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The Ministry of Health of the Republic of Uzbekistan
Tashkent Medical Academy
The department of internal diseases № 3 of medical an
Medical Pedagogical Faculty
"APPROVED"
Vice Rector for Academic Affairs, TMA,
Professor Teshaev OR
«_____» ______________
2016 year
Discipline: INTERNAL DISEASES
7 curs
THE TECHNOLOGY OF TRAINING
Cycle: Pulmonology
SYNDROMES:
«Cough with expectoration»
«Shortness of breath, choking»
Themes 1-6
_____________________________________________________________________
(educational-methodical recommendation for teachers and students of
medical University)
Tashkent-2016
1
REQUIREMENTS TO KNOWLEDGE AND SKILLS IN TEACHING
STUDENTS ON the BASIS of the DECISION of PROBLEMS of SICK
With a COUGH
Objective: to Teach students on syndrome the decision of problems of patients
with cough, as well as the principles of their use in the conditions of primary health
care in the framework of the qualification characteristics of the GP
The main objectives of the training:
To teach students solve problems, associated with cough.
To teach students the timely diagnosis of the presence of the problems associated with cough.
To train the students distinguish disease, accompanied by coughing.
To improve the necessary knowledge and practical skills in solving the problem of patients with cough
(information gathering, identification of problems and physical examination, as well as the ability to
reasonably assign laboratory and instrumental methods of study);
To train the students informed choice of tactics of conducting;
To train the students reasonably carry out treatment-and-prophylactic measures and surveillance in the
conditions of the SVPs and the joint venture.
1.2. In the analysis of the problems of sick key aspects of the evaluation of students ' knowledge
should be:
The ability to allocate the basic problem, which is reflected on the quality of life of patients.
The ability to ask support questions rational history.
Ability to distinguish the presence of risk factors.
Ability to transfer the disease or condition that may be the cause of the problem.
Ability to reasonably conduct a physical examination.
Ability to informed destination laboratory-laboratory researches in the conditions of the SVP or joint
venture.
The ability to highlight the need for additional research beyond the SVP or joint venture.
On the basis of the information obtained, the ability to install the main reason (diagnosis) of this problem.
The ability to determine the tactics of conducting on the basis of the qualification characteristics of the
GP.
The ability to provide drug-free tips.
Ability to identify medical treatment on the basis of evidence-based medicine
Ability to identify preventive measures at the level of primary health care.
• Ability to define the principles of prophylactic medical examination and rehabilitation of patients in the
conditions of the SVP or joint venture.
What should know the student in solving the problem of patients with cough:
№
1
2
3
4
5
6
7
List of knowledge
Basic level
The student should know at least
List of diseases which occur with cough
10 of the most common diseases
The list of the most dangerous diseases which occur with
The student should know at least
cough
5 diseases
List of States that require management in the conditions of the According to the qualification
SVP or CP (1 category)
characteristics of the GP
List of States requiring consultation of a specialist or hospital According to the qualification
(2nd category)
characteristics of the GP
The list of research, requiring in the conditions of the SVP or According to the qualification
joint venture (3.1-category)
characteristics of the GP
The list of studies that required areas beyond the limits of the According to the qualification
SVP or joint venture (3.2-category)
characteristics of the GP
Key points (criterion) of diagnostics of the diseases
2
The student should know the
proceeding with a cough
8
Signs of cardiac asthma or pulmonary edema
9
Signs of bronchial asthma
10
Signs of circulatory insufficiency
11
Signs of respiratory failure
12
The symptoms of the destruction of internal organs
13
The principle of «traffic light»
14
Results of laboratory and instrumental investigations
15
Therapeutic tactics
16
Principles of primary, secondary and tertiary prevention
of
17
Principles of clinical examination and rehabilitation of
patients in the conditions of the SVP or op (4 category)
special characteristics and
manifestations of each disease,
as well as the criteria for their
diagnostics.
The student should list the
symptoms of the
The student should list the
symptoms of the
The student should know the
manifestations of
The student should know the
manifestations of
The student should be aware
of the symptoms of defeat
The student should know the
levels of peak expiratory flow
(PSV Eindhoven) depending
on the color of the traffic light
The student should know:
- normal indicators, as well as
their shifts when the
pathology.
The student should know the
methods and principles of
treatment (including
medication-free).
The student should know the
basic measures needed for
primary, secondary and
tertiary prevention of
The student should list the
main activities on clinical
examination and rehabilitation
of the
That must be a student at solving the problem of patients with cough:
№
The list of skills
1
2Ask of the patient and his relatives
2
To identify risk factors
Basic level
The student should be able to ask brief
questions of rational question, which really
helps to install probable diagnosis.
The student should be able to purposefully
identify and assess the patient's complaints.
The student should be able to analyze the
anamnesis of disease: the beginning of the
disease, the first symptoms, the causal their
relationship and dynamics of development.
The student should be able to analyze the
anamnesis of disease: the beginning of the
disease, the first symptoms, the causal their
relationship and dynamics of development.
The student should be able to identify the
managed and unmanaged risk factors as with
3
3
To calculate the index of weight/body
4
Measure the blood pressure.
5
Conduct an examination of the skin
6
Examination of the throat
7
See and feel the rib cage
8
Spend a percussion of the respiratory
organs
9
Spend auscultation of respiratory organs
10
Spend palpation of the heart
11
Spend percussion heart
12
Spend auscultation heart
ask the patient, as on the basis of an objective
approach
The student should be able to identify signs:
- insufficiency of weight
- high weight.
The student should be able to hold tonometry
given step-by-step principle.
The student should be able to detect the
presence of:
-paleness
- cyanosis
- presence of rash
The student should be able to conduct an
examination of the throat with a given stepby-step principle and to identify the signs of a
sore throat.
The student should be able to:
- evaluate the tour chest cells
- evaluate the voice shake
- estimate the elasticity of the chest cells
- identify strain
The student should be able
identify changes in pulmonary sound and
their interpret
The student should be able
evaluate the vesicular and the bronchial
breathing, as well as the presence of
pathological noise and screams, interpret их.
The student should be able to identify:
- heart push
- the systolic and diastolic shake
The student should be able to evaluate the
apical push
The student must be able to determine:
- the borders of relative and absolute dullness
of heart
- the borders of vascular beam
- diameter of heart
-the configuration and waist heart
The student should be able to identify:
- signs of a hypertrophy of departments heart
- mitral configuration
-aortic configuration
The student must be able to identify:
- Easing I and II sound
- I gain tones on top
- Accent II tone of the aorta or pulmonary
artery
- Systolic and diastolic murmur, and to
identify their epicenter
To be able to differentiate functional from
organic heart murmur.
4
13
Inspect the limb
14
Perform a visual inspection of bones and
joints
15
Examine the thyroid gland.
16
Conduct a peak flow meter
17
Interpret the results of peak flow
18
Conduct ophthalmoscopy
19
Interpret clinical, instrumental and
biochemical analyzes
20
Interpret the X-ray picture of light
21
Remove the ECG and decrypt it
22
Differentiate the disease, accompanied
with cough
- Noise pericardial friction
The student should see the limbs and body,
and to be able to find:
- Local or generalized edema. The fingers
must be able to exert pressure on the back of
the foot to discover:
- There is a hole or not.
The student should be able to find:
- The presence of articular syndrome
The student should be able to inspect and
palpate the thyroid gland and identify signs of
increase, and depending on the size of the
thyroid gland to distinguish the degree of
goiter
The student should be able to hold the peak
flow meter, taking into account the principle
of step
The student must:
- Know how to use tables and charts PSV
normal values based on gender, age and
height of the patient.
- Be able to calculate the percentage of
predicted PEF values depending on gender,
age and height of the patient.
- Be able to analyze and predict the results
The student should be able to
ophthalmoscopy with the principle of
incremental viewing fundus
The student must be able to detect a shift from
the norm
The student must be able to identify signs:
- pneumonia
- pneumothorax
- pleurisy
- Lung cancer and tuberculosis
- Chronic Bronchitis
- PE
The student should be able to record the ECG
with the incremental principle.
The student must be able to decipher the
results of the ECG and identify signs:
- Hypertrophy of the heart.
-rhythm disturbances
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination, laboratory and
instrumental investigations).
The student must be able to differentiate
asthma from cardiac asthma on the basis of
objective data.
The student must be able to differentiate NC
from respiratory failure on the basis of
5
23
Post a non-drug advice
24
To provide pre-hospital care
25
To hold the pleural puncture
26
Rational use of medicines in the
treatment of diseases that occur with
coughing
27
Conduct monitoring and surveillance of
patients
objective data.
The student should be able to:
- Educate patients on self-monitoring
- Advise on diet
- Advise on healthy lifestyles
The student must be able to provide prehospital care in a fit of asthma, spontaneous
pneumothorax, cardiac asthma or pulmonary
edema and myocardial infarction.
The student must be able to carry out pleural
puncture technique for spontaneous
pneumothorax.
The student should be able to choose drugs
with proven efficacy.
When selecting a drug student should be able
to evaluate:
- Efficiency
- Safety
- Eligibility
- Profitability.
The student must be able to monitor and
control:
- ОАК
- The general analysis of sputum
- x-ray
- peak flow
Practical session № 1-2
Topic: Topic: "Cough with expectoration. Diseases that occur cough. The most dangerous diseases
that occur with coughing. Differential diagnosis of acute respiratory infections, viral respiratory
infections, acute bronchitis and pneumonia. Tactics GPs. Indications for referral to a specialist or
hospital in the profile department. The principles of treatment, observation, monitoring in a
hovercraft or joint venture. The principles of prevention "
Iearhing Technology
Study time: 6, 4 hours +
Training themed room.
The structure of the training session
Cabinet GPs.
Tutorials, phantoms, models, handouts, a collection of
case studies and tests
TV, video equipment, multimedia
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis of cough.
The clinical course and the principles of management of patients in primary care, provided the
requirements of the "Qualification characteristics of the general practitioner."
Pedagogical objectives:
Learning outcomes:
1. Teach GP diagnosis - bronchitis, pneumonia,
The student must:
the clinical course depending on the etiology and
GPs should be aware of:
stage.
The list of diseases which occur with coughing.
2. Teach GP diagnosis and differential diagnosis
A list of the most dangerous diseases that occur with
of diseases in which there is a cough.
coughing
3. GPs familiarize with the list of communicable
Clinical manifestations of acute respiratory infections,
and non-communicable diseases associated with
viral respiratory infections, bronchitis, pneumonia
cough and is being treated in the FCP (GWP) or
(especially current).
specialized hospitals.
The differential diagnosis of cough.
6
4. Discuss questions about tactics in the qualifying
characteristics of GPs
5. The principles of treatment (medication and
non-medication).
6. Principles of management, follow-up and
monitoring of patients in a hovercraft or a joint
venture.
7. The principles of primary, secondary and
tertiary prevention in these diseases.
Training Methods
Forms of organization of learning activities
learning Tools
Methods and feedback means
Principles of supervision and management of patients in a
hovercraft or a joint venture.
The principles of prevention in these diseases.
GPs should be able to:
Analyze the data and history of complaints for the
diagnosis of diseases associated cough.
Diagnose, differentiated by clinical, laboratory studies,
radiographs different types of cough.
Advise on non-drug therapies.
the method of "tour of the gallery."
demonstration, entertainment experience, discussion,
conversation, decision tests and case studies
Individual work, group work, team, classroom,
extracurricular.
Hand-learning materials viziualnye materials, videos,
models, graphic organizers, sputum smears, sets of medical
records, tables, stands, kits radiographs.
Quiz, test, presentation of the results of the learning task,
filling medical records implementation of practical skill
"professional debriefing"
Flow chart classes
Topic: Topic: "Cough with expectoration. Diseases that occur cough. The most dangerous diseases
that occur with coughing. Differential diagnosis of acute respiratory infections, viral respiratory
infections, acute bronchitis and pneumonia. Tactics GPs. Indications directions to a narrow
specialist or hospitalization profile department. The principles of treatment, observation,
monitoring in a hovercraft or joint venture. The principles of prevention "
№
1
2
3
4
5
Stages of the practice session
Form classes
Venue
Chapeau (justification themes)
The discussion on the practical lessons with the use of new The survey, discussion
educational technologies (method "tour of the gallery"), as
well as demonstration material (sets of medical charts,
tables, posters, x-ray), define the initial level.
Classroom, GP
surgeries
conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the provisions
and recommendations for the job by filling in medical
charts.
Mastering the practical part of the training under the
guidance of a teacher.
discussion
10
20
GP doctor's office
Prof. questioning. A
conversation with
patients and honey
filling cards,
situational problems.
Admission of patients
in the clinic,
examination at home
7
Duration
classes
225
10
40
20
6
7
8
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research OAM KLA, radiographs, and a general
analysis of the tank. sputum culture and biochemical
analysis and diagnosis
Discussion of theoretical and practical knowledge of the
students, securing the material to determine the level of
assimilation of knowledge assessment.
Defining output on practical sessions on a 100-point rating
system and ad evaluations. Homework next practice
session (a collection of questions).
Medical history,
laboratory data
situational problems
25
Oral questioning, tests,
discussion,
identification of
practical skills
75
Classroom in a clinic
Information, questions
for homework.
Classroom in a clinic
25
2. Motivation
The majority of patients with acute bronchitis, pneumonia, acute respiratory
disease, SARS seek medical help. In this situation, the force of a general
practitioner (GP) is directed to the diagnosis of cough due to various diseases. In
case of cough GPs should diagnose acute respiratory disease, SARS, bronchitis,
pneumonia, and he needed to determine the reasons behind the disease for medical
care and clarifications locations of this group of patients.
Interdisciplinary communication and Intra
The teaching of this subject is based on the knowledge of students of basic anatomy, embryology and
Ggistologii with cytology, biology, normal physiology, biochemistry, pathology, pathophysiology,
topographic anatomy and operative surgery, propaedeutics internal diseases, tuberculosis, oncology,
radiology and nuclear medicine, physical therapy, endocrinology, faculty therapy, in-hospital therapy,
orthopedics. The results obtained in the course of training knowledge will be used during the passage of
the GP - internal medicine and other clinical disciplines.
4. The content of classes
4.1. The theoretical part
On a practical lesson in the theoretical part includes analysis of the clinical features of the diagnosis of
cough.
Infections: pneumonia of various etiologies (causative agents of acute pneumonia should first identify all
types of pneumococci and streptococci - and staphylococci, gram-negative bacteria - E. coli, Pfeiffer coli,
Proteus, Pseudomonas aeruginosa) - widely used in the hospital, causing nosocomial pneumonia gramnegative rod Legionella contained in the water, Klebsiella (Friedlander pneumonia), viral pneumonia
(influenza, adenovirus, cytomegalovirus), viral-bacterial pneumonia, mycoplasma, {PCP in patients with
severe impaired cellular immunity, especially in AIDS, pneumonia caused by fungi , rickettsia,
chlamydia, etc). It should be emphasized tendency to increase atypical pathogens: Chlamydia, Legionella,
Mycoplasma.
Basic principles of treatment of acute pneumonia
Selection of antibiotics is directly related to the type of pathogen
establishment and refinement of its sensitivity.
Pneumococci.
In this connection, in recent years, become widely used as inhibitors of beta-lactamase - 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
with amokitsillinom - amoxiclav.
Second-line drugs - cephalosporins
First generation: cefazolin (Kefzol) to 4-6 g per os cephalexin, 1-2 grams per day. These drugs are highly
active against staphylococci, streptococci, Escherichia coli, Klebsiella, destroyed most of the betalactamase.
8
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 betalactamases.
Third generation: klaforan - 3-6 grams per day; dardum (tsefaperazon) - 2-4 grams per day is 2 times
intravenously; Fortum - 3 grams a day for 3 doses, only parenterally, Rocephin (ceftriaxone) - 1-2 g day
(single dose) intravenously or intramuscularly.
The drug is the third generation of sulbactam +: sulperadon (tsefaperazen) - 2-4 grams per day in 2
divided doses intravenously or intramuscularly.
Third-line - macrolide antibiotics: erythromycin - 200 mg 2-3 times a day intravenously (up 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.
II. Staphylococci: large doses of penicillin - up to 20 million units, semi-synthetic penicillins
(oxacillin, methicillin), second row: lincomycin - 500 mg 3 times a day, aminoglycosides: gentamicin 80 mg 3 times a day, kanamycin - 500 mg 3 times day.
III. Escherichia coli, Pseudomonas aeruginosa, Proteus (nosocomial infection) semi-synthetic
penicillins, aminoglycosides, chloramphenicol and 1 g per day.
IV. Klebsiella (pneumobaccillus) aminoglycosides in combination with chloramphenicol or tetracycline
(doksatsiklina hydrochloride) prolonged scheme - the first day, 200 mg (100 mg two times a day), then
100 mg 1 time per day for 5-10 days.
V. Chlamydia, Legionella, Mycoplasma: macrolides (erythromycin, rulid, clarithromycin), tetracyclines
(doksatsiklina hydrochloride).
VI. 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 can be related to antibiotics. Along with cephalosporins are widely
used for the treatment of bacterial infections. Fluoroquinolones have an advantage over many antibiotics:
well into the cells active against T and T positive bi bi negative, anaerobic bacteria, they are sensitive
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 per day for 1-2 weeks, ofloxacin (tarevid) 200-400 mg 2 times per day (more active
against S. aureus).
VII. Fungi: amphotericin B (daily dose - 250 U / kg intravenously every other day or 2 times a week for
4-8 weeks).
VIII. Virus - interferon.
Tactics GP acute pneumonia - hospitalization the patient.
USE OF THE "TOUR GALLERY."
Objective: To teach students critically evaluate information and identify the
completeness of knowledge on the subject.
Each small group is invited one problem they solve for 10 minutes in writing
and then exchange tasks. Revealing mistakes of the previous group, and additions
made to the answers discussed by all members of the adoption of the final version
of the responses. Methodology tour gallery requires students to maximum
concentration and a good theoretical background for this section.
Example: subject classes "Cough with expectoration." Three small groups are
given on a question: A variant of issues.
1. Features of the course of lobar pneumonia
2. Features of acute obstructive bronchitis.
3. Prevention of acute respiratory disease, SARS.
So for 30 minutes, the teacher gets an idea of the level of training of students on
various sections of topics and their ability to defend their views.
Answers.
9
Pneumonia - an acute infectious and inflammatory disease mainly bacterial
etiology, involving the respiratory inflammation of the lungs, alveolar exudation
mandatory that spreads to adjacent bronchi, vessels, pleura. Prolonged pneumonia an acute infectious inflammatory disease of the lungs in which the pneumonic
infiltration is not permitted at the usual time (4 weeks), and slower for 5-8 weeks,
and is usually finished, recovery. SARS - is pneumonia, which is caused by
microorganisms will multiply intracellularly: Legionella, Chlamydia, Mycoplasma.
These pneumonia occur without typical clinical and radiological (infiltrative)
displays, for the pathogenesis - mainly secondary, difficult to treat with antibiotics
penicillin and cephalosporin.
Diffuse acute inflammation of the tracheobronchial tree. Refers to frequent illness.
Bronchitis infectious etiology often starts with acute rhinitis, laryngitis. In mild
disease occur sadneiie the sternum, dry, less productive cough, feeling of
weakness, and weakness. Physical signs are absent or ill-defined above lungs
breathing, wheezing, dry. The body temperature is normal or low-grade. The
composition of the peripheral blood does not change. This occurs more frequently
during the defeat of the trachea and major bronchi. At moderate flow significantly
expressed general malaise, weakness, characterized by a strong dry cough with
difficulty breathing and shortness of breath, pain in the lower chest and abdomen
associated with overexertion of muscles when you cough. The cough gradually
becomes wet, phlegm gets slizistognoyny or purulent. Above the surface of the
lungs listened hard breathing, dry and wet finely wheezing. Body temperature is
within a few days subfebril. Pronounced changes in the composition of the
peripheral blood there. Severe disease is observed, as a rule, primary lesion of the
bronchial tubes (bronchioles). Acute symptoms subside to 4MU day and at a
favorable outcome to completely disappear 7mu day.
Prevention of influenza is vaccination. Who developed the vaccine, which
guarantees almost 100% of the body's defense against infection.
Vaccines are delivered in ready-dose disposable syringe, which is convenient and
secure. Non-specific prevention - to take ascorbic acid and multivitamins, which
increase the body's resistance.
Pneumonia - an acute infectious and inflammatory disease mainly bacterial
etiology, involving the respiratory inflammation of the lungs, alveolar exudation
mandatory that spreads to adjacent bronchi, vessels, pleura. Prolonged pneumonia an acute infectious inflammatory disease of the lungs in which the pneumonic
infiltration is not permitted at the usual time (4 weeks), and slower for 5-8 weeks,
and is usually finished, recovery. SARS - is pneumonia, which is caused by
microorganisms will multiply intracellularly: Legionella, Chlamydia, Mycoplasma.
These pneumonia occur without typical clinical and radiological (infiltrative)
displays, for the pathogenesis - mainly secondary, difficult to treat with antibiotics
penicillin and cephalosporin. Diffuse acute inflammation of the tracheobronchial
tree. Refers to frequent illness. Bronchitis infectious etiology often starts with
acute rhinitis, laryngitis. In mild disease occur sadneiie the sternum, dry, less
productive cough, feeling of weakness, and weakness. Physical signs are absent or
ill-defined above lungs breathing, wheezing, dry. The body temperature of a low10
grade or normal. The composition of the peripheral blood does not change. This
flow is observed more often in lesions of the trachea and major bronchi. At
moderate flow significantly expressed general malaise, weakness, characterized by
a strong dry cough with difficulty breathing and shortness of breath, pain in the
lower chest and abdomen associated with overexertion of muscles when you
cough. The cough gradually becomes wet, phlegm gets slizistognoyny or purulent.
Above the surface of the lungs listened hard breathing, dry and wet finely
wheezing. Body temperature is within a few days subfebril. Pronounced changes in
the composition of the peripheral blood there. Severe disease is observed, as a rule,
primary lesion of the bronchial tubes (bronchioles). Acute symptoms subside to
4MU day and at a favorable outcome to completely disappear 7mu day.
Prevention of influenza is vaccination. Who developed the vaccine, which
guarantees almost 100% of the body's defense against infection.
Vaccines are delivered in ready-dose disposable syringe, which is convenient and
secure. Non-specific prevention - to take ascorbic acid and multivitamins, which
increase the body's resistance.
№ evaluation
Assimilation in%
fine
100%-86%
good
85%-71%
Satisfactory
70-55%
unsatisfactory
54%-37%
1
20-17,2
mark
17-14,2
mark
14-11 mark
10,8-7,4
mark
The theoretical part
poorly
36% or
less
7,2 mark
4.2. The analytical part of
4.2.1. Case Studies:
The patient 61god, hypothermia after complaining of fever 39-40C, chills, cough with sputum production
is not large, shortness of breath, severe weakness, pain in the chest and abdomen. He was treated at home,
took 3 days for penicillin, but the condition has not improved. His condition was grave, his face pale,
cyanosis, BH :30-40 min, heart rate of 100-120 beats per minute. In the right light in the lower dullness.
Weakened vesicular respiration, fine bubble wet and dry rales. The right side of the chest is slightly
behind in the act of breathing. Cor muted tones, accent II tone on the pulmonary artery.
1. List at least four diseases which infiltrates are observed in the lungs;
2. Your preliminary diagnosis;
3. What changes can be found in the overall analysis of sputum and chest X-ray;
4. The tactics of the GP (principles of treatment and secondary prevention).
Answers:
№
1
2
3
4
Answers:
a) Chronic pneumonia, b) Central lung cancer, c) infiltrative
pulmonary tuberculosis, g) Eosinophilic pneumonia.
Right-sided nizhnedolevaya lobar pneumonia, severe course. NAM
II Art.
The increase in the number of white blood cells in the sputum, red
blood cells, epithelial cells (rusty sputum), various pathogens (coca).
When X-rays increased vascular pattern in the lower regions of the
right lung infiltrate. Pleural thickening in the lower section. Aperture
thickened.
Bed rest. Causative treatment: antibiotics. Pathogenic: improving the
drainage function of bronchi and bronchopulmonary defense.
Immunomodulatory Therapy: prodigiozon, T-activin, timolin and
other antioxidants: vit. E emoksipin. Detoxification therapy,
11
Mark
20
35
20
25
symptomatic therapy, physiotherapy.
2. The patient on day 3 after holetsistoektomii increased body temperature up to 38C, there was a
shortness of breath, chest pain, coughing up blood. The wound is dry, no discharge from the
wound. Serious condition, respiratory rate 40 per minute., Heart rate 120 per minute. Above the
right light in the lower divisions weakened vesicular breathing, moist finely wheezing. 22.8
leukocytosis, neutrophilia, left shift.
1. List at least 5 diseases in which there is pain in the chest and coughing up blood;
2. The preliminary diagnosis;
3. What changes do you find by chest X-ray;
4. The tactics of the GP (treatment guidelines);
3. A patient 28 years old, was treated for postpartum endometritis about. On the 10th day of
illness there were pains in the chest, lost consciousness, blood pressure 90/60 mm T. Art. After /
in the 300mg prednisone and hydrocortisone 250mg patient's condition has improved
significantly, but as the pressure has not risen patient was transferred to the intensive care unit.
Objectively: general condition is serious, BH 22 minutes, in consciousness, heart rate 120 per
minute, blood pressure 80/60.
1. The preliminary diagnosis;
2. What changes do you find the part of the ECG;
3. Informative research methods;
4. The tactics of the GP (treatment guidelines);
_____________________________________________________________________________
__
4. Patient N., 22 years old. On admission complaints fever, cough with mucous expectoration,
loss of appetite. From history feels sick for 3 days. Prior to admission to the hospital was not
treated. During the year, 3-4 times cold. Do not smoke. Objectively: general condition is
relatively satisfactory. The skin is moist. Percussion slightly dull lung sounds. Auscultation fine
moist rales in the chuck on the right. Fluoroscopy: infiltration in the lung root and V-VI ribs on
the right. ERF: restrictive changes VC-74%, FEV1, 95% of IT-106%. Biochemical parameters:
sialic acid-310 units., Seromucoid-250ed.
1. List at least four diseases occurring with pulmonary infiltrates;
2. The preliminary diagnosis;
3. What changes do you find by the KLA;
4. The tactics of the GP (treatment, secondary prevention);
_____________________________________________________________________________
_
5. A patient 46 years old, complains of increased body temperature 39.6 C, initially dry cough
with a small amount of mucous expectoration, then paroxysmal cough with "rusty" sputum. The
patient takes alcohol in large quantities. Bronchial breathing and moist rales in the right finely
chuck area. Despite intensive treatment with penicillin in the hospital the patient's condition unchanged,
shortness of breath and signs of intoxication are preserved. In sputum: Staphylococcus aureus in a large
quantity. On Fluoroscopic: both multiple small infiltrative lung shadow. At the top and bottom of the lung
cavity destruction. The patient was treated for tuberculosis of the lungs.
1. List at least four diseases occurring in a dry cough;
2. The preliminary diagnosis;
3. What changes do you find by the KLA;
4. What complications can occur;
5.Taktika GP (principles of treatment, secondary prevention);
______________________________________________________________________________
6. Sick '53 appealed to the GP complaining of hoarseness, cough with sputum difficult, increased body
temperature 38.2 C, chest pain and general weakness. He considers himself sick for 4 days. The disease
began acutely. General state of moderate severity. Skin is clean, moist, cyanosis of the lips. Percussion
12
over the lungs lung sounds. Auscultation: in the lower left lung sounding fine moist rales, pulse 84 beats /
min. Jabs: HB - 104, L-10, 3; p/ya-6; s/ya-71, M-4, L-20, ESR-24 mm / h
1. What type of ventilation in the lungs observed in this patient;
2. The preliminary diagnosis;
3. Informative research methods;
4. The tactics of the GP;
______________________________________________________________________________
7. 32-years old patient complained of tiredness and a dry cough. As a child several times treated for
pneumonia. OBJECTIVE: lung disease were found. Radiological findings: in the upper part of the right
lung is determined by the blackout with no clear boundaries, not homogeneous and associated with the
root of the lung around the focal inflammation. KLA: Hb 130 g / L, WBC 9.9 × 10 ^ 9 / L, the formula
unchanged, erythrocyte sedimentation rate 33 mm / h
1. What do you recommend examination to confirm the diagnosis;
2. The preliminary diagnosis;
3. What changes are specific to the sputum of the patient;
4. The tactics of the GP;
______________________________________________________________________________
8. Patient G. During 6ti been suffering from chronic bronchitis. Recently, low-grade fever of the body,
cough with a small amount of sputum. Independently treated at home. In the last week body temperature
increased up to 39-40C. Increased separation of the mucous expectoration. Shortness of breath, pain in
the left side of the chest, irradiation of the pain in his arm and back. The general condition is serious,
forced position, pale skin, cyanosis of the lips, behind the left chest in breathing and in the lower blunting
sound, voice trembling, bronchial breathing, are heard in other parts of the wet and dry rales. The liver is
enlarged 2 cm, swelling in the legs.
1. List at least four diseases for which there are higher these signs and symptoms;
2. The preliminary diagnosis;
3. What changes are characterized by chest radiography in this patient;
4. Tactics GPs and treatment guidelines;
________________________________________________________________________________
9. 24 year old patient is turned to the GP with complaints of fever up to 39,6 º C, chills, pain in the right
side of the chest and around the heart, shortness of breath, cough with sputum difficult, headaches,
palpitations. Patient's condition is severe, cyanosis of the lips, rosy cheeks, the temperature of 39,2 º C.
When light percussion back to the 6th rib blunting lung sound auscultation on this site bronchial
breathing. Respiratory rate 30 per minute. Heart sounds, accent II tone on the pulmonary artery. Pulse of
110 beats per minute, arrhythmic due to rare premature beats. Liver + 2 cm UAC: Hb 89 g / l,
erythrocyte-3 5h1012 / l cs 0.7, Lake 17.0 x 109 / L, EPZs 1% p / 9%, w / I 76%, 10% lymph, Mon 4%,
erythrocyte sedimentation rate of 35 mm / hour. In the analysis of traces of urine protein. Chest
x-ray on the right below the 6th rib intense homogeneous darkening with clear margins merging
with a dome diaphragm.
1. List at least 5 possible diseases in which the above symptoms occur.
2. Your preliminary diagnosis.
3. List at least 5 of complications that can occur with this disease.
4. Tactics GPs.
5. The principles of treatment.
_____________________________________________________________________________
_
10. A patient 68 years old, long-term chronic bronchitis and calculous cholecystitis. At clinical
examination revealed GPs: shortness of breath, flushing of the face, injection of blood vessels of
the sclera, epigastric pulsating, throbbing neck veins. In the lungs, weakened vesicular breathing,
dry, wet and buzzing finely wheezing. Respiratory rate 26 per minute. Heart: percussion hypertrophy of the left and right ventricle, right atrium. The tones are muted, accent and splitting
II tone of the aorta, the accent II tone on the pulmonary artery. Heart rate of 88 beats per minute.
Blood pressure 140/70 mm T. Art. The abdomen was soft, b / w, liver 4 cm, the edge is rounded,
painful. On her feet swelling. UAC: 160 g Hb / l, 5,6 • Erythrocytes 1012 / L, Lake 8.7 x109 / l
13
reticulocytes 5% p / 5% w / I 44% ELUR 3% lymphs 35% Mon 7 % base 1%, platelets 280,
erythrocyte sedimentation rate 15 mm / h; PTI 105%. Chest X-ray - a picture of chronic
bronchitis, pulmonary fibrosis, expanding the boundaries of the heart.
1. List at least five probable diseases in which the above symptoms occur.
2. Your preliminary diagnosis.
3. Specify the criteria for acute respiratory characteristic of this disease.
4. Tactics GPs.
5. The principles of treatment.
_____________________________________________________________________________
__
11 .. House Call GPs: a patient 32 years old, complained of fever, cough with difficult
expectoration, pain in the right side of the chest and stabbing pains in the heart, palpitations,
shortness of breath.
From history: the disease associates with hypothermia. Home treatment is not effective. Three
children, cotton grower. Uses "nasvaya."
Objectively: the patient's condition serious.
When percussion on the front of the chest with the V intercostal space and zadneypoverhnosti
from the corner of the blade on the right is marked shortening of percussion sounds, here are
heard ringing dry and moist rales, pleural friction rub. Heart sounds, arrhythmic due to
arrythmia. Pulse 110 in 1 minute.
KLA-Hb 110 g \ l, erit.-3, 6, leyk.-10, -28 ESR
OAM-diuresis-1600-1010 density, color, transparency sol.zhel - full, protein - abs
General analysis of sputum - muco-purulent, white blood cells - in large numbers, the red
blood cells are unit. Chest X-ray - clearly delimited intense infiltration of the right lower lung
field, the root of the right lung strengthened the presenting pleura lumpy underlined.
I
Registration:
II
complaints:
III
Anamnesis
14Т14bid:
IV
Anamnesis vitae:
V
Risk factors:
VI
problem:
VII
General inspection:
The patient is 56 years old, the seller, the floor - M Index
smoker - 60 -72. T0C = 36,5, Pulse 98 min. A / D 120/70 mm.
T. Article.
cough with difficult expectoration, asthma attacks, shortness of
breath with difficulty breath, weakness.
He considers himself a patient for many years, is at the
dispensary in the last 3 months shortness of breath and asthma
have increased
Growing and developing in satisfactory conditions, smoked for
many years, dropped out, was sick with hepatitis, hereditary,
allergies and Epidemiological anamnesis denies.
Managed: smoking, hypothermia
Unmanaged: gender, age,
Key: asthma, cough with difficult expectoration, dyspnea
with labored breath.
Related: weakness
The general condition of the patient of moderate severity, the
position of the forced-orthopnea, cyanotic skin, wet cheeks
bloodshot, swollen neck veins
Respiratory system: Inspection - barrel-shaped chest, her tour is
limited. When percussion of the chest - box sound.
Auscultation: against the hard breathing dry whistling dry rales.
Respiratory rate 24 per minute.
Cardio - vascular system: Heart sounds, accent II tone of the
pulmonary artery. Pulse 98 in minutu.A \ D 120 \ 70 mm Hg T
14
VIII
IX
X
XI
XII
XIII
XIV
XV
The rest of the system without features.
DOS. Community-acquired pneumonia nizhnedolevaya sided.
Donkey. Dry pleurisy on the right. Toxic myocarditis.
3.1 Category:
- Professional questioning and examination
- KLA, OAM
- pikfluometriya
ECG
Category 3.2:
general analysis and bacterial culture of sputum from the
definition of sensitivity to antibiotics
- X-ray methods
KLA-Hb 110 g \ l, erit.-3, 6, leyk.-10, -28 ESR
Study on the
OAM-diuresis-1600-1010 density, color, transparency sol.zhel
category 3.1:
- full, protein - abs
General analysis of sputum - muco-purulent, white blood cells in large numbers, the red blood cells are unit.
Chest X-ray - clearly delimited intense infiltration of the right
lower lung field, the root of the right lung strengthened the
presenting pleura lumpy underlined.
Interpretation Clinic KLA-leukocytosis, accelerated erythrocyte sedimentation rate
Sputum analysis - typical for infectious-inflammatory
- laboratory and
instrumental exams: lung
Chest X-ray - right-nizhnedolevaya pleuropneumonia
Bronchoalveolitis - develops most often in times of outbreaks
The differential
of SARS, the frail, the elderly, the symptoms of intoxication
diagnosis:
are less pronounced, is not typical of pleural involvement, does
not listen crackles, pleural friction rub, radiologically - focal
peribronchial infiltration of non-homogenous.
Pulmonary tuberculosis: a study of sputum revealed
mycobacteria, a long history of contact with a smear,
infiltrative pulmonary tuberculosis is often localized in the S1,
S2, S6 segments of the lung.
Lung cancer: asymptomatic for a long time, choking and
shortness of breath bother with compression of the bronchial
tubes, possible hemoptysis, weight loss, depression, anemia,
changes in the diagnostic X-ray and CT scan, sputum - atypical
cells, red blood cells.
Preliminary
diagnosis:
Plan Survey by
category:
DOS. Community-acquired pneumonia nizhnedolevaya sided.
Donkey. Dry pleurisy on the right. Toxic myocarditis with
jetlag (beats).
Secondary prevention: to identify and make an accurate
Specifies whether a
prevention requires diagnosis in the early stages of the disease, nonpharmacological treatment of disease and drug therapy of
the patient:
proven efficacy.
Tertiary diagnosis of complications, treatment
Nemedikomentoznoe 1. bed rest
2. Health food - easily digestible, enriched with vitamins and
treatment:
proteins food
3.Lechebnaya breathing exercises
4. No smoking and alcohol.
Clinical diagnosis:
15
XVI
Drug treatment:
XVII
Spent the feedback,
set the date and time
of follow-up visit the
patient in the SP or
SAP to monitor the
effectiveness of
treatment:
XVIII Took patient
registration, predefining a group of
sulfur-dispensary
observation
XIX
All types of
prevention:
XX
Stages of clinical
examination:
5. The positional drainage, chest compressions
6. oxygen therapy
1.Antibiotiki - cephalosporins tsefamezim 1.0 x 3 times a day /
m or 1.0 g of ceftriaxone x 1 per day - 5-7 days
2. The anti-inflammatory treatment
- NSAIDs - diclofenac sodium 3.0 ml / m or 100 mg nimesil 1
sachet 1 times a day after meals.
- Antihistamines (suprastin, ketotifen
3. Mucolytics - ambrobene in tablets of 30 mg 3-4 times a day,
sodium bicarbonate 4% -200 ml / drip
4. Drugs to reduce pulmonary hypertension - calcium
antagonists (verapamil)
Convinced of the need for patient hospitalization in a
specialized pulmonary department, on an extract visit to the
GP, set a date for re-examination and investigation
A follow-up group III b
Primary prevention - a range of activities for the prevention
of the disease:
a) promotion of healthy lifestyles among the population;
b) an active early detection of risk factors that predetermine the
possibility of developing the disease and their correction.
Secondary prevention:
a) active detection of the disease in its early stages of
development (baseline medical examination, screening);
b) the correction of non-pharmacological and pharmacological
treatment svoevremennoeadekvatnoe newly diagnosed disease
drugs of proven efficacy.
Tertiary prevention:
a) the prevention of acute and chronic complications, timely
examination of patients, monitoring necessary laboratory and
instrumental studies, continuation of the correction of existing
risk factors and baseline treatment with proven efficacy,
dynamic monitoring;
b) the continuation of treatment is rehabilitation
ikachestvennaya available Complications.
STEPS clinical examination, after establishing the final
diagnosis:
1st - to prove and establish the nosological form of the disease
with the definition of follow-up (D-II; D-III);
2nd - to determine the frequency of observations (medical
examinations) GP scheduled for the year: 1 month. After the
treatment, then every 4 months. Throughout the year
3rd - justify examinations other doctors if this is necessary:
ENT, TB doctor if indicated
16
4th - determine justify the name and frequency of laboratory
and other diagnostic studies for the planned year: KLA, OAM 1
every year, an electrocardiogram, fluoroscopy, radiography 1
every year.
5th - GPs should make a coherent plan of therapeutic measures
for the relevant year of observation:, physical therapy,
exercise, sanitary-and-spa treatment.
6th - set and know the criteria for the effectiveness of follow-up
of the patient on the appropriate form of the disease nosology
and subsequent conversion to a group of follow-up (L-I ;).
№ evaluation
2
fine
good
Satisfactory
unsatisfactory
poorly
Assimilation in%
100%-86%
85%71%
70-55%
54%-37%
36% and
enlarge
The theoretical part
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
TESTS.
TESTS:
1. In the group of chronic nonspecific lung diseases include:
a) posttuberkulezny pneumosclerosis
b) chronic obstructive bronchitis
in) bronchial asthma
d) fibrosing alveolitis
e) chronic pneumonia (e) chronic lung abscess
g) empyema light
2. For lobar pneumonia is characterized by:
a) chest pain
b) "rusty" sputum
c) expiratory dyspnea
d) acute onset
d) purulent sputum
e) increase of body temperature
3. At the stage of "tide" lobar pneumonia percussion determined:
a) lung sounds
b) sound box
c) the dullness
g) tympanic sound
e) the disappearance of the percussion sound
4. Acid-drugs used in, are:
a) methicillin
b) oxacillin
c) ampicillin
d) Penicillin
d) carbenicillin
5. Rational combinations of antibiotics are considered:
a) ampicillin + penicillin
b) tsefamezin + gentamicin
c) ampicillin + gentamicin
z) tetracycline + penicillin
17
d) ampicillin + tetracycline
6. In the treatment of pneumonia in pregnancy in the 1st trimester can be used:
a) tetracycline
b) Penicillin
c) Erythromycin
d) chloramphenicol
e) gentamycin
7. For lobar pneumonia (unlike focal) characterized by:
a) evidence of overloading the left chambers of the heart on an electrocardiogram
b) marked leukocytosis
c) the detection of toxic grain rare neutrophils
d) signs of stress right heart chambers on the ECG
d) one-way flush on the cheek on the affected side
e) evidence of hypertrophy of the left atrium on the ECG
8. More often than in the general population, in alcoholics, there are:
a) pneumonia caused by gram-positive
b) aspiration pneumonia
c) abscessed pneumonia
g) klebsielleznaya pneumonia
e) Legionella pnenmoniya
e) viral pneumonia
g) with mild pneumonia
9. Of the following symptoms for bronchiectasis is characterized by:
a) hemoptysis
b) "drumsticks"
c) paroxysmal hacking cough
d) a significant amount of purulent sputum
e) wheezing with prolonged exhalation
e) diffuse cyanosis
10. The most informative objective clinical evidence for the diagnosis of localized form of
bronchiectasis is:
a) localized moist rales srednepuzyrchatye
b) dry rattles
c) the shortening of percussion tones
d) hard breathing
e) localized moist large bubbling rale
e) fine moist rales
g) strengthening voice
№ evaluation
fine
Assimilation in% 100%-86%
3
TEST.
15-12,9 mark
good
85%-71%
Satisfactory
70-55%
unsatisfactory
54%-37%
12,7-10,6
mark
10,5-8,25
mark
8,1-5,5 mark
poorly
36% and
enlarge
5,4 mark
4.2.2 Graphic Organizer: Venn Diagram
used for comparison or matching iliprotivopostavleniya 2 to 3 dimensions and show them both traits.
• Develop systems thinking, the ability to compare, compare, analyze and synthesis.
18
Acquainted with the rules of construction of a Venn diagram. Individually / in pairs construct a Venn
diagram and fill part of the non-overlapping circles (X)
Are paired, compare and complete their charts.
The intersection of circles make a list of those features that, in their opinion, are common to information 2
to 3 laps (хх/ххх).
Generality
Venn diagram
Nothing in
common
Something in
common
Much in
common
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with acute respiratory disease, SARS, bronchitis and pneumonia
2. Interpretation of the analyzes. (Clinical and biochemical blood tests, coagulation tests, sputum, sputum,
pleural fluid analysis, data, laboratory and instrumental examinations, radiographs of patients with
diseases soprovozhdayushihsya cough, sputum, hemoptysis. Interpretation of radiographic images of the
chest, the results of function studies external respiration).
3. Prescription of drugs depending on the etiology of disease, soprovozhdayushihsya cough, sputum,
hemoptysis.
Cough with expectoration
No stage
indicators /
interpretation
Curation of the patient
Complete blood
General analysis of sputum
Bak.posev sputum antibiogram
Pikfloumetry
Spirography
Chest X-ray
CT and MRI
Consultation phthisiatrician
Consulting oncologist
Differential diagnosis
Justification diagnosis
Tactics GP
Recommendations
TOTAL
19
not done
Achieved in full
0
50 points
0
0
0
0
0
20
10
10
10
100
№ evaluation
Assimilation in%
4
Практическая часть
fine
good
Satisfactory
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% and
enlarge
15-12,9 mark
12,75-10,6
mark
8,1-5,5mark
10,5-8,25
mark
5,4 mark
5. Control forms of knowledge, skills and abilities
- Oral
- The decision of situational problems
- Demonstration of practical skills
- CDS
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
№ evaluation
fine
good
Satisfactory
Assimilation in%
100%85%-71% 70-55%
86%
unsatisfactory poorly
54%-37% 36% and
enlarge
1
The theoretical part
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2
mark
2
Case Studies
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
3
Test
15-12,9 mark
12,7-10,6
mark
10,5-8,25
mark
8,1-5,5
mark
5,4
mark
4
The practical part
15-12,9 mark
12,75-10,6
mark
10,5-8,25
mark
8,1-5,5mark
5,4 mark
6. The evaluation criteria of the current control
levels of
Rating
Characteristics of the student
estimates
points
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not
20
ready for practical employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and
skills, at least one of the following:
Do not know the clinical signs of the most dangerous
diseases are accompanied with cough: pulmonary
tuberculosis, lung cancer
Do not know the pathogenetic treatment of acute respiratory
infections, viral respiratory infections, acute bronchitis and
pneumonia of various etiologies.
not
20 - 54,9
Do not know the risk factors for acute respiratory infections,
satisfactory
viral respiratory infections, acute bronchitis
Do not know the groups of drugs used in treatment of acute
respiratory infections, viral respiratory infections, acute
bronchitis
• Can not indicate the radiographic signs of the most
dangerous diseases are accompanied with cough: pulmonary
tuberculosis, lung cancer
• Not able to assemble a rational history during the
20
Supervision of patients with acute respiratory infections,
viral respiratory infections, acute bronchitis and pneumonia
of various etiologies.
• During Supervision is not able to objectively evaluate
состояние больных с ОРЗ, ОРВИ, острым бронхитом и
пневмонией различной этиологии..
Not able to rationally make a plan of examination of patients
with acute respiratory disease, SARS, acute bronchitis and
pneumonia of various etiologies in a hovercraft or a joint
venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and
55-60,9
skills (see below), but when replying or performing skills
make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but
61-65,9
when replying or performing skills make mistakes (subject
to certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of
knowledge and skills:
Know the clinical signs of the most dangerous diseases are
accompanied with cough: pulmonary tuberculosis, lung
cancer
Knows the pathogenetic treatment of acute respiratory
infections, viral respiratory infections, acute bronchitis and
pneumonia of various etiologies.
Know the risk factors for acute respiratory infections, viral
respiratory infections, acute bronchitis
Knows the groups of drugs used in treatment of acute
Satisfactorily
respiratory disease, SARS, acute bronchitis
55-70,9%
Can point to radiological signs of the most dangerous
diseases are accompanied with cough: pulmonary
tuberculosis, lung cancer
Able to build a rational history during the Supervision of
66-70,9
patients with acute respiratory infections, viral respiratory
infections, acute bronchitis and pneumonia of various
etiologies.
During Supervision able to objectively assess the condition
of patients with acute respiratory disease, SARS, acute
bronchitis and pneumonia of various etiologies ..
Able to efficiently make a plan of examination of patients
with acute respiratory infections, viral respiratory infections,
acute bronchitis and pneumonia of various etiologies in a
hovercraft or a joint venture.
Can interpret the results of laboratory and instrumental
methods of research - may indicate the presence of
leukocytosis, leykoformuly shift to the right or to the left,
elevated ESR.
Can show the technique of taking blood count
Can show the technique of taking the overall analysis
21
sputum
Able to correctly fill in the patient diary.
Advanced level of knowledge
Well
71-85,9%
71-75,9
76-80
81-85,9
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has the
following knowledge and skills:
Knows the stages of the most dangerous diseases are
accompanied with cough: pulmonary tuberculosis, lung
cancer
• Knows the clinical symptoms and morphological changes
characteristic of each stage of acute bronchitis
• Know the classification of acute respiratory disease, SARS
and acute bronchitis
• Knows the mechanism of action of the medicament is used
for acute respiratory infections, viral respiratory infections
and acute bronchitis
Rationally choose drugs used in the treatment of acute
respiratory disease, SARS and acute bronchitis
The student is wholly owned by the basic levels of
knowledge and skills (see above) the knowledge referred to
in paragraph "71-75,9", and also owns the following
knowledge and skills:
• Knows the pathogenesis of pneumonia and acute
bronchitis, and may also be called morphology of
pneumonia depending on the pathogen
Knows the principles of primary, secondary and tertiary
prevention of acute respiratory disease, SARS and acute
bronchitis
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9" and "76-80", and also owns the
following knowledge and skills:
• Can specify the localization of the most dangerous diseases
are accompanied with cough: pulmonary tuberculosis and
lung cancer
Principles of management, supervision and monitoring of
patients with acute respiratory infections, viral respiratory
infections, acute bronchitis and pneumonia different etiology
in a hovercraft or a joint venture.
Is able to advise you on the boards of non-drug and drugusing skills of IPC.
Principles of clinical examination and rehabilitation of
patients with acute respiratory disease, SARS, acute
bronchitis and pneumonia of various etiologies in a
hovercraft or joint venture
22
86-90
Fine
91-95
86-100%
96-100
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "81-85,9", and also owns the following
knowledge and skills:
• Knows the principles of treatment of acute respiratory
infections, viral respiratory infections, acute bronchitis and
pneumonia of various etiologies.
• Know the indications and contraindications for X-ray
examination at the most dangerous diseases are accompanied
with cough: lung cancer and pulmonary tuberculosis
Is able to provide reliable information on ARI, ARI, acute
bronchitis and pneumonia of various etiologies based on
internet data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "86-90", and also owns the following
knowledge and skills:
• Knows the radiological signs of the most dangerous
diseases are accompanied with cough: lung cancer and
tuberculosis of the lung, and can also help with x-ray image
to determine the stage of lung cancer and pulmonary
tuberculosis
Is able to identify the location of focus of lung cancer and
pulmonary tuberculosis method of objective examination.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "91-95", and also owns the following
knowledge and skills:
• to provide scientific data from the literature (articles
and the Internet).
Knows the stages of clinical examination and rehabilitation
of patients with acute respiratory infections, viral respiratory
infections, acute bronchitis and pneumonia of various
etiologies
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
Test questions.
1. The classification of ARI, acute respiratory infections, bronchitis, pneumonia
2. Clinical features of acute respiratory viral infections, acute respiratory infections, bronchitis,
pneumonia.
3. Differential diagnosis of viral respiratory infections, acute respiratory infections, bronchitis,
pneumonia
4. The etiology and pathogenesis of viral respiratory infections, acute respiratory infections,
bronchitis, pneumonia
5. The main clinical and laboratory tests for the diagnosis and.
6. Features of treatment of ARI, acute respiratory infections, bronchitis, pneumonia
23
8. REFERENCES:
Summary
testes kasalliklar, Sharapov UF T: Ibn Sina, 2003
testes kasalliklar, Bobozhanov S. T: Yangi Asr avlod 2008
. Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009
• Internal Medicine, Volume 2 Mukhin, NA M. GEOTAR - Media 2009
• Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012
General medical practice under red.F.G.Nazirova, A.G.Gadaeva. M. GEOTAR Media, 2009.
Directory GP. Dzh.Merta. M.: Practice, 1998.
The collection of practical skills for general practitioners. Gadaev A. Akhmedov Kh.S. T., 2010.
Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS, 2010.
Т.
• Therapeutic Reference Washington Ed. M.Vudli M. Practice, 2000.
• Umumy amaliet shifokori Uchun kullanma F.G.Nazirov, A.G.Gadaev Tahrah. M. GEOTARMedia, 2007.
• Diagnosis of diseases of the internal organs. A.N.2005 hams.
• Treatment of diseases of the internal organs. A.N.2005 hams.
• Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News Agency,
2009.
• Internal Medicine: a textbook. - In 2 volumes (1t), Ed. Martynov, etc. M: GEOTAR - Media,
2005:
Internet Resources:
http://www.meducation.net/ http://www.thecochranelibrary.com
Medical sites:
Med.-site.narod.ru
www.medlook.ru
www.medbok.ru
24
Practical lesson number 3
Theme: "Cough with expectoration. Differential diagnosis of chronic bronchitis (CB) and
bronchiectasis (BEB). Tactics GPs. Indications for referral to a specialist or hospital in the
profile department. The principles of treatment, follow-up, control and rehabilitation in a
hovercraft or a joint venture. The principles of prevention. Definition of disability. The
principles of teaching topics. "
learning Technology
Study time: 6, 4:00
The structure of the training session
Training themed room.
Study of GPs.
Tutorials, phantoms, models, handouts, a
collection of case studies and tests
TV, video equipment, multimedia
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis of
chronic lung disease (chronic bronchitis and BEB). The clinical course and the principles of
management of patients in primary care, provided the requirements of the "Qualification characteristics
of the GP"
Pedagogical objectives:
Learning outcomes:
1. Teach GP diagnosis - chronic bronchitis
The student must:
and BEB, the clinical course depending on the GPs should be aware of:
etiology and on the stage.
1. Clinical manifestations of chronic bronchitis, BEB.
2. Teach GP diagnosis and differential
2. The differential diagnosis of these.
diagnosis of diseases in which there is a
3. Key points (test) diagnostics.
cough with phlegm.
4. Signs of respiratory distress.
3. GPs familiarize with the list of diseases
5. The principles of treatment (medication and nonassociated with cough with phlegm and is
medication) in these diseases.
being treated in the FCP (GWP) or
6. Principles of follow-up and monitoring of patients
specialized hospitals.
in a hovercraft or a joint venture.
4. Discuss questions about tactics in the
7. The principles of primary, secondary and tertiary
qualifying characteristics of GPs
prevention in these diseases.
5. The principles of treatment (medication and
non-medication).
GPs should be able to:
6. Principles of management, follow-up and
1. Analyze the data and history of complaints for the
monitoring of patients in a hovercraft or a
diagnosis of diseases associated with shortness of
joint venture.
breath and suffocation.
7. The principles of primary, secondary and
2. Diagnose, differentiated by clinical, laboratory
tertiary prevention in these diseases.
studies, radiographs different kinds of diseases.
3. Choose drugs with proven efficacy
4. Advise on non-drug therapies.
5. To monitor.
Methods of teaching
Forms of organization of educational
activities
Learning tools
Methods and means of feedback
the method of «tour of the gallery».
demonstration, entertainment experience, discussion,
interview, the decision of tests and situational
problems
Individual work, group work, collective, teaching,
extracurricular.
Distributing training materials visual materials,
videos, models, graphic organizers, sputum smears,
sets of medical records, tables, stands, sets of x-ray
films.
Blitz-interview, testing, presentation of the results of
25
the execution of the educational tasks, filling the
medical card, the implementation of practical skill
«professional questioning »
Technological map classes
Topic: “Cough with sputum. The differential diagnostics of chronic bronchitis (CB) and
bronchiectasis disease (BAB). The tactics of the GP. Indications for referral to a specialist or
hospitalization in the main Department of. Principles treatment, follow-up, control and
rehabilitation in the conditions of the SVP or joint venture. Principles of prevention. The definition
of disability. Principles of teaching the topic”.
№ Stages of the practical training
Form classes
Duration
classes
Venue
225
1
Introductory part (justification of the topic)
10
2
3
4
5
6
7
8
Discussion on the topic of practical classes with the use of new
pedagogical technologies (the method of «tour of the gallery»),
as well as the demonstration material (sets of medical records,
tables, posters, x-ray), the definition of the initial level.
Conclusion the discussion of
The definition of tasks for the implementation of the practical
part of the professional questioning. Explanation of the
provisions and recommendations for the implementation of the
requirements of the medical card.
The survey, discussion
Development of the practical part of the classes under the
guidance of the teacher.
Prof. questioning. A
20
conversation with
patients and honey filling
cards, situational
problems.
The interpretation of the data of examination of patients complaints, inspection, palpation, percussion, auscultation of
patients, as well as research OAM, the KLA, x-ray, urine
analysis and empty. sowing of sputum and biochemical analysis
and diagnosis
Discussion of theoretical and practical knowledge of the
students, fixing of material, determination of the level of
assimilation of the assessment of knowledge.
The definition of output on the topic of the practical training, the
estimation of the 100 point system, and the announcement of the
estimates. Homework the next tutorial (collection of questions).
Motivation
26
40
Classroom, GP surgeries
discussion
10
20
GP doctor's office
Admission of patients in
the clinic, examination at
home
The history of the
disease
laboratory data
situational task
25
Oral interviews, tests,
discussion, definition of
practical skills
A training room in clinic
75
Information, questions
for self work.
A training room in clinic
25
The majority of patients with chronic lung diseases (ХЗЛ) this group includes chronic bronchitis (CB)
bronhoektatical disease (BAB) seek medical help. In this situation, the force of the General practitioner
(GP) is sent on the diagnosis of ХЗЛ, caused by various diseases. In case of detection of ХЗЛ GP
must diagnose the disease, but also he must determine the cause, have conditioned the disease for
medical care and clarify the location of this group of patients.
Interdisciplinary and Intra connection
The teaching of this topic is based on the knowledge of the students of the fundamentals of
anatomy, histology with embryology and Cytology, biology, normal physiology, biochemistry,
pathology, Obtained in the course of sessions of knowledge will be used when completing the
GP - internal diseases and other clinical disciplines. pathological physiology, topographic
anatomy and operative surgery, propaedeutics of internal diseases, tuberculosis, Oncology,
radiology and medical radiology, physical therapy, endocrinology, faculty therapy, hospital
therapy, orthopedics.
4. The workshop sessions
4.1. The theoretical part of the
On a practical lesson in the theoretical part includes analysis of the clinical features of the
diagnosis of COPD.
Chronic obstructive pulmonary disease (COPD) - a term that has a 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 growth
of chronic respiratory failure.
The main risk factor (in 80-70% of cases) COPD - smoking. Smokers have the highest mortality
rates, they quickly 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%) the cause of COPD is chronic obstructive bronchitis, about
1% of the EL (due to a1-antitrypsin deficiency), the remaining percentage accounted for severe
asthma. COB allocation in a separate nosological form is crucial from the point of early
diagnosis and treatment at the stage of intact reversible component of airflow obstruction, that is,
when the disease has not lost its identity and there is a real possibility of inhibition of
progression of the disease by affecting the reversible component of airflow obstruction.
The first signs, which patients usually go to the doctor, is a cough and shortness of breath,
sometimes accompanied by wheezing with phlegm. These symptoms are most pronounced in the
morning. The earliest symptom of appearing to 40-50 years of life, is a cough. By this time in the
cold seasons are beginning to have episodes of respiratory infections that were not connected to
the first one disease. Shortness of breath, initially perceived exertion, there is an average of 10
years after cough onset.
Sputum production in a small number (rarely more than 60 mL /
day) in the morning, a slimy character and becomes purulent only during infectious episodes,
which are usually regarded as an exacerbation.
Results of physical examination of patients with COB depends on the severity of airflow
obstruction, the severity of pulmonary hyperinflation and physique. As the disease progresses to
coughing joins wheezing, most notable in rapid exhalation. Often auscultation revealed rales dry
raznotembrovye. Shortness of breath can vary over a wide range: from the feeling of lack of air
at standard physical exercise to severe respiratory failure. As the progression of airflow
obstruction and lung hyperinflation rise anteroposterior chest size increases. Limited mobility of
the diaphragm, auscultation picture changes: reduced the severity of wheezing, prolonged
exhalation.
27
The sensitivity of physical methods for determining the severity of COPD is low. Among
the classic signs can be called a whistling breath and extended expiration time (> 5 s), which
may be indicative of bronchial obstruction.
Thus, the development and progression of COPD occurs in times of risk factors
characterized by a slow gradual onset. The first (the earliest) COPD symptom is a cough. Other
characters join later in the progression of the disease, with a gradual acceleration of the
progression of the disease.
Physical examination in patients with COPD is not enough for a diagnosis of the disease,
it provides only guidelines for the future direction of the diagnostic studies using instrumental
and laboratory methods. Conventionally, all diagnostic methods can be divided into methods of
mandatory minimum, is used in all patients (complete blood count, urine, sputum, chest
radiography, the study of respiratory function (ERF), an electrocardiogram), and additional
methods used for special indications.
For routine clinical work with patients with chronic
obstructive bronchitis in addition to general clinical tests recommended to study respiratory
function (FEV 1, forced vital capacity or FVC), a test with bronchodilators (b2-agonists and
holinolitikami), chest X-ray. The other research methods are recommended for special
indications, depending on the severity and nature of its progression.
In everyday practice, the patients apply COB tests bronchodilators (b-agonists and / or
holinolitikami), which to some extent characterized by the ability to fast regression of bronchial
obstruction, in other words, "reversible" component of obstruction. The increase in FEV1 during
the test by more than 15% of the baseline conditional commonly characterized as a reversible
obstruction.
1. Smoking cessation and limitation of external risk factors.
2. Education of patients.
3. Bronhodilatiruyuschee therapy.
4. Mukoregulyatornaya therapy.
5. Anti-infective therapy.
6. Correction of respiratory failure.
7. Rehabilitation therapy.
In the formation of the strategy and tactics of treatment of patients with COPD is crucial to
allocate two treatment regimens: non-acute treatment (maintenance therapy) and treatment of
COPD exacerbations
How is the method of "tour of the gallery."
Objective: To teach students critically evaluate information and identify the completeness
of knowledge on the subject.
Each small group is invited one problem they solve for 10 minutes in writing and then exchange
tasks. Revealing mistakes of the previous group, and additions made to the answers discussed by
all members of the adoption of the final version of the responses. Methodology tour gallery
requires students to maximum concentration and a good theoretical background for this section.
Example: subject classes "Cough with expectoration. Differential diagnosis of chronic bronchitis
and bronchiectasis. The tactics of the GP. "
Three small groups are given on a question:
1.Perechislite disease is accompanied by symptoms of wheezing and breathlessness.
2.Differentsialnaya diagnosis of chronic bronchitis and bronchiectasis.
3.Vedenie patients with chronic bronchitis and bronchiectasis in an outpatient setting. Definition
of disability.
So for 30 minutes, the teacher gets an idea of the level of training of students on various
sections of topics and their ability to defend their views.
№ evaluation
fine
good
Satisfactory unsatisfactory poorly
Assimilation in%
100%85%70-55%
54%-37% 36% or
28
86%
1
The theoretical part
20-17,2
mark
71%
17-14,2
mark
less
14-11
mark
10,8-7,4
mark
7,2
mark
4.2. The analytical part of
4.2.1. Case Studies:
The patient 61god, hypothermia after complaining of fever 39-40C, chills, cough with sputum
production is not large, shortness of breath, severe weakness, pain in the chest and abdomen. He
was treated at home, took 3 days for penicillin, but the condition has not improved. His condition
was grave, his face pale, cyanosis, BH :30-40 min, heart rate of 100-120 beats per minute. In the
right light in the lower dullness. Weakened vesicular respiration, fine bubble wet and dry rales.
The right side of the chest is slightly behind in the act of breathing. Cor muted tones, accent II
tone on the pulmonary artery.
1. List at least four diseases which infiltrates are observed in the lungs;
2. Your preliminary diagnosis;
3. What changes can be found in the overall analysis of sputum and chest X-ray,
4. The tactics of the GP (principles of treatment and secondary prevention).
Answers:
№
Answers:
Балл
1
a) Chronic pneumonia, b) Central lung cancer, c) infiltrative
20
pulmonary tuberculosis, g) Eosinophilic pneumonia.
2
Right-sided nizhnedolevaya lobar pneumonia, severe course. NAM
35
II Art.
3
The increase in the number of white blood cells in the sputum, red
20
blood cells, epithelial cells (rusty sputum), various pathogens (coca).
When X-rays increased vascular pattern in the lower regions of the
right lung infiltrate. Pleural thickening in the lower section. Aperture
thickened.
4
Bed rest. Causative treatment: antibiotics. Pathogenic: improving the 25
drainage function of bronchi and bronchopulmonary defense.
Immunomodulatory Therapy: prodigiozon, T-activin, timolin and
other antioxidants: vit. E emoksipin. Detoxification therapy,
symptomatic therapy, physiotherapy.
2. The patient on day 3 after holetsistoektomii increased body temperature up to 38C, there was a
shortness of breath, chest pain, coughing up blood. The wound is dry, no discharge from the
wound. Serious condition, respiratory rate 40 per minute., Heart rate 120 per minute. Above the
right light in the lower divisions weakened vesicular breathing, moist finely wheezing. 22.8
leukocytosis, neutrophilia, left shift.
1. List at least 5 diseases in which there is pain in the chest and coughing up blood;
2. The preliminary diagnosis;
3. What changes do you find by chest X-ray;
4. The tactics of the GP (treatment guidelines);
3. A patient 28 years old, was treated for postpartum endometritis about. On the 10th day of
illness there were pains in the chest, lost consciousness, blood pressure 90/60 mm T. Art. After /
in the 300mg prednisone and hydrocortisone 250mg patient's condition has improved
significantly, but as the pressure has not risen patient was transferred to the intensive care unit.
29
Objectively: general condition is serious, BH 22 minutes, in consciousness, heart rate 120 per
minute, blood pressure 80/60.
1. The preliminary diagnosis;
2. What changes do you find the part of the ECG;
3. Informative research methods;
4. The tactics of the GP (treatment guidelines);
4. Patient N., 22 years old. On admission complaints fever, cough with mucous expectoration,
loss of appetite. From history feels sick for 3 days. Prior to admission to the hospital was not
treated. During the year, 3-4 times cold. Do not smoke. Objectively: general condition is
relatively satisfactory. The skin is moist. Percussion slightly dull lung sounds. Auscultation fine
moist rales in the chuck on the right. Fluoroscopy: infiltration in the lung root and V-VI ribs on
the right. ERF: restrictive changes VC-74%, FEV1, 95% of IT-106%. Biochemical parameters:
sialic acid-310 units., Seromucoid-250ed.
1. List at least four diseases occurring with pulmonary infiltrates;
2. The preliminary diagnosis;
3. What changes do you find by the KLA;
The tactics of the GP (treatment, secondary prevention);
5. A patient 46 years old, complains of increased body temperature 39.6 C, initially dry cough
with a small amount of mucous expectoration, then paroxysmal cough with "rusty" sputum. The
patient takes alcohol in large quantities. Bronchial breathing and moist rales in the right finely
chuck area. Despite intensive treatment with penicillin in the hospital the patient's condition
unchanged, shortness of breath and signs of intoxication are preserved. In sputum:
Staphylococcus aureus in a large quantity. On Fluoroscopic: both multiple small infiltrative lung
shadow. At the top and bottom of the lung cavity destruction. The patient was treated for
tuberculosis of the lungs.
1. List at least four diseases occurring in a dry cough;
2. The preliminary diagnosis;
3. What changes do you find by the KLA;
4. What complications can occur;
5.Taktika GP (principles of treatment, secondary prevention);
6. Sick '53 appealed to the GP complaining of hoarseness, cough with sputum difficult, increased body
temperature 38.2 C, chest pain and general weakness. He considers himself sick for 4 days. The disease
began acutely. General state of moderate severity. Skin is clean, moist, cyanosis of the lips. Percussion
over the lungs lung sounds. Auscultation: in the lower left lung sonorous fine moist rales, pulse 84 beats /
min. Jabs: HB - 104, L-10, 3; p/ya-6; s/ya-71, M-4, L-20, ESR-24 mm / h
1. What type of ventilation in the lungs observed in this patient;
2. The preliminary diagnosis;
3. Informative research methods;
4. The tactics of the GP;
7. 32-years old patient complained of tiredness and a dry cough. As a child several times treated for
pneumonia. OBJECTIVE: lung disease were found. Radiological findings: in the upper part of the right
lung is determined by the blackout with no clear boundaries, not homogeneous and associated with the
root of the lung around the focal inflammation. KLA: Hb 130 g / L, WBC 9.9 × 10 ^ 9 / L, the formula
unchanged, erythrocyte sedimentation rate 33 mm / h
1. What do you recommend examination to confirm the diagnosis;
2. The preliminary diagnosis;
3. What changes are specific to the sputum of the patient;
30
4. The tactics of the GP;
8. Patient G. During 6ti been suffering from chronic bronchitis. Recently, low-grade fever of the
body, cough with a small amount of sputum. Independently treated at home. In the last week the
body temperature rose to 39-40C. Increased separation of the mucous expectoration. Shortness
of breath, pain in the left side of the chest, irradiation of the pain in his arm and back. The
general condition is serious, forced position, pale skin, cyanosis of the lips, behind the left chest
in breathing and in the lower blunting sound, voice trembling, bronchial breathing, are heard in
other parts of the wet and dry rales. The liver is enlarged 2 cm, swelling in the legs.
1. List at least four diseases for which there are higher these signs and symptoms;
2. The preliminary diagnosis;
3. What changes are characterized by chest radiography in this patient;
4. Tactics GPs and treatment guidelines;
9. 24 year old patient is turned to the GP with complaints of fever up to 39,6 º C, chills, pain in
the right side of the chest and around the heart, shortness of breath, cough with sputum difficult,
headaches, palpitations. Patient's condition is severe, cyanosis of the lips, rosy cheeks, the
temperature of 39,2 º C. When light percussion back to the 6th rib blunting lung sound
auscultation on this site bronchial breathing. Respiratory rate 30 per minute. Heart sounds,
accent II tone on the pulmonary artery. Pulse of 110 beats per minute, arrhythmic due to rare
premature beats. Liver + 2 cm UAC: Hb 89 g / l, erythrocyte-3 5h1012 / l cs 0.7, Lake 17.0 x
109 / L, EPZs 1% p / 9%, w / I 76%, 10% lymph, Mon 4%, erythrocyte sedimentation rate of 35
mm / hour. In the analysis of traces of urine protein. Chest x-ray on the right below the 6th rib
intense homogeneous darkening with clear margins merging with a dome diaphragm.
1. List at least 5 possible diseases in which the above symptoms occur.
2. Your preliminary diagnosis.
3. List at least 5 of complications that can occur with this disease.
4. Tactics GPs.
5. The principles of treatment.
10. A patient 68 years old, long-term chronic bronchitis and calculous cholecystitis. At clinical
examination revealed GPs: shortness of breath, flushing of the face, injection of blood vessels of
the sclera, epigastric pulsating, throbbing neck veins. In the lungs, weakened vesicular breathing,
dry, wet and buzzing finely wheezing. Respiratory rate 26 per minute. Heart: percussion hypertrophy of the left and right ventricle, right atrium. The tones are muted, accent and splitting
II tone of the aorta, the accent II tone on the pulmonary artery. Heart rate of 88 beats per minute.
Blood pressure 140/70 mm T. Art. The abdomen was soft, b / w, liver 4 cm, the edge is rounded,
painful. On her feet swelling. UAC: 160 g Hb / l, 5,6 • Erythrocytes 1012 / L, Lake 8.7 x109 / l
reticulocytes 5% p / 5% w / I 44% ELUR 3% lymph 35% mon 7% base 1%, platelets 280,
erythrocyte sedimentation rate 15 mm / h; PTI 105%. Chest X-ray - a picture of chronic
bronchitis, pulmonary fibrosis, expanding the boundaries of the heart.
1. List at least five probable diseases in which the above symptoms occur.
2. Your preliminary diagnosis.
3. Specify the criteria for acute respiratory characteristic of this disease.
4. Tactics GPs.
5. The principles of treatment.
11. House Call GPs: a patient 32 years old, complained of fever, cough with difficult
expectoration, pain in the right side of the chest and stabbing pains in the heart, palpitations,
shortness of breath.
31
From history: The disease connects with hypothermia. Home treatment is not effective. Three
children, cotton grower. Uses “nasvaya”.
Objectively: The patient's condition serious. When percussion on the front of the chest with the
V intercostal space and zadneypoverhnosti from the corner of the blade on the right is marked
shortening of percussion sounds, here are heard ringing dry and moist rales, pleural friction rub.
Heart sounds, arrhythmic due to arrythmia. Pulse 110 in 1 minute.
KLA-Hb 110 g \ l, erit.-3, 6, leyk.-10, -28 ESR
OAM-diuresis-1600-1010 density, color, transparency sol.zhel - full, protein - abs
General analysis of sputum - muco-purulent, white blood cells - in large numbers, the red blood
cells are unit.
Chest X-ray - clearly delimited intense infiltration of the right lower lung field, the root of the
right lung strengthened the presenting pleura lumpy underlined.
Solution of the problem according to the 20-step principles (see Clarification)
№ evaluation
2
fine
good
Assimilation in%
100%86%
85%71%
Case study
50-43 mark 42,535,5
mark
Satisfactor unsatisfactor poorly
y
y
36% or
7054%less
55%
37%
35- 27,5
mark
TESTS.
TESTS.
1. In the group of chronic non-specific lung diseases include:
a) posttuberkulezny fibrosis
b) chronic obstructive bronchitis
c) asthma
g) fibrosing alveolitis
d) chronic pneumonia
e) chronic lung abscess
g) lung empyema
2. For lobar pneumonia is characterized by:
a) chest pain
b) "rusty" sputum
c) expiratory dyspnea
d) acute onset
d) purulent sputum
e) increase of body temperature
3. At the stage of "tide" lobar pneumonia percussion determined:
a) lung sounds
b) sound box
c) the dullness
g) tympanic sound
e) the disappearance of the percussion sound
4. Acid-drugs used in, are:
a) methicillin
32
27-18,5
mark
18 mark
b) oxacillin
c) ampicillin
d) Penicillin
d) carbenicillin
5. Rational combinations of antibiotics are considered:
a) + ampicillin penicillin
b) tsefamezin plus gentamicin
c) ampicillin plus gentamicin
z) + tetracycline penicillin
d) ampicillin + tetracycline
6. In the treatment of pneumonia in pregnancy in the 1st trimester can be used:
a) tetracycline
b) Penicillin
c) Erythromycin
d) chloramphenicol
e) gentamycin
7. For lobar pneumonia (unlike focal) characterized by:
a) evidence of overloading the left chambers of the heart on an electrocardiogram
b) marked leukocytosis
c) the detection of toxic grain rare neutrophils
d) signs of stress right heart chambers on the ECG
d) one-way flush on the cheek on the affected side
e) evidence of hypertrophy of the left atrium on the ECG
8. More often than in the general population, in alcoholics, there are:
a) pneumonia caused by gram-positive
b) aspiration pneumonia
c) abscessed pneumonia
g) klebsielleznaya pneumonia
e) Legionella pnenmoniya
e) viral pneumonia
g) with mild pneumonia
9. Of the following symptoms for bronchiectasis is characterized by:
a) hemoptysis
b) "drumsticks"
c) paroxysmal hacking cough
d) a significant amount of purulent sputum
e) wheezing with prolonged exhalation
e) diffuse cyanosis
10. The most informative objective clinical evidence for the diagnosis of localized form of
bronchiectasis is:
a) localized moist rales srednepuzyrchatye
b) dry rattles
c) the shortening of percussion tones
d) hard breathing
e) localized moist large bubbling raleе) мелкопузырчатые влажные хрипы
33
g) strengthening voice tremor
№ evaluation
Assimilation
in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
3
15-12,9 mark
12,7-10,6
mark
8,1-5,5
mark
Test
Satisfactory
10,5-8,25
mark
5,4 mark
Graphic Organizer: Venn Diagram
• used for comparison or matching iliprotivopostavleniya 2 to 3 dimensions and show them both traits.
• Develop systems thinking, the ability to compare, compare, analyze and synthesis.
Acquainted with the rules of construction of a Venn diagram. Individually / in pairs construct a Venn
diagram and fill part of the non-overlapping circles (X)
Are paired, compare and complete their charts.
The intersection of circles make a list of those features that, in their opinion, are common to information 2
to 3 laps (хх/ххх).
Generality
Venn diagram
Nothing in
common
Something in
common
Much in
common
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with COPD, accompanied by shortness of breath and choking
2. Data interpretation of laboratory and instrumental studies in patients with COPD, accompanied by
shortness of breath and suffocation.
3. To analyze and forecast the results of peak flow.
4. To monitor in a hovercraft or a joint venture.
5. Control forms of knowledge, skills and abilities
- Oral
34
- The decision of situational problems
- Demonstration of practical skills
– CDS
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
№ evaluation
Assimilation in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
1
The theoretical part
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2 mark
2
Case Studies
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
3
Test
15-12,9 mark
12,7-10,6
mark
10,5-8,25
mark
8,1-5,5
mark
5,4 mark
4
The practical part
15-12,9 mark
12,75-10,6
mark
10,5-8,25
mark
8,1-5,5mark
5,4 mark
Satisfactory
The evaluation criteria of the current control
levels of
estimates
rating
points
Characteristics of the student
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not
ready for practical employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and
skills, at least one of the following:
Do not know the clinical signs of chronic bronchitis and
bronchiectasis.
Do not know the pathogenetic treatment of chronic
bronchitis and bronchiectasis.
Do not know the risk factors for chronic bronchitis and
bronchiectasis.
Do not know the groups of drugs used in treatment of
chronic bronchitis and bronchiectasis.
unsatisfactoril
20 - 54,9
Can not indicate the radiological signs of chronic bronchitis
y
and bronchiectasis.
Not able to assemble a rational history during the
Supervision of patients with chronic bronchitis and
bronchiectasis.
During Supervision is not able to objectively assess the
condition of patients with chronic bronchitis and
bronchiectasis.
Not able to rationally make a plan of examination of
patients with chronic bronchitis and bronchiectasis in a
hovercraft or a joint venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
satisfactorily
55-60,9
55-70,9%
The student tries to hold the basic levels of knowledge and
20
35
61-65,9
66-70,9
skills (see below), but when replying or performing skills
make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but
when replying or performing skills make mistakes (subject
to certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of
knowledge and skills:
• Know the clinical signs of chronic bronchitis and
bronchiectasis.
• Can differentiate chronic bronchitis and bronchiectasis for
subjective, objective, and laboratory and instrumental data
from other chronic lung diseases
• Knows differentiated pathogenetic treatment of chronic
bronchitis and bronchiectasis.
• Know the risk factors for chronic bronchitis and
bronchiectasis.
• Knows the groups of drugs used in treatment of chronic
bronchitis and bronchiectasis.
• Can point to radiological signs of chronic bronchitis and
bronchiectasis.
• Able to build a rational history during the Supervision of
patients with chronic bronchitis and bronchiectasis.
• During Supervision is able to objectively assess the
condition of patients with chronic bronchitis and
bronchiectasis.
• Able to efficiently make a plan of examination of patients
with chronic bronchitis and bronchiectasis in a hovercraft or
a joint venture.
• Can interpret the results of laboratory and instrumental
methods of research - may indicate the presence of
leukocytosis, leykoformuly shift to the right or to the left,
elevated ESR.
• Can show the technique of taking blood count
• Can show the technique of taking the overall analysis of
sputum
• Can carry a peak flow meter
Able to correctly fill in the patient diary.
Advanced level of knowledge
well
71-85,9%
71-75,9
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has the
following knowledge and skills:
• Knows the stage of development of chronic bronchitis and
bronchiectasis.
Knows the clinical symptoms and morphological changes
characteristic of each stage of development chronic
bronchitis and bronchiectasis.
Know the classification of chronic bronchitis and
bronchiectasis.
Knows the mechanism of action of drugs used for chronic
bronchitis and bronchiectasis.
36
Rationally selected drugs used in the treatment of chronic
bronchitis and bronchiectasis.
76-80
81-85,9
86-90
Fine
91-95
86-100%
96-100
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9", and also owns the following
knowledge and skills:
Knows the pathogenesis of chronic bronchitis and
bronchiectasis, and may also be called morphology
Knows the principles of primary, secondary and tertiary
prevention of chronic bronchitis and bronchiectasis.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9" and "76-80", and also owns the
following knowledge and skills:
Can point to signs of chronic bronchitis and bronchiectasis
by an X-ray image.
Principles of management, supervision and monitoring of
patients with chronic bronchitis and bronchiectasis in a
hovercraft or a joint venture.
Is able to advise you on the boards of non-drug and drugusing skills of IPC.
Principles of clinical examination and rehabilitation of
patients with chronic bronchitis and bronchiectasis in a
hovercraft or joint venture
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "81-85,9", and also owns the following
knowledge and skills:
Knows the principles of treatment of chronic bronchitis and
bronchiectasis.
Know the indications and contraindications for X-ray
examination
Is able to provide reliable information about chronic
bronchitis and bronchiectasis on the basis of Internet data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "86-90", and also owns the following
knowledge and skills:
Knows the radiological signs of chronic bronchitis and
bronchiectasis.
Is able to identify the signs of chronic bronchitis and
bronchiectasis objective methods inspection.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "91-95", and also owns the following
knowledge and skills:
To provide scientific data from the literature (articles and
Internet)
Knows the stages of clinical examination and rehabilitation
of patients with chronic bronchitis and bronchiectasis.
37
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
7.Test questions.
Classification of chronic bronchitis, BEB
The clinical course of chronic bronchitis, BEB.
Differential diagnosis of chronic bronchitis, BEB
The aetiology and pathogenesis of chronic bronchitis, BEB
The main clinical and laboratory tests for the diagnosis and.
Special treatment of chronic bronchitis, BEB
REFERENCES:
Summary
Testes kasalliklar, Sharapov UF T: Ibn Sina, 2003
Testes kasalliklar, Bobozhanov S. T: Yangi Asr avlod 2008
Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009
Internal Medicine, Volume 2 Mukhin, NA M. GEOTAR - Media 2009
Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012
General medical practice under red.F.G.Nazirova, A.G.Gadaeva. M. GEOTAR Media, 2009.
Directory GP. Dzh.Merta. M.: Practice, 1998.
The collection of practical skills for general practitioners. Gadaev A. Akhmedov Kh.S. T., 2010.
Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS, 2010.Т.
• Diagnosis of diseases of the internal organs. A.N.2005 hams.
• Treatment of diseases of the internal organs. A.N.2005 hams.
• Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News Agency,
2009.
• Internal Medicine: a textbook. - In 2 volumes (1t), Ed. Martynov, etc. M: GEOTAR - Media,
2005:
Internet Resources:
http://www.lib.uiowa.edu/hardin/md/index.html,http://dir.rusmedserv.c,http://www.medlinks.ru/,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
http://elibrary.ru http://www.freebooks4doctors.com/ http://www.medscape.com/
http://www.meducation.net/ http://www.thecochranelibrary.com
Medical sites:
Med.-site.narod.ru
38
www.medlook.ru
www.medbok.ru
www.medicum.ru
www.medtext.ru
www.medkniga.ru
www.cardioline.ru
39
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND SKILLS TRAINING FOR
STUDENTS ON THE BASIS OF SOLVING THE PROBLEM OF PATIENTS
WITH SHORTNESS OF BREATH OR CHOKING
Objective: To teach students posindromalnomu addressing patients with shortness of breath or
choking, as well as the principles of their management in primary health care as part of the
qualifying characteristics of GPs
The main learning objectives:
• To teach students problem solving associated with shortness of breath or choking.
• To train students in a timely diagnosis of the problems associated with shortness of breath or
choking.
• To teach students to differentiate the disease, accompanied with shortness of breath or choking.
• Improve the knowledge, skills and practical skills in solving problems of patients with
shortness of breath or choking (gathering information, identifying problems and physical
examination, as well as the ability to reasonably prescribe laboratory and instrumental methods
of research);
• To teach students to reasonably choose the tactics;
• To teach students to exercise reasonable medical and preventive measures and monitoring in
SAP and SP.
When parsing the problem of patients the key moments of assessing students must be:
• Ability to identify the underlying problem, which is reflected in the quality of life of patients.
• Ability to ask support questions rational history.
• Ability to identify risk factors.
• Ability to transfer a disease or condition that may be causing the problem.
• Ability to conduct reasonable physical examination.
• Ability to use sound laboratory and laboratory studies in a hovercraft or a joint venture.
• Ability to identify the need for additional research outside of SVP or joint venture.
• Based on the information received ability to establish the root cause (diagnosis) of the problem.
• Ability to determine the tactics on the basis of qualifying characteristics of GPs.
• Ability to provide non-pharmacological advice.
• Ability to identify drug treatment based on evidence-based medicine
• Ability to identify preventive measures at the level of primary health care.
• Ability to define the principles of clinical examination and rehabilitation of patients in a
hovercraft or a joint venture.
What the student needs to know to solve the problems of patients with shortness of breath
or choking:
№
The list of knowledge
The basic level
The student should know at
The list of diseases that present with shortness of breath
1
least 10 of the most common
and choking
diseases
A list of the most dangerous diseases that present with
The student should know at
2
shortness of breath and choking
least 5 diseases
According to the
The list of conditions that require management in SAP
3
characteristics of the GP
(1 category)
qualifying
The list of states that require a specialist consultation or According to the
4
hospitalization (category 2)
characteristics of the GP
40
5
6
7
8
9
10
11
12
13
14
15
16
17
qualifying
According to the
A list of studies requiring in FCP (3.1 category)
characteristics of the GP
qualifying
According to the
The list of research areas requiring outside SVP (3.2
characteristics of the GP
category)
qualifying
The student must know the
characteristics and
Key points (criteria) diagnosis of diseases occurring with
manifestations of each disease,
shortness of breath and choking
and the criteria for their
diagnostic.
The student must list the
Symptoms of cardiac asthma and pulmonary edema
symptoms
The student must list the
Symptoms of asthma
symptoms
The student must know the
Symptoms of heart failure
manifestation
The student must know the
The student must know the manifestation..
manifestation
The student should know the
Symptoms of internal organ
symptoms of
The student must know the
levels of peak expiratory flow
The principle of "traffic light"
(PEF), depending on the color
of the traffic light
The student should know:
Indicators of laboratory results
- Normal values, as well as
their changes in pathology.
The student must know the
techniques and principles of
Therapeutic tactics
treatment (including nondrug).
The student should know the
The principles of primary, secondary and tertiary
basic activities required for the
prevention
primary, secondary and
tertiary prevention
The principles of clinical examination and rehabilitation The student must list the main
of disorders that occur with shortness of breath or
activities for clinical
choking in a hovercraft or OP (category 4)
examination and rehabilitation
What the student should be able to solve the problems of patients with shortness of breath
or choking:
№
The list of skills
The basic level
The student must be able to ask questions of
management concise questions that really
helps to set the probable diagnosis.
The student must be able to specifically
Ask the patient and his relatives
identify and assess the patient's complaints.
The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the
41
dynamics of their development.
The student must be able to analyze the
history of life: the identification of risk
factors, the health of the parents and close
relatives.
The student must be able to identify the
managed and unmanaged risk factors such as
Identify risk factors
on questioning the patient, so on the basis of
an objective approach
The student must be able to identify signs:
Calculate the index weight / body
- Underweight
- Increased weight.
The student should be able to tonometry with
Measure blood pressure.
the incremental principle.
The student must be able to detect the
presence of:
Perform visual inspection of the skin
pale- Cyanosis
- the presence of lesions
The student should be able to find:
Explore the pulse of the carotid, brachial - The presence or absence of a pulse
and femoral arteries
The student should be able to evaluate the
performance of the radial artery.
The student should be able to inspect and
palpate the thyroid gland and identify signs of
Examine the thyroid gland
increase, and depending on the size of the
thyroid gland to distinguish the degree of
goiter
The student should be able to:
- To evaluate the excursion of the chest
Palpate the chest
- To evaluate voice trembling
- To estimate the elasticity of the chest
The student should be able to
Conduct percussion respiratory
a change in pulmonary sound and interpret
them
The student should be able to
assess bronchial and vesicular breathing, as
To conduct auscultation of the respiratory
well as the presence of abnormal noise or
wheezing, interpret them.
The student must be able to identify:
- Cardiac impulse
To conduct palpation of the heart
- Systolic and diastolic tremor
The student must be able to assess the apical
impulse.
The student must be able to identify:
- Boundaries of relative and absolute dullness
of heart
- The boundaries of the vascular bundle
Conduct percussion heart
- The diameter of the heart
configuration and the waist of the heart.
The student must be able to identify:
- Signs of hypertrophy of the heart
42
Conduct a cardiac auscultation
To conduct palpation, percussion of the
abdomen
Inspect the limb
Perform a visual inspection of bones and
joints
Inspection of the throat
Conduct a peak flow meter
Interpret the results of peak flow
Interpret clinical, instrumental and
biochemical analyzes
Interpret the X-ray picture of light
Remove the ECG and decrypt it
43
- Configuration of the mitral
-aortic configuration
The student must be able to identify:
- Easing I and II sound
- I gain tones on top
- Accent II tone of the aorta or pulmonary
artery
- Systolic and diastolic murmur, and to
identify their epicenter
To be able to differentiate functional from
organic heart murmur.
- Noise pericardial friction
The student should be able to superficial and
deep palpation of the abdomen
The student must be able to identify:
- Hepatomegaly splenomegaliiyu
The student should see the limbs and body,
and to be able to find:
- Local or generalized edema. The fingers
must be able to exert pressure on the back of
the foot to discover:
- There is a hole or not.
The student should be able to find:
- The presence of articular syndrome
The student should be able to inspect the
throat with the principle of step and identify
evidence angina.
The student should be able to hold the peak
flow meter, taking into account the principle
of step
The student must:
- Know how to use tables and charts PSV
normal values based on gender, age and
height of the patient.
- Be able to calculate the percentage of
predicted PEF values depending on gender,
age and height of the patient.
- Be able to analyze and predict the results
The student must be able to detect a shift from
the norm
The student must be able to identify signs:
- pneumonia
- pneumothorax
- pleurisy
- Lung cancer and tuberculosis
The student should be able to record the ECG
with the incremental principle.
The student must be able to decipher the
results of the ECG and identify signs:
- Ischemia
- Myocardial infarction
- Hypertrophy of the heart.
- Rhythm and conduction disturbances
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination, laboratory and
instrumental investigations).
The student must be able to differentiate
asthma from cardiac asthma on the basis of
objective data.
The student must be able to differentiate NC
from respiratory failure on the basis of
objective data.
The student should be able to:
- Educate patients on self-monitoring
- Advise on diet
- Advise on healthy lifestyles
The student must be able to provide prehospital care in a fit of asthma, spontaneous
pneumothorax, cardiac asthma or pulmonary
edema and myocardial infarction.
The student must be able to carry out pleural
puncture technique for spontaneous
pneumothorax.
The student should be able to choose drugs
with proven efficacy.
When selecting a drug student should be able
to evaluate:
- Efficiency
- Safety
- Eligibility
- Profitability.
The student must be able to monitor and
control:
- OAK
- Level A / D.
- x-ray
- PSV
Differentiate between diseases
accompanied with shortness of breath or
choking
Post a non-drug advice
To provide pre-hospital care
To hold the pleural puncture
Rational use of medicines in the
treatment of diseases that occur with
shortness of breath or choking
Conduct monitoring and surveillance of
patients
Practical class number 4
Theme: "Shortness of breath and choking." Diseases that present with shortness of breath
or choking. The most dangerous diseases that present with shortness of breath or choking.
Differential diagnosis of asthma, emphysema, pulmonary fibrosis. Chronic respiratory
failure. Tactics GPs. Indications for referral to a specialist or hospital in the profile
department. The principles of treatment, follow-up, control and rehabilitation in a
hovercraft or a joint venture. The principles of prevention. The principles of teaching
topics »
learning Technology.
Study time: 6.4 hours
Training themed office chair.
The structure of the training session
Teaching aids, x-ray. pictures
Hospital wards.
TV, video equipment
44
The purpose of the training session:
Teach GPs on timely diagnosis and differential diagnosis of COPD (chronic obstructive bronchitis (COB),
emphysema (EL), bronchial asthma (BA) with the increase of irreversible airflow obstruction. Features of
the clinical course and the principles of management of patients in primary health care provided
requirements of the "Qualification characteristics of the GP"
Pedagogical objectives:
Learning outcomes:
Teach GP diagnosis - COPD, the clinical course
The student should know:
depending on the etiology and on the stage.
Clinical manifestations of COB, EL, non-atopic
Teach GP diagnosis and differential diagnosis of
asthma.
diseases in which there is shortness of breath and
The differential diagnosis of COPD.
asthma.
The differential diagnosis of these.
GPs familiarize with the list of diseases
Signs of respiratory distress.
associated with shortness of breath and choking
Tactics GPs.
and being treated in a hovercraft (SP) or
The principles of treatment (medication and nonspecialized hospitals.
medication) in these diseases.
Discuss the tactics in the qualifying
Principles of follow-up and monitoring of patients in
characteristics of GPs
a hovercraft or a joint venture.
Discuss the principles of treatment (medication
8. The principles of primary, secondary and tertiary
and non-medication).
prevention in these diseases.
Discuss the principles of management,
supervision and monitoring of patients in a
The student should be able to:
hovercraft or a joint venture.
1. Analyze the data and history of complaints for the
7. Discuss the principles of primary,
diagnosis of diseases associated with shortness of
secondary and tertiary prevention in these
breath and suffocation.
diseases.
2.Diagnostirovat, differentiated by clinical,
laboratory studies, radiographs different types of
COPD.
3.Provesti pikfloumetry
4.Interpretirovat results of peak flow:
- Proper use of tables and charts of normal values
PSV according to gender, age and height of the
patient.
- Be able to calculate the percentage of predicted PEF
values depending on gender, age and height of the
patient.
- Be able to analyze and predict the results
Choose drugs with proven efficacy
Advise on non-medicated treatments.
To monitor in SAP or joint venture.
The method of "City Gallery", a graphic organizer - a
Training Methods
cluster, display, video viewing, discussion,
conversation, decision tests and case studies
Individual work, group work, team, classroom,
Forms of organization of learning activities
extracurricular.
Hand-learning materials viziualnye materials, videos,
learning Tools
models, graphic organizers, kits medical charts,
tables, benches, training manuals, training materials,
ECG of patients
Quiz, test, presentation of the results of the learning
Methods and feedback means
task, filling medical records implementation of
practical skill "professional debriefing"
Flow chart classes
Topic: Shortness of breath, choking. Differential diagnosis of asthma, emphysema, pulmonary fibrosis.
Chronic respiratory failure. tactics
45
Stages of the practice session
Form classes
№
Venue
1
Chapeau (justification themes)
2
The discussion on the practical lessons with the use of new
educational technologies (method "City Gallery"), as well
as demonstration material (sets of medical charts, tables,
posters, x-ray), define the initial level.
3
4
5
6
7
Conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the provisions and
recommendations for the job by filling in medical charts.
Mastering the practical part of the training under the
guidance of a teacher.
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research OAM KLA and biochemical analysis
and diagnosis
Discussion of theoretical and practical knowledge of the
students, securing the material to determine the level of
assimilation of knowledge assessment.
8
Defining output on practical sessions on a 100-point rating
system and ad evaluations. Homework next practice session
(a collection of questions).
2.Motivation
The survey, discussion
Duration
classes
225
10
40
Classroom, GP surgeries
Discussion
10
20
GP doctor's office
Mastering the practical
part of the training under
the guidance of a teacher.
Prof. questioning. A
conversation with patients
and honey filling cards,
situational problems.
Admission of patients in
the clinic, examination at
home
Medical history,
laboratory data
situational problems
Oral questioning, tests,
discussion, identification
of practical skills
Classroom in clinic
Information, questions for
homework.
Classroom in a clinic
20
25
75
25
The majority of patients with shortness of breath and suffocation, particularly with chronic obstructive
pulmonary disease (COPD), this group includes chronic obstructive bronchitis (COB), emphysema (EL),
some forms of bronchial asthma (BA) with the increase of irreversible airflow obstruction (usually nonatopic asthma )) to seek medical help. In this situation, the force of a general practitioner (GP) is directed
to the diagnosis of COPD is caused by various diseases. In the case of COPD, GPs should diagnose the
disease, and he needed to determine the reasons behind the disease for medical care and clarifications
locations of this group of patients.
3. Interdisciplinary communication and Intra
Anatomy, histology and cytology with embryology, biology, normal physiology, Biochemistry,
Pathology, Pathological Physiology, Topographic anatomy and operative surgery, internal
46
medicine Propedeutics, Tuberculosis, Oncology, Radiology and Nuclear Medicine,
Physiotherapy, Endocrinology, Faculty Therapy, Hospital therapy, orthopedics
4. The content of classes
4.1. The theoretical part
On a practical lesson in the theoretical part includes analysis of the clinical features of the
diagnosis of COPD.
Chronic obstructive pulmonary disease (COPD) - a term that has a 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 growth
of chronic respiratory failure.
This group includes chronic obstructive bronchitis (COB), emphysema (EL), some forms of
bronchial asthma (BA) with the increase of irreversible airflow obstruction (usually non-atopic
asthma).
Second, as a distinct disease COPD (nosological form) is the final stage of progressive course of
COB, EL, ie the stage at which the disease progresses is lost due to a reversible component of
airflow obstruction, and disease, leading to COPD, lose their individuality. This attitude
corresponds to the problem, and the International Classification of Diseases, 10th Revision
(ICD-10), it is highlighted, under the heading J.44.8 chronic obstructive bronchitis, without
further elaboration, that is part of the updated COPD.
In accordance with the GOLD (2003) the concept of COPD includes chronic obstructive
bronchitis and emphysema.
Thus, in patients with COPD, there are at least two main features, fundamentally distinguishing
them from HP - diffuse damage the respiratory system and progressive respiratory failure on
obstructive type.
Chronic obstructive pulmonary disease (COPD) occupy a leading place among the causes of
morbidity and mortality in the adult population.
COPD is a chronic inflammatory process is shown with a primary lesion of the distal airways.
For this category of patients characterized by reduced maximum expiratory flow and slow the
progressive deterioration of gas exchange function of the lungs, which reflects the irreversible
airway obstruction. Biomarkers of chronic inflammation in COPD is the participation of
neutrophils with increased activity of myeloperoxidase, elastase, an imbalance in the systems of
proteolysis-antiproteoliz-oxidants and antioxidants. The main clinical manifestations of COPD
are cough varying degrees of severity, sputum production and shortness of breath. COPD relates
to a group of diseases multigeneticheskih.
Externally and internally etiological factors of COPD (risk factors) are separated by the
significance.
The main risk factor (in 80-70% of cases) COPD - smoking. Smokers have the highest mortality
rates, they quickly develop irreversible obstructive changes in respiratory function and all of the
known symptoms of COPD. It is believed that the demographic COPD reflects the prevalence of
smoking. The most frequently (70%) the cause of COPD is chronic obstructive bronchitis, about
1% of the EL (due to a1-antitrypsin deficiency), the remaining interest is accounted for severe
asthma. COB allocation in a separate nosological form is crucial from the point of early
diagnosis and treatment at the stage of intact reversible component of airflow obstruction, that is,
when the disease has not lost its identity and there is a real possibility of inhibition of
progression of the disease by affecting the reversible component of airflow obstruction.
The clinical picture of COPD depends on the stage of the disease, the rate of progression of the
disease and the priority level of destruction of the bronchial tree. COB as a major component of
COPD develops in times of risk factors slowly and progresses gradually. The rate of progression
47
and severity of symptoms depends on the intensity of the COB effects of etiologic factors and
their summation.
The first signs, which patients usually go to the doctor, is a cough and shortness of breath,
sometimes accompanied by wheezing with phlegm. These symptoms are most pronounced in the
morning. The earliest symptom of appearing to 40-50 years of life, is a cough. By this time in the
cold seasons are beginning to have episodes of respiratory infections that were not connected to
the first one disease. Shortness of breath, initially perceived exertion, there is an average of 10
years after cough onset.
Sputum production in a small number (rarely more than 60 mL / day) in the morning, a slimy
character and becomes purulent only during infectious episodes, which are usually regarded as
an exacerbation.
As the progression of COB intervals between exacerbations grow shorter.
Results of physical examination of patients with COB depends on the severity of airflow
obstruction, the severity of pulmonary hyperinflation and physique. As the disease progresses to
coughing joins wheezing, most notable in rapid exhalation. Often auscultation revealed rales dry
raznotembrovye. Shortness of breath can vary over a wide range: from the feeling of lack of air
at standard physical exercise to severe respiratory failure. As the progression of airflow
obstruction and lung hyperinflation rise anteroposterior chest size increases. Limited mobility of
the diaphragm, auscultation picture changes: reduced the severity of wheezing, prolonged
exhalation.
The sensitivity of physical methods for determining the severity of COPD is low. Among the
classic signs can be called a whistling breath and extended expiration time (> 5 s), which may be
indicative of bronchial obstruction.
Thus, the development and progression of COPD occurs in times of risk factors characterized by
a slow gradual onset. The first (the earliest) COPD symptom is a cough. Other characters join
later in the progression of the disease, with a gradual acceleration of the progression of the
disease.
Physical examination in patients with COPD is not enough for a diagnosis of the disease,
it provides only guidelines for the future direction of the diagnostic studies using instrumental
and laboratory methods. Conventionally, all diagnostic methods can be divided into methods of
mandatory minimum, is used in all patients (complete blood count, urine, sputum, chest
radiography, the study of respiratory function (ERF, an electrocardiogram), and additional
methods used for special indications.
For routine clinical work with patients with chronic obstructive bronchitis in addition to general
clinical tests recommended to study respiratory function (FEV 1, forced vital capacity or FVC), a
test with bronchodilators (b2-agonists and holinolitikami), chest X-ray. The other research
methods are recommended for special indications, depending on the severity and nature of its
progression.
In everyday practice, the patients apply COB tests bronchodilators (b-agonists and / or
holinolitikami), which to some extent characterized by the ability to fast regression of bronchial
obstruction, in other words, "reversible" component of obstruction. The increase in FEV1 during
the test by more than 15% of the baseline conditional commonly characterized as a reversible
obstruction.
1. Smoking cessation and limitation of external risk factors.
2. Education of patients.
3. Bronhodilatiruyuschee therapy.
4. Mukoregulyatornaya therapy.
5. Anti-infective therapy.
6. Correction of respiratory failure.
7. Rehabilitation therapy.
48
The sensitivity of physical methods for determining the severity of COPD is low. Among the
classic signs can be called a whistling breath and extended expiration time (> 5 s), which may be
indicative of bronchial obstruction.
Thus, the development and progression of COPD occurs in times of risk factors characterized by
a slow gradual onset. The first (the earliest) COPD symptom is a cough. Other characters join
later in the progression of the disease, with a gradual acceleration of the progression of the
disease.
In the formation of the strategy and tactics of treatment of patients with COPD is crucial
to allocate two treatment regimens: non-acute treatment (maintenance therapy) and treatment of
COPD exacerbations
Theoretical survey can be carried out using the 'Tour Gallery »
The method of "Tour Gallery»
Steps:
1. Students are divided into teams of 4 people.
2. Each team is responsible for the assigned tasks, for 3 minutes, and changing jobs, if there is a
need then adds his own answers.
3. According to the number of correct answers, each student is evaluated.
The teacher asks students questions about classes:
1. Define the term "chronic obstructive pulmonary disease" (COPD) and asthma.
2. Tell classification of COPD and asthma.
3. List the diagnostic criteria for COPD and asthma.
4. List the laboratory and instrumental methods for the diagnosis of COPD and asthma
complications and diseases.
5. Give a predisposing factor to the development of COPD and asthma.
6. Differential diagnosis of asthma and COPD.
7. Tell the wording of the diagnosis of COPD.
8. List the treatment of exacerbations and non-acute asthma and COPD.
9. Tell the clinical manifestations, laboratory and instrumental methods of diagnosis and
complications of lung tumors.
Answer:
1. COPD - primary chronic inflammatory disease mainly affecting the distal airways of the lung
parenchyma and the formation of emphysema and is characterized by airflow limitation to the
development of irreversible (or not fully reversible) airflow obstruction caused by the productive
persistent non-specific inflammatory response. The disease manifests cough, sputum and
increasing shortness of breath, has been steadily progressive nature with the outcome in chronic
respiratory failure and pulmonary heart. In accordance with the GOLD (2003) the concept of
COPD includes chronic obstructive bronchitis and emphysema.
Asthma - a disease which is based on airway inflammation, accompanied by changes in the
sensitivity and bronchial reactivity and manifested an attack of breathlessness, status
asthmaticus, or, in the absence thereof, respiratory discomfort (paroxysmal cough, wheezing and
shortness of breath distant), accompanied by reversible airflow obstruction against the hereditary
predisposition to allergic diseases extrapulmonary allergy symptoms, blood eosinophilia and / or
eosinophils in the sputum.
2. Recommended classification of COPD severity with the release of four stages is given in
accordance with the latest version of the international program "Global Initiative for Chronic
Obstructive Lung Disease» (GOLD, 2003).
49
Classification of COPD severity (GOLD, 2003)
Stage
The main clinical signs
I: light
cough, sputum, usually but not
always.
II: Moderate
• Persistent cough, most
pronounced in the morning,
scanty sputum is usually, but
not always
• Shortness of breath with
mild-tion of physical load ke
III: severe
persistent cough, sputum,
shortness of breath
IV: Very Severe
кашель, выделение мокроты,
dyspnea
Functional indicators
• FEV1/FVC (IT) <70%
• FEV1 ≥ 80% of predicted
• FEV1/FVC (IT) <70% •
50% ≤ FEV1 <80% of
predicted
• IT <70% • 30% <FEV1
<50% of predicted
•ИТ<70%
• FEV1 <30% predicted
velichiniliOFV1 <50% of
predicted, combined with
chronic right ventricular
failure or NAM
Note: FEV1 - forced expiratory volume in 1 s, FVC - forced vital capacity
Classification of asthma sm.teoreticheskuyu part.
1. Examples of the wording of the diagnosis;
A) COPD, mainly bronhitichesky type, moderate flow (stage II), remission or exacerbation, MD
II, chronic pulmonary heart, the degree of heart failure.
B) COPD is predominantly emphysematous type, it is extremely difficult for a (stage IV),
remission or exacerbation, NAM III, chronic pulmonary heart, the degree of heart failure.
№ evaluation
fine
good
Satisfactory unsatisfactory poorly
Assimilation in%
100%85%70-55%
54%-37% 36% or
less
86%
71%
1
The theoretical part
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2
mark
4.2.Analiticheskaya part
Case Studies:
1. A patient 50 years appealed to the GP complaining of shortness of breath, cough with purulent
sputum. Smoking history of 30 years. General state of moderate severity, cyanosis, neck veins
bulging, epigastric pulsation. In lung auscultation dry and moist rales. Heart sounds are muffled,
rhythmic, 2 tone accent on a.pulmonalis. Blood pressure 130/90 mm Hg Ps-90 ud.v min.OAK
HB-173 g / l er-3, 9-Leu 10 × 109 / L, erythrocyte sedimentation rate, 18 mm.ch. FVD-FEV 1,
45%, Index Tiffno-57%, VC-75%.
1. Determine the severity of COPD in clinical and functional criteria (GOLD, 2003);
2. The preliminary diagnosis;
3. Enter the X-ray and ECG data;
4. The tactics of the GP;
Answers:
№
Answers:
Mark
50
1
2
3
4
I-stage light: cough, sputum production, usually, but not always.
FEV1/FVC (IT) <70%, FEV1 ≥ 80%. II-stage, mid-weight: persistent
cough, most pronounced in the morning, scanty sputum is usually, but
not always, shortness of breath on mild exertion. IT <70%, ≥ 50% FEV1
<80%. III-stage, severe: persistent cough, sputum, shortness of breath.
IT <70% FEV1> 30% <50%. IV-stage kraynetyazhelaya: cough,
sputum, shortness of breath. IT <70% FEV1 <30% or <50% of
predicted values in conjunction with chronic NAM or right ventricular
failure.
Chronic obstructive pulmonary disease (COPD), primarily
bronhitichesky type, III severity, heavy current, phase
obostreniya.Oslozhneniya: NAM II.
Peribronchial infiltration, diffuse pulmonary fibrosis, emphysema
symptoms.
Referral to inpatient treatment, observation of general practitioners,
outpatient observation, the definition of disability.
20
35
20
25
2. A patient 40 years appealed to the GP complaining of shortness of breath, breathlessness, dry
cough. Deterioration of ties with the use of a pill anaprilina. Overall condition of relatively
heavy, expiratory dyspnea, cyanosis of the lips. In the lung auscultation scattered dry wheezing.
BH-30 min. Heart sounds tachycardia, muffled AD 140-90 mm Hg Ps-100 min. OAK HB-120g /
l, er-4, 0 Leu-7 ,8-7 EPZs ESR-14 mm / h
1. The preliminary diagnosis;
2. Treatment of patients with asthma by desensitatsii;
3. Enter the pathogenetic mechanisms of aspirin asthma;
4. The tactics of the GP;
3. Patient 18 years. Complaints about udushbe, wheezing and shortness of breath during physical
stress. In the lungs, wheezing. No history of disease was not sick. Auscultation in the lungs of
hard breathing. Heart sounds are clear, rhythmic.
1. Enter the immunological and non-immunological mechanisms of asthma;
2. Informative survey methods;
3. The preliminary diagnosis;
4. The tactics of the GP;
4. A patient 57 years appealed to the GP with complaints of cough, hemoptysis, hoarseness, loss
of weight. OBJECTIVE: astenik, clubbing as "drumsticks", the increase in cervical l / at the right
Horner's syndrome positive right. R-graphy: the upper lobe atelectasis. right lung.
1. List at least five diseases for which there are the above mentioned signs and symptoms
(drumsticks);
2. The preliminary diagnosis;
3. Informative survey methods;
4. The tactics of the GP;
_____________________________________________________________________________
_
51
5. An appointment with the GP patient received 50 years, complaining of frequent harassing
chest pain, cough, weight loss, shortness of breath, fluctuating fever and general weakness. From
history, the patient over 30 years of experience in the workshop production of asbestos.
OBJECTIVE: lagging behind left rib cage in the act of breathing. Percussion: dullness of sound
from left, Auscultation: from left auscultated dyhanie.Obschy weakened blood Hb - 80 g / l,
Lake. - 12 000, ESR - 30 mm / s.
1.Ukazhite characteristic radiographic signs of this pathology;
2. The preliminary diagnosis;
3. Informative survey methods;
4. The tactics of the GP;
6. The patient was 42 years old, due to frequent inflammations of the airways complaining of
hard phlegm and coughing fits, shortness of breath after minor physical activity and rapid
fatigue. From history, the patient over the age of 12 suffering from bronchial asthma. To prevent
the disease took a day for the 10-15mg prednisolone and did Ventolin inhalation. An objective
examination of notes expiratory dyspnea, cyanosis, 30 breaths per minute. Heart rate of 120
beats per minute, blood pressure 150/90 mm Hg Percussion: there is a box sound. Auscultation:
marked common wheezing. FEV1 <60%.
1.You patient what type of respiratory failure is observed;
2. The preliminary diagnosis;
3. Specify the groups of bronchodilators;
4. Specify the characteristic radiographic changes;
5. Treatment. Tactics GPs and secondary prevention;
__________________________________________________________________
7. The patient was 58 years old, works as a driver, he entered the reception GP complaining of
shortness of breath with minimal exertion, the lack of air, choking, cough, rapid heart beat, on
the right upper quadrant. From history, repeatedly ill with pneumonia. In this regard, the colder
times of the year the disease is often acute, smoking for 25 years. OBJECTIVE: Patients with
severe general condition, cyanosis of the lips, the lungs are common dry and moist rales. Heart
sounds are dramatically suppressed, in pulmonary artery auscultated accent II-tone, heart rate 1,002 bpm. per min. BP -140 / 80 mm Hg CBC HB - 182 g / l, WBC - 13 × 109 / L, wand 13%
neutrophils, segmented neutrophils - 62% lymphocytes, 9% monocytes -2% ESR - 22 mm / s;
FVD - FEV 1 - 29%, IT - 45%.
1. List at least five diseases for which there are the above mentioned signs and symptoms;
2. The preliminary diagnosis;
3. What kind of change do you find the part of the ECG (data).
4. The tactics of the GP;
__________________________________________________________________
8. At the reception of GPs admitted patient complaining of vasomotor rhinitis, and rashes on the
body, shortness of breath, a dry cough. After taking the pill tetracycline rash appeared on the
body. Auscultation: in the lungs marked dry wheezing and prolonged expiration, the index Tifno
50%. After inhalation berotokom Tifno index was 55%, the number of eosinophils in the blood
of 12%. 11h109 leukocytes / l.
1. The preliminary diagnosis;
2. Enter the pathogenetic mechanisms of this disease;
52
3. Index coefficient index Tiffno OK;
4. Treatment. The tactics of the GP;
__________________________________________________________________
9. Patient D. 50 years old, examined by GPs. Complaints of shortness of breath during the
inspection at the slightest exertion, swelling in the legs. For 10 years, suffers from chronic
bronchitis. In the past 5 years has increased shortness of breath, headache, worry, fatigue.
OBJECTIVE: cyanosis of the face, swollen neck veins, swelling of the veins on the exhale
increases, bleeding in the sclera of the eye, swelling in the legs. Respiratory rate 26 times in 1
min. In the lungs, both sides are heard, dry and moist rales. Heart sounds, rhythmic, II tone on
the pulmonary artery is emphasized. HR 110 in 1min. Liver + 4 cm painful.
In the blood: red blood. - 6 million, hematocrit - 65/35.
What complication has arisen? Your diagnosis?
List the four diseases for which there are a complication of the above;
List the typical 8 Signs for complications of the disease that are present in this patient;
Methods of research;
Tactics GPs and treatment.
__________________________________________________________________
10. In the hospital the patient is 60 years old with a diagnosis of bronchial asthma, pulmonary
emphysema. CAD: Angina FC III. PEAKS. Donkey.: LN III. NC II B Art. in the direction of the
GP. During the last days of the patient's condition was serious. There are chest pain, hemoptysis,
cyanosis, edema of the legs, shortness of breath worsened. Nitroglycerin did not remove the
pain. NPV 28 in 1min. In mild diffuse dry whistling and fine moist rales unvoiced. Heart sounds,
rhythmic, focus and splitting II tone on the pulmonary artery. HR 96 in 1min. Blood pressure
100/60 mm Hg Liver 3 cm
ECG showed hypertrophy of the right ventricle and right atrium.
On chest radiograph: the roots of lung congestion, "a symptom of amputation," an arc of
pulmonary artery bulging.
What was the reason for the deterioration of the patient? 2.Perechislite 4 diseases for which there
is a complication of the above;
List the typical 7 features for complications of the disease that are present in this patient;
Methods of research;
Treatment.
__________________________________________________________________
11. A patient 48 years old, the home inspected by GPs. Complaints about the increase of
breathlessness at the slightest exertion, headache, drowsiness. Had a history of cough with a
minor amount of sputum. Year ago found elevated levels of red blood cells and hemoglobin in
the blood, in connection with which it was produced bloodletting. Somewhat retarded patient
communication with him difficult. OBJECTIVE: falling asleep while sitting on a chair, dyspnea
at rest, cyanosis of the lips, obesity (height 170 cm, weight 110 kg). The lungs are listened
diffuse dry and moist rales. Heart sounds, stress and break down of II tone on the pulmonary
artery. Blood pressure 160/90 mm Hg
ECG: high and sharp tooth "P" in the II-III and AVF leads. Axis deviation to the right, in the
right chest leads high R (R/SV1 greater than 1.0) in the left chest leads increases prong S (R /
SV6 than 1.0)
In the blood, red blood cells 5.5 million
On radiographs: bulging arc pulmonary artery.
53
List the three diseases in which the above symptoms are observed;
Your diagnosis;
List the typical 10 signs of the disease that are present in this patient;
What interpret ECG data?
Tactics GPs and treatment.
№ evaluation
fine
good
Satisfactory
Assimilation in%
100%85%70-55%
2
Case study
86%
71%
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
unsatisfactory poorly
54%-37% 36% or
less
27-18,5
mark
Tests:
1. What is not a reversible component of bronchospasm in patients with COPD:
a) hypersecretion of mucus
b) smooth muscle cell hyperplasia
c) the swelling of the bronchial mucosa
d) smooth muscle spasm
e) bronchial epithelial hyperplasia
2. What is not a permanent component of bronchoconstriction in patients with COPD:
a) hypersecretion of mucus
b) epithelial hyperplasia
c) the spasm of smooth muscles of the bronchi
d) peribronchial fibrosis
d) hypertrophy of smooth muscle cells of the bronchial
3. What drugs are not used in the treatment of COPD:
a) expectorants
b) agonists
c) antibiotics
g) mucolytics
e) cytostatics
e) beta blockers
4. Preparations for the basic treatment of bronchial asthma:
a) 2-agonists, short-acting
b) systemic corticosteroids
c) Cromones
g) inhaled corticosteroids
e) anticholinergics
e) Antibiotics
5. Preparations for the relief of bronchial asthma:
a) cromones
b) systemic corticosteroids by mouth or intravenously
c) short-acting methylxanthines / in
g) B-2 agonists long acting
e) inhaled corticosteroids
e) inhaled B-2 agonists, short-acting
6. For prolonged drug theophylline are:
54
18 mark
a) eufillin
b) diafillin
c) teopek
g) retafil
e) diprofillin
e) Ditek
7. By selective adrenomimetikami (with a predominant effect on β2-receptors) are:
a) brikanil
b) izadrin
c) salbutamol
g) Euspiran
e) berotek
e) astmopent
8. The use of ipratropium bromide, as appropriate:
a) for the treatment of young patients
b) for the treatment of elderly patients
c) in abundant sputum (bronhoree)
g) with scanty sputum or no
d) at sympathicotonia
e) When vagotonia
9. Contraindications to ipratropium bromide are:
a) glaucoma
b) bradycardia
c) adenoma of the prostate
d) AV block 1 - degree
e) bundle branch block
10. For aspirin asthma is characterized by:
a) nasal polyposis
b) easy for asthma
c) the severity of the asthma
g) is very easy for asthma
d) sensitization to house dust
11. For moderate asthma is characterized by:
a) sharpening 1-2 times per year
b) symptom relief injections bronchodilators
b) sharpening 3-4 times per year
d) the presence of status asthmaticus
d) repeating attacks in 2-3 days
12. Asthmatic triad includes:
a) chronic sinusitis
b) asthma
c) non-steroidal antiinflammatory drugs intolerance
d) nasal polyposis
e) vasomotor rhinosinusopathy
55
13. Attacks of breathlessness at night (occurring in 3-4 am)
to recommend to the patient better at night:
a) ingalyapiyu beroteka
b) teopek (teodur) inside
c) 2 tablets suprastina
g) inhalation Intalum
d) 2 tablets prednisolone
№ evaluation
Assimilation in%
3
Tests:
fine
good
Satisfactory
100%86%
85%-71% 70-55%
unsatisfactory poorly
36% or
54%-37% less
15-12,9
mark
12,7-10,6
mark
8,1-5,5
mark
10,5-8,25
mark
5,4
mark
4.2.2. Graphic organizer of "cluster".
Cluster (Cluster - bundle, the bundle) - a way of mapping information - gathering ideas around of
any of the main factors for determining the meaning and focus of all konstruktsii.Stimuliruet
updating knowledge helps freely and openly engage in associative thinking process new
perspective on a topic.
Acquainted with the rules of drawing up the cluster. In the center of the chalkboard or a large
sheet of paper is written the name of the keyword or topic of 1-2 words.
By association with the key word is credited alongside it in the circles smaller "satellite" - the
words or sentences that are related to that topic. Connect their lines with the "main" word. These
"satellite" can be "small satellites", etc. record goes before the expiration of the allotted time, or
until they are exhausted ideas.
Exchanged between clusters for discussion.
56
My breast is
constrained
My breath is
complicated
I feel how my
breath stops
I can't inhale
My breath is
complicated
Chronic obstructive
illness of lungs
I can't inhale
Bronchial
asthma
My breath is
complicated
Interstitsialny diseases
of lungs
Characteristic of the main
complaints to short breath at
various diseases
I can't inhale
My breast is
constrained
It is difficult to
breathe to me
I am disturbed by the
speeded-up breath
I am disturbed by the
speeded-up breath
Mucoviscidosis
Hyperventilation
syndrome
Neuromuscular
disease
It is difficult to
breathe to me
I feel weight in a
breast
I feel how my
breath stops
I am disturbed by
the speeded-up
breath
57
I can't inhale a
full breast
It is difficult to inhale
to me
The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with diseases soprovozhdayushihsya breathlessness
and suffocation.
2. Interpretation of the analyzes, the data of laboratory and instrumental studies, radiographs of
patients with diseases soprovozhdayushihsya breathlessness and suffocation (clinical and
biochemical blood tests, coagulation tests, sputum examination, chest x-ray images, the results of
pulmonary function, ECG, immunological research, knowledge extraction of foreign technology
bodies in the upper respiratory tract).
3. Prescription of drugs depending on the etiology of shortness of breath and choking
№ evaluation
4
fine
good
Satisfactory
Assimilation in%
100%86%
85%-71% 70-55%
The practical part
15-12,9 mark
12,75-10,6
mark
10,5-8,25
mark
unsatisfactory poorly
36% or
54%-37% less
8,1-5,55,4 mark
mark
5. Control forms of knowledge, skills and abilities
-Orally
-The writing
-Decision situational problems
-Demonstration of practical skills mastered
Criteria for evaluation of knowledge and skill to practical skills of students.
№ evaluation
1
2
3
4
fine
good
Satisfactory
Assimilation in%
100%86%
85%-71% 70-55%
unsatisfactory poorly
36% or
54%-37% less
The theoretical part
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2
mark
Case Studies
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
Test
15-12,9 mark
12,7-10,6
балл
10,5-8,25
балл
8,1-5,5
mark
5,4
mark
The practical part
15-12,9 mark
12,75-10,6
mark
10,5-8,25
mark
8,1-5,5mark
5,4 mark
6. The evaluation criteria of the current control
levels of
rating
Characteristics of the student
estimates
points
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not
20
ready for practical employment.
58
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and
skills, at least one of the following:
Do not know the clinical signs of pulmonary embolism,
asthma status and spontaneous pneumothorax
Do not know the pathogenetic treatment of bronchial
asthma
Do not know the risk factors for pulmonary embolism,
asthma status and spontaneous pneumothorax
Do not know the groups of drugs used in treatment of
pulmonary embolism, asthma status and spontaneous
pneumothorax
Do not know how to provide pre-hospital care for
Not
20 - 54,9
pulmonary embolism, status asthmaticus and spontaneous
satisfactory
pneumothorax
Can not indicate the radiological signs of pulmonary
embolism, asthma status and spontaneous pneumothorax
Not able to assemble a rational history during the
Supervision of patients with pulmonary embolism, status
asthmaticus and spontaneous pneumothorax
During Supervision is not able to objectively assess the
status of patients with pulmonary embolism, status
asthmaticus and spontaneous pneumothorax
Not able to rationally make a plan of examination of
patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax in a hovercraft or a joint venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and
55-60,9
skills (see below), but when replying or performing skills
make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below), but
61-65,9
when replying or performing skills make mistakes (subject
to certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of
knowledge and skills:
• Know the clinical signs of pulmonary embolism, asthma
Satisfactorily
status and spontaneous pneumothorax
55-70,9%
• Can differentiate pulmonary embolism, asthma status and
spontaneous pneumothorax with other lung diseases for
subjective, objective, and laboratory and instrumental data
• Knows differentiated pathogenetic treatment of pulmonary
66-70,9
embolism, asthma status and spontaneous pneumothorax
Know the risk factors for pulmonary artery disease, asthma
status and spontaneous pneumothorax
Knows the groups of drugs used in treatment of pulmonary
embolism, and asthma status spontaneous pneumothorax
Can point to radiological signs of pulmonary embolism,
asthma status and spontaneous pneumothorax
Able to build a rational history during the Supervision of
59
patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax
During Supervision is able to objectively assess the
condition of patients with pulmonary embolism, status
asthmaticus and spontaneous pneumothorax
Able to efficiently make a plan of examination of patients
with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax in a hovercraft or a joint venture.
Can interpret the results of laboratory and instrumental
methods of research - may indicate the presence of
leukocytosis, leykoformuly shift to the right or to the left,
elevated ESR.
Can show the technique of taking blood count
Can show the technique of taking the overall analysis of
sputum
Can demonstrate the technique of peak flow
Can display technology providing pre-hospital care for
patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax
Able to correctly fill in the patient diary.
Advanced level of knowledge
Well
71-85,9%
71-75,9
76-80
81-85,9
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has the
following knowledge and skills:
• Knows the stage of development of asthma
• Knows the clinical symptoms and morphological changes
characteristic of each stage of the development of asthma
• Know the classification of asthma, pulmonary fibrosis and
emphysema
• Knows the mechanism of action of drugs applies when
pulmonary embolism, status asthmaticus and spontaneous
pneumothorax
Rationally selected drugs used in the treatment of
pulmonary embolism, asthma status and spontaneous
pneumothorax
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9", and also owns the following
knowledge and skills:
• Knows the pathogenesis of pulmonary embolism, asthma
status and spontaneous pneumothorax, and can also be called
a morphological picture of
Knows the principles of primary, secondary and tertiary
prevention of pulmonary embolism, asthma status and
spontaneous pneumothorax
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9" and "76-80", and also owns the
following knowledge and skills:
• Can point to radiological signs of pulmonary embolism,
asthma status and spontaneous pneumothorax
• Know the indications for pulmonary arteriography
60
86-90
Fine
91-95
86-100%
96-100
• Principles of management, supervision and monitoring of
patients with bronchial asthma in a hovercraft or a joint
venture.
• Principles of management, supervision and monitoring of
patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax in the pre-hospital environment
SVP or joint venture.
• Is able to advise you on the boards of non-drug and drugusing skills of IPC.
Principles of clinical examination and rehabilitation of
patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax in a hovercraft or joint venture
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "81-85,9", and also owns the following
knowledge and skills:
• Knows the principles of treatment of pulmonary embolism,
asthma status and spontaneous pneumothorax in the
prehospital and hospital stage
• Know the indications and contraindications for X-ray
examination of patients with pulmonary embolism, status
asthmaticus and spontaneous pneumothorax
Is able to provide reliable information about pulmonary
embolism, status asthmaticus and spontaneous
pneumothorax on the basis of Internet data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "86-90", and also owns the following
knowledge and skills:
• Knows the radiological signs of pulmonary infarction and
infiltrative pulmonary tuberculosis
Is able to identify hearth pneumonia methods of objective
examination.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "91-95", and also owns the following
knowledge and skills:
• to provide scientific data from the literature (articles and
Internet)
Knows the stages of clinical examination and rehabilitation
of patients with pulmonary embolism, status asthmaticus and
spontaneous pneumothorax
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
7. Test Questions
-Classification of COPD
-The clinical course of COPD.
-Differential diagnosis of COPD.
-The etiology and pathogenesis of COPD.
61
-Basic clinical and laboratory tests for the diagnosis of COPD.
-What are the radiographic changes are detected COPD?
-Features of COPD?
Recommended reading
Summary
Ttestes kasalliklar, Bobozhanov S. T: Yangi Asr avlod 2008
Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009
Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
• Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012
• General medical practice under red.F.G.Nazirova, A.G.Gadaeva. M. GEOTAR Media, 2009.
• Directory GP. Dzh.Merta. M.: Practice, 1998.
• The collection of practical skills for general practitioners. Gadaev A. Akhmedov Kh.S. T.,
2010.
• Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS, 2010.
T.
• Umumy amaliet shifokori Uchun kullanma F.G.Nazirov, A.G.Gadaev Tahrah. M. GEOTARMedia, 2007.
• Diagnosis of diseases of the internal organs. A.N.2005 hams.
• Treatment of diseases of the internal organs. A.N.2005 hams.
• Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News Agency,
2009.
• Internal Medicine: a textbook. - In 2 volumes (1t), Ed. Martynov, etc. M: GEOTAR - Media,
2005:
Internet Resources:
http://www.lib.uiowa.edu/hardin/md/index.html,http://dir.rusmedserv.c,http://www.medlinks.ru/,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
http://elibrary.ru http://www.freebooks4doctors.com/ http://www.medscape.com/
http://www.meducation.net/ http://www.thecochranelibrary.com
Medical sites:
Med.-site.narod.ru
www.medlook.ru
Practical session number 5
Topic: Principles of prevention and treatment of COPD in SAP. Tactics in primary care.
The principles of teaching topics.
Technology training.
Study time: 6:00
The structure of the training session
Training themed room.
Cabinet GPs.
Tutorials, phantoms, models, handouts, a
collection of case studies and tests
TV, video equipment, multimedia
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis of
62
diseases associated with cough.
Pedagogical objectives:
Discuss questions about tactics reference in
within the qualifying characteristics of GPs
The principles of treatment (medication and
non-medication).
Principles of management, follow-up and
monitoring of patients in a hovercraft or a
joint venture.
The principles of primary, secondary and
tertiary prevention of COPD.
Training Methods
Forms of organization of learning activities
learning Tools
Methods and feedback means
Learning outcomes:
The student must:
Principles of supervision and management of patients
with COPD in a hovercraft or a joint venture.
Principles for the prevention of COPD.
GPs should be able to:
Diagnose, differentiated by clinical, laboratory
studies, radiographs different types of cough.
Advise on non-drug therapies.
The method of "Tour of the gallery."
Demonstration, entertainment experience, discussion,
conversation, decision tests and case studies
Individual work, group work, team, classroom,
extracurricular.
Hand-learning materials viziualnye materials, videos,
models, graphic organizers, sputum smears, sets of
medical records, tables, stands, kits radiographs.
Quiz, test, presentation of the results of the learning
task, filling medical records implementation of
practical skill "professional debriefing"
Flow chart classes
Topic: Principles of prevention and treatment of COPD in SAP. Tactics in primary care.
The principles of teaching topics.
Stages of the practice session
Form classes
№
Venue
1
2
3
4
5
Chapeau (justification themes)
The discussion on the practical lessons with the use of new
educational technologies (method "City Gallery"), as well
as demonstration material (sets of medical charts, tables,
posters, x-ray), define the initial level.
Conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the provisions
and recommendations for the job by filling in medical
charts.
Mastering the practical part of the training under the
guidance of a teacher.
The survey, discussion
Classroom, GP surgeries
Discussion
10
20
GP doctor's office
Prof. questioning. A
conversation with patients
and honey filling cards,
situational problems.
Admission of patients in
63
Duration
classes
225
10
40
20
the clinic, examination at
home
6
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research OAM KLA and biochemical analysis
and diagnosis
Medical history,
laboratory data
situational problems
25
7
Discussion of theoretical and practical knowledge of the
students, securing the material to determine the level of
assimilation of knowledge assessment.
Oral questioning, tests,
discussion, identification
of practical skills
75
Defining output on practical sessions on a 100-point rating
system and ad evaluations. Homework next practice
session (a collection of questions).
Classroom in a clinic
Information, questions for
homework.
Classroom in a clinic
8
25
2.Motivation
Patients with complaints of shortness of breath and asthma often occur in the practice of general
practitioners (GPs). In this situation, the effort is directed at doctors diagnose diseases associated
with shortness of breath and suffocation due to various reasons. In the case of diagnosis of GPs
have to solve the question of the definition of the group of patients to be treated in a hovercraft
or a joint venture, or referral to specialized hospitals. These and other conditions are the basis for
the inclusion of this subject in the training of GPs.
3.Interdisciplinary communication and Intra
Anatomy, histology and cytology with embryology, biology, normal physiology, Biochemistry,
Pathology, Pathological Physiology, Topographic anatomy and operative surgery, internal
medicine Propedeutics, Tuberculosis, Oncology, Radiology and Nuclear Medicine,
Physiotherapy, Endocrinology, Faculty Therapy, Hospital therapy, orthopedics
4. The content of classes
4.1. The theoretical part
On a practical lesson in the theoretical part series is considered a differential diagnosis of
diseases associated with suffocation.
Bronhospastichesky syndrome - a syndrome caused by bronchial obstruction, the leading place
in the genesis of which is bronchospasm. The immediate cause of seizures is unusually high
bronchial reactivity to endogenous and exogenous stimuli. Diagnosis of pathogenic mechanisms
of atopic asthma by the following scheme:
1. Allergic history, taking into account family history of allergic diseases;
2. Clinical manifestations - for atopic asthma is characterized by clearly defined attacks of
asthma, which in a few minutes cropped conventional bronchodilators, cough often occurs at the
end attack and ends with separation of a small amount of viscous mucus. Outside attack on
percussion and auscultation no pathology.
3. Allergic skin test (intraoral, skarifikatsionnye, intradermal).
4. Provocative tests (inhalation, nasal, conjunctival).
5. Laboratory diagnostics:
• Direct and indirect test basophilic Shelley;
• Test blast transformation of lymphocytes;
64
• An indirect test of destruction of fat cells;
• Reaction Praustnitsa-Kyustnera;
• Glycogenolysis lymphocyte vvdenii adrenaline in the presence of the allergen;
6. An elimination diet followed by food allergen provocation;
7. Determining the level of IgE in the serum;
8. Radio allergen sorbent test.
3-8 Studies conducted in Allergic center.
The clinic attack in infection-dependent asthma (hut) is divided into 2 types:
1. Prolonged breathing difficulties - from several hours to several days, accompanied by a nearly
constant cough with branch mucopurulent sputum.
Similar to the classic asthma, but with a less clear beginning and end, slowly stoped
bronchodilators. Outside attack the lungs listened dry and moist rales. Dishormonal pathogenic
variant of AD primarily involves changing glucocorticoid activity adrenal hormone activity
ovaries in women. Clinical signs directly indicating glucocorticoid insufficiency, no.
A possible violation of hormonal ovarian function judged by 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, stihanie or
exacerbation of the disease during pregnancy and after childbirth allows to suspect involvement
of hormonal ovarian function in the pathogenesis of AD.
Adrenergic imbalance in the diagnosis of medical history should be considered evidence of the
presence of the reasons that could lead to changes adrenoreactivity. An important role in the
formation of this mechanism plays a viral infection, hypoxemia, acidosis, endogenous
giperkateholaminemii associated with various stress effects, excessive use of sympathomimetic
agents. The use of complex diagnostic laboratory and instrumental methods reveals the violation
adrenoreactivity in different parts of the regulation - the cellular, organ, organism.
In addition, asthma attacks in asthma may be influenced not only specific, but non-specific
stimuli - emotions, breathing cold air, changes in barometric pressure, humidity, etc.
Failure of the left ventricle, which is the cause of congestion, pulmonary edema can mimic
asthma. In addition to shortness of breath, which carry distinct inspiration in nature, it must be
remembered that in cardiac asthma in history there is evidence of heart disease, its dimensions
are increased, on auscultation of the lungs - stagnant wheezing in basal parts, auscultation of the
heart-beat canter, with defects - noise ECG changes, increased 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 includes the implementation of measures such as the removal of
the cause of significant environmental allergens and irritants in the workplace and at home, with
the rational employment, readjustment of foci of infection, the cessation of neuro-psychological
trauma using this therapy.
The main objective of the pathogenetic treatment - rehabilitation of bronchial obstruction. For
this purpose, appointed agents that stops the main elements of bronchial obstruction:
bronchospasm, swelling of the bronchial mucosa, dyscrinia, warning their development.
General principles of treatment measures:
atopic form - the identification and elimination of allergens for specific desensitizing therapy
(histamine, gistoglobulin, polio, etc.).
in hut - antibiotic therapy - treatment of various inflammatory foci bronchopulmonary system.
at Dishormonal pathogenic form - correction of glucocorticoid insufficiency (GCS therapy,
inhalation and Becotidum beklometa, the activation function of the adrenal cortex - corticotropin
etimizol, etc.) for the correction of production and exchange of the female sex hormones olenodren.
at vagotonic version - Atrovent, berodual, efantin, Belloidum etc.
under option to the imbalance of adrenergic therapy is aimed at:
65
a) increase in the activity 2-adrenergic receptors (GCS)
b) reducing the activity of phosphodiesterase - methylxanthines, INTAL,
c) reducing the activity of alpha-adrenoretseptsii and direct impact on 2 - adrenergic
(sympathomimetics after recovery sensitivity adrenoretseptsii 2).
Under option BA with primary altered reactivity is assigned bronchodilator therapy
(sympathomimetic bronchodilators), means that stabilize the membrane of mast cells (INTAL,
Becotidum, beklomet, zaditen) held ARD prevention, exacerbation of chronic inflammatory
diseases of the bronchi (rimantadine), treatment of asthmatic triad ( specific desensitization small
increasing doses of aspirin antilimfomina scheme), physical rehabilitation is carried out in poor
exercise tolerance (exercise stress, breathing exercises).
Along with drug rehabilitation therapy, the importance of physical methods is given (functional)
Rehabilitation (EPR), whose objectives is to accelerate and achieve the most complete recovery
of body functions, increasing its defensive capabilities to perform more intense exercise
compared to those who were under the power patient during the development of the disease. The
need for the DF is that even persistent cessation of attacks of breathlessness, achieved as a result
of drug rehabilitation, not a guarantee of full recovery of function of pulmonary respiration,
myocardium, central hemodynamics. For this purpose, for each patient selected set of
physiotherapy (physical therapy), taking into account age, physical fitness, the severity of the
disease, pulmonary ventilation disorders, chest massage, bicycle ergometry. Lesson LFC
improve neuro-psychological status of the patient, patient adapts to increasing physical activity,
thereby contributing to the conservation of efficiency. To develop in patient normal reaction to
physical activity recommended exercises from 30 seconds to 1 minute, repeated at short
intervals. An important factor in the restructuring of breathing is to train delays after normal
exhalation of breath, volitional control of breathing.
Treatment of patients with asthma include planned treatment in acute phase, emergency
treatment aimed at symptom relief and treatment in the remission phase.
The indications for hormonal therapy is a severe attack of asthma, bronchodilators is not
stopped, threatens to go to the asthma status, as well as frequent and prolonged aggravation, not
amenable to conventional treatment with full doses of bronchodilators. From natural
glucocorticoids for the treatment of asthma using hydrocortisone hemisuccinate, synthetic prednisolone, methylprednisolone (urbazon, metipred) triamtsinalon (kenokort, polkortolon,
berlikort), dexamethasone. The most rational way of introducing inhaled steroids (Becotidum,
beklomet), significantly reducing their negative impact on other systems and organs, in case of
need expressed exacerbation of asthma, oral or intravenous use them. Because of the risk of
severe complications of steroid therapy, the basic rule is the appointment from the start of large
doses (50-100 mg based on prednisolone) to eliminate the symptoms of the disease, and then a
rapid decline until the complete withdrawal within 5-7 days. Large doses should be spread into
2-3 doses are relatively small - once in the morning.
By means of biological prevention is Intalum. It effectively prevents the bronchoconstriction that
occurs in response to exercise. Pharmacological analogue Intalum is ketotifen (zaditen) - a new
antihistamine.
When remission of exacerbation and remission that a strategic therapy, outpatient rehabilitation.
The main objective of the rehabilitation phase is to prevent relapse of the disease and the
achievement of full and sustained remission. In this widely used by a variety of nonpharmacological treatments (specific desensitization therapy, acupuncture, physiotherapy,
aeropiezotherapy, spa treatment). Universal purpose of pathogenetic treatment for any
pathogenic variants of the disease is to restore the bronchial obstruction by eliminating
bronchospasm, edema and hypersecretion. For drugs acting on these mechanisms include
bronchodilators (agonists, methylxanthines, anticholinergics), INTAL, corticosteroids. At this
stage, the treatment should be used immunomodulatory therapy including immune status,
severity of asthma, complications and comorbidities, as well as maintenance and preventive
treatment.
66
For asthma patients with mild to moderate course, infection-dependent form to include in a
course of anti reaferon therapy at a dose of 15 thousand units. per kg of body weight, on the
course of 5 injections in the spring and autumn period, for patients with severe asthma advisable
to conduct a year-round immunization - 2 times a month at 1,000,000 units. i / m
In the appointment of maintenance therapy with bronchodilators, Intalum, tranquilizers
appropriate use of the principles of chronotherapy. Must take into account the deterioration of
bronchial obstruction at different times of day: as a rule, the maximum pathological changes of
the respiratory function parameters that define the airway patency and result gipersinhronizatsii
and increase the amplitude of circadian rhythms occur in the period from 0 to 8 hours for each
patient should be advised to receive optimal intervals drugs, including nighttime.
Circulatory failure (NC) - a pathological condition is a failure of the circulatory system to deliver
organs and tissues of the amount of blood necessary for their proper functioning.
Depending on the speed of development are acute NC, which manifests itself in a matter of
minutes and hours, and chronic NK, which is formed during the period of several weeks to
several years. In addition, the isolated heart failure associated with cardiac and vascular
insufficiency, in which the fore in the mechanism of impaired circulation acts predominantly
vascular component.
Classification of heart failure
According to the classification, ND Strazhesko and VH Vasilenko HNK distinguish 3 stages:
Stage I-Primary: The Hidden circulatory failure, manifested by shortness of breath, palpitations,
fatigue only during exercise. Hemodynamics at rest is not broken.
Stage II-a period: Signs Tax alone expressed moderately, exercise tolerance is reduced, there are
congestion in large or small circle of blood, the severity of mild, period used: severe symptoms
of heart failure at rest, severe hemodynamic abnormalities in a large, and in the pulmonary
circulation. stage III-final: dystrophic stage of infringement with severe hemodynamic,
metabolic, irreversible changes in the organs and tissues.
In 1978, FI Mosquitoes and LI Olbinskaya identified in stage I, two periods - a and b.
period-I and preclinical or early predzastoyny characterized by the absence of complaints and
hemodynamic compromise, but there are signs of physical activity to reduce the pumping
function of the heart: decreased cardiac output by 10-20%, a slight increase end-diastolic
pressure and volume increase in diastolic pressure in the pulmonary artery, the decrease in the
rate of circulatory shortening of the myocardial fibers in its reduction.
b-I period is characterized by signs of stage I classification n Strazhesko and VH Vasilenko, ie
appearance coming stagnation in the pulmonary circulation under the load. NM Mukharlyamov
(1978) proposed in stage III-HNK also distinguish two stages.
period III, and partly irreversible stage of heart failure, in which there are marked stagnation in
small and large circulation, low cardiac output, a significant dilatation of the heart, pronounced
increase in end-diastolic pressure and volume, but with adequate modern treatment possible to
achieve improvement of the patients (reduction of edema, anasarca, stagnation in the internal
organs).
period III-b completely irreversible stage corresponds to stage III classification ND Strazhesko
and VH Vasilenko.
With the additions out above classification corresponds to the classification of heart failure of
New York Heart Association (NYHA).
ФК
I
II
Definition
Terminology
patients with heart disease, but without limitation of
physical activity.
patients with diseases of the heart, causing a slight
limitation of physical activity
asymptomatic left ventricular
dysfunction
67
mild heart failure
III
IV
patients with diseases of the heart, causing a significant
reduction in physical activity.
Patients with cardiac disease who perform even minimal
physical exertion causes discomfort
heart failure of moderate
severity
Severe heart failure
CHF clinically manifested 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 venous distention, anasarca, ascites.
Treatment of the underlying disease, which led to the HNK, can significantly reduce
its manifestation, to increase the effectiveness of therapeutic interventions. A rational
therapeutic regimen.
Health food. When the Tax tables are assigned number 10 or 10a. limited water and salt. Power
should be 5-6 times a day (with the use at one time a small amount of food), food should be
easily digestible, fortified, calorie diet 1900-2500 calories a day.
Gain decreased myocardial contractility is conducted through the use of cardiac glycosides and
neglikozidnyh inotropic agents.
Diuretics, ACE inhibitors, angiotensin -adrenergic receptors, peripheral vasodilators,
angiotensin receptor antagonists II, anti-arrhythmic drugs.
Drug-free treatment of patients with HNS. Among the non-drug therapies for HNS often use
isolated ultrafiltration of blood.
Intra-aortic balloon kontripulsatsiya used in clinical practice as a method of 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 TC. It is
indicated for patients with end-stage heart failure who are preparing for a heart transplant and
surgery to support the work of the heart after the transplantation, the development of patients
with ventricular arrhythmias refractory to medical therapy.
In addition to the intra-aortic balloon kontripulsatsii in patients with end-NC as a method of
"bridge to transplant" is also used mechanical devices to support ventricular gemopompy and
sometimes artificial heart. Surgical treatment of chronic heart failure. Heart transplantation is the
only effective treatment for most patients with end-stage heart failure. In many cases, a heart
transplant can not only extend the life of the patient, but also partially and sometimes completely
restore disabled patients.
Theoretical survey can be carried out using the 'Tour Gallery »
The method of "Tour Gallery»
Steps:
1. Students are divided into teams of 4 people.
2. Each team is responsible for the assigned tasks, for 3 minutes, and changing jobs, if there is a
need then adds his own answers.
3. According to the number of correct answers, each student is evaluated.
The teacher asks students questions about classes:
1. Define the term syndrome, wheezing and asthma.
2. Tell classification nedostatotochnost krovoobrasheniya and pulmonary insufficiency.
3. List the diagnostic criteria for cardiac and pulmonary insufficiency.
4. List the laboratory and instrumental methods for the diagnosis of heart and lung failure.
5. Give a predisposing factor to the development of cardiac and pulmonary insufficiency.
6 .. Tell the wording of the diagnosis of heart and lung failure.
68
№ evaluation
Assimilation in%
fine
good
Satisfactory
100%86%
70-55%
1
20-17,2
mark
85%71%
17-14,2
mark
unsatisfactory poorly
54%-37% 36% or
less
14-11
mark
10,8-7,4
mark
The theoretical part
7,2
mark
4.2.Analiticheskaya part
Situational problems.
1. At the reception GPs turned sick 43 years old, complained of dry cough, shortness of breath,
sometimes fever. From history: a disease not how it connects. Objectively: the state of the patient
of moderate severity. Cyanosis of the face. BH-32 at rest in 1 minute, fingers, reminiscent of the
"drumsticks". Auscultation: against the hard breathing, there is crackling in both lungs. On
radiographs: in the lower lung lobes marked thickening of the fibrous pattern.
1.Perichislite at least four diseases in which there is a crackling lungs.
2. The preliminary diagnosis.
3. Specify the types of impairment of respiratory failure.
4.Taktika GPs.
№
Answers
1
Pneumonia, allergic alveolitis, infiltrative tuberculosis of the lungs,
pleurisy
2
fibrosing alveolitis
3
III-degree
4
Consultation pulmonologist, TB specialist. Hospitalization in a
specialized clinic.
Mark
20
35
20
25
1.In hospital admissions 63 years old, with chronic bronchitis, emphysema, cardiopulmonary
failure, coronary artery disease, myocardial infarction, FC-W, NC-PB degree. Despite the fact
that the patient was administered Euphyllinum strofantin, propranolol and diuretics. A few days
later, her general condition uhuchshilos it difficult expectoration. There was pain in the chest,
shortness of breath, swelling in the lower extremities. Admission nitroglitsirina pain did not
dispel. Objectively: diffuse cyanosis, dry wheezing, breathing weakened. Cardiac rhythmic,
accent and tone of the P. pulmonalis. On the X-ray pattern of light clearly expressed, the arc of
the pulmonary artery widened.
1. List the diagnostic criteria for heart-lung syndrome.
2. The preliminary diagnosis.
3. What causes the deterioration of the general condition of the patient.
4.Taktika GPs.
2. The patient was 58 years old, suffers from arterial hypertension for 4 years. He came to accept
the GP to fill outpatient's card. The clinic began sudden attacks of breathlessness, coughing with
foam and bloody, heart pain and severe headaches. BP 230/140.Sostoyanie patients with severe,
there is cyanosis of the face.
RR-30 min. Heart rate of 98 bpm. Heart sounds on the lower lobes of the lungs differently
kolibrnye crackles. The liver is not increased.
1.Perechisleti types of pulmonary edema.
69
2.Predvaritelny diagnosis.
3.Informativnye survey methods.
4.Taktika GPs.
_____________________________________________________________________________
_______
3. A patient 67 years appealed to the GP with complaints of cough, shortness of breath, swelling
in the legs, OBJECTIVE: astenik, clubbing as "drumsticks". In the history of 13 years have
COPD. Consistently receives outpatient treatment and sitatsionarnnoe. In a chest radiograph
noted increased bronchopulmonary figure, the roots of light gravity, x-ray picture of emphysema
of the lungs.
1. The preliminary diagnosis.
2. Patogeniticheskie treatment.
3. Tactics GPs.
________________________________________________________________
4. A patient 57 years appealed to the GP complaining of shortness of breath, breathlessness, dry
cough, swelling in the legs. From the anamnesis for many years suffering from bronchial asthma.
Deterioration of ties with the common cold. General state of relatively heavy, expiratory
dyspnea, cyanosis of the lips. In the lung auscultation scattered dry wheezing. BH-30 min. Heart
sounds tachycardia, muffled AD 140-90 mm Hg Ps-100 min. OAK HB-120g / l, er-4, 0 Leu-7 ,87 EPZs ESR-14 mm / h
1. The preliminary diagnosis;
2. Treatment of patients with asthma 3 steps.
3. Enter the pathogenic mechanisms of bronchial asthma;
4. The tactics of the GP;
__________________________________________________________________
5. Patient 38 years. Complaints of shortness of breath and feeling short of breath, cough with
expectoration of sputum large number of the morning, weight loss, swelling of the legs. History
of patients consider themselves to be in 20 years. Exacerbation of the disease is seasonal. In the
lungs, wheezing, dry wheezing. Auscultation in the lungs of hard breathing, wheezing, dry on
both sides. Heart sounds are clear, rhythmic.
1. The preliminary diagnosis.
2. Informative survey methods;
3. Pokazaniyai to surgical treatment.
4. The tactics of the GP;
__________________________________________________________________
6. An appointment with the GP patient received 64 years old, complaining of frequent harassing
chest pain, cough, weight loss, shortness of breath, swelling in the legs and general weakness.
From history, the patient over 30 years of experience in the workshop production of asbestos.
OBJECTIVE: lagging behind left rib cage in the act of breathing. Percussion: dullness of sound
from left, auscultation, Hear decreased breath, dry wheezing. Complete blood Hb - 100 g / l,
Lake. - 7000, ESR - 30 mm / s.
1.Ukazhite characteristic radiographic signs of this pathology;
2. The preliminary diagnosis;
70
3. Informative survey methods;
4. The tactics of the GP;
__________________________________________________________________
7. A patient 47 years old, due to frequent inflammations of the airways complaining of hard
phlegm and coughing fits, shortness of breath after minor physical activity and rapid fatigue,
swelling in the legs periodically. From history, the patient over 15 years old suffering from
bronchial asthma. To prevent the disease took a day for the 10-15mg prednisolone and did
Ventolin inhalation. An objective examination of notes expiratory dyspnea, cyanosis, 30 breaths
per minute. Heart rate of 120 beats per minute, blood pressure 160/90 mm Hg Percussion: there
is a box sound. Auscultation: marked common wheezing. FEV1 <60%.
1.You patient what type of respiratory failure is observed;
2. The preliminary diagnosis;
3. Specify a group of B-agonists;
4. Specify the characteristic X-ray and ECG data izmeneniyai.
5. Treatment.
6. Tactics GPs and secondary prevention;
__________________________________________________________________
8. The patient was 58 years old, works as a teacher, he entered the reception GP complaining of
shortness of breath with minimal exertion, the lack of air, occasionally pain in the retrosternal
area, frequent palpitations. In history there is an increase in blood pressure to 180/100 smoking
for 25 years. OBJECTIVE: Patients with severe general condition, cyanosis of the lips, the lungs
are common dry and moist rales. Heart sounds are dramatically suppressed, in the pulmonary
artery auscultated accent II-tone, heart rate - 102 bpm. per min. BP -170 / 90 mm Hg CBC HB 182 g / l, WBC - 13 × 109 / L, wand 13% neutrophils, segmented neutrophils - 62%
lymphocytes, 9% monocytes -2% ESR - 22 mm / s; FVD - FEV 1 - 29%, IT - 45%.
1. List at least five diseases for which there are the above mentioned signs and symptoms;
2. The preliminary diagnosis;
3. What kind of change do you find the part of the ECG (data).
4. The tactics of the GP;
__________________________________________________________________
9. On receiving the GP patient appealed (62 years) with complaints of pain in the retrosternal
area recurring character, serdtsebenie, headaches, swelling in the legs, occasionally dry cough.
History of patients consider themselves to be in a period of 7 years. Suffered a myocardial
infarction. Consistently receives outpatient treatment. AD-150/90. Pulse-102 hit in 1 minute. In
the last 2 years dyspnoea, cough with expectoration of sputum, and a small amount of swelling
in the legs. Periodichski taking B-blockers.
1. The preliminary diagnosis;
2. Enter the pathogenetic mechanisms of this disease;
3. Informative methods.
4. Treatment. The tactics of the GP;
__________________________________________________________________
10. To the sick, 56 years old. Admitted with complaints of paroxysmal cough, shortness of
breath, wheezing, minor chest pain, general weakness, pastoznost feet. Recently, the above
complaints have increased. History of the patient for 3 years suffering from chronic bronchitis.
During the 27 years of smoking. On-no: BH 30 min., Cyanosis of the lips, heart rate 100 beats
71
per minute, the emphasis on a 2 tone. pulmonalis. Dullness to percussion on the right, and the
decreased vesicular breathing. The liver performs at 3 cm from under the costal arch. X-rays on a
fluid level III to the ribs. The ECG: sinus tachycardia.
1. Informative survey methods;
2. The patient what type of respiratory failure is observed;
3. The preliminary diagnosis;
4. The tactics of the GP;
__________________________________________________________________
12.Bolnoy 58, a miner for 30 years, complaints of cough, pain in the chest on deep breathing,
shortness of breath with little physical. load, swelling in the legs. Objectively: the state of
moderate severity, cyanosis of the lips, fingers in the form of "drumsticks". Percussion: sound
box. Auscultation: hard breathing and dry rales.
List at least five diseases for which there are the above mentioned signs and symptoms;
Specify the characteristic radiographic changes and ECG data.
The preliminary diagnosis;
The tactics of the GP;
__________________________________________________________________
13. Patient G. 52. During the 10 years of suffering from chronic bronchitis. Smoking for 20
years. In the last week there was a low-grade fever. Increased separation of the mucous
expectoration. Shortness of breath, a minor pain in the left side of the chest. The general
condition of medium gravity, pale skin, cyanosis of the lips. Auscultation dry rales. The liver is
enlarged 2 cm, swelling in the legs.
1. List at least four diseases for which there are higher these signs and symptoms;
2. The preliminary diagnosis;
3. What changes are characterized by chest radiography in this patient;
4. Tactics GPs and treatment guidelines;
№ evaluation
Assimilation in%
fine
good
Satisfactory
100%86%
85%71%
70-55%
unsatisfactory poorly
54%-37% 36% or
less
2
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
Case study
Tests
1. Which of the following lead to chronic pulmonary heart:
a) respiratory diseases and alveoli
b) the disease resulting in limitation of motion of the chest
c) myocarditis
g) ischemic heart disease
e) pericarditis
e) pulmonary vascular disease
2. The following lead to acute pulmonary heart:
a) cystic lung
b) a valve pneumothorax
c) bronchiectasis
72
18 mark
d) pulmonary embolism
e) nodular periartereit
3. The typical ECG changes of chronic pulmonary heart disease:
a) axis deviation to the right
b) Ppulmonale
c) axis deviation to the left
g) evidence of hypertrophy of the left atrium
d) the signs of left ventricular hypertrophy
4. Is not the cause of chronic pulmonary heart disease:
a) chronic obstructive bronchitis
b) acute catarrhal bronchitis
c) acute pneumonia
d) pulmonary emphysema
e) bronchiectasis
5. Which symptom is not typical of pulmonary hypertension:
a) jugular veins
b) bradycardia
c) "Dance carotid"
d) tachycardia
d) cyanosis
6. Changes in the blood in patients with chronic pulmonary heart disease:
a) high ESR
b) leukocytosis
c) anemia
d) increase in hemoglobin
e) polycythemia
7. Early clinical signs of central lung cancer are:
a) a dry hacking cough
b) loss of body weight
c) shortness of breath
d) cough with mucous expectoration, sometimes streaked with blood
e) unmotivated weakness, fatigue
e) all of the above
8. The combination of what is necessary for the diagnosis of symptoms of asthma:
a) asthma, cough, shortness of breath, wheezing
b) persistent fever
c) the presence of reversible airflow obstruction
d) the presence of irreversible airflow obstruction
d) inspiratory dyspnea attacks
e) Sputum eosinophilia,
9. By the formation of chronic pulmonary heart disease can cause:
a) chronic obstructive bronchitis
b) tricuspid stenosis
a) primary pulmonary hypertension
d) pulmonary artery stenosis
73
e) The Pickwick syndrome
e) acute pneumonia
g) polycystic lung
h) aortic parkas
10. The causes of acute pulmonary heart disease are:
a) severe bilateral pneumonia
b) open pneumothorax
c) lung cancer
g) status asthmaticus in bronchial asthma
e) pulmonary embolism
e) valve pneumothorax
g) chronic pneumonia
h) pulmonary stenosis
11. For the treatment of patients with decompensated pulmonary heart on the basis of obstructive
lung disease should be applied:
a) β-blockers
b) nitrate
c) calcium antagonists
g) anticholinergics
d) corticosteroids
12.Perechislite clinical signs of sudden cardiac arrest:
a) loss of consciousness
b) a sharp rise in blood pressure
c) the absence of pulsations
g) pulse deficit
e) normal blood pressure
e) tonic and clonic convulsions
№ evaluation
Assimilation in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
3
15-12,9mark
12,7-10,6
mark
8,1-5,5
mark
Tests
Satisfactory
10,5-8,25
mark
5,4
mark
4.2.2. Graphic organizer of "cluster".
Cluster (Cluster - bundle, the bundle) - a way of mapping information - gathering ideas around of
any of the main factors for determining the meaning and focus of all konstruktsii.Stimuliruet
updating knowledge helps freely and openly engage in associative thinking process new
perspective on a topic.
Acquainted with the rules of drawing up the cluster. In the center of the chalkboard or a large
sheet of paper is written the name of the keyword or topic of 1-2 words.
By association with the key word is credited alongside it in the circles smaller "satellite" - the
words or sentences that are related to that topic. Connect their lines with the "main" word. These
74
"satellite" can be "small satellites", etc. record goes before the expiration of the allotted time, or
until they are exhausted ideas.
Exchanged between clusters for discussion.
75
My breast is
constrained
My breath is
complicated
I feel how my
breath stops
I can't inhale
My breath is
complicated
Chronic obstructive
illness of lungs
I can't inhale
Bronchial
asthma
My breath is
complicated
Interstitsialny diseases
of lungs
Characteristic of the main
complaints to short breath at
various diseases
I can't inhale
My breast is
constrained
It is difficult to
breathe to me
I am disturbed by the
speeded-up breath
I am disturbed by the
speeded-up breath
Mucoviscidosis
Hyperventilation
syndrome
Neuromuscular
disease
It is difficult to
breathe to me
I feel weight in a
breast
I feel how my
breath stops
I am disturbed by
the speeded-up
breath
76
I can't inhale a
full breast
It is difficult to inhale
to me
4.3. The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with diseases soprovozhdayushihsya breathlessness
and suffocation.
2. Interpretation of the analyzes, the data of laboratory and instrumental studies, radiographs of
patients with diseases soprovozhdayushihsya breathlessness and suffocation (clinical and
biochemical blood tests, coagulation tests, sputum, pleural zhitkosti, x-ray pictures of the chest,
the results of lung function, knowledge of the technology in the removal of foreign bodies upper
respiratory tract).
3. Prescription of drugs depending on the etiology of shortness of breath and asthma.
№ evaluation
Assimilation in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
4
15-12,9 mark
12,75-10,6
mark
8,1-5,5mark
The practical part of the
Satisfactory
10,5-8,25
mark
5,4 mark
Control forms of knowledge, skills and abilities
- Oral
- In writing
- Decision of case studies
- Demonstration of practical skills mastered
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
№
1
2
3
4
evaluation
fine
good
Assimilation in%
100%86%
85%-71% 70-55%
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2
mark
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
15-12,9 mark
12,7-10,6
mark
10,5-8,25
mark
8,1-5,5
mark
5,4
mark
15-12,9 mark
12,75-10,6
mark
10,5-8,25
mark
8,1-5,5mark
5,4 mark
The theoretical part
Case Studies
Test
The practical part
Satisfactory
unsatisfactory poorly
54%-37% 36% or
less
6. The evaluation criteria of the current control
Levels of
Rating
Characteristics of the student
assessments
points
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not
20
ready for practical employment.
77
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and
skills, at least one of the following:
• Do not know the clinical features of asthma, emphysema
and pulmonary fibrosis.
• Do not know the pathogenetic treatment of bronchial
asthma.
• Do not know the clinical signs of chronic respiratory
failure
• Do not know the risk factors for asthma and emphysema.
• Do not know the groups of drugs used in treatment of
bronchial asthma
Not
20 - 54,9
• Can not indicate the radiographic signs of asthma
satisfactory
• Not able to assemble a rational history during the
Supervision of patients with asthma, emphysema and
pneumosclerosis.
• During Supervision is not able to objectively assess the
condition of patients with asthma, emphysema and
pneumosclerosis.
• During Supervision is not able to objectively assess the
condition of patients with chronic respiratory insufficiency.
Not able to rationally make a plan of examination of
patients with bronchial asthma in a hovercraft or a joint
venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge
55-60,9
and skills (see below), but when replying or performing
skills make serious mistakes.
Moderately satisfactory answer.
The student has basic knowledge and skills (see below),
61-65,9
but when replying or performing skills make mistakes
(subject to certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of
knowledge and skills:
• Knows the clinical features of asthma and can correctly
differentiate stage.
Satisfactorily
• Can differentiate asthma, emphysema, pulmonary fibrosis
55-70,9%
and other diseases of the lungs to the subjective, objective,
and laboratory and instrumental data
• Knows differentiated pathogenetic treatment of bronchial
asthma, depending on the stage.
66-70,9
• Know the risk factors for pulmonary fibrosis and
emphysema
• Knows the groups of drugs used in treatment of
emphysema and pulmonary fibrosis
Knows the groups of drugs used in treatment of chronic
respiratory failure May indicate a radiographic pulmonary
fibrosis and emphysema
Able to build a rational history during Supervision of
patients with emphysema and pneumosclerosis.
78
During Supervision can objectively assess the condition of
patients with pneumosclerosis and emphysema.
Able to efficiently make a plan of examination of patients
with bronchial asthma in a hovercraft or a joint venture.
Can interpret the results of laboratory and instrumental
methods of research - may indicate the presence of changes
leykoformuly, leykoformuly shift to the right or to the left,
elevated ESR.
Can show the technique of taking blood count
Can show the technique of taking the overall analysis of
sputum
Can demonstrate the technique of peak flow
Able to correctly fill in the patient diary.
Advanced level of knowledge
Good
71-85,9%
71-75,9
76-80
81-85,9
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has the
following knowledge and skills:
• Knows the stage of development of asthma and the
etiological factors leading to it
• Knows the clinical symptoms and morphological changes
characteristic of each stage of the development of asthma
• Know the classification of asthma, pulmonary fibrosis
and emphysema
• Knows the mechanism of action of drugs applies when
pnevmoskleroze and emphysema
Rationally selected drugs used in the treatment of
pulmonary fibrosis and emphysema.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9", and also owns the following
knowledge and skills:
• Knows the pathogenesis of emphysema, and may also be
called the morphological picture of the development of
emphysema
• Knows the pathogenetic mechanisms of asthma
Knows the principles of primary, secondary and tertiary
prevention of bronchial asthma and emphysema.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9" and "76-80", and also owns the
following knowledge and skills:
Can point to signs of pulmonary fibrosis and emphysema
on radiological image.
Knows the principles of management, supervision and
monitoring of patients with asthma, emphysema or SVP in
the joint venture.
Is able to advise you on the boards of non-drug and drugusing skills of IPC.
Principles of clinical examination and rehabilitation of
patients with bronchial asthma, emphysema, lung
conditions, SVP or joint venture
79
86-90
91-95
96-100
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "81-85,9", and also owns the following
knowledge and skills:
• Knows the principles of treatment of chronic respiratory
failure
• Know the indications and contraindications for X-ray
examination
• Know the indications and contraindications for the peak
flow
Is able to provide reliable information of bronchial asthma,
emphysema, pnevmoskleroze and chronic respiratory
failure on the basis of Internet data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "86-90", and also owns the following
knowledge and skills:
• Knows the radiographic signs of asthma, pulmonary
fibrosis and emphysema
Knows how to determine the stage of bronchial asthma
and chronic respiratory failure methods of objective
examination.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "91-95", and also owns the following
knowledge and skills:
• to provide scientific data from the literature (articles and
Internet)
• Knows the stages of clinical examination and
rehabilitation of patients with bronchial asthma,
emphysema and lung pneumosclerosis.
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
7. Test Questions
1. Differential diagnosis of asthma and shortness of breath.
2. Determination of breathlessness and suffocation
3. Differences between cardiac and bronchial asthma.
5.Neotlozhnaya help and differentiated treatment of diseases involving suffocation.
6. Tactics GPs in asthma and shortness of breath.
7. Indications for hospitalization.
8. Prevention.
8. Recommended reading
Summary
Testes kasalliklar, Sharapov UF T: Ibn Sina, 2003
Testes kasalliklar, Bobozhanov S. T: Yangi Asr avlod 2008
Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009
Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
80
Additional
Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012
• General medical practice under red.F.G.Nazirova, A.G.Gadaeva. M. GEOTAR Media, 2009.
• Directory GP. Dzh.Merta. M.: Practice, 1998.
• The collection of practical skills for general practitioners. Gadaev A. Akhmedov Kh.S. T.,
2010.
• Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS, 2010.
T.
• Therapeutic Reference Washington Ed. M.Vudli M. Practice, 2000.
• Umumy amaliet shifokori Uchun kullanma F.G.Nazirov, A.G.Gadaev Tahrah. M. GEOTARMedia, 2007.
• Diagnosis of diseases of the internal organs. A.N.2005 hams.
• Treatment of diseases of the internal organs. A.N.2005 hams.
• Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News Agency,
2009.
• Internal Medicine: a textbook. - In 2 volumes (1t), Ed. Martynov, etc. M: GEOTAR - Media,
2005:
Internet Resources:
http://www.intute.ac.uk/medicine/
http://elibrary.ru http://www.freebooks4doctors.com/ http://www.medscape.com/
http://www.meducation.net/ http://www.thecochranelibrary.com
Medical sites:
Med.-site.narod.ru
www.medlook.ru
www.medbok.ru
Practical session number 6
Theme: "Shortness of breath, choking. Differential diagnosis of pulmonary heart disease.
Clinical management of patients with chronic pulmonary heart disease. Indications for
referral to a specialist or hospital in the profile department. The principles of treatment,
follow-up, control and rehabilitation in a hovercraft or a joint venture. The principles of
prevention. Definition of disability. The principles of teaching topics. "
learning Technology
Study time: 6.4 hours
The structure of the training session
Training themed room.
Cabinet GPs.
3. Tutorials, phantoms, models, handouts, a collection
of case studies and tests
TV, video equipment, multimedia
The purpose of the training session: - To teach GPs on timely diagnosis and
differential diagnosis of pulmonary heart disease, as well as the principles of
management of patients in primary care, provided the requirements of the
"Qualification characteristics of the GP"
Pedagogical objectives:
1. Teach GP diagnosis of diseases associated
Learning outcomes:
GPs should be aware of:
81
with pulmonary heart disease.
2. Educate GPs emergency care for acute and
subacute pulmonary heart.
3. Educate GPs Management of patients with
chronic pulmonary heart disease.
4. To teach self-control patients with chronic
pulmonary heart disease.
5. Familiarize GPs with indications for
hospitalization treatment of patients with
chronic pulmonary heart disease.
6. Educate GPs definition of disability in
patients with chronic pulmonary heart
disease.
7. Discuss questions about tactics in the
qualifying characteristics of GPs
8. The principles of treatment (medication and
non-medication).
9. Principles of management, follow-up and
monitoring of patients in a hovercraft or a
joint venture.
10. The principles of primary, secondary and
tertiary prevention in these diseases.
11. Demonstrate patients with pulmonary
heart disease.
Training Methods
Forms of organization of learning activities
learning Tools
Methods and feedback means
№
1
1. The clinical manifestations of diseases associated
with pulmonary heart disease;
2. Acute care, and differentiated treatment of diseases
involving acute and chronic pulmonary heart disease.
3. GP tactics in acute and chronic pulmonary heart.
4. Management of patients with chronic pulmonary
heart disease.
5. Indications for hospitalization.
6. Principles of follow-up and monitoring of patients
in a hovercraft or a joint venture.
7. The principles of primary, secondary and tertiary
prevention of pulmonary heart disease.
8. Definition of disability.
GPs should be able to:
1. Analyze the data and history of complaints for the
diagnosis of diseases associated with pulmonary heart
disease.
2. Diagnose, differentiated by the clinic to the
laboratory and instrumental investigations diseases
associated with pulmonary heart disease.
3. To provide emergency assistance in cases involving
pulmonary heart.
4. Conduct outpatient treatment of patients with
chronic pulmonary heart disease.
5. Determine the ability to work with patients with
chronic pulmonary heart disease.
the method of "tour of the gallery."
demonstration, entertainment experience, discussion,
conversation, decision tests and case studies
Individual work, group work, team, classroom,
extracurricular.
Hand-learning materials viziualnye materials, videos,
models, graphic organizers, sputum smears, sets of
medical records, tables, stands, kits radiographs.
Quiz, test, presentation of the results of the learning
task, filling medical records implementation of
practical skill "professional debriefing"
Flow chart classes
Theme: "Shortness of breath, choking. Differential diagnosis of pulmonary heart disease.
Clinical management of patients with chronic pulmonary heart disease. Indications for
referral to a specialist or hospital in the profile department. The principles of treatment,
follow-up, monitoring and rehabilitation SVP conditions or joint venture. The principles of
prevention. Definition of disability. The principles of teaching topics. "
Stages of the practice session
Form classes
Duration
classes
Venue
225
Chapeau (justification themes)
10
82
2
3
4
5
6
7
8
The discussion on the practical lessons with the use of new
educational technologies (method "tour of the gallery"), as
well as demonstration material (sets of medical charts,
tables, posters, x-ray), define the initial level.
conclusion discussion
Definition of tasks to perform the practical part professional questioning. Explanation of the provisions
and recommendations for the job by filling in medical
charts.
Mastering the practical part of the training under the
guidance of a teacher.
Interpretation of the survey data of patients, complaints,
inspection, palpation, percussion, auscultation of patients,
as well as research OAM KLA, the general analysis of
feces, tank stool cultures, stool occult blood test, x-rays of
the joints and biochemical analysis and diagnosis
Discussion of theoretical and practical knowledge of the
students, securing the material to determine the level of
assimilation of knowledge assessment.
Defining output on practical sessions on a 100-point rating
system and ad evaluations. Homework next practice
session (a collection of questions).
The survey, discussion
40
Classroom, GP surgeries
discussion
10
20
GP doctor's office
Prof. questioning. A
conversation with patients
and honey filling cards,
situational problems.
Admission of patients in
the clinic, examination at
home
Medical history,
laboratory data
situational problems
Oral questioning, tests,
discussion, identification
of practical skills
Classroom in a clinic
Information, questions for
homework.
Classroom in a clinic
20
25
75
25
Motivation
Pulmonary heart disease is the endpoint of many diseases of broncho-pulmonary system,
particularly COPD. Therefore, the force GPs should be directed to the timely diagnosis and
prevention of COPD is caused by various diseases. In the case of COPD, GPs should diagnose
the disease, and he needed to determine the reasons behind the disease for medical care and
clarifications locations of this group of patients.
3. Interdisciplinary communication and Intra
The teaching of this subject is based on the knowledge of students of basic anatomy, embryology
and Ggistologii with cytology, biology, normal physiology, biochemistry, pathology,
pathophysiology, topographic anatomy and of Surgery, Internal Medicine Propaedeutics,
tuberculosis, oncology, radiology and nuclear medicine, physiotherapy, cardiology,
endocrinology, faculty therapy, in-hospital therapy, orthopedics. The results obtained in the
course of training knowledge will be used during the passage of the GP - internal medicine and
other clinical disciplines.
83
4. The content of classes
4.1. The theoretical part
Pulmonary heart - is hypertrophy and dilatation, or just right ventricular dilatation resulting from
hypertension, pulmonary circulation, which developed as a result of diseases of the bronchi and
lungs, chest wall deformity, or primary pulmonary artery lesions. (WHO 1961).
Right ventricular hypertrophy and dilatation as a result of changes in the primary lesion of the
heart, or congenital defects are not relevant to the concept of pulmonary heart.
Recently, clinicians have observed that hypertrophy and dilatation of the right ventricle are
already late manifestations of pulmonary heart disease, when it can not be rational to treat these
patients, so it was an offer a new definition of pulmonary heart disease:
"Pulmonary heart - a set of hemodynamic disorders in the pulmonary circulation, which develops
as a result of diseases of bronchopulmonary system, deformities of the chest, and the primary
lesion of pulmonary arteries, which is in the final stage shows right ventricular hypertrophy and
progressive heart failure."
Etiology PULMONARY HEART
Pulmonary heart disease is the result of three groups:
1. Bronchus and lung disease, primarily affecting the passage of air and alveoli. This group
consists of about 69 diseases (chronic obstructive bronchitis, pulmonary fibrosis of any etiology,
pneumoconiosis, tuberculosis, not in itself, as posttuberkuleznye outcomes, SLE, sarkoidoiz
Beck (Boeck), fibrosing alveolitis (endogenous and exogenous) and others). Are the cause of
pulmonary heart disease in 80% of cases.
2. Disease, primarily affecting the chest, diaphragm with limited mobility (kyphoscoliosis,
multiple rib injury, Pickwick syndrome in obesity, ankylosing spondylitis, pleural sepsis after
suffering pleurisy, etc.)
3. Disease primarily affecting the pulmonary vessels (primary arterial hypertension (Aerza
illness, disease Ayerza `s), recurrent pulmonary embolism (PE), and compression of the
pulmonary arteries from veins (aneurysm, tumor, etc.) and so on.
Diseases of the second and third groups are the cause of pulmonary heart disease in 20% of
cases. That's why they say that, depending on the etiology, there are three forms of pulmonary
heart disease:
1. Bronchopulmonary
2. Torakodiafragmalnaya
3. Vascular
Norms of the quantities characterizing the hemodynamics of the pulmonary circulation.
Index
systolic pulmonary artery pressure
systolic pulmonary artery pressure
Mean pulmonary arterial pressure
total pulmonary resistance
rate
15-30 torr
3-15 torr
7-19 torr
150-200 dyn/cm2 10-5
Systolic blood pressure in the pulmonary artery systolic pressure less than in the
systemic circulation is about five times.
About Pulmonary Hypertension say if the systolic pulmonary artery pressure at rest
greater than 30 mm Hg, diastolic blood pressure greater than 15, and the average pressure greater
than 22 mmHg
Pathogenesis.
The pathogenesis of pulmonary heart disease is pulmonary hypertension. Since the most
frequent pulmonary heart develops in bronchopulmonary diseases, then it'll start. All diseases
84
and in particular obstructive chronic bronchitis, primarily lead to the respiratory (lung) disease.
Pulmonary failure - it is a condition in which disrupted the normal blood gases.
There are 3 stages of pulmonary insufficiency.
Index
first step
the second stage
third stage
gas composition
no changes
hypoxemia (decreased partial
hypoxemia and
pressure of oxygen in the blood), hypercapnia, and
but combined with eucapnia (45
metabolic acidosis
mm Hg)
Arterial hypoxemia is at the heart of pathogenesis is the basis for chronic diseases of the
heart, particularly in chronic obstructive bronchitis.
All these diseases lead to respiratory failure. Arterial hypoxemia lead to alveolar hypoxia at the
same time due to the development of pulmonary fibrosis, emphysema increases intraalveolar
pressure. Under arterial hypoxemia disturbed non-respiratory function of lungs - begins to
produce biologically active substances that are not only bronchospastic but vasospastic effect.
Simultaneously, it is a violation of vascular architecture of the lungs - the vessels are killed,
some expanding, etc. Arterial hypoxemia leads to tissue hypoxia.
The second stage of pathogenesis: arterial hypoxemia will lead to the restructuring of central
hemodynamics - in particular increasing the number of circulating blood, polycythemia
poliglobulii, increased blood viscosity. Alveolar hypoxia lead to hypoxemic by reflex
vasoconstriction by reflex reflex called the Euler-Liestranda. Alveolar hypoxia resulted
hypoxemic vasoconstriction, increased intra-pressure, which leads to an increase in hydrostatic
pressure in the capillaries. Breach of non-respiratory functions of the lungs leads to the release of
serotonin, histamine, prostaglandins, catecholamines, but most importantly, that in the tissue
interstitium and alveolar hypoxia starts to develop in a more angiotensin-converting enzyme.
Light - is the main organ where the enzyme is produced. It converts angiotensin 1 into
angiotensin 2. Hypoxemic vasoconstriction, release of biologically active substances in the
restructuring of central hemodynamics lead not just to increased pressure in the pulmonary
artery, but persistent increase it (higher than 30 mm Hg), that is, to the development of
pulmonary hypertension. If the process continues further, if the underlying condition is not
treated, it is natural to some of the vessels in the pulmonary artery is dying due to pulmonary
fibrosis, and the pressure increases with firmness in the pulmonary artery. At the same time
stable secondary pulmonary hypertension lead to that disclosed shunts between the pulmonary
artery and bronchial arteries and neoksigenirovannaya blood enters the systemic circulation on
bronchial veins and also contributes to the work of the right ventricle.
So, the third stage - the persistent pulmonary hypertension, the development of vein graft, which
enhance the work of the right ventricle. The right ventricle is not powerful in itself, and it
quickly developed hypertrophy with dilatation of the elements.
The fourth stage - the hypertrophy or dilatation of the right ventricle. Right ventricular
myocardial degeneration will also help, as well as tissue hypoxia. So, arterial hypoxemia led to
secondary pulmonary hypertension and right ventricular hypertrophy, dilatation, and his
development of predominantly right ventricular heart failure.
The pathogenesis of pulmonary heart disease at torakodiafragmalnoy form: in this form is the
leading hypoventilation due to kyphoscoliosis, pleural suppuration, spinal deformities, or obesity
at which rises high aperture. Hypoventilation, first of all, lead to restrictive type respiratory in
contrast to the failure which is caused by obstructive chronic pulmonary heart. A further
mechanism is the same - a restrictive type of respiratory failure would lead to arterial
hypoxemia, alveolar hypoxemia, etc.
The pathogenesis of pulmonary vascular heart in form is that thrombosis major branches of the
pulmonary arteries, the blood supply is sharply reduced lung tissue, as well as thrombosis core
branches is friendly reflex constriction of small branches. In addition, vascular form, in
85
particular in the development of primary pulmonary hypertension, cor pulmonale promote
humoral shifts expressed, i.e. a significant increase in the amount sertonina, prostaglandins,
catecholamines selection convertase angiotensin converting enzyme.
CLASSIFICATION OF PULMONARY HEART.
Uniform classification of pulmonary heart disease does not exist, but the first international
classification mainly etiological (WHO, 1960):
• bronchial and heart
• torakodiafragmalnoe
• vascular
Proposed domestic classification of pulmonary heart, which involves the division of pulmonary
heart disease in terms of development:
• acute
• subacute
• chronic
Acute cor pulmonale develops within a few hours, minutes, days maximum. Subacute
pulmonary heart develops within a few weeks or months. Chronic cor pulmonale develops over
several years (5-20 years).
This classification provides for compensation, but acute lung decompensated heart always, that
is, require immediate assistance. Sub-acute and decompensated can offset mainly by right
ventricular type. Chronic pulmonary heart can be compensated, subcompensated,
decompensated.
On the genesis of acute pulmonary heart develops in the vascular and broncho-pulmonary
forms. Subacute and chronic pulmonary heart may be vascular, bronchopulmonary,
torakodiafragmalnym.
Acute pulmonary heart develops in the first place:
• embolism - not only in the thromboembolic and gas but, tumor, adipose, etc.
• When pneumothorax (especially valve)
• When an attack of asthma (especially in asthmatic status - a qualitatively new state of patients
with bronchial asthma, a complete blockade of the β2-adrenergic receptors, and acute pulmonary
heart disease);
• acute pneumonia drain
• right-sided pleural effusion total
A practical example of subacute pulmonary heart disease is recurrent thromboembolism of small
branches of the pulmonary arteries, attack of asthma. A classic example is the cancer
lymphangitis, especially when chorionepithelioma, in peripheral lung cancer.
Torakodifragmalnaya form develops in central hypoventilation or peripheral origin - myasthenia
gravis, botulism, polio, etc.
To distinguish between what stage pulmonary heart of the stage respiratory failure develops into
heart failure has been proposed another classification. Cor pulmonale is divided into three steps:
hidden latent failure - a violation of respiratory function is - reduced VC / KZHEL to 40%, but
there is no change in the gas composition of the blood, that is, this stage is characterized by
respiratory insufficiency 1-2 stages.
• Stage severe pulmonary disease - the development of hypoxemia, hypercapnia, but no signs of
heart failure at the periphery. Have shortness of breath at rest, which can not be attributed to the
defeat of the heart. stage cardiopulmonary diseases varying degrees (swelling of the extremities,
increased belly, etc.).
Chronic pulmonary heart in terms of pulmonary insufficiency, arterial oxygen saturation, right
ventricular hypertrophy and heart failure is divided into 4 stages:
86
Pulmonary insufficiency of I degree - VC / KZHEL reduced to 20%, the gas composition is not
broken. Right ventricular hypertrophy is not on an electrocardiogram, echocardiogram but
hypertrophy is. Circulatory failure at this stage is not.
Pulmonary failure of II degree - VC / KZHEL to 40% oxygen saturation to 80%, there are the
first indirect evidence of right ventricular hypertrophy, circulatory failure + / -, then there is only
shortness of breath at rest.
Pulmonary insufficiency III degree - VC / KZHEL less than 40% saturation of arterial blood to
50%, there are signs of right ventricular hypertrophy on the ECG as direct evidence. A
circulatory insufficiency II Art.
Pulmonary insufficiency grade IV. Oxygen saturation less than 50%, right ventricular
hypertrophy with dilatation, nedostachnost circulation II B (dystrophic, refractory).
CLINIC OF ACUTE PULMONARY HEART
The most common cause of a pulmonary embolism, acute increase in intrathoracic pressure due
to bronchial asthma. Prekapilljarnyh arterial hypertension in acute pulmonary heart, as in the
vascular form of chronic pulmonary heart disease is accompanied by increased pulmonary
resistance. Next is the rapid development of dilatation of the right ventricle. Acute right
ventricular failure manifested severe shortness of breath passing in inspiratory gasp character,
quickly rising cyanosis, chest pain of various kinds, shock or collapse. Rapidly increase the size
of the liver, swelling in the legs appear, ascites, epigastric pulsation, tachycardia (120-140),
breathing hard, in some places a weakened vesicular; tapped moist rales variegated especially in
the lower regions of the lungs. Of great importance in the development of acute pulmonary heart
disease are additional methods of research especially ECG showed a sharp right axis deviation
(R3> R2> R1, S1> S2> S3), there is P-pulmonale - a pointed P wave, the second, third standard
leads. Right bundle branch block, complete or incomplete, the inversion of ST (often rise), S in
the first abduction deep, Q in the third abduction deep. The same characteristics can and in acute
myocardial infarction back wall.
Emergency treatment depends on the cause of cause acute pulmonary heart. If PE was then
prescribed painkillers, fibrinolytic and anticoagulant drugs (heparin, fibrinolysin, Streptodekaza,
streptokinase), up to the surgery.
The status asthmaticus - high doses of intravenous corticosteroids, bronchodilators through the
bronchoscope, translated into mechanical ventilation and bronchial lavage. If this is not done
then the patient dies.
When the valve pneumothorax - surgical treatment. When the drain along with the treatment of
pneumonia with antibiotics, be sure to prescribe diuretics and cardiac glycosides.
CLINIC OF CHRONIC PULMONARY HEART
Patients concerned about shortness of breath, the nature of which depends on the pathological
process in the lungs, such as respiratory failure (obstructive, restrictive, mixed). When
obstructive dyspnea expiratory character with an unchanged rate of breathing in restrictive
processes decreases the duration of exhalation, and breathing rate increases. An objective study,
along with evidence of underlying disease appears cyanosis, often diffuse, Heated peripheral
blood conservation because, unlike patients with heart failure. Some patients with cyanosis
expressed so that the skin color of acquiring iron. The swollen neck veins, edema of the lower
extremities, ascites. Pulse speeded up, expanding the boundaries of the heart to the right and then
to the left, tones are deaf due to emphysema, the focus of the second tone of the pulmonary
artery.
Systolic murmur at the xiphoid process at the expense of the right ventricular dilatation and the
relative lack of the right tricuspid valve. In some cases, severe heart failure, diastolic murmur
can be heard in the pulmonary artery - Still-noise Graham, who is associated with a relative lack
87
of the pulmonary valve. Over light percussion sound boxed, vesicular breathing, tough. In the
lower lung congestion, moist rales nezvuchnye. On palpation of the abdomen - liver enlargement
(one of the reliable, but no early signs of pulmonary heart disease, as the liver may be displaced
due to emphysema). Severity of symptoms depends on the stage.
First stage: on the background of the main disease increased dyspnea, cyanosis occurs because of
acrocyanosis, but the right border of the heart is not enlarged, the liver is not increased in the
lungs of physical data depends on the underlying disease.
The second stage - shortness of breath goes in asthma, with labored breath, cyanosis becomes
diffuse, the objective of these studies: there is a surge in the epigastric region, dull tones, the
focus of the second tone of the pulmonary artery is not constant. The liver is not increased can be
omitted.
The third stage - joining signs of right heart failure - increase in the right border of cardiac
dullness, enlarged liver. Persistent swelling in the lower extremities.
The fourth stage - shortness of breath at rest, a forced situation, often joined by the rhythm of
breathing disorders such as Cheyne-Stokes and Biota. Swelling permanent, untreatable, weak
pulse frequent, beef heart, dull tones, systolic murmur at the xiphoid process. In the light weight
of moist rales. The liver is of considerable size, is not reduced by the action of glycosides and
diuretics as developing fibrosis. Patients are constantly asleep.
Diagnosis is often difficult torakodiafragmalnogo hearts, we must always bear in mind the
possibility of its development, with kyphoscoliosis, ankylosing spondylitis, etc. The most
important feature is the early appearance of cyanosis, and a marked increase of breathlessness
without asthma attacks. Pickwick syndrome characterized by a triad of symptoms - obesity,
drowsiness, marked cyanosis. This syndrome was first described in Dickens' Pickwick Papers. "
Associated with traumatic brain injury, obesity is accompanied by thirst, bulimia, and arterial
hypertension. Often develops diabetes.
Chronic pulmonary heart with primary pulmonary hypertension, a disease called Aerza
(described in 1901). Polietiologic disease is not clear origin, mainly women suffer from 20 to 40
years. Pathological examination revealed that in primary pulmonary hypertension occurs
prekapilljarnyh intimal thickening of the arteries, the arteries that is marked thickening of the
muscle-type media, and develops fibrinoid necrosis with subsequent sclerosis and rapid
development of pulmonary hypertension. The symptoms are varied, usually complaints of
weakness, fatigue, pain in the heart or in the joints, with one third of patients may appear
fainting, dizziness, Raynaud's syndrome. A further increases dyspnea, which is the feature that
suggests that primary pulmonary hypertension becomes stable final stage. Rapidly growing
cyanosis, which is expressed to the extent cast shade becomes permanent, grow rapidly swelling.
The diagnosis of primary pulmonary hypertension is established by exclusion. Most often the
diagnosis anatomicopathological. In these patients, the entire clinic progresses without a
background in the form of obstructive or restrictive respiratory disorders. Echocardiography in
pulmonary artery pressure reaches the maximum number. Ineffective treatment, death occurs
from thromboembolism.
Additional methods of research in pulmonary heart: the chronic process in the lungs leukocytosis, an increase in the number of red blood cells (polycythemia associated with
increased erythropoiesis due to arterial hypoxemia). Radiological findings: there are very late.
One of the early symptoms of a bulging of the pulmonary artery trunk on the radiograph.
Pulmonary artery vybuhaya, often smoothing the waist of the heart, and the heart of many
physicians accept for mitral configuration of the heart.
ECG: there are indirect and direct signs of right ventricular hypertrophy:
1. The deviation of the electrical axis of the heart to the right - R3> R2> R1, S1> S2> S3, an
angle greater than 120 degrees. The most basic indirect sign - is to increase the interval of the R
wave in V1 greater than 7 mm.
88
2. Direct indicators - right bundle branch block, the amplitude of the R wave in V1 more than 10
mm when fully right bundle branch block. The appearance of negative T wave offset lower tooth
contours in the third, the second standard lead, V1-V3.
Of great importance is spirography that identifies the type and degree of respiratory failure. The
ECG signs of right ventricular hypertrophy appear very late, and if there are only a deviation of
the electrical axis to the right, you are already talking about severe hypertrophy. The most basic
diagnostics - is doplerokardiografiya, echocardiography - right heart enlargement, increased
pressure in the pulmonary artery.
PRINCIPLES OF TREATMENT OF PULMONARY HEART
Treatment of pulmonary heart disease is to treat the underlying disease. During exacerbation of
obstructive diseases administered bronchodilators, expectorants. At Pickwick syndrome obesity, etc.
Reduce the pressure in the pulmonary artery calcium antagonists (nifedipine, verapamil),
peripheral vasodilators reduce preload (nitrates, korvaton, sodium nitroprusside). Greatest
importance sodium nitroprusside in combination with ACE inhibitors. Nitroprusside 50-100 mg /
in, the hood 25 mg 2-3 times a day, or enalapril 10 mg per day. Is used as treatment
prostaglandin E antiserotoninovym preparations, etc. But all these drugs are effective only at the
beginning of the disease.
Treatment of heart failure: diuretics, glycosides, oxygen therapy.
Anticoagulant, antiaggregantnaya therapy - heparin, Trental, etc. As a result of tissue hypoxia
rapidly evolving myocardial therefore appoint cardioprotectors (potassium orotate, Panangin,
riboksin). Very carefully prescribed cardiac glycosides.
PREVENTION.
Primary - prevention of chronic bronchitis. Secondary - Treatment of chronic bronchitis.
Theoretical survey can be carried out using the 'round the gallery »
USE OF THE "TOUR GALLERY."
Objective: To teach students critically evaluate information and identify the completeness of
knowledge on the subject.
Each small group is invited one problem they solve for 10 minutes in writing and then
exchange tasks. Revealing mistakes of the previous group, and additions made to the answers
discussed by all members of the adoption of the final version of the responses. Methodology tour
gallery requires students to maximum concentration and a good theoretical background for this
section.
Example: subject classes "Articular syndrome (arthralgia, arthritis)." Three small groups are
given on a question: A variant of issues.
1) Development of pulmonary heart disease.
2) Clinical signs of pulmonary heart disease.
3) Taktki GPs in pulmonary heart.
So for 30 minutes, the teacher gets an idea of the level of training of students on various sections
of topics and their ability to defend their views.
№ evaluation
fine
good
Satisfactory unsatisfactory poorly
Assimilation in%
100%85%70-55%
54%-37% 36% or
less
86%
71%
1
The theoretical part
20-17,2
mark
17-14,2
mark
4.2. The analytical part of
4.2.1. Case Studies:
89
14-11
mark
10,8-7,4
mark
7,2
mark
Case Studies:
1. A patient 50 years appealed to the GP complaining of shortness of breath, cough with purulent
sputum. Smoking history of 30 years. General state of moderate severity, cyanosis, neck veins
bulging, epigastric pulsation. In lung auscultation dry and moist rales. Heart sounds are muffled,
rhythmic, 2 tone accent on a.pulmonalis. Blood pressure 130/90 mm Hg Ps-90 ud.v min.OAK
HB-173 g / l er-3, 9-Leu 10 × 109 / L, erythrocyte sedimentation rate, 18 mm.ch. FVD-FEV 1,
45%, Index Tiffno-57%, VC-75%.
1. Determine the severity of COPD in clinical and functional criteria (GOLD, 2003);
2. The preliminary diagnosis;
3. Enter the X-ray and ECG data;
4. The tactics of the GP;
Answers:
№
Answers:
Mark
1
I-stage light: cough, sputum production, usually, but not always.
20
FEV1/FVC (IT) <70%, FEV1 ≥ 80%. II-stage, mid-weight: persistent
cough, most pronounced in the morning, scanty sputum is usually, but
not always, shortness of breath on mild exertion. IT <70%, ≥ 50% FEV1
<80%. III-stage, severe: persistent cough, sputum, shortness of breath.
IT <70% FEV1> 30% <50%. IV-stage kraynetyazhelaya: cough,
sputum, shortness of breath. IT <70% FEV1 <30% or <50% of
predicted values in conjunction with chronic NAM or right ventricular
failure.
2
Chronic obstructive pulmonary disease (COPD), primarily
35
bronhitichesky type, III severity, heavy current, phase
obostreniya.Oslozhneniya: NAM II.
3
Peribronchial infiltration, diffuse pulmonary fibrosis, emphysema
20
symptoms.
4
Referral to inpatient treatment, observation of general practitioners,
25
outpatient observation, the definition of disability.
2. A patient 40 years appealed to the GP complaining of shortness of breath, breathlessness, dry
cough. Deterioration of ties with the use of a pill anaprilina. Overall condition of relatively
heavy, expiratory dyspnea, cyanosis of the lips. In the lung auscultation scattered dry wheezing.
BH-30 min. Heart sounds tachycardia, muffled AD 140-90 mm Hg Ps-100 min. OAK HB-120g /
l, er-4, 0 Leu-7 ,8-7 EPZs ESR-14 mm / h
1. The preliminary diagnosis;
2. Treatment of patients with asthma by desensitatsii;
3. Enter the pathogenetic mechanisms of aspirin asthma;
4. The tactics of the GP;
_____________________________________________________________________________
3. Patient 18 years. Complaints about udushbe, wheezing and shortness of breath during physical
stress. In the lungs, wheezing. No history of disease was not sick. Auscultation in the lungs of
hard breathing. Heart sounds are clear, rhythmic.
1. Enter the immunological and non-immunological mechanisms of asthma;
2. Informative survey methods;
3. The preliminary diagnosis;
4. The tactics of the GP;
90
4. A patient 57 years appealed to the GP with complaints of cough, hemoptysis, hoarseness, loss
of weight. OBJECTIVE: astenik, clubbing as "drumsticks", the increase in cervical l / at the right
Horner's syndrome positive right. R-graphy: the upper lobe atelectasis. right lung.
1. List at least five diseases for which there are the above mentioned signs and symptoms
(drumsticks);
2. The preliminary diagnosis;
3. Informative survey methods;
4. The tactics of the GP;
5. An appointment with the GP patient received 50 years, complaining of frequent harassing
chest pain, cough, weight loss, shortness of breath, fluctuating fever and general weakness. From
history, the patient over 30 years of experience in the workshop production of asbestos.
OBJECTIVE: lagging behind left rib cage in the act of breathing. Percussion: dullness of sound
from left, Auscultation: from left auscultated dyhanie.Obschy weakened blood Hb - 80 g / l,
Lake. - 12 000, ESR - 30 mm / s.
1.Ukazhite characteristic radiographic signs of this pathology;
2. The preliminary diagnosis;
3. Informative survey methods;
4. The tactics of the GP;
_____________________________________________________________________________
Test:
1. What is not a reversible component of bronchospasm in patients with COPD:
a) hypersecretion of mucus
b) smooth muscle cell hyperplasia
c) the swelling of the bronchial mucosa
d) smooth muscle spasm
e) bronchial epithelial hyperplasia
2. What is not a permanent component of bronchoconstriction in patients with COPD:
a) hypersecretion of mucus
b) epithelial hyperplasia
c) the spasm of smooth muscles of the bronchi
d) peribronchial fibrosis
d) hypertrophy of smooth muscle cells of the bronchial
3. What drugs are not used in the treatment of COPD:
a) expectorants
b) agonists
c) antibiotics
g) mucolytics
e) cytostatics
e) beta blockers
4. Preparations for the basic treatment of bronchial asthma:
a) 2-agonists, short-acting
b) systemic corticosteroids
c) Cromones
g) inhaled corticosteroids
91
e) anticholinergics
e) Antibiotics
5. Preparations for the relief of bronchial asthma:
a) cromones
b) systemic corticosteroids by mouth or intravenously
c) short-acting methylxanthines / in
g) B-2 agonists long acting
e) inhaled corticosteroids
e) inhaled B-2 agonists, short-acting
6. For prolonged drug theophylline are:
a) eufillin
b) diafillin
c) teopek
g) retafil
e) diprofillin
e) Ditek
7. By selective adrenomimetikami (with a predominant effect on β2-receptors) are:
a) brikanil
b) izadrin
c) salbutamol
g) Euspiran
e) berotek
e) astmopent
8. The use of ipratropium bromide, as appropriate:
a) for the treatment of young patients
b) for the treatment of elderly patients
c) in abundant sputum (bronhoree)
g) with scanty sputum or no
d) at sympathicotonia
e) When vagotonia
The list of skills
9. Contraindications to ipratropium bromide are:
a) glaucoma
b) bradycardia
c) adenoma of the prostate
d) AV block 1 - degree
e) bundle branch block
10. For aspirin asthma is characterized by:
a) nasal polyposis
b) easy for asthma
c) the severity of the asthma
g) is very easy for asthma
d) sensitization to house dust
№ evaluation
fine
good
Satisfactory
Assimilation in% 100%85%-71% 70-55%
92
unsatisfactory poorly
54%-37% 36% or
less
86%
3
Test
15-12,9mark
12,7-10,6
mark
10,5-8,25
mark
8,1-5,5
mark
5,4
mark
1.2.2 Graphic Organizer: chamomile
Pulmonar
y heart
The practical part
The list of skills that GPs should possess after completing training on the subject
1. Perform a visual inspection of patients with diseases with pulmonary heart disease.
2. Interpretation of the analyzes, the data of laboratory and instrumental studies, radiographs of
patients with diseases with pulmonary heart disease.
3. Prescription of drugs, depending on the etiology of pulmonary heart disease.
4. To monitor in a hovercraft or a joint venture.
№ evaluation
Assimilation
in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
4
15-12,9 mark
12,75-10,6
mark
8,1-5,5mark
The practical part
Satisfactory
10,5-8,25
mark
Control forms of knowledge, skills and abilities
- Oral
- The decision of situational problems
- Demonstration of practical skills
- CDS
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
93
5,4 mark
№ evaluation
Assimilation
in%
fine
good
100%86%
85%-71% 70-55%
unsatisfactory poorly
54%-37% 36% or
less
1
20-17,2
mark
17-14,2
mark
14-11
mark
10,8-7,4
mark
7,2 mark
50-43 mark
42,5- 35,5
mark
35- 27,5
mark
27-18,5
mark
18 mark
15-12,9 mark
12,7-10,6
балл
10,5-8,25
mark
8,1-5,5
mark
5,4 mark
15-12,9 mark
12,75-10,6
балл
10,5-8,25
mark
8,1-5,5mark
5,4 mark
2
3
4
The theoretical part
Case Studies
Test
The practical part
Satisfactory
6. The evaluation criteria of the current control
levels of
Rating
Characteristics of the student
estimates
points
Point of presence on the practical session. Complete lack of
knowledge and ability to perform a skill - the student is not
20
ready for practical employment.
The student answers unsatisfactory.
Students do not know the fundamentals of knowledge and
skills, at least one of the following:
• Do not know the clinical signs of pulmonary heart disease
in patients with chronic lung disease.
• Do not know the pathogenetic treatment of pulmonary
heart disease.
• Do not know the risk factors for acute and chronic
pulmonary heart disease.
• Do not know the groups of drugs used in treatment of
not
pulmonary heart disease
20 - 54,9
satisfactory
• Can not indicate the radiological signs of pulmonary heart
• Can not specify the ECG signs of pulmonary heart
• Not able to assemble a rational history during the
Supervision of patients with chronic pulmonary heart
disease.
• During Supervision is not able to objectively assess the
condition of patients with chronic pulmonary heart disease.
Not able to rationally make a plan of examination of
patients with chronic pulmonary heart disease in a hovercraft
or a joint venture.
Providing basic knowledge and skills
Satisfactory answer of poor quality.
The student tries to hold the basic levels of knowledge and
55-60,9
skills (see below), but when replying or performing skills
make serious mistakes.
Moderately satisfactory answer.
satisfactorily
55-70,9%
The student has basic knowledge and skills (see below), but
61-65,9
when replying or performing skills make mistakes (subject
to certain margin of error)
Satisfactory answer quality.
The student is wholly owned by the basic levels of
94
66-70,9
knowledge and skills:
• Know the clinical signs of acute and chronic pulmonary
heart
• Can differentiate between acute and chronic pulmonary
heart for subjective, objective, and laboratory and
instrumental data
• Knows differentiated pathogenetic treatment of pulmonary
heart disease
• Know the risk factors for development of chronic
pulmonary heart disease.
• Knows the groups of drugs used in treatment of chronic
pulmonary heart disease.
• Can point to radiological signs of chronic pulmonary heart
disease.
• Can specify the ECG signs of pulmonary heart
• Able to build a rational history during the Supervision of
patients with chronic pulmonary heart disease.
• During Supervision able to objectively assess the condition
of patients with chronic pulmonary heart disease.
• Able to efficiently make a plan of examination of patients
with chronic pulmonary heart disease in a hovercraft or a
joint venture.
• Able to efficiently make a plan of examination of patients
with chronic pulmonary heart disease in a hovercraft or a
joint venture.
• Can interpret the results of laboratory and instrumental
methods of research - may indicate the presence of elevated
erythrocyte sedimentation rate, an increase in coagulation
parameters.
• Can show the technique of taking blood count
• Can show the technique of ECG recording.
Able to correctly fill in the patient diary.
Advanced level of knowledge
Good
71-75,9
71-85,9%
76-80
The student is wholly owned by the basic levels of
knowledge and skills (listed under "66-70,9") + has the
following knowledge and skills:
• Knows the stage of development of pulmonary heart
• Knows the clinical symptoms and morphological changes
characteristic of each stage of the development of pulmonary
heart
• Know the classification of pulmonary heart
• Knows the mechanism of action of drugs
• Rationally selected drugs used in the treatment of
pulmonary heart disease.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9", and also owns the following
knowledge and skills:
• Knows the pathogenesis of pulmonary heart disease, and
may also be called morphology.
• Knows the principles of primary, secondary and tertiary
prevention of pulmonary heart
95
81-85,9
86-90
91-95
Fine
86-100%
96-100
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "71-75,9" and "76-80", and also owns the
following knowledge and skills:
• Can using history and physical examination to establish the
etiology of pulmonary heart disease, as well as to determine
the stage of development of pulmonary heart disease.
• Knows the principles of management, supervision and
monitoring of patients with chronic pulmonary heart disease
in a hovercraft or a joint venture.
• Is able to advise you on the boards of non-drug and drugusing skills of IPC.
Knows the principles of clinical examination and
rehabilitation of patients with pneumonia, pulmonary
tuberculosis and pulmonary infarction in a hovercraft or joint
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "81-85,9", and also owns the following
knowledge and skills:
• Knows the principles of treatment of chronic pulmonary
heart disease depending on the etiological
• Know the indications and contraindications for
echocardiography
• Is able to provide reliable information about pulmonary
heart on the basis of Internet data
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "86-90", and also owns the following
knowledge and skills:
• Knows echocardiographic evidence of chronic pulmonary
heart disease
Knows how to determine the stage of development of
pulmonary heart methods of objective examination.
The student is wholly owned by the basic levels of
knowledge and skills (see above) + knowledge referred to
in paragraph "91-95", and also owns the following
knowledge and skills:
• to provide scientific data from the literature (articles and
Internet)
Knows the stages of clinical examination and
rehabilitation of patients with chronic pulmonary heart
disease.
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the
principle of "security" for the patient.
Test questions.
1.Klassifikatsiya pulmonary heart.
2.Differentsialnaya diagnosis of pulmonary heart disease.
96
3.Neotlozhnaya assistance in acute and subacute pulmonary heart.
4.Taktika management of patients with chronic pulmonary heart disease.
5.Ambulatornoe treatment of patients with chronic pulmonary heart disease.
6.Pokazaniya to hospitalization.
7.Opredelenie disability of patients with chronic pulmonary heart disease.
8. Prevention.
9. Principles of supervision, management and monitoring in SAP or joint venture.
8. REFERENCES:
Summary
• testes kasalliklar, Sharapov UF T: Ibn Sina, 2003
• testes kasalliklar, Bobozhanov S. T: Yangi Asr avlod 2008
• Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009
• Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
• Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012
• General medical practice under red.F.G.Nazirova, A.G.Gadaeva. M. GEOTAR Media,
2009.
• The collection of practical skills for general practitioners. Gadaev A. Akhmedov Kh.S. T.,
2010.
• Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS,
2010. T.
• Umumy amaliet shifokori Uchun kullanma F.G.Nazirov, A.G.Gadaev Tahrah. M.
GEOTAR-Media, 2007.
• Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News
Agency, 2009.
• Internal Medicine: a textbook. - A 2-ton (2 volumes), ed. Martynov, etc. M: GEOTAR Media, 2005:
Internet Resources:
http://www.lib.uiowa.edu/hardin/md/index.html,http://dir.rusmedserv.c,http://www.medlinks.ru/,
http://www.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgi-bin/mbook,http://www.intute.ac.uk/medicine/
97