesis are swelling the deficit supply neurotic loss of appetite.
Swelling with heart disease associated with the development of heart failure.
Circulatory failure (NC) - a pathological condition is failure of the circulatory system to deliver
organs and tissues of the amount of blood required for their normal functioning.
Clinically, heart failure manifests a number of characteristic symptoms: Shortness of breath,
orthopnea, cardiac asthma, nocturia, peripheral edema and enlargement of the liver, sometimes
ascites, anorexia, wheezing over the lungs, enlargement of the heart, atrial gallop, a third heart
sound, jugular veins, anasarca, ascites.
Treatment of the underlying disease, which led to the HNK, can significantly reduce its
manifestation, to increase the effectiveness of therapeutic measures.
Rational
treatment regimen. Clinical nutrition. HNK appointed tables at number 10 or 10a. restriction of
salt and water. meals should be 5-6 times a day (with the use of a small amount of food intake);
food should be easily digestible, fortified, koloriynost diet 1900-2500 kcal per day.Strengthening
reduced myocardial contractility is conducted through the application of cardiac glycosides and
non-glycoside inotropic agents. Diuretics, ACE inhibitors, blo
-adrenergic receptors,
peripheral vasodilators, angiotensin receptor antagonists II, anti-arrhythmic drugs.Drug-free
treatment of patients with HNS. Among the non-drug therapies in the HNS often use isolated
ultrafiltration of blood. Intraaortic balloon kontripulsatsiya used in clinical practice as a method
for temporary mechanical support of the pumping function of the left ventricle.
kontripulsatsiyu balloon is most often used in acute heart failure. however, this method is also used
in patients with CHF. it is indicated for patients with end-stage heart failure, which is preparing
for a heart transplant and surgery, to maintain heart function after transplantation, patients in the
development of ventricular arrhythmias refractory to medical therapy.
Conducting business problem-based learning games.Literature: O: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
43. "edematous syndrome. Differential diagnosis of edema of various etiologies (local allergic, cardiovascular, inflammatory, general - circulatory insufficiency, renal, endocrine,
hungry). Tactics GPs. Indications for referral to a specialist or hospitalization in
specialized department. Principles of treatment, clinical supervision, control and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about "(6:00).
59
On a practical lesson in the theoretical part series discusses the following topics: Classification of
edema: I General edema: 1.zabolevaniya heart; 2.zabolevaniya kidney; 3.zabolevaniya liver;
4.oteki gipoproteinemic; 5.idiopaticheskie swelling.
Local edemeoes.A II. venous edema: 1.ostry deep vein thrombosis; 2.hronicheskaya venous
insufficiency; 3.venoznaya obstruction; B. lymph edema: swelling of lymph 1.idiopaticheskie: a)
congenital idiopathic lymphedema; b) early lymph edema. 2.vospalitelnye lymph edema;
3.obstruktivnye lymphedemA V. body swelling. G. other types of edema: swelling
1.ortostaticheskie; 2.arterio-venous edema; 3.oteki after vascular surgery; 4. The swelling caused
by lesions of the musculoskeletal system: a) muscle pathology; b) an inflammation of the tendon
sheath; c) fracture of the metatarsals; d) Baker's cyst; 5.reflektornaya sympathetic dystrophy.III
Swelling caused by medication. a) hormones. b) antihypertensive drugs. c) anti-inflammatory
drugs. r) other drugs.
Recall only that for kidney swelling occur so-called nephrotic syndrome. In the primary
nephrotic syndrome pathogenesis of edema caused by kidney disease, including
glomerulonephritis leading role. Secondary nephrotic syndrome is a consequence of many
diseases in which the kidneys are involved in the pathological process of secondary
(amyloidosis, nephropathy pregnant, tuberculosis, syphilis, DBST, vasculitis, poisoning by salts
of heavy metals, hypernephroma and more) for it, in addition to edema, characterized by massive
proteinuria, hyperproteinemia, hyperlipidemia, hypercoagulable often.
When edema caused by bowel disease, a history there are indications of diseases associated with
impaired digestive and absorptive function of his diarrhea, leading to gipoproteinemicheskim
states. The same genesis are swelling the deficit supply neurotic loss of appetite.
Swelling with heart disease associated with the development of heart failure.Circulatory failure
(NC) - a pathological condition is failure of the circulatory system to deliver organs and tissues
of the amount of blood required for their normal functioning.Clinically, heart failure manifests a
number of characteristic symptoms: Shortness of breath, orthopnea, cardiac asthma, nocturia,
peripheral edema and enlargement of the liver, sometimes ascites, anorexia, wheezing over the
lungs, enlargement of the heart, atrial gallop, a third heart sound, jugular veins, anasarca, ascites.
Treatment of the underlying disease, which led to the HNK, can significantly reduce its
manifestation, to increase the effectiveness of therapeutic measures. Rational treatment regimen.
Strengthening reduced myocardial contractility is conducted through the application of cardiac
glycosides and non-adrenergic
receptors, peripheral vasodilators, angiotensin receptor antagonists II, anti-arrhythmic
drugs.Drug-free treatment of patients with HNS. Among the non-drug therapies in the HNS often
use isolated ultrafiltration of blood. Intraaortic balloon kontripulsatsiya used in clinical practice
as a method for temporary mechanical support of the pumping function of the left ventricle.
kontripulsatsiyu balloon is most often used in acute heart failure. however, this method is also
used in patients with CHF. it is indicated for patients with end-stage heart failure, which is
preparing for a heart transplant and surgery, to maintain heart function after transplantation,
patients in the development of ventricular arrhythmias refractory to medical therapy.
Conducting business game case study.Literature: O: 1,2,4,5,6. D: 1,2,3,4,5,8,9,10,11,12.
44. The problem of the age norm. Functional and organic changes in aging. Physiology and
hygiene of food of older (6 hours).
Geriatrics - part of gerontology and medicine, having affairs with all aspects of health elderly. By
gerontology include the biology of aging and social gerontology.Safety and health at work of
older workers. Ageing is an individual process, but the aging process can be accelerated in cases
of hard work, for example as a manual lifting of heavy loads, excessive noise impact is not
normal working hours or excessive cleanly and organizational change. Among the wide range of
occupational safety and health issues that are relevant to older workers, the following are
particularly important:
Muscle strength. Despite the fact that the individual capacities differ from each other, muscle
strength generally decreases with age, so older workers work, perhaps closer to the limit of its
60
normal. Manual transport of goods and other activities that require muscle strength should be
regulated properly: for that you need to know about potential abilities of older workers.- The
amplitude of the movement and position of the body. Reduced joint mobility may affect the
performance of certain types of work that require rapid movement, or intractable, and the
workers may have restrictions on movements. The ergonomic design of work equipment and
processes is an important principle for all workers, but again, the job must be checked and
adjusted properly to prevent excess individual capabilities.
sharp View. The ability to see well, and the ability to determine the distance required for many
types of work, for example, drivers of vehicles or equipment operators. Employers should ensure
a good visual environment (for example with good lighting), but in addition, for some workers it
is necessary to carry out inspection of, to ensure safety and health in the workplace for them and
for others, and not to create dangerous situations due to visual impairment. Such checks of even
more necessary for older workers.
-Sluh. Hearing loss caused by age-related changes, the most common among older workers: this,
together with hearing loss from exposure to noise, older workers complicates the distinction of
sounds, especially high. Employers should take steps to reduce the intensity of noise in the
environment to an acceptable level, but individual hearing loss can have a negative impact on the
ability to hear alarms and shouts, endangering, both the workers and the people around them. In
such cases, a hearing test should be carried out and testing to ensure that good status hearing. In
order to keep the experience, knowledge and skills of older workers for the benefit of the
company and the individual, the enterprise must be aware of the opportunities of older workers
and provide them with relevant work, thereby avoiding age discrimination.
Conducting business game case study.Literature: O: 1,2,4,5,6. D: 1,2,3,4,5,8,9,10,11,12.
45.Dvigately mode and health. Clinical manifestations of osteoporosis and prevention of
fractures. Secondary osteoporosis prevention and treatment. The principles of teaching
subjects (6 hours).
Compliance with the labor regime, motor mode and rational recreation is an important
element in maintaining the health of the elderly. Sudden changes in the body's biorhythm,
developed over decades a negative impact on health and life expectancy. Prevention and
overwork, lack of sleep, malnutrition, nervous and mental breakdowns promotes a healthy
lifestyle and longevity.Therefore, GPs should take into account all the above. There is no doubt
that the medical expertise and experience plays a significant role in the assessment of the elderly
in developing adaptation mechanisms of the body of elderly and old age. Preventive measures
that promote professional longevity. The rational organization of labor people elderly. The value
of the motor mode, outdoor activities, systematic vocational training in maintaining physical and
mental health, the prevention of early professional aging.Food hygiene - Hygiene section
devoted to the study of food quality and value in human nutrition, as well as the development of
nutrition, aimed at preserving and improving the health of the population. Examined the
relationship between measures of health and disease, and the state of nutrition in a variety of
professional and age groups, engaged in the research and prevention of nutritional diseases in
Vol. H. Having the character of an edge (regional) pathology such example. as endemic goiter.
involved in complex investigations to find new food sources of protein and so on. A great value
in a Hilbert space. are out of work and activities for the prevention of poisoning by toxic
impurities in foods and food poisoning.
Protein needs. In old age, the growth and formation of body tissues completed., In connection with
which the need for plastic materials, including in the protein much less. It is found that older
people regenerative protein needs sufficiently high. Animal protein should make up about 55%
of the total protein intake.
The need for fats. Fat in the diet of the elderly should be limited. The relationship of abundant fat
intake with the development of the atherosclerotic process.
The need for carbohydrates. In the conventional balanced diet formula amount of carbohydrate in
average 4/1/2 times the amount of protein. Such a ratio of protein and carbohydrates is
61
acceptable for the elderly only with the active, mobile lifestyles. At low exertion of
carbohydrates must be reduced.
The need for vitamins. Vitamins thanks to catalytic properties can to some extent slow down the
aging process. Sufficient level of vitamin provision makes it possible to maintain the intensity of
metabolism at a normal level, avoiding the accumulation of acid in connective tissue sulfited
mucopolysaccharides, and warn, so the development of connective tissue sclerotic changes.Vit C
is considered as one of the essential in the elderly in food processing substances in the diet of
elderly persons of sufficient Vit C allows you to create the best conditions for the oxidative
processes and normalize metabolism.Demand for mineral solid matter. The balance of minerals
in the diet of elderly persons is required to a lesser extent than in mature and middle age.
However, it is known that the elderly are accumulated in the body of minerals, especially
calcium salts.It recommended four meals a day.
May be set to supply meal five times per day. This mode is the most rational in old age, when
food should take smaller portions and more often than usual. If 4 meals a day diet is as follows:
for the first breakfast - 25%. at lunch, 15% - for lunch - 35% and for dinner - 25% of the value
energetical daily diet.
Therefore, GPs should consider all of the above. There is no doubt that medical professional
knowledge and experience to play a significant role in the critical evaluation of the application of
food hygiene in the elderly.
Conducting business game case study.Literature: O: 1,2,4,5,6. D: 1,2,3,4,5,8,9,10,11,12.
46. Clinical manifestations of atherosclerosis in the elderly, and dynamic observation.
Emphysema older. The principles of teaching subjects (6 hours).
Aging - is inevitably evolving over time naturally flowing process of weakening of the functioning
of the body, reducing the adaptive potential, leading to the likelihood of death. Aging - is not a
disease, but changes occurring as a result of aging create conditions for the emergence of
diseases.
Some believe that atherosclerosis is a disease of old people, but it occurs in children. Diagnosis of
atherosclerosis consists of the establishment of a genetic predisposition to it and verifying zones
deposition of atherosclerotic plaque on the clinical manifestations of coronary heart disease,
vascular lesions of the brain, kidneys and lower limbs, etc .; hypercholesterolemia, dyslipidemia,
LDL and VLDL cholesterol in the skin detection.
Atherosclerotic changes in the cardiovascular system are expressed, in particular, the kind of
arterial hypertension. Older including hypertension increases the proportion with systolic
hypertension than systolic. In 70 years, systolic hypertension occurs almost twice as often than
systolic. Blood pressure during systolic hypertension is systolic pressure ≥180, and ≤90 mm Hg
diastolic However, the biological age does not always coincide with the chronological, the
general background is important in blood pressure. In old age, systolic blood pressure increased
significantly, compared with diastolic. For the elderly after 70 years is more typical of the
termination of further increase in systolic blood pressure, with a gradual decrease in diastolic
blood pressure.
In old age there are changes in the blood vessels. The respiratory system is changing with age,
reduced capacity of the capillary network, are reduced mezhalveolyarnyh partitions, increased
residual volume, there is a senile emphysema.
In old age, along with other forms of pulmonary emphysema occur ivolyutivnye or senile
emphysema. Pathomorphological substrate is to expand the alveoli and respiratory passages
without reduction of the vascular system of the lungs. These changes are considered to be the
result of atrophy, aging easy as manifestations of the general aging process.
Characterized by small changes of physiological parameters of the respiratory system. There is a
moderate decrease in vital capacity, a slight increase in the TOE ivolyutivnaya emphysema does
not lead to the development of pulmonary hypertension and chronic pulmonary
heart.Hypotension muscle intrapulmonary restructuring, falling vital capacity, decrease in the
production of surfactant, deferred lifetime lung and bronchus create conditions for emphysema.
62
Therefore, GPs should take into account these changes in the pulmonary system, and the
appointment of therapy to appoint no more than 4 drugs, the possibility to take into account the
cumulative products due to changes in the blood (hypoalbuminemia): changes in the
gastrointestinal tract (hypocinesia, hipofermentemiya) and other organs and systems.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
47. gastrointestinal disease in the elderly. Problems and age-related changes that predispose
to disease SBP.Printsipy teaching subjects (6 hours).
Older people often have functional disorders of the gastrointestinal tract - reduces the activity of
secretory apparatus, peristalsis of the stomach and intestines, digestive gland atrophy. In old age
often observed decrease in the tone of the bowel and constipation. Last deliver a lot of trouble,
disturb the normal state of the gastrointestinal tract, and even contribute to the emergence of a
common neurosis. The main reasons for habitual constipation are: low mobility, lack of fiber in
processed foods, low fluid intake. Constipation can and must be eliminated. For this mode of the
day must be morning exercises, massage, walks (up to 7 km per day, which is about 1.5 hours
away in a calm pace).
It is necessary to consume daily foods rich in fiber.Exacerbation of peptic ulcer disease in elderly
patients are more likely than middle-aged, proceed with complications (bleeding, etc.); scarring
process is slowed down. The risk of malignant transformation of gastric ulcers. The frequency
and intensity of relapse of duodenal ulcer usually decrease with age. Gastric ulcer occurs in old
age (so-called. Senile ulcers), in most cases is symptomatic and most often due to trophic
disturbances in the gastric mucosa. These disorders are associated with atherosclerotic changes
in the vascular system of the stomach, leading to the deterioration of its blood supply and thereby
reduce the intensity biochem. processes. Matter and side effects of certain drugs (eg., Reserpine,
corticosteroids, salicylates), resulting in their prolonged use.
For senile ulcers characterized by a relatively short history. Much more often than with ulcers in
young, determined reduced gastric acidity and achlorhydria. Almost 50% of the wedge. for
ulcers is latent or oligosymptomatic. Atypical frequent complaints of pain in the right half of the
abdomen or the left side of the chest (which is wrongly regarded as a symptom of angina
pectoris). Unlike peptic ulcer disease of old age is not typical relationship of pain to food. No
seasonal frequency of exacerbations; appetite usually not broken; vomiting in uncomplicated
ulcer usually does not happen. In old age often asymptomatic or low-symptom observed ulcers,
which first manifested clinically complications such as bleeding or perforation.
Conducting business problem-based learning games.Literature: A: 1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
48. Diseases of the urinary system in the elderly. Problems and age-related changes that
predispose to diseases of the urinary sistemy.Printsipy teaching subjects (6 hours).
In old age the following physiological changes occur in the kidneys:
1. Decrease in kidney hemodynamics A.
2.Change renal vessels - collagen, glucosamine congestion - Increasesconcentration ability
ofthe kidneys.
3.Snizhenie osmolarity kidney (NK even if there occurs an accumulation of fluid in
theinterstitial fluid space).
4. THE SOUTH atrophy, it leads to a cell-type "regime depots
5. interstitial kidney tissue normally produces a prostaglandin, and the oldcollagen and
glikozaminoglikopilyar - aggravating sclerotic changes, slowsrenal blood flow.
6. reduce the production of aldosterone. but reactivity to it increases. thereforeIn addition to the
physiological aging process is often observed, and other diseases MBC: prostate adenoma
(causes stagnation of urine and hence the retrograde infection MIF), the IBC tumor and others. In
the elderly in the urinary system are observed following morphological changes: sclerosis of
small renal arteries and arteriaol; interstitial fibrosis of the medulla; focal glomerulosclerosis.In
old age often occurs pyelonephritis and acute renalfailure. The frequency increases with
63
pyelonephritis 70 years. An old man is a secondary pyelonephritis, develops on the background
of urinary tract obstruction. ICD. Diseases of the prostate gland.
The causes of acute renal failure are hemodynamic changes (heart failure), acute respiratory
failure, cancerdisease.
Nephrotic syndrome in the elderly is caused by diabetesnefropatni, renal vein thrombosis, renal
glomerular filtration after four decadesage decreases by 1% per year.
This means that from 40 to 80 years, the total number ofglomerular reduced by almost half.
Treatment of renal disease carried lincomycin, levomitsinom in combination with 5-NOC or
nevigramon, recommended cytostatics. When the dosage of drugs excreted by the kidneys
should take into account age-related decline of glomerular filtration function of the kidneys.For
the prevention of kidney damage in elderly and senile age it is necessaryavoid fluid overload,
electrolyte loss. Degidrotatsii, a sharp fallrenal blood flow. It is necessary to refrain from salty
and hot spices in the diet.Therefore, GPs should consider all of the above. There is no doubt that
Medical expertise and experience play a significant role in the critical evaluation of the use of
diagnostic and therapeutic procedures for diseases of the MBC in the elderly
Conducting business problem-based learning games.Literature:O1,2,4,5,6. D:
1,2,3,4,5,8,9,10,11,12.
Calendar-thematic plan of practical lessons on the subject of Internal Medicine
Number TOPICS PRACTICAL CLASSES Watches
Basics of Family Medicine
1
"Fundamentals of Family Medicine. Features GP. Features of work. Medical
records. Visiting patients at home. Involving the public. Rights physician and
the patient. Ethics and deontology in the GP. Principles of teaching about
2
Working with the family. Features of work. The psychological climate in the
family. Problems of religious rites. Advising family. Principles of teaching
about "
3
The art of communication. Factors contributing to the dialogue. Difficulties in
communication. Interpersonal communication. Practical advice. Advising.
Types of consultations. The principles of counseling. Responsibility for the
health of the patient. Principles of teaching about
4
"Prevention in the GP. Types of prevention. Promoting a healthy lifestyle. Food
hygiene and living conditions. Prophylactic examinations, screening.
Prevention of infectious and noninfectious diseases. Immunization. Programs
and activities
5
Impact on risk factors. Health education. Impact on the main causes of
morbidity and mortality. Strengthening the mental status. Environmental and
occupational factors. Education of patients, "school".
Cardiology
6
7
6,0
6,0
6,0
6,0
6,0
Arrhythmias. Differential diagnosis migration pacemaker, sick sinus syndrome, 6,0
arrhythmia, as well as sinus tachycardia, bradycardia, sinus arrhythmia,
extrasystoles Forms. Tactics GPs. Indications for referral to a specialist or
hospitalization in specialized department. Principles of treatment, clinical
supervision, control and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching about
Arrhythmias. Differential diagnosis flicker, flutter or fibrillation (permanent and 6,0
paroxysmal), paroxysmal tachycardia syndrome, premature ventricular.
Tactics GPs. Indications for referral to a specialist or hospitalization in
64
8
9
10
11
12
13
14
15
16
specialized department. Principles of treatment, clinical supervision, control
and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about
"Arrhythmias. Differential diagnosis of blockades: sinoatrial, intraatrial,
atrioventricularf inside ventricle. Morgani- syndrome Adams-Stokes. Routine
and emergency treatment at the blockade. Indications for cardioversion,
pacing. Principles of treatment, clinical supervision, control and rehabilitation
in a hovercraft or a joint venture. Principles of prophylaxis. Principles of
teaching about
"Hypertension. Differential diagnosis of hypertensive disease with renal
hypertension. Risk factors, stage of hypertension, renal types of arterial
hypertension (parenchymal and renovascular). The syndrome of malignant
hypertension. Tactics GPs. Principles of treatment, clinical supervision,
control and rehabilitation in a hovercraft or a joint venture. Principles of
teaching topics.
Hypertension. Differential diagnosis of hypertensive disease with endocrine
hypertension. Types of endocrine hypertension (pheochromocytoma syndrome
Kona Itsenko-Kushenga, thyrotoxicosis) Differential diagnosis of
hypertensive crises. Tactics GPs. Principles of treatment, clinical supervision,
control and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about
Hypertension. Differential diagnosis of hypertensive crises. Tactics GPs.
Principles of treatment, clinical supervision, control and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching
about "
"Pain in the heart. Differential diagnosis of pain priIBS stable angina - different
functional classes (FC I-IV). Acute coronary syndrome. Indications for
surgical treatment. Tactics GP for angina. Clinical examination, primary and
secondary prevention of CHD. Principles of teaching about "
"Pain in the heart. Differential diagnosis of pain in ischemic heart disease
unstable angina pectoris (new-onset angina, progressive angina, spontaneous
angina, and postoperative early post-infarction angina). Acute coronary
syndrome. Indications for surgical treatment. Tactics GP for angina. Clinical
examination, primary and secondary prevention of CHD. Principles of
teaching about "6
The pain in the heart. Differential diagnosis of pain in angina and myocardial
infarction. Differential diagnosis of complications of myocardial infarction,
cardiogenic shock, types, severity, pulmonary edema, arrhythmias, conduction
disturbances, thromboembolism, cardiac aneurysm, myocardial rupture,
nonbacterial thrombotic endocarditis, Dressler's syndrome. The tactics of the
general practitioner. Prehospital care in myocardial infarction. The principles
of follow-up, monitoring and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching topics
'heart murmur and cardiomegaly. Differential diagnosis of the presence of noise
on the top of the heart and aorta. Evaluation of functional (myocardial,
anemic, with changes in the blood, fever) and organic (mitral insufficiency,
mitral stenosis holes, mitral valve prolapse, acquired defect of the aortic
valve) heart murmurs. Tactics GPs. Principles of teaching topics.
'heart murmur and cardiomegaly. Differential diagnosis in congenital heart and
great vessels. Tactics GPs. The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
65
6,0
6,0
6,0
6,0
6,0
6,0
6,0
6,0
6,0
Principles of teaching topics.
Heart murmur and cardiomegaly. Differential diagnosis of different clinical 6,0
forms of cardiomyopathy (dilated, restrictive, hypertrophic, arrhythmogenic
right ventricular dysplasia). Differential diagnosis between cardiomyopathies,
valvular heart disease, coronary artery disease, hypertension. Tactics GPs. The
principles of follow-up, monitoring and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching topics
18
"edematous syndrome. The differential diagnosis of acute and chronic heart 6,0
failure. Differentiated therapy for heart failure. Tactics GP When edema.
Principles of treatment, clinical supervision, control and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Determination
trudosposobnosti.Printsipy teaching about.
Pulmonology
17
'
19
'cough with sputum. Diseases that occur cough. The most dangerous diseases that
occur with coughing. Differential diagnosis in the equity and segmental
lesions of the lung. Lobar pneumonia, infiltrative pulmonary tuberculosis,
pulmonary infarction. Community-acquired pneumonia and nosocomial.
Tactics GPs. The principles of follow-up, monitoring and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Defining disability.
Principles of teaching topics.
'cough with sputum. Differential diagnosis of lung lesions in the round. Focal
pneumonia, tuberculoma, abscess of lungs, lung tumors, lung echinococcus.
Pneumonia of different etiology (bacterial, viral, mycoplasma). Differential
diagnosis in diffuse disseminatsii.Ochagovaya pneumonia, hematogenicdisseminated form of pulmonary tuberculosis, pneumoconiosis, cancer
metastases. Tactics GPs. The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching topics.
"Chest pain associated with lung disease. Differential diagnosis of pleural
effusion and dry. Types of exudative pleurisy. The principles of follow-up,
monitoring and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about
"Bronhoo syndrome. Differential diagnosis of diseases occurring with bronchial
obstruction (asthma, COPD, lung tumors). Tactics GPs. Indications for
referral to a specialist or hospitalization in specialized department. Principles
of treatment, clinical supervision, control and rehabilitation in a hovercraft or
a joint venture. Principles of prophylaxis. Principles of teaching topics.
"Shortness of breath, choking. Differential diagnosis of diseases occurring with
bronchial obstruction (asthma, COPD, lung tumors). Tactics GPs. Indications
for referral to a specialist or hospitalization in specialized department.
Principles of treatment, clinical supervision, control and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching
topics. "
Shortness of breath, choking. Differential diagnosis of dyspnea in heart and lung
disease. Circulatory failure and pulmonary discfunction.Printsipy teaching
about. "
Problem-oriented training on "Cough with phlegm", "shortness of breath,
choking."
20
21
22
23
24
25
Gastroenterology
66
6,0
6,0
6,0
6,0
6,0
6,0
6,0
26
Dysphagia. Differential diagnosis of esophagitis, reflux esophagitis, dysphagia in
scleroderma and esophageal tumors. Tactics GPs. Principles of treatment,
clinical supervision, control and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching topics.
27
"Abdominal pain. Differential diagnosis of gastritis and peptic ulcer disease
(gastric and 12 duodenal ulcer). Tactics GPs. Indications for referral to a
specialist or hospitalization in specialized department. Principles of treatment,
clinical supervision, control and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching topicS
28
"Abdominal pain. Differential diagnosis of gastritis and peptic ulcer disease
(gastric and 12 duodenal ulcer). Tactics GPs. Indications for referral to a
specialist or hospitalization in specialized department. Principles of treatment,
clinical supervision, control and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching topics. "
28
"Abdominal pain. Differential diagnosis of ulcerative colitis and Crohn's disease.
The tactics of the general practitioner. The principles of follow-up, monitoring
and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching topics.
29
Abdominal pain. Differential diagnosis of ulcerative colitis and Crohn's disease.
The tactics of the general practitioner. The principles of follow-up, monitoring
and rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching topics.
30
"hepatomegaly. Differential diagnosis of chronic hepatitis and cirrhosis. Tactics
GPs. Indications for referral to a specialist or hospitalization in specialized
department. Principles of treatment, clinical supervision, control and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
Principles of teaching about
31
Differential diagnosis of cholelithiasis with biliary-pancreatic tumor area (cancer
of the liver, gallbladder, pancreas). Tactics GPs. The principles of follow-up,
monitoring and rehabilitation in a hovercraft or a joint venture. Principles of
prophylaxis. Principles of teaching about "
32
Problem-based learning on "Abdominal pain", "Dysphagia" and "Jaundice
Rheumatology
33
34
35
6,0
6,0
6,0
6,0
6,0
6,0
6,0
6,0
"Articular Syndrome. Diseases that occur with articular syndrome. The most 6,0
dangerous diseases that occur with articular syndrome. Differential diagnosis
of rheumatism and rheumatoid arthritis. Tactics GPs. Tactics GPs. Indications
for referral to a specialist or hospitalization in specialized department.
Principles of treatment, clinical supervision, control and rehabilitation in a
hovercraft or a joint venture. Principles of prophylaxis. Principles of teaching
topics. "
"Differential diagnosis of seronegative spondyloarthritis (reactive arthritis, 6,0
ankylosing spondylitis, psoriatic arthritis). Tactics GPs. Indications for referral
to a specialist or hospitalization in specialized department. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching about
"Differential diagnosis of seronegative spondyloarthritis (reactive arthritis, 6,0
ankylosing spondylitis, psoriatic arthritis). Tactics GPs. Indications for referral
to a specialist or hospitalization in specialized department. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching about "
67
36
"Articular Syndrome. Differential diagnosis of SLE, SSc. Tactics GPs. The 6,0
principles of follow-up, monitoring and rehabilitation in a hovercraft or a joint
venture. Principles of prophylaxis. Principles of teaching about
37
Differential diagnosis of hemorrhagic vasculitis, nonspecific aortoarteritis and 6,0
periarteritis nodosa. The tactics of the general practitioner. The principles of
follow-up, monitoring and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. The principles of teaching subjectS
38
Problem-oriented training on "Articular Syndrome
6,0
Nephrology
39
Changes in the urinary sediment. Differential diagnosis of immuno and
inflammatory diseases of the kidneys (acute and chronic glomerulonephritis,
interstitial nephritis. The principles of follow-up, monitoring and rehabilitation
in a hovercraft or a joint venture. The principles of prevention. The principles
of teaching about
40
"Changes in the urinary sediment. Differential diagnosis of nephropathy
(pregnant, diabetic, drug) Indications for referral to a specialist or
hospitalization in specialized department. Principles of treatment, clinical
supervision, control and rehabilitation in a hovercraft or a joint venture.
Principles of prophylaxis. Principles of teaching about
41
"GP tactics when proteinuria and altered urinary sediment. Differential diagnosis
of the different stages of chronic renal failure. Treatment according to steps.
Indications for hemodialysis. . The principles of follow-up, monitoring and
rehabilitation in a hovercraft or a joint venture. Principles of prophylaxis.
42
"edematous syndrome. Differential diagnosis of edema of various etiologies local
- allergic, cardiovascular, inflammatory; General - circulatory insufficiency,
renal, endocrine, hungry. Principles of teaching topics
43
"edematous syndrome. Differential diagnosis of edema of various etiologies
(local - allergic, cardiovascular, inflammatory, general - circulatory
insufficiency, renal, endocrine, hungry). Tactics GPs. Indications for referral
to a specialist or hospitalization in specialized department. Principles of
treatment, clinical supervision, control and rehabilitation in a hovercraft or a
joint venture. Principles of prophylaxis. Principles of teaching topics.
Geriatrics
6,0
44
6,0
45
46
47
48
The problem of the age norm. Functional and organic changes in aging.
Physiology and food hygiene older
motor mode and health. Clinical manifestations of osteoporosis and prevention of
fractures. Secondary osteoporosis prevention and treatment. The principles of
teaching subjects.
Clinical manifestations of atherosclerosis in the elderly, and dynamic
observation. Emphysema older. The principles of teaching subjects
gastrointestinal disease in the elderly. Problems and age-related changes that
predispose to disease ZhKT.Prinsipal teaching topics
Diseases of the urinary system in the elderly. Problems and age-related changes
that predispose to diseases of the urinary sistemy.Principal teaching topics
6,0
6,0
6,0
6,0
6,0
6,0
6,0
6,0
2.3. Guidelines on the organization of the laboratory workIn a typical program on the subject of
Internal Medicine labs are not provided
2.4. Guidelines on the organization of the course workIn a typical program on the subject of
Internal Medicine coursework is not provided
68
2.5. Form and content of independent workIndependent work on the subject of Internal Medicine
is part of the study of the subject and fully equipped with methodological and information
resources.The forms of independent work on the subject:1. Self-absorption of some theoretical
topics using textbooks;2. Preparation of information on a given topic (abstract);3. Preparation for
practical exercises;4. Writing summaries on topics of practical lessons;5. Preparation of reports
and communications on certain topics with the help of literature (monographs, articles);6.
Preparation of scientific articles and abstracts for conferences;7. The decision of cases;8.
Preparation and filling of graphic organizers;9. Preparation and crossword puzzles;10. The
decision of situational problems.Independent work of students is carried out in the classroom and
extracurricular.
Classroom independent work
Classroom independent work carried out during the practical training under the guidance of the
teacher, and the student performs individual tasks in the form of supervision of patients, analysis
of the medical records, laboratory data analysis, the decision of situational problems, the solution
of cases, the composition of the organizers. During the execution of independent work of the
teacher works individually with each student, consults them, checks the work.
Extracurricular independent work
Students' independent work includes preparation for practical training, writing abstracts for a given
topic, homework, learning some theoretical tasks on their own with the help of teaching
materials, preparation of essays on a given topic, the preparation of a scientific paper or thesis
for the conference. Extracurricular CP helps to deepen the knowledge of students, teaches them
to make their own decisions.
Classroom independent work
Classroom independent work carried out during the practical training under the guidance of the
teacher, and the student performs individual tasks in the form of supervision of patients, analysis
of the medical records, laboratory data analysis, the decision of situational problems, the solution
of cases, the composition of the organizers. During the execution of independent work of the
teacher works individually with each student, consults them, checks the work.
Extracurricular independent work
Students' independent work includes preparation for practical training, writing abstracts for a given
topic, homework, learning some theoretical tasks on their own with the help of teaching
materials, preparation of essays on a given topic, the preparation of a scientific paper or thesis
for the conference. Extracurricular CP helps to deepen the knowledge of students, teaches them
to make their own decisions.
he content and scope of independent work of students
5510100- therapeutic work 5111000- Professional Education ((5,510,100 - Medicine)
Number Content CPC
Tasks for independent work
Deadline
Volume
(hours)
1
The physiological function Writing a brief synopsis of the 8 weeks
of the heart muscle.
literature data the past 10
Normal ECG.
years. Preparing tables and
figures on this subject
spelling abstract.
Providing clinical audit on this
nosology.
2
2
Pharmacodynamics drugs Writing a brief synopsis of the 8 weeks
2
69
for arrhythmia.
3
Etiology and pathogenesis
dysfunction
conductivity
4
The etiology, pathogenesis,
classification
of
hypertension, including
hypertension and renal
hypertension
5
etiology,
pathogenesis,
classification
of
hypertension, including
hypertension
and
hypertension
in
endocrine diseases
6
Classification
of
antihypertensive drugs
7
Etiology, pathogenesis of
hemodynamic
and
cerebral
hypertension
and classification of
antihypertensive drugs
8
etiology, pathogenesis and
classification
of
coronary heart disease
9
Etiology and pathogenesis
of
myocardial
literature data the past 10
years. Preparing tables and
figures
on
this
subjects.spelling
abstract.
Providing clinical audit on
this nosology.
Writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
. Writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Principles of treatment of
coronary artery disease.
Writing a brief synopsis of
the literature data the past 10
years. Preparing tables and
figures on the subject.
Writing the essay.
Providing clinical audit on this
nosology.
Writing a brief synopsis of the
literature data the past 10
70
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
10
11
12
13
14
infarction.
Pharmacodynamics of
drugs used in the
treatment of myocardial
infarction.
Causes of cardiomegaly,
mold cardiomegaly, a
variety
of
clinical
symptoms, ECG and Xray
diagnostics,
treatment.
Etiology,
pathogenesis,
clinical
picture of mitral heart
defects.
The causes of defects in
rheumatism, infective
endocarditis,
aortic
atherosclerosis.
ECG
and X-ray diagnostics,
treatment.
Etiology,
pathogenesis,
clinical
manifestations,
diagnosis
of aortic
valvular heart disease.
The etiology of occurrence
of defects, pathogenesis,
mechanism
of
occurrence of noise,
functional and organic,
auscultatory
picture
noise, direct and indirect
signs, signs of increased
pressure
in
the
pulmonary circulation,
for vices.
Causes of cardiomegaly,
mold cardiomegaly, a
variety
of
clinical
symptoms. ECG and Xray
diagnostics.
Treatment, particularly
the use of β-blockers
and cardiac glycosides
The etiology, pathogenesis,
classification
of
circulatory failure, the
clinical picture. The use
of cardiac glycosides, ablockers,
ACE
inhibitors,
diuretics,
treatment of HF.
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
2
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
2
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures on this subject
spelling abstract.
Providing clinical audit on this
nosology
2
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
2
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
2
71
15
The
etiology, Writing a brief synopsis of the 8 weeks
pathogenesis, treatment
literature data the past 10
of myocarditis and
years. Preparing tables and
myocardial dystrophy.
figures
on
this
Pharmacodynamics of
subject.spelling abstract.
drugs used in the Providing clinical audit on this
treatment of myocarditis
nosology
and
myocardial
dystrophy.
2
16
The causes of pericarditis, Writing a brief synopsis of the
diagnosis.
literature data the past 10
Etiopathogenesis
and
years. Preparing tables and
clinical
pulmonary
figures
on
this
embolism,
dissecting
subject.spelling abstract.
aortic aneurysm
Providing clinical audit on this
nosology
The etiology, classification . Writing a brief synopsis of the
of
pneumonia,
literature data the past 10
tuberculosis, pulmonary
years. Preparing tables and
infarction,
clinical
figures
on
this
features and options
subject.spelling abstract.
pneumonia, tuberculosis Providing clinical audit on this
and
pulmonary
nosology
infarction,
research
methods, complications
The etiology, classification Writing a brief synopsis of the
of pneumonia, clinical
literature data the past 10
features and options of
years. Preparing tables and
pneumonia,
abscess,
figures
on
this
cancer
and
lung
subject.spellingv abstract.
echinococcus, research Providing clinical audit on this
methods, complications
nosology
The etiology, classification . Writing a brief synopsis of the
of
pneumonia,
literature data the past 10
tuberculosis and lung
years. Preparing tables and
cancer
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
Clinical
features
and Writing a brief synopsis of the
options of pneumonia,
literature data the past 10
tuberculosis,
lung
years. Preparing tables and
cancer, methods of
figures
on
this
research, complications.
subject.spelling abstract.
Etiology, pathogenesis, Providing clinical audit on this
clinical and research
nosology
methods at pleurisy
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
Etiology, classification of Writing a brief synopsis of the 8 weeks
COPD, clinical signs,
literature data the past 10
methods of research,
years. Preparing tables and
2
17
18
19
20
21
72
complications.
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology. 8
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
22
Diagnostic
criteria
rheumatism, rheumatoid
arthritis. The criteria for
the
diagnosis
of
rheumatic fever.
23
Diagnostic
criteria
seronegative
spondyloarthritis
(reactive
arthritis,
ankylosing spondylitis,
psoriatic arthritis. "The
criteria for the diagnosis
of rheumatic fever
Diagnosis and criteria for Writing a brief synopsis of the
activity
DBST
literature data the past 10
treatments.
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
Diagnosis and criteria of Writing a brief synopsis of the
activity, methods of
literature data the past 10
treatment, prevention of
years. Preparing tables and
DM
and
DM.
figures
on
this
Pharmacodynamics of
subject.spelling abstract.
drugs used in the Providing clinical audit on this
treatment of DM and
nosology.
DM
Diagnosis and criteria of Writing a brief synopsis of the
activity, methods of
literature data the past 10
treatment, prevention of
years. Preparing tables and
NPP
and
UP.
figures
on
this
Pharmacodynamics of
subject.spelling abstract.
drugs used in the Providing clinical audit on this
treatment of NVP and
nosology.
UP.
The etiology, pathogenesis, Writing a brief synopsis of the
clinical manifestation of
literature data the past 10
the disease, diagnostic
years. Preparing tables and
criteria
figures
on
this
immunoinflammatory
subject.spelling abstract.
activity
and Providing clinical audit on this
inflammatory diseases
nosology
of the kidneys
The definition, etiology, Writing a brief synopsis of the
pathogenesis
of
literature data the past 10
24
25
26
27
28
73
2
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
2
nephropathy.
29
30
31
32
33
34
35
years. Preparing tables and
figures on this subject.
spelling abstract.
Providing clinical audit on this
nosology.
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
The etiology, pathogenesis,
classification, clinical
syndromes, diagnosis,
treatment,
pharmacodynamics of
drugs used for the
treatment of chronic
renal failure
Etiology,
pathogenesis, Writing a brief synopsis of the
clinical manifestation of
literature data the past 10
the disease, diagnosis,
years. Preparing tables and
edema syndrome
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
etiology of occurrence of Writing a brief synopsis of the
dysphagia,
literature data the past 10
pathogenesis,
years. Preparing tables and
mechanism of pain.
figures
on
this
Risk factors for the
subject.spelling abstract.
development
of Providing clinical audit on this
dysphagia.
nosology
clinical
manifestations, Writing a brief synopsis of the
clinical and laboratory
literature data the past 10
criteria, complications,
years. Preparing tables and
treatment of peptic
figures
on
this
ulcer.
subject.spelling abstract.
Providing clinical audit on this
nosology
Etopatogenez
Writing a brief synopsis of the
classification
literature data the past 10
pancreatitis. Diagnosis
years. Preparing tables and
of pancreatic tumors.
figures
on
this
tematike.spelling abstract.
Providing clinical audit on this
nosology
diagnostic
procedures Writing a brief synopsis of the
bowel complications of
literature data the past 10
ulcerative colitis
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology.
Etiology and pathogenesis, Writing a brief synopsis of the
clinical manifestations,
literature data the past 10
diagnosis of diseases
years. Preparing tables and
posindromnaya
figures
on
this
74
2
8 weeks
2
8 weeks
2
8 weeks
2
8 weeks
4
8 weeks
4
8 weeks
4
accompanied
hepatomegaly
by
subject.spelling
abstract.
Providing clinical audit on
this nosology.
. Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract.
Providing clinical audit on this
nosology
Writing a brief synopsis of the 8 weeks
literature data the past 10
years. Preparing tables and
figures
on
this
subject.Napisanie abstract.
Providing clinical audit on this
nosology
writing a brief synopsis of the
literature data the past 10
years. Preparing tables and
figures
on
this
subject.spelling abstract
36
Etiology and pathogenesis,
clinical manifestations,
diagnosis of diseases
posindromnaya
accompanied
by
hepatomegaly
37
Etiopathogenesis, clinical
manifestations,
diagnosis
of
liver
cirrhosis
38
Features
of
pharmacotherapy
of
gastrointestinal
disorders and tactics
complications
39
Diagnostic criteria for
aging, senile physiology
of the body, age norms.
Etiology, pathogenesis,
diagnostic criteria for
osteoporosis,
senile
physiology of the body
Diagnostic criteria for the Providing clinical audit on this
classification
of
nosologY
atherosclerosis,
emphysema
Diagnostic criteria for the Writing a brief synopsis of the
classification
of
literature data the past 10
gastritis, peptic ulcer,
years. Preparing tables and
colitis
figures
on
this
subject.spelling abstract
Diagnostic
criteria . Providing clinical audit on this
pyelonephritis, chronic
nosology.
renal failure, etc
40
41
42
total
4
4
4
4
4
4
4
104
2.6. A list of practical skills on the subject1. Ophthalmoscopy.2. Removing and ECG
interpretation3.Paltsevoe rectal examination.4. palpation of mammary glands.5. Measurement of
blood pressure.6. CCC palpation.7. Percussion CCC.8. Auscultation CCC9. The peak flow
meter.10. Delimitation of the liver Kurlov.11. palpation of the abdomen12. palpation of the
chest.13.
Percussion
of
the
lungs
14. Auscultation of bronchopulmonary system.15. Determining whether an acute abdomen.16.
75
The determination of cholecystitis17. Determination of signs of pancreatitis19.Opredelenie signs
of appendicitis20. Carrying out a joint examination.
2.7. Information and methodological support program
In the learning process of the subject Internal Medicine provides for the application of
modern pedagogical and information and communication technologies. On the practical and
lecture classes used multimedia presentations, educational films and computer programs.
2.8. Ranking criteria for monitoring and evaluation of knowledge and skills in
the discipline
The main criterion for the quality of training of students is its rating, the term of the
current evaluation, the evaluation of the intermediate monitoring and evaluation of the
final control.General provisions on the types of control of knowledge of students in all
faculties.Types and forms of assessment of student learning:- Current control (TC)Evaluation of independent work of students (IWS)- Interim control (PC)- Final control
(IR)The coefficients of the 100-point rating system of students' knowledge, depending on
the type and form of control is as follows:
N
Types of control number
Maximum
coefficient
Minimum
score
ratio
(passing
) score
1
Evaluation of classroom practice 45
0.45
24.75
session
2
Evaluation of independent work of 5
0.05
2.75
student
3
Evaluation of interim control
20
0.2
11.0
4
Evaluation of the final control
30
0.3
16.5
Total
100
1
55.0
100-point rating system of knowledge Studenov includes all aspects of the educational process,
such as the active participation of students in the practical and lecture classes, timely testing of
missed lessons, high performance, both in theoretical knowledge and in practical skills, the
formation of logical, clinical thinking , improving the quality of students' independent work,
logging subordinators, lecture notes, the active participation of students in scientific societies,
competitions on the subject. 100 point rating redundant system of assessment, including various
kinds of control, showing the amount of recruit students of the rating of the ball, and the
percentage of achievement in the subject.Principles of the rating assessment of student
knowledge, evaluation of performance, evaluation criteria, the level of preparation are presented
in Table 2. According to regulatory guidelines used 8 rank score of knowledge with a positive 5
1 6-8 degree neudovetvoritelnaya assessment requires retake, 8 degree - points of presence of the
student in the class, the student is absolutely not ready to engage and participate in the discussion
system of assessing students Table number 2
N
Progress
in Defining Assessment
Criteria for assessing
level of training
number and%
points
1
91-100
. Excellent 5
evaluate,
synthesize, 4th level
analyze, apply,
creativity
He knows, understands
2
86-90
90 Very good
Analyzes applies,
3rd level
"5"
Knows the
skills
3
71-85
4
65-70
. Good
"4"
is quite satisfactory
is used, he understands
Knows
Understands, know
76
the 3rd level of
skills
Level 2
reproduction
5
55-64
Satisfactory , ie, meet knows
minimum
requirements "3"
Poor, weak, more work does not speak
is needed "2"
" knows Level 1
representations
6
54-41
7
Less 40-21
Disappointing require does not know
significant additional
work to "1"
about the second
level. It does
not represent
8
20-10
"O"
O-Level
Point the presence
About Level
badly
Current control:
training in internal medicine
course at the VI288
course at the VII240 The maximum score for the 1 practical occupation- 100 points55% of
the maximum rating score of 1 lesson is - 55 pointsVisit 1 credit practical training10-20
pointsNumber of lectures on international
at the VI cource
10point
at the VIIcource 9pointScore 1 visits lectures10
points
A student who receives at least 55% of the maximum rating score for the current control has the
ability to learn for 1 week and retake the activity, if the student is not able to deliver the material
within a week of practical classes, then score remains the same without the right Criteria for
evaluation of this survey:
Levels
rating
Characteristic points of the student
grade
96-100%
The answer is original and of the highest quality, exceeding the
Excellent
requirements of the program. High quality clinical thinking and
the implementation of practical work, registration of medical
history and the presence of lecture notes, books subordinators and
86-100
workbook, presentation and active participation with reports in
morning meetings, the use of the responses on employment data
over the Internet, actively involved in the clinical and case parse
duty of supervision and the patients in the hospital, as well as
service calls in the clinic
91-95%
The high quality of the response exceeds the requirements of the
program, good works and execution of, the availability of lecture
notes, books subordinators and workbook, make presentations at
the morning conferences, active participation in clinical and case
parse duty and Supervision of hospital and service calls polyclinic
high degree of design history and outpatients.
86-90%
Correct, performances by the secondary literature, the proper
execution of skills, availability of lecture notes, books
subordinators and workbook, the correct maintenance histories,
and active participation in morning conferences, clinical and case
parse duty and Supervision of hospital and service calls in the
77
clinic .
Good
81-85,9%
71-85,9
76-80%
Will satisfy
A good quality, relevant programs, active implementation of
practical work, the availability of lecture notes, books and
subordinators workbook, timely and correct completion histories
and outpatients, quality Curation of patients and duty in a hospital
and call service in the clinic.
The answer is good, basically corresponding to the requirements of
the program. Good execution skills, the availability of lecture
notes, books and subordinators workbook, timely and correct
completion histories and outpatients, quality Curation of patients
and duty in the hospital, call service in the clinic.
71-75.9%
The answer is above average, the individual errors are possible
during the work or negligence in the design of protocols and
lecture notes, books subordinators and workbook, as well as
record-keeping in the hospital and clinic.
66-70.9%
Satisfactory answer highly having inaccuracies, some errors in the
execution of works, reception of patients and service calls in the
clinic, duty of supervision of patients in hospital, the availability
of lecture notebooks, books subordinators and workbook, but
insufficient maintenance of, inaccurate and untimely clearance
records in the hospital and in the clinic.
61-65.9%
Moderate satisfactory answer, the answer is a serious error, the error
is in the implementation of practical skills in record keeping in the
hospital and in the clinic, lecture notebooks, duty, Supervision of
hospital and service calls in the clinic performed well enough.
55-60.9%
A satisfactory response of poor quality - is a serious error, the
practical skills have not been fully, when completing the
documentation in the clinic and the clinic, book subordinators and
workbook mistakes, lack of lecture notebooks, low quality
reception of patients and service calls in the clinic, duty of
supervision of patients hospital
unsatisfactory response - a critical error (not certified) is not capable
of performing skills, delayed filling, Serious errors in recordkeeping in the hospital and in the clinic, subordinators book and
workbook, no lecture notebooks, untimely fulfillment tasks in the
clinic. Admission of patients, service calls, Curation of patients in
the clinic and duty performed poorly.
55-70,9
Not
20-54.9%
Satisfact
ory 20 54.9
20
points of presence in the lab. Lack of implementation any
requirements imposed on employment, the lack of necessary
documentation and failure to fill them, poor duty, Curation of
78
patients in a hospital and service calls in the clinic.
Criteria for assessing the monitoring
55% of the maximum rating of the current survey points - 55 points.Current rating score of
practical training in a hospital is composed of:
- Assessment of theoretical knowledge of students in each practical class and participation in
interactive teaching methods (theoretical approach), a maximum of 30 points;
- Assessment of the ability to analyze the data obtained in the analysis of thematic and supervised
patients, reports of duty and the application of knowledge in a practical situation (decision of
situational problems) - analytical approach, a maximum of 30 points;
- Assess the development of practical skills, interpretation of laboratory, instrumental, functional
studies and prescribing treatment, documentation (a practical approach), a maximum of 40
points.Current rating score of practical classes at the clinic consists of:
- Assessment of theoretical knowledge of students in each practical class and participation in
interactive teaching methods (theoretical approach), a maximum of 30 points;
- Assessment of the ability to analyze the data obtained in the analysis of case-patients and received
a report on service calls and the use of knowledge in terms of clinical situations (decision of
situational problems) - analytical approach, a maximum of 30 points;
- Assess the development of practical skills, interpretation of laboratory, instrumental, functional
studies and prescribing treatment, documentation (a practical approach), a maximum of 40
points.Monitoring of theoretical knowledge to practical exercises evaluated various interactive
methods: role play, the decision of situational tasks, test, "brainstorming", "pen in the middle of
the table," "tour of the gallery," "snowballs", "Incident", and clinical audit m. al ..The assessment
of the current control is to control the presence of visiting lectures and texts of lectures.If the
student was present in class, but he was not prepared for it and do not learn the necessary
theoretical material and practical skills, he put only "points of presence", which is 20 points. The
student during the week given the opportunity to re-take the lesson. If it did not work activity
during the week, a minimum score remains unchanged.
Visiting lectures and practical classes is mandatory. Students who receive three or more "NB" or
row 2 "NB" must obtain permission from the dean's office to work out practical training. Orders
recorded in the school magazine. Testing sessions in all courses held in the form of night, for
students with children and pregnant women daily duty in the clinic and demonstration of
theoretical knowledge and practical skills in the morning of the conference. Preparation of
students estimated present on the morning of the conference teachers collectively.
In developing the practical training using a factor of 0.8. If the student will be able to work out
lectures, then the average score for this one lecture deducted 3 points, if you do not run for -5
points. Development of practical and lecture classes, and their rating points are fixed in the
relevant section in the school magazine and notebook morning conferences and shall be signed
by head of the department.The final rating of each of the current exhibition at the end of classes
in an educational magazine, announced to students and is written to the screen
performance.Upon completion of the current studies are summarized scores of workshops and
divided by the number of practical training. Then the average score of practical employment
multiplied by a factor of 0.45.
Independent work of students
Based on independent work of students (IWS) is exposed as 100 point system on a daily basis in a
special part of the school magazine. CPC carried out by students outside of class on the chosen
theme, in accordance with the curriculum of discipline, based on the latest modern world these
materials in the form of reporting, scenario movies, cooking tables, slides, preparation of case
studies, clinical situations, tests, crossword puzzles, patterns laboratory and instrumental studies,
participation in clinical and post-mortem conferences, clinical analyzes of patients and audits
performed by duty at the clinic.
79
CPC for the current academic year at the Department of pre-planned, and at the beginning of the
school year detailed information on its forms (list of topics and assignments) are offered to
students. Students are given the right to choose the topics and tasks, and during the semester, in
accordance with the developed and approved schedule shall prepopodavatelyu conducting
workshops in the group and is kept for 2 years at the department.To calculate the average score
for the CPC summed up the points and divide by the number of evaluations. Then, the resulting
average score on the CDS multiplied by a factor of 0.05, and is added to the average of the
current score. Assessment of the current control and independent work of the student is offered
as a single mean score. Information about the CPC in the department detail rassmotreeny
position of independent work in the department.
Intermediate control
The maximum score of the intermediate control Are (PC) - is equal to 100 points.PC is carried out
in the form of problem analysis tasks. Thus the student in accordance with the syndromes studied
the problem should solve the problem 2, the decision of which is allocated 60 minutes. For each
of the tasks allocated separate points, and their sum is divided by 2. If the student in the analysis
of at least one problem the problem is not scored 55 points, it is considered not passed the PC.
Problem tasks are based on the list of diseases presented in note 12 of the order of the Ministry
of Health of the Republic of Uzbekistan dated 23 March 2009, as well as the qualifying
characteristics GPs. The teaching staff involved in the reception of the PC is determined by
supervisors of the department on the day of inspection.To PC allowed only those students who
do not have permits for lectures and workshops. Students not admitted or scored at the first
delivery of the PC at least 55 points are allowed to retake only after the permission of the
department head
1
Criteria for assessing students at the intermediate control
Assimilation% scores
response scores rank
level of training
in
the
number
and quality
. 91 - 100
Excellent "5"
collate, assess, analyze, , know 4 degrees:
apply, understand
High
clinical
thinking, mastery
of practical skills
and
theoretical
knowledge
2
86-90
Very good "5"
Analyze,
apply, the 3 degree: the
understand, know
degree
of
knowledge
and
skills
3
. 71 - 85
Good, "4"
is
4
65 - 70
5
55 - 64
6
54,9-41
N
understands 3 degree: the degree
of knowledge and
skills
Total satisfactory Understands, knows
2 degrees: the ability
"3"
to learn
Satisfactory,
" Knows
1 degree: the degree
minimum
of representation
requirements
met "3"
not
satisfactory, knows not satisfactory
0
degree:
weak
further work is
representation
80
used,
knows
needed "2"
given pastes are not does not know the extent
0 - absolute lack of
satisfactory,
representation
require
the
constant extra
work "1
10-20
"0"
" Point of presence on the 0
8
intermediate level of
the survey
Note: Due to the fact that on the subject of endocrinology small hours of the interim control is not
carried out.The intermediate survey is carried out once per cycle. The resulting score
intermediate survey multiplied by a factor of 0.2. The maximum score based on factors of 20
points.
55% of the maximum rating score of intermediate survey of 11 points.
Final control
Final control (IR) is carried out on completion of training in the discipline. By IR admitted students
who have successfully completed a training course of general practitioners and have a positive
assessment (over 55 points) in the current studies, the CDS and the PC.
Maximum rating score of the final survey – 10055% of the maximum rating score of the final
survey - 55Type of IR determined by the Academic Council of the Institute and will take place in
2 stages:
The first phase of 6-7 training courses for GPs in internal medicine will take place by the method
of "OSCE" (it is allocated 50% of the points IR) and 6 courses on the subject of endocrinology
(due to the fact that the test is not carried out an examination of 100% of points allocated IR and
scored points multiplied by a factor of 0.5) in the module of rural health units at the department.
A student who receives at least 55% of the maximum score "OSCE", not solved the problem of
the patient or to perform basic stages of practical skills (even if the collected total score is equal
to or greater than 55 points) receives a failing grade and not be allowed to further stages of Osca.
In accordance with established procedure in future students are allowed to retake the exam.
When drawing up the problem of the problem, examination of patients and performing skills will
be based on a list of disease presented in note 12 of the order of the Ministry of Health of the
Republic of Uzbekistan dated 23 March 2009, as well as the qualifying characteristics GPs.
On the subject of endocrinology for students 4 courses will be held at the clinic in the form
drawn up in accordance with the curriculum problematic tasks, practical skills and analysis of
laboratory and instrumental investigations.
The second stage will be held in the form of test examination, and he also released 50% of the
maximum score of IR. A student who receives at least 55% of the maximum score of the test
exam is inconclusive certification and was the dean's office to resolve once given the opportunity
to retake the exam. If the result of both phases of the IR test scores are added together and
displayed their OSSE and total score. The total score of the final control on the subject of
internal diseases multiplied by a factor of 0.3. Thus, the maximum score is 30, final control
points.
The criteria for assessment of the final survey, conducted by the method of "OSCE".
The maximum score is - 100
N
response
scores level of training
Assimilation% scores
rank
in
the
number
and quality
1
91-100
Excellent "5"
collate,
assess, know 4 degrees:
analyze,
apply, High clinical thinking,
understand
mastery of practical
skills and theoretical
7
40,9-21
81
knowledge
2
86-90,9
Very Good "5"
"
3
. 71-85,9
good "4"
is
4
5
6
7
Analyze, apply, the 3 degree: the degree
understand, know
of knowledge and
skills
used,
he 3 degree: the degree of
understands
knowledge and skills
knows
65-70,9
satisfactory "3"
Understands, knows the
degree
of
2:
stepensposobnosti to
learn
. 55-64,9
satisfactory minimum " Knows
1 degree: the degree of
requirements met
representation
"3"
54,9-41
not
satisfactory, knows Poor
0
degree:
weak
further work is
representation
needed "2"
Less than 40.9 - is not satisfactory, Do not know
0-degree - the degree of
21
further work is
absolute
lack
of
required
to
representation
constantly "1"
Part of the IR method OSSE will be based on the provisions of the «OSCE», adopted at the general
meeting of the department and approved by the Vice-Rector for Academic Affairs of the
Tashkent Medical Academy.
If his assessment is based on the situation for the OSCE and the table above number 5.At the end of
the cycle points TC, PC and IC are summed and based on their overall assessment of the amount
of output on the subject.
Indicators of progress on the subject of the following (the amount of current, intermediate and final
control)
86-100% - excellent - the top score - 86 – 10071-85,9% -good - the top score - 71 - 85.955-70,9% satisfactory - the top score - 55 - 70.9less than 55% - unsatisfactory - the top score of less than 55.
If the student has received at least 55 points on OSKE it is NOT permissible in the test exam.
Ranking the student on the subjectRating student on the subject is determined by the following
V  O'
formula
Rf =
100
Rf where: V- total load on the subject (in hours) - The level of assimilation of the subject (in
points).A passing score on the TC, PC and IR is 55 and above.The total score of the student in
the subject is the arithmetic sum of the TC, PC and IR.Timing of control
Interim and final control are conducted according to the calendar and thematic plan approved by the
education department of the schedule of the final control. Students do not receive a passing grade
or not participate in the interim and final control are given the opportunity and time to retake the
exam.
A student who missed practice sessions or intermediate, final control due to illness according to the
order of the dean of the faculty provided the two week period after the start of school for
castings.
Student which in the current, interim or final control has not received a passing grade is considered
academic debtors on the subject.
82
Academic debtors after the end of the semester includes 1 month for castings. If within this period
the student will not be able to master the subject on the recommendation of the dean of the
faculty and the order of the rector expelled from the ranks of students.
If a student does not agree with the assessment of the evaluation with the announcement during the
day has the right to apply to the Dean of the Faculty. In such cases, on the recommendation of
the dean of the Rector's order drawn up Appeals Commission consisting of 3 people.
The Appeals Board after reviewing the student's application on the same day is to give its opinion.
The assessment of students' knowledge in accordance with the approved time and should be
monitored dean, head of the department, the education department and the department of internal
inspection and monitoring.
References
Main
1. Ichki kasalliklar, Sharapov U.F. T: Ibn Sino, 2003
2. Ichki kasalliklar, Bobojanov S. T: YAngi asr avlod, 2008
3. Ichki kasalliklar, Kamolov N.N., 1991
4. Vnutrennie bolezni, tom 1,2 Muxin N.A. M.: GEOTAR - Media,2009
5. Geriatriya v deyatelьnosti vracha obщey praktiki Nasreddinova N.N. T: Shark, 2004
6. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
7. Textbook of famali Medicine Robert УЮ Rakel.David P. Rakel.2016
8. Textbook of Harrison principles of internal medicine 19th edition. 2015
Contributory1. The collection of practical skills for general practitioners, Gadaev AG, T. 2012
2. General practice, Under red.F.G.Nazirova, A.G.Gadaeva. M .: GEOTAR Media 2009.
3. Guide GP. Dzh.Mёrta. M .: Practice, 1998.
4. The collection of practical skills for general practitioners. Gadaev A. Akhmedov HS T. 2010.
5. for the practicals habit Gadaev AG Akhmedov HS, 2010. T.
6. Therapeutic Handbook Washington, Ed. M.Vudli M .: Practice 2000.
7. The manual for general practitioners F.G.Nazirov, A.G.Gadaev maxp. M .: GEOTAR Media
2007.
8. Diagnosis of diseases of internal organs. Hams AN 2005.
9. Treatment of diseases of the internal organs. Hams AN 2005.
10. Differential diagnosis of internal diseases. Vinogradov AV M .: Medical information agency,
2009.
11. Internal Medicine: textbook.- 2 Vols. (1t), Ed. Martynov and others. M .: GEOTAR - Media
2005:
12. Internal Medicine: textbook.- 2 Vols. (2 m.), Ed. Martynov and others. M .: GEOTAR - Media
2005:
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http://www.lib.uiowa.edu/hardin/md/index.html,http://dir.rusmedserv.c,http://www.medlinks.ru/,htt
p://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/
http://elibrary.ru
http://www.freebooks4doctors.com/
http://www.medscape.com/
http://www.meducation.net/ http://www.thecochranelibrary.comOnline medicine sayteMed.site.narod.ruwww.medlook.ruwww.medbok.ruwww.medicum.ruwww.medtext.ruwww.medknig
a.ru
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