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THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN TASHKENT MEDICAL ACADEMY THE DEPARTMENT OF INTERNAL DISEASES № 3 OF MEDICAL AND PEDAGOGICAL FACULTY 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. 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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. 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