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THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
THE DEPARTMENT OF GP’s TRAINING WITH ENDOCRINOLOGY
FACULTY OF MEDICAL EDUCATION
WORK PROGRAM
On the SUBJECT:
INTERNAL DISEASES
Field of science - Health
Direction - General Medicine
Tashkent - 2013
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THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
THE DEPARTMENT OF GP’s TRAINING WITH ENDOCRINOLOGY
FACULTY OF MEDICAL EDUCATION
APPROVED:
Vice Rector on Academic
Professor O.R. Teshaev
Affairs,
TMA,
«___________»____________ 20______ year
WORK PROGRAM
On the SUBJECT:
INTERNAL DISEASES
Field of science 720000 - Health
Direction - General Medicine
For the 7th year bachelor students
Tashkent - 2013
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Compiled by: Professor of the GP’s training with endocrinology Department of
TMA, PhD, Gadaev A.G.
Head of the GP’s training with endocrinology Department of TMA,
Associate Professor Akhmedov Kh.S.
Associate Professor of the GP’s training with endocrinology Department of TMA
Rakhimov M.E.
Senior lecturer of the GP’s training with endocrinology Department of TMA
Razikov A.A.
The work program was discussed at and approved by the Academic Council of the Faculty of Medical
Education of Tashkent Medical Academy
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Forеword
The program is designed to develop theoretical and practical skills in the disciplineLina
"Internal Medicine" for the students of the course seven medical and pedagogical faculty.Program
clearly reflects the goals and objectives of trainedeniya, mandatory requirements for a practical and
self-knowledge, skills and experience with the use of modern technology and literature, methods of
control assessment.
PURPOSE AND OBJECTIVES ACADEMIC DISCIPLINES.
The purpose of training:
Teach students syndromal addressing patients and their management principles in primary care to
provide medical care, including prevention, early diagnosis, differential diagnosis and management
tactics for patients with diseases of the internal organs, provided the requirements of "Qualification
characteristics of a general practitioner (GP)" -graduate specialty "Medicine."
Learning objectives:

Giving students timely and early detection of disease based on syndromic approach.

To teach students to differentiate the disease, accompanied with a certain syndrome.

Improve the knowledge, skills and practical skills (information gathering, problem
identification and physical examination, as well as the ability to reasonably assign laboratory
and instrumental methods of research, counseling skills);

Giving students a reasonably choose tactics.

Giving students focus their treatment and prevention measures.

To teach students the principles of follow-up and monitoring in rural health units (RHU)
or of family policlinic (FP).
Requirements for knowledge, skills and abilities in various academic disciplines
I. Must know:
1. The basis of the principles and philosophy of family medicine.
2. Principles of counseling
3. The list of diseases that occur with a certain syndrome.
4. A list of the most dangerous diseases that occur with a certain syndrome.
5. The list of states that require management in a rural health units or SP (as qualifying
characteristics of GPs).
6. The list of states that require a specialist consultation or hospitalization (as qualifying
characteristics of GPs).
7. The list of needed research, requiring in RHU or SP (as qualifying characteristics of GPs).
8. The main clinical manifestations of the most common diseases.
9. Key points (criteria) diagnosis, occurring with a specific syndrome.
10. Symptoms of internal organs.
11. Principles and methods of treatment (including non-medical) disease based on evidence-based
medicine.
12. The principles of primary, secondary and tertiary prevention in RHU or family policlinics.
13. Principles of management (including, after consulting a specialist and discharge), follow-up
and rehabilitation in rural health units or family policlinics.
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II. Should be able to:
1. Observe medical ethics and deontology.
2. Highlight the main issues that affect the quality of life of patients.
3. Conduct the clinical examination of the patient, including medical history (ask the patient and
his relatives, to ask support questions rational history, identify risk factors), examination of
systems and organs.
4. Based on history and physical examination to establish a preliminary diagnosis.
5. Assign meaningful examination.
6. Interpret the clinical and biochemical tests, and the results of instrumental studies (ECG, X-ray
pictures peak flow metry)
7. Differentiated disease (clinical decision logic).
8. A definitive diagnosis.
9. Make a decision about sending a consultation, an additional medical examination and
hospitalization.
10. Appoint a rational therapy (medication and non-medication advice).
11. Provide pre-hospital care in case of emergency.
12. Monitor and medical check-up of patients in a rural health units, or family policlinics.
13. Resolve the issue of disability (temporary and permanent). Making medical documentation.
14. The rehabilitation and return to sanatorium-spa treatments.
15. Considered in the context of the patient's family.
16. Carry out preventive, health, sanitation and hygiene activities in a RHU or family policlinics.
17. Implement nursing care and vulnerable groups.
III. Must have skills:
1. Independent patient reception
2. Counseling
3. Inspection, palpation, percussion and auscultation of the systems and organs
4. Identifying the leading syndrome
5. Identifying risk factors
6. Compilation of survey required
7. ECG equipment
8. Technology peak flow metry
9. Tonometry
10. The choice of drugs with proven efficacy
11. Monitor the effectiveness of treatment
12. Monitoring conditions
13. Delivery of health care for pregnant women with extragenital pathology.
14. Health promotion (with the risk group and the public).
15. The rehabilitation and medical examination.
16. Preventive actions.
List of educational disciplines and their partitions needed to study this training disciplines
1. Anatomy
2. Histology with embryology and cytology
3. Biology
4. Normal physiology
5. Biochemistry
6. Patomorphology
7. Physiopathology
8. Topographical anatomy and operative surgery
9. Propaedeutics of internal medicine
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10.Tuberculosis
11.Oncology
12.Radiology and nuclear medicine
13.Physiotherapy
14.Endocrinology
15.Of Therapy
16.Hospital Therapy
17.Orthopedics
MINIMUM REQUIREMENTS NUMBER TASKS FOR THE PRACTICAL CLASSES
1. The interpretation of laboratory and instrumental methods of investigation:
- Clinical (general analysis of blood, urine, sputum, pleural analysis).
- Biochemical (total protein and protein fractions, enzymes, bilirubin, lipids, electrolytes,
coagulation, acid-base status, acute phase reactant test).
- Bacteriological (seeding biomaterial with antimicrobial susceptibility).
- Immunological, (immunoglobulins, T - and B-lymphocytes, T-helper cells, suppressor,
serological tests, HLA).
2. Interpret the data and toolsesearch (ECG, X-ray, peak flow metry)
3. Performing diagnostic and therapeutic procedures:
Diagnostic: conducting peak flow, ECG.
Treatment:oxygen therapy, subcutaneous, intramuscular, intravenous, bronchial lavage, pleural
puncture in spontaneous pneumothorax, gastric lavage with sensing.
The number and types of control measures to assess knowledge students.
Evaluation of the quality of students' knowledge in the discipline by three kinds of control in
accordance with the Model Regulations:
A) Current control (CC) is implemented in a practical training. The maximum daily rate
current control 100. It consists of a theoretical survey of 30 points, on duty in the hospital, the
supervision of patients, clinical audit, participation in special parsing patients completed medical
documentation in the hospital and in the clinic, as well as diaries subordinators and workbooks - 30
points; interpreted orientation of the laboratory, instrumental, functional studies and assignments of
treatment - 40 points. Max and maximal rate monitoring 100. Average score of the current control is
displayed by folding points and dividing by the number of practical training. Average score is
multiplied by the current control to the coefficient of 0.45.
B) Self-study. Score self-study also exhibited a 100 point system for homework cycle in a
special part of the school magazine. Self-study perform student extracurricular optional one topic, in
accordance with the curriculum disciplines.Independent work will be conducted in the form of training
abstracts, reports specifically selected topic using materials obtained from internet, scripting movies,
cooking tables, slides, making situational problems, clinical situations, tests, puzzles, patterns,
laboratory and instrumental studies participation in clinical and post-mortem conferences, clinical
analysis of patients, supervision and discussion of case patients duty at the hospital, participate in the
reception of patients and service calls in the clinic..
To calculate the average score for the self-study scores summed and divided by the number of
evaluations. The resulting average score is multiplied by the coefficient self-study that is 0.05.
B) Intermediate control (IC) - held once during the entire cycle of internaltion of the
disease. IC - the decision of clinical cases where analytical skills are assessedspine, the clinical
judgment of the student, as well as the ability to correctly assign each plan onfollowing, treatment in
the clinical situation. IC - is curation patient in the office, or in the clinic. Thus evaluated the ability of
each student to collect patient history, right to inspect the patient, a preliminary diagnosis, to appoint
the requisite plan laboratory - instrumental research and treatment, followed by a clinical staging
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diagnosia. The maximum score on each IC - 100 points. IC total score - 100 points. IC score is
multiplied by the coefficientitsient 0.2.
B) The final control (FC) is conducted at the end of the cycle the GP-therapy with
application of OSCE- Stage 1, as well as testing - Stage 2. In addition to the results of OSCE assessed
clearance diaries subordinator on duties, lecture notes, student participation during the morning
conferences, clinical conferences, clinical audits, case rounds. Maximum score of FR 100. FC score is
multiplied by the coefficientient 0.3.
Grading points intermediate and final control provisions contained in the rating department.
NEW TECHNOLOGY IN TEACHING DISCIPLINE
Knowledge students must meet the requirements and level of development of the world science
and practice of gastroenterology.In the educational process in the discipline to focus on the computer
with the use of the technological information base "Internet" to improve the quality of teaching aids,
audio and visual media, the new educational technology in learning control. Much attention and
adequate time self-examination should be given the patient students staged a preliminary diagnosis,
plan survey, interpretation of laboratory and instrumental data, differential diagnosis, establish a
definitive diagnosis, differential therapy patient depending on the underlying disease, comorbidities
and complications, and also work with the literature.
During the practical sessions to evaluate the theoretical knowledge of the students, the
following methods of training in small groups, "brainstorming", work in pairs, "a tour of the gallery,"
"round table", "pen in the middle of the table", the method of rotation, "snowball "," swarm ", as well
as methods that optimize the learning process in the group: case studies, business games clinical,
clinical audit.
Technical training.
Slidescope.
Educational boards.
Overhet.
At the department there library.
TYPES OF CONTROL KNOWLEDGE, ABILITIES AND SKILLS.
The degree of mastery of skills and abilities is determined during the clinical analysis curated
patients. Specified level of theoretical knowledge on the riverhe findings of oral responses to the
decision-card problems, self-admission of patients, processing medical records and medical records in
a hospital.
Correct answer to "excellent" at 86% and above, as "good" - with 71-85,9%, "satisfactory" - 5570,9% and "unsatisfactory" - below 55%. Students who received a failing grade exercise, work out
according to the current theme of the academy "rating position."
TEACHING NOTES EMPLOYMENT
Work on practical training consists of theoretical and analytical parts followed for fixing topics
classes. Theoretical survey conducted by the traditional didactic method, with the intensive training and "brainstorming", work in pairs, "a tour of the gallery," "round table", "pen in the middle of the
table", the method of rotation, "snowball", " a swarm of bees, "as well as with the analysis of the issues
by main topics, for example, list the disease manifested rhythm disorders, abdominal pain, arthritis and
arthralgia, to make a diagnosis and differential diagnosis of ischemic boheart disease, rheumatic and
rheumatoid arthritis, or Reiter's disease and ankylosing spondylitis, etc..This will allow for 7-10
minutes to orient teachers to the survey in the future for those moments in which students made
uncertain knowledge.
The analytical part of the class continues with the use of situational tasks and role-playing.
The practical part of training - Supervision of sick students - performed under the supervision
of a teacher at the Department of Rheumatology.
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To prepare thematic bypass patients with a 3.2 pathology, with the presence of a history of
sufficient minimum surveys, for example, the common blood and urine tests, blood tests for
rheumatoid factor, CRP, seromucoid, sialic, sublimate test, ASO, ASK, LRA, uric acid, X-graphy
joints and organs of the chest. During rounds fixed attention on the characteristics of complaints of
patients, depending on the nature of the defeat of organsI and systems, pain, swelling, points to defeat
any of the bodies, the time of day worries pain and what it involves, etc.
The attention to the sequence of history-taking, depending on the nature of the disease.
Physical examinations aimed at identifying the nature of the damage internal organs and their
symptoms
VOLUME
Total
labor
input
(hours)
THE DISTRIBUTION OF THE TEACHING LOAD BY TYPE
OF CLASSROOM
(In hours)
Total
416
286
Lectures
18
Practical lessons
Self
(extracurricular)
work
(hours)
Teaching
practice
268
---
130
Content of the material
Contents of the lecture material
№
1
2
3
4
5
6
Topics of the lectures
Sudden death
Differential diagnosis of arrhythmia. Clinical and ECG diagnostic. Emergency.
Differential diagnosis of chest pain non-coronary character.
Differential diagnosis of cough, sputum and hemoptysis. Tactics of GPs.
Differential diagnosis of abdominal pain.
The differential diagnosis of intestinal dysfunction. Dysbiosis. Modern
principles of treatment and prevention.
Differential diagnosis in fever. Tactics of GPs.
Differential diagnosis of diffuse connective tissue diseases.
Differential diagnosis of nephrotic syndrome.
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8
9
Hours
2 hours
2 hours
2 hours
2 hours
2 hours
2 hours
2 hours
2 hours
2 hours
CONTENTS CASE STUDIES
In the family medicine
№
1
2
Themes of workshops
№ 1. «Prevention in GP's work. Types of preventive work. Healthy lifestyle
promotion. Hygiene of nutrition and everyday life. Prevention
examinations, screening. Prevention of infectious and non- infectious
diseases. Immunization. Programs and actions. Principles of teaching the
topic»
№ 2. «Work with various groups of population. Children, adolescents,
women (women of fertile age, pregnant women), males, the elderly.
Industrial and agricultural workers. Socially vulnerable people. Patients, the
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The
references
3
4
5
difficult patient, the dying patient. Issues of rehabilitation and prophylactic
medical examination. Working capacity examination. Principles of teaching
the topic».
№ 3. Influence on risk factors. Health education. Influencing principal
causes of morbidity and mortality. Strengthening of the mental status.
Ecology and occupational factors. Training of patients, "schools"
№ 4. «Medicine for travellers. Consultancy prior to travel. Consultancy
after travel. Immunization. Change of climate and time zones. Air sickness
and mountain disease. A travel medical kit. Principles of teaching the
topic»
№5. «Differential diagnostics in GP's work. Diagnosis suggested. Most
dangerous diseases. Diagnostic mistakes. Mimicking diseases. Mental
disturbances and simulation. Principles of teaching the topic».
Practice session № 1
Topic: "«Prevention in GP's work. Types of preventive work. Healthy lifestyle promotion. Hygiene of
nutrition and everyday life. Prevention examinations, screening. Prevention of infectious and noninfectious diseases. Immunization. Programs and actions. Principles of teaching the topic»"
Justification topic:Activities GP 80-90% consists of prevention. Propagator of healthy lifestyle and
responsible attitude of people towards their health, exposure and risk factors for various diseases, early
diagnosis and prompt treatment, prevention of complications, provision of social and home for the
disabled, all contribute to improving the health of the population.
The aim of teaching: GPs make preventive immunization and promotion of healthy lifestyles among
the population.
Learning objectives:
1. Familiarize GPs with species prevention.
2. Teach GPs promoting healthy lifestyles among the population, food hygiene and living
conditions.
3. Teach GPs how to conduct routine inspections and screening.
4. Educate immunization activities among the population.
Expected results:use of active methods of primary, secondary and tertiary prevention will improve
health outcomes, stabilize and reduce morbidity, loss of permanent disability, reduce mortality and
improve the quality and length of life of healthy and sick, which will increase the overall life
expectancy of the population and reduce economic losses.
GPs should know:
1. Types of prevention in the work of GPs.
2. On the principles of healthy lifestyles and their use in educating the public and patients.
3. How to conduct interviews in the mahalla and prepare lecture themes.
4. How to make brochures, lectures and notes to the media.
5. Immunization, screening principles and methods of implementation.
GPs should be able to:
1. Prepare brochures, lectures and notes to the media on the topics: alcoholism, drug
addiction, smoking, tuberculosis, hepatitis, AIDS, contraception.
2. Prepare healthy food pyramid.
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3. To map and evaluate the results of screening.
4. Planning campaigns.
GPs should do:
1.Conduct routine inspections to improve public health
2.Screening of the population for the most common diseases.
3. Giving talks and lectures in local communities (schools, mahalla).
4. Conduct immunization activities.
The list of skills that GPs should possess after completing training on the subject:
1. Conduct a routine inspection.
2. To be screened.
3. Interpretation of results of routine inspection, screening and immunization.
4. Maintain medical records checkups.
The course is taught.
The structure of the lessons:
Checking the initial level of preparedness of students to engage in "Prevention in the RHU.
Types of prevention. Promotion of healthy lifestyles. Food hygiene and living conditions. Prophylactic
examinations and screening. Prevention of communicable and non-communicable diseases.
Immunization. Programs and measure. "
The course is taught:
Time
Events
8.30-9.30 Morning
conference.
9.3010.30
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
Content
Report on subordinators
examined by patients in the
clinic and the challenges at
home.
Admission
Each student is receiving
outpatients under patients with GPs, followed
control of the by a discussion of patients
teacher.
examined in the audience.
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory and instrumental
studies, preliminary study
consuming and final clinical
diagnoses.About
the
determining further tactics.
Break.
Study skills.
Student
under
the
supervision of a teacher
must complete a minimum
of two skills.
Theoretical
Checking
analysis of the baselineSTIpreparedstudents
topic.
using
the
"snowball".
Solution with case problems
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Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
tonometer. Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Folders with case 80 minutes
studies, educational
boards,
posters
appropriate subject
using counseling skills.
classes.
Prevention in the work of GPs
The activities of a general practitioner is focused not only on the treatment set, but primarily on the
prevention of diseases.This means that at each meeting the physician should try to change the
attitudeeniyapopulation health,and the patient to the health, develop in him a desire to actively
participate in the treatment of this disease and prevent new ones.
Preventive work is a major part or the core of the family doctor. Studies conducted in
developed countries have shown that 85% of humanity attends cabinet family doctor at least once a
year, an average of five visits to the human.When patients come to the anxiety and symptoms of the
disease for a talk to a doctor, they are more receptive to advice as to protect the health and respectively
recover.
A family doctor is a key person in the process of improving the health and disease prevention at the
community and, in particular, at the individual level. The purpose of work in the two areas is
arepresentation of a person the opportunity to be healthy and stay healthy, improve the quality of life,
prevent disease, reduce disability and mortality, and thus prolong his life.
Prevention - is a set of activities aimed at maintaining and promoting health and preventing
disease, promoting healthy lifestyles is responsible attitudes to their health.
Types of prevention.
Primary prevention- are activities designed to maximize the preservation of health,
identifying and managing risks (of which unmanaged- age, gender, family history can not be changed,
but they pay attention to families at risk and help identify control lable risk factors - smoking,
"nosvoy" , alcohol, lack of exercise, obesity, poor nutrition, etc.) of various diseases among healthy
population.This includes advice on healthy lifestyles, including advice on nutrition, control of
harmfulhabitsandetc, regular physical exercise.Primary preventionalsoimpliedevaet sanitation: water
treatment, toilets, fighting flies, hand washing, health education (san.byulletni, booklets and lectures).
Secondary prevention- is early diagnosis and early treatment of disease. Here relative to the
screening, baseline medical examination, the use of questionnaires.We know that tumors are more
common in the elderly, such as breast cancer (breast). For early detection of changes in the breast,
family physicians Recomends breast self-examination for all women from 25 years and mammography
in women with risk factors, ranging from 40 years 1 every 2 years.
Tertiary prevention- a treatment of the disease, for the prevention of complications. For
example, all patients with hypertension and diabetes we prescribe aspirin as a preventive doses for
professionalilaktiki stroke and myocardial infarction.
Counseling patients about lifestyle changes is a matter of activity sequences GP. Family physician
should be able and willing to discuss with the patient strategy to style Mrs.situ and encouraged him to
start to change.
Healthy lifestyle (HLS) in a narrower sense includes biological optimum feeding, nutrition,
maturation, function and aging in accordance with the physiological ageof TNO-sexual characteristics
of man. The struggle for HLS involves deep knowledge of family physicians.
For example, for the prevention and early detection of cardiovascular disease family practice focuses
on leading healthy lifestyles. Smoking, lack of exercise, excessive intake of fat and excess
weightexceeds the riskforcardiovascular disease not only at risk, but for all people.Each risk factor
fortdelnosti affects risk, but to the combinationof two or three factors greatly increases the chance of
disease.Improving the way people live, including the restriction of smoking is the most effective
means of reducing the incidence of heart diseases.
Among adults, tobacco and alcohol are the main causes of premature deathti.Quitting smoking is not
easy, but even a short consultation family doctor about it can give good results. Passive toUren are
associated with many diseases, such as children of sudden death, respiratory diseases, asthma, lung
cancer, adult lung and heart ailments.
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Nutrition and physical activity play a significant role in the prevention of cardiovascular disease, but to
the same extent and in maintaining quality of life and reducing overall Zabolevaemosti.Balanced diet
and moderate exercise up to 30 minutes 3-5 times a week are necessary to ensure bldgonrovya at any
age.GP can give advice on healthy eating, and if the patient is troubled andzbytochnogo weight, your
doctor can recommend the suitable nutrition program.
Thus, the family physician has the skills counseling for lifestyle changes such as quitting smoking,
avoiding abuse of alcoholism, food with health benefits, the movement for all, etc. In contrast to other
specialists in general practice is a unique opportunity to influence the lives of patients as well as longterm, continuous and comprehensive observation of the patient and his family makes it possible to
identify risk factors, control over implementation of preventive and therapeutic measures.
Promotion of healthy lifestyles. GPs can be trained HLS. Through interviews with people in
the mahalla, teahouse, school, sports halls, etc., with the distribution of pamphlets, visual aids,
farmstead rounds, involving activists Mahalla, respected people, lectures and notes to the media about
the problems of common communicable and non-communicable diseases (alcoholism, drug addiction,
smoking, tuberculosis, viral hepatitis, contraception, AIDS, influenza).
Food hygiene and living conditions.
The value of a systematic scheme of supply:
eat three times a day, but not before going to bed and in between meals, chew carefully allotted in your
mouth, do not rush to the next portion, for a meal drink a glass of water, but no juice in a state of stress
or boredom, the desire to eat to replace walking, if weather permits, do not miss the set meal times,
which could result in hastily snacking and overeating, food cut into small pieces.
Ideally, a balanced diet should be part of everyday life of Noah since childhood, and it should
be followed for life. Many of the factors that increase the risk of CV diseases can be avoided or to
influence them through a healthy diet and increasing physical activity.
Ten steps to healthy eating
-Healthy food, mostly plant-based diet, which is diverse and nutritious.
Starch-rich food should be more than half of the energy absorbed.
-Vegetables and fruits should be more than 7% of energy, the choice should be diverse and mostly
local produce.
-Meat, if it is, should be less than 10% of the energy consumed.
-Consume milk and dairy products should be low-fat.
-Fats should be only 15-30% of the energy consumed.
-Salt intake should be less than 6 grams per day.
-Body weight should not exceed the recommended standards.
-Physical activity should be performed daily.
-Eat a variety of foods, not supplements of the same.
In general, recommendations for a healthy diet, the following:

Eat plenty of foods from the group "Bread, cereals and potatoes" and choose foods
coarse, unground, rye bread or high fiber types, where possible rye bread is very good.

Eat plenty of fruits and vegetables and choose a diverse set of data products.

Growing vegetables in the area as good as exotic fruits and vegetables for salads as they
are fresh and more nutritious.

Eat or drink milk and dairy products in moderation and choose low fat products where
possible.

Eat moderate amounts of foods from the group "meat, fish and similar products" and
choose low-fat products, and similar products such as eggs, nuts, beans, lentils and peas, where
possible.

Eat fatty and sugary write very sparingly in small quantities. Or too often - and youBiran
foods low in fat and sugar.Remember, fat and sugar are often hidden in sampledriver run
products, and may not appear on the label.
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Serving sizes are based on the amount of key nutrients in a given amount of product.Thus,
food-based products in the ratio recommended by the Pyramid and corresponding general
recommendations, the first step to healthy eating. This food ensures receipt of all essential nutrients
and prevents excessive consumption of less nutritious food.Is all that is used for balance.
However, many consume much more food, overeat, get the excess amountof energy and honors fat.
Some eat enough food and lose weight. Consumption and correct amount of food is very
important, and needs of each are different. If you are overweight, the portion size you need to look
at the lower limit provided by the plug. If your weight is not enough, you need to eat more. Still,
try to keep your balance.
Product Group
Minimum
Average
Maximum
5
5
2
2
10
5 or more
2.5
2.5
14
5 or more
3
3
1
0
3
1
5
2
Bread, cereals and potatoes
Fruits and Vegetables
Milk and milk products
Meat, fish and similar products
Fat and sweet:
Oil and fats
Other products
Checkups.
By GP refers to 86% of the population, each seeking makes it an average of five times a
year. This allows actively use this phase of care for checkups.
Preventive examinations include a history and physical, and basic laboratory instruments
andexperimental research.Such inspections are useful for holding mass investigation.
Purpose routine inspections:
1.
Allocation of risk of common diseases, such as atherosclerosis risk - patients
with obesity, hypertension, hyperlipidaemia.
2.
Identification of patients at the preclinical and initial stages of the disease,
such as understanding and bacteriuria in pregnant women, cervical cancer, early diagnosis of
glaucoma, hip dysplasia, cryptorchidism.
3.
Identification of patients with irreversible lesions requiring medical or social
assistance, such as people with low vision and hearing, mental retardation.
Screening - a process to identify patients with a wide population survey.
Conducted for the early diagnosis and refers to secondary prevention.
Ten questions we should ask before you start screening certain diseases:

Is the disease an important health problem?

Is there an acceptable method of treatment of this disease?

For diagnosis and treatment should be available tools and features.

Is there a recognizable latent or early course of the disease?

Appropriate method of analysis, the study?

Is this an acceptable method of research for a large part of the population?

Should be familiar with the natural history of the disease.

There must be an agreed policy on who should be regarded as a patient.

The cost of "detect", including the cost of treatment, must be equally balanced on the cost of
treatment in general.

"Identification of cases" should be continuous work, not a campaign -"once and for all."
Prevention of communicable and non-communicable diseases.
At the heart of the planning of preventive measures on the analysis of morbidity and
mortality.Over time, these values vary: for example, in the past, the main causes of morbidity and
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mortalityspine were infectious diseases - tuberculosis, syphilis, diphtheria, smallpox, today, they were
replaced by atherosclerosis, cancer, and HIV infection.
Disease prevention in adults:

Calendar-adult immunization.

Measurement of blood glucose with a glucometer.

Peak flow metera use.

Counseling patients on healthy lifestyles.

Standards of clinical and biochemical tests (cholesterol, blood sugar, blood count,
urinalysis, etc.).

To be able to advise smokers.

To be able to advise patients on alcohol consumption.

To be able to counsel patients on physical activity.

To be able to advise patients on a normal diet.
Immunization.
According to the recommendations of the National Board of Health and Medical Research, all
children are immunized against diphtheria, tetanus, pertussis, polio, measles, mumps and rubella.
Adults every 10 years boosted against diphtheria and tetanus. All women age of pregnancy
determine titer of antibodies to rubella.
Td for adults (16, 26, and 46) contains adult dose of tetanus toxoid and reduced diphtheria
toxoid dose.
To reduce the risk of adverse reactions, baby sequins and 4 hours after injection vaccines give
paracetamol.
Immunization against influenza is recommended for patients with chronic diseases, especially the
heart, lungs, kidneys, severe metabolic disorders receiving immunosuppressive drugs and those over
65 years old.
Hepatitis B immunization is carried out to all persons at risk of the disease - coppercare providers and
medical students, prisoners, prison staff and other persons. Have parts contacts with patients with
hepatitis B.
Immunization against Haemophilus influenzae type B is recommended for all children, especially in
the closed institutions. The best age for immunization 2-18 months.
Immunization against measles, mumps and rubella in children spend one year revaccination between
10 and 16 years. During an epidemic of measles vaccination of all children spend up to 5 months,
subsequent vaccine administration - according to schedule.
Vaccination is certainly one of the best achievements of medicine and HN cornerstone of child
preventive medicine.Vaccination is a task of national importance, and it is important connectors its
primary care physicians need, parents and the whole population
Proper time to vaccinate a child and stick to the stricter schedule vaccinations, especially as a
strong deterrent against infectious diseases child will be, and the less side effects caused by
vaccination.
Handout:
Students dealt with the content of the theme lists, examples of laboratory and instrumental
studies.
Equipment Workshop:
1.Table with the data of the family.
2. Educational and scientific literature containing data prevention skills
3. Booklets.
4.Templates laboratory and instrumental Methods.
Independent work and self-education.
14
Topic: "Prevention in the RHU. Types of prevention. Promotion of healthy lifestyles. Food hygiene.
1. Independent oversight of patients while receiving outpatient and development pStarted on
prevention of communicable and non-communicable diseases.
2. The development of skills in time service calls to your home.
3. Prepare and deliver a presentation on the subject of clinical studies at the morning conference atthe
Department of polyclinics.
4. Improving skills in interpreting medical history, physical and laboratory-instrumental methods.
Teaching practice during the lesson.
Supervision of patients.
Number of hours - 1 hour.
Quiz
1. The importance of prevention in GP
2. Types of prevention
3. Promotion of healthy lifestyles
4. Household hygiene and nutrition
5. Food pyramid
6. Screening and preventive examinations
7. Prevention of communicable and non-communicable diseases
8. Principles of immunization
9. Programs and activities to prevent
Practice session № 2
Theme: "Work with various groups of population. Children, adolescents, women (women of
fertile age, pregnant women), males, the elderly. Industrial and agricultural workers. Socially
vulnerable people. Patients, the difficult patient, the dying patient. Issues of rehabilitation and
prophylactic medical examination. Working capacity examination. Principles of teaching the
topic"- 6.7 hours
Justification of the theme:
Observation and treatment of the patient throughout life - the essence of general practice. Doctor about
knows the patient and his family, the conditions of work and leisure. Caring, responsible and
knowledgeable physician - patient and reliable support of his family. Unfortunately, families do not
always perceive the GP of both respondent shall not know that they can ask him questions not only
medical treatment, so the doctor will have to tactfully offer themselves as such.This is particularly
relevant during the consultation couples are going to get married when we take, when observing the
growth of children and adolescents, women of childbearing age, pregnant governmental, men, well,
especially the elderly. Communication in this period establishes a new relationship between doctor and
patient, theblegchaet further work with the family.
The aim of teaching:Getting GPs –Work with different groups of people - children, adolescents,
women (women of childbearing age, pregnant women), men, the elderly, workers, industries and
agriculture, socially unprotected people, difficult patients, dying patients, address issues of
rehabilitation and medical examination, to prepare the documents for examination disability .
Learning objectives:
1. Learn to work with different groups of people: children, adolescents, women (women fertile age,
pregnant women), men, the elderly.
2. Learn to work with the workers in production and agriculture.
3. Learn to work socially unprotected people.
15
4. Learn how to work with difficult patients, dying patients.
5. Conduct the rehabilitation and clinical examination.
6. Know how to prepare documents for examination disability.
Expected result: the lesson allows working with different groups of people: children, adolescents,
women (women of childbearing age, pregnant women), men, elderly patients. Be able to work with
workers of industries and agriculture, socially unprotected people with difficult patients, dying
patients, the rehabilitation and clinical examination, to prepare the documents for examination
disability.
GPs should know:
1. Able to work with different groups of people: children, adolescents, women (women of childbearing
age, pregnant), men, elderly patients.
2. Be able to work with employees and production agriculture.
3. Be able to work socially unprotected people.
4. Be able to work with difficult patients, dying patients.
GPs should be able to:
1. Conduct the rehabilitation and clinical examination.
2. Prepare documents for examination able working.
GPs should do:
1. Able to work with different groups of people: children, adolescents, women (women of childbearing
age, pregnant), men, elderly patients.
2. Be able to work with employees and production agriculture.
3. Be able to work socially unprotected people.
4. Be able to work with difficult patients, dying patients.
5. Conduct the rehabilitation and clinical examination.
6. Prepare documents for examination disability.
The list of skills that GPs should possess after completing studies on the subject
1.GPs should be able to identify the reasons why the appeal of the population: children adolescents,
women (women of childbearing age, pregnant women), men, elderly patients.
2. Consider other issues: a) problems with long-term nature, b) risk factors have traded workers
industries and agriculture,
3. Reach an understanding on the issue with the socially unprotected people and to regulate
Aveoblemy and efficient use of time and resources.
4. Difficult to reach an understanding with the sick, the dying ballnymi.
5. Conduct the rehabilitation and clinical examination.
6. Prepare documents for examination disability.
Place of activity:
1. Training themed room.
2. Cabinet receive GPs.
Contents classes
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in: "Working with different groups.
Children, adolescents, women (women of childbearing age, pregnant women), men, elderly patients.
Workers production and agriculture. Socially disadvantaged people. Difficult patients dying patient.
Questions and reabilitation and clinical examination.Examination working ability. "
2. Decision analysis and situational problems.
16
3. Consultations at the reception at the GP on the subject.
4. Clinical analysis of the whole group on the consultation.
5. Role-play on the difficult work sick or dying sick.
The course is taught:
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the
clinic
and
the
challenges at home.
9.30-10.30 Admission
Each student is receiving
outpatients under patients
with
GPs,
control of the followed by a discussion
teacher.
of patients examined in the
audience.
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory
and
instrumental
studies,
preliminary
studyconsuming and final
clinical diagnoses.About
the determining further
tactics.
Break.
Study skills.
Theoretical
analysis of
topic.
Student
under
the
supervision of a teacher
must complete a minimum
of two skills.
Checking the initial level
the of
preparedness
of
students. "Address the
situation case problems
using counseling skills.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Folders with case 30 minutes
studies, educational
boards,
posters
appropriate subject
classes.
When parsing the theme focuses on the following aspects: the duty of every physician - to
provide assistance and support to any patient.
1. Take patients as they are. Give up trying to fix them. Numerous complaints may be just an excuse to
keep in touch with you.About such complaints as a prospect on the phenomenon of neurosis.Put the
diagnosis if necessary, assign examiners.
2. If the patient is too often appeals to you, offer a schedule of meetings.
3. During the consultation, ask the patient about family and work.
4. Spend enough time to the patient, but to make him understand that it is bounded.
5. Comforting, remember that every word must be justified.
6. Be honest. Tell the patient, as well as your understanding vyglyadyat his problem.
7. Be polite, but persistent.
8. Do not assign a placebo, the conversation with the doctor alone - a cure.
9. Do not discuss with patients and other doctors do not give up on them bad.
17
10. Set a realistic goal.
11. Do not end the relationship with the relationship with the patient.
12. Do not refuse a patient if he appeals to your colleagues.
13. Be especially careful when treating friends and when you give the heart.Observe medical ethics.
14. If you find it difficult to communicate with patients.
15.Accept the fact that some patients can not help.
Case studies: 1.For you to receive a woman came 48 years with complaints of pain in the breast. Pain
became concerned within a month. Her neighbor case that one woman had the same pain in the breast,
and she died within six months. So she came to you, very much afraid that she would die. What do you
advice her village?
2. You went to a call where the patient suffers from a tumor of the colon. He put down a structure
called, pain, and constipation.What do you recommend to him, and how you will wire advice?
3. For you to receive a young man, who a week before his wife died. He's depressed mood, there is no
desire to live.Your tactics and future action?
Handout:
Students dealt with the content of the theme lists, examples of laboratory and instrumental
studies.
Equipment Workshop:
1. Table with the data of the family.
2. Educational and scientific literature containing data prevention skills
3. Booklets.
4. Templates laboratory and instrumental studies.
Independent work and self-education.
Topic: "Working with different groups. Socially disadvantaged people. Patients, difficult patient, sick.
Rehabilitation. Examination of disability
1. Independent oversight of patients while receiving outpatient and development started with different
groups
2. The development of skills in time service calls to your home.
3. Prepare and deliver a presentation on the subject of clinical studies at the morning conference atthe
Department ofpolyclinicsgical.
4. Improving skills in interpreting medical history, physical and laboratory-instrumental methods.
Teaching practice during the lesson.
Supervision of patients in the clinic
Number of hours - 1 hour.
Quiz
1. The work of GPs with different groups
2. Types of prevention with different groups
3. Promoting a healthy lifestyle among women of childbearing age, pregnant women, men, seniors,
workers manufacturing and agriculture, socially vulnerable people
4. Promoting healthy lifestyles among eetey, teens
6. The rehabilitation and clinical examination.
7. Employable spine examination
Practice session № 3
Topic: Influence on risk factors. Health education. Influencing principal causes of morbidity and
mortality. Strengthening of the mental status. Ecology and occupational factors. Training of
patients, "schools" - 6.7 hours
18
Justification of the theme: Health Education is designed to maintain and enhance human health and
on society. His main goal - a healthy way of life of each person. Training of the patient - it is
accessible explanation of its etiology and pathogenesis of the disease, treatment guidelines, and the
need for adherence to the diet. Training can take place in face meetings or by the patient and his
family.In the latter case, along with health education are his relatives. Training of the patient should
occur during eachconsultationton.This also use special brochures and other materials.
The aim of teaching:Getting GPs - Prevention of CHD and stroke, cancer (particularly lung cancer,
breast cancer, cervical cancer and skin), injuries and intoxications, infections, diseases of the
musculoskeletal system, diabetes, dental disease, asthma, mental disorders and disability.
Learning objectives:
1. Reducing the prevalence of smoking, alcoholism, drug abuse, poor diet, lack ofBraz life.
2. Reduction of hypertension.
3. Reduction of hyperlipidaemia.
4. Learning about the dangers of sexual promiscuity.
5. Reducing the impact of occupational exposures and adverse factors of environment.
Expected result:this session will lead to significant advances in the prevention of cardiovascular
diseases, cancer, injuries and mental health problems.
GPs should know:
1.
Health education.
2.
The impact of the main causes of morbidity and mortality.
3.
Mental status.
4.
Environmental and occupational factors.
5.
Education of patients, "school".
GPs should be able to:
1.To be able to carry out prevention of CHD and stroke, cancer (particularly lung cancer, young
cancer, cervix and skin), injuries and intoxications, infections, diseases of the musculoskeletal system,
diabetes, dental disease, asthma, mental health problems, disabilities.
GPs should do:
1.Educate the patient - that is the major causes of morbidity and mortality (sufficient explanation he
etiology and pathogenesis of his disease, treatment guidelines, and the need for adherence to the diet).
2. Educate the patient - a healthy way of life of each person
3.Teach the patient how to influence risk factors (smoking, alcoholism, drug addiction, eating right,
environmental factors, sexual promiscuity).
4.Educate patient prevention of mental disorders.
5.Teach the patient how to conduct prevention against professional diseases.
6.Teach the patient how to reduce the impact of adverse factors of environment.
7.Make the patient feel responsible for their own health, and stress to a healthy lifestyle.
The list of skills that GPs should possess after completing training on the subject.
1. Be able to convince the patient and sent to a healthylife azu arr.
2. Conduct prevention of CHD and stroke, cancer (particularly lung cancer, breast cancer, cervical
cancer and skin), injuries and intoxications, infections, diseases of the musculoskeletal system,
diabetes, dental disease, asthma, mental disorders and disability.
Place of activity:
1.Training themed room.
19
2. Cabinet receive GPs.
The content of lessons.
The structure of the lessons:
1.Checking the initial level of preparedness of students for employment: "Effect on the risk factors.
Health education. The impact of the main reasons for morbidity and mortality. Mental status. Ecology
and profiles withl factors. Education of patients, "school".
2. Decision analysis and situational problems.
3. Consultations at the reception at the GP on the subject.
4. Clinical analysis of the whole group on the consultation.
5. Role-play on the theme: patient education.
The course is taught:
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the
clinic
and
the
challenges at home.
9.30-10.30 Admission
Each student is receiving
outpatients under patients
with
GPs,
control of the followed by a discussion
teacher.
of patients examined in the
audience.
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory
and
instrumental
studies,
preliminary
study
consuming
and
final
clinical diagnoses.About
the determining further
tactics.
Break.
Study skills.
Theoretical
analysis of
topic.
Student
under
the
supervision of a teacher
must complete a minimum
of two skills.
Checking the initial level
the of
preparedness
of
students using the 'tameka
in the middle of the table.
"Solution
situational
problems.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Folders with case 80 minutes
studies, educational
boards,
posters
appropriate subject
classes.
When parsing the theme focuses on the following aspects of the training the patient, should be
such that he felt a responsibility for their own health, to send him to a healthy lifestyle, to support and
encourage him on the difficult road to help quit smoking, alcohol abuse, to change the nature of power,
start to play sports.
20
GPs can use for health education every consultationtion.Themselves consultations are usually held on
the initiative of the patient, and health education – Sun when thou initiated by a physician.
Tactics of the doctor during the consultation can be both passive and active, and in his practicespace
activities doctor should be able to use one and the other.Passive tactic requires the patient complaints,
initiatives and treatment while the patient is from.
Active tactics provides proactive management of the patient, the use of eachof the treatment for the
identification of risk factors, early detection of diseases and for health education.Active tactics include:

Continuous observation of such frequent measurement of blood pressure in the treatment of
hypertension, frequent glucose monitoring, therapy for pathological reactions loss.

Coordination of the efforts of all involved in patient care - medical specialists, social
services,

Changing the attitude of the patient to the health, such habits do not go to the doctor or, for
example, to do it too often.
For health - health education required:

Date knowledge and training of doctors,

Literature and visual materials, such as brochures, posters, videos in the waiting room

Treated patients registration system,

Active invitation to the consultation of those who are at risk,

Advice on nutrition, weight loss, exercise, anti-emotional tension.
Case studies:
1. To you come to the reception boy of 14 years who has a mental disorder. Talk to you, does not
answer your questions.But he needs help in a specialized school. Your tactics ?
2. Young woman 27 years old, works at a textile factory. She has a bad cough and there were stains on
the face connected their symptoms to work, because it works in the dye shop.Your tactics?
3. Male 68 years old, retired. Suffers from type 2 diabetes. Recently there were complaints of dry
mouth, itching, thirst. Connects its onset of symptoms with stress at home had quarreled with his eldest
son. Your tactics and gave her recommendations?
Of the role-playing game each teacher must have an example of an RPG:
A patient 60 years old, concerned with a bad cough phlegm difficult to separate, smokes a pack a day.
The problem of the patient at this time:cough.
Behavior of the patient during the consultation:quiet, but he wants to finish it faster to go to smoke.
The behavior of the doctor during consultation:
Teaching the doctor's perspective
After the role play, discuss the behavior of the entire group of doctors during the consultation, and how
he made the patient feel responsible for their own health, and sent the patient to a healthy lifestyle.
Handout:
Students dealt with the content of the theme lists, examples of laboratory and instrumental
studies.
Equipment Workshop:
1.Table with the data of the family.
2. Educational and scientific literature containing data on the impact of the factors riska
3. Health education booklets
4.Templates laboratory and instrumental studies.
Independent work and self-education.
Topic:"The impact of risk factors.Health education. Ecology, professional factors.
1. Independent oversight of patients while receiving outpatient and development started to identify risk
factors, morbidity and mortality.
2. The development of skills in time service calls to your home.
21
3. Prepare and deliver a presentation on the subject of clinical studies at the morning conference at the
Department of polyclinics.
4. Improving skills in interpreting medical history, physical and laboratory-instrumental methods.
Teaching practice during the lesson.
Supervision of patients in a half-ke
Number of hours - 1 hour.
Quiz
1. The value of the risk factors in the work of GPs
2. Concept and health education
3. The main causes of morbidity and mortality
4. Mental health
5. Environmental and occupational
6. Education of patients
Practice session № 4
Topic: "Medicine for travellers. Consultancy prior to travel. Consultancy after travel.
Immunization. Change of climate and time zones. Air sickness and mountain disease. A travel
medical kit. Principles of teaching the topic"- 6.7 hours
Justification of the theme:Every year more than 400 million people visit other countries.These people
have alight sensitivityvalemotional and physical stress in air travel, and faced with are those diseases
that are not met at home.The probability of the disease in this case depends on the characteristics of the
country visited, and by the lifestyle traveler. Often, going on a trip, people do not even imagine the
difficulties which he might encounter. Not all trips are equally safe. Traveler podsteregayut both light
and very heavy, sometimes fatal disease.In countries with unstable political high risk of injury. During
the trip, car accidents are frequent, so you need to advance posses started on insurance.
The aim of teaching: Getting GPs - hold consultations prior to travel, after travel advice, immunize,
the change of climate and time zones with motion sickness and altitude sickness.
Learning objectives:
1.
Consulted before traveling,
2.
Conduct consultation after travel
3.
Immunize,
4.
Consulted in the change of climate and time zones
5.
Be consulted with motion sickness and altitude sickness.
6.
To be able to collect medical travel kit.
Expected result:this session will lead to significant advances both be consulted before travel advice
after traveling, immunize, the change of climate and time singingowls, with motion sickness and
altitude sickness.To be able to collect medical travel kit.
GPs should know:
1. In consultation before travel include intestinal infections, diarrhea, travelers, chronic diarrhea
and prevention, malaria. Prevention of sexually transmitted diseases and drug.
2. In consultation after traveling should know about preventing sexually transmitted diseases,
gastrointestinal dysfunction, fever, malaria, typhoid fever, dengue fever, meningococcal
disease and Japanese encephalitis. Rare infection, sleeping sickness (African trypanosomiasis),
cutaneous leishmaniasis, Sheastosomoz, hookworm, strongyloidiasis, Lyme disease,
melioidosis, ciguatera.
3. Syndrome jet flights.
22
4. The symptoms of motion sickness, altitude sickness.
GPs should be able to:
1.Immunize: mandatory - cholera, yellow fever, tobrovolnuyu - Hepatitis "A" and "B", typhoid
fever, Japanese encephalitis, meningococcal, rabies, typhus, plague.
GPs should do:
1. Immunization mandatory - cholera, yellow fever, volunteer - Hepatitis A and B, typhoid,
Japanese encephalitis, meningococcal, rabies, typhoid fever, plague.
2. Collect road medical kit.
The list of skills that GPs should possess after completing studies on the subject
1. Consulted before traveling,
2. Conduct consultation after travel
3. Immunize,
4. Consulted in the change of climate and time zones
5. Be consulted with motion sickness and altitude sickness.
6. To be able to collect medical travel kit.
Place of activity:
1. Training themed room.
2. Cabinet receive GPs.
Contents classes
The structure of the lessons:
1.Checking the initial level of preparedness of students to engage on the topic: "Medicine for
travelers.Consultation prior to travel. Consultation after traveling. Immunization. The change of
climate and time zones. Motion sickness and altitude sickness. Travel medical kit. Principles of
teaching the topic.. "
The course is taught:
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the
clinic
and
the
challenges at home.
9.30-10.30 Admission
Each student is receiving
outpatients under patients
with
GPs,
control of the followed by a discussion
teacher.
of patients examined in the
audience.
10.3011.30.
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory
and
instrumental
studies,
preliminary
studyconsuming and final
clinical
diagnoses.
Determining
further
23
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
tactics.
11.3012.15.
12.2012.40.
Break.
12.4014.00
Theoretical
analysis of
topic.
Study skills.
Student
under
the
supervision of a teacher
must complete a minimum
of two skills.
Checking the initial level
the of
preparedness
of
students
using
the
'braingovoy
storm
"Solution
with
case
problems using counseling
skills.
Patient or volunteer.
20 minutes
Folders with case 80 minutes
studies, educational
boards,
posters
appropriate subject
classes.
When parsing the topic, we must remember that the doctor should advise the patient to plan long
journeys in advance, a last resort for two months. Consultation should be sufficiently long, at least 3045 minutes.
The traveler explains that for his health he answers himself.Based on a new and reliable
and information, talk about the difficulties he may have encounteredmein time. Give recommendations
both orally and in writing.
Traveler to provide detailed extract from medical records showing its available disease and its
treatment. Before leaving recommend visiting dentolog.
Most frequent travelers suffer intestinal infections.These diseases before fecal-oral route, they are
common in areas with poor sanitationmi.The most common disease of this group - travelers' diarrhea,
frequent as hepatitis A and helmintosis.
Travelers' diarrhea cause different impact revivalist.The incubation period of 6-12 hours. The
disease is usually mild. Characterized by cramping abdominal pain, frequent and abundant hydrated
watery diarrhea and sometimes vomiting. Duration of traveler's diarrhea - 2-3 days, rarely more than 5
days. Severe diarrhea with blood and mucus release observed in severe intestinal infections, such as
amoebiasis.
Treatment of mild diarrhea or sweetened beverages. Antidiarrheals (version form a, if there is no
blood in the stool). Diarrhea moderate - standard solutions of glucose and electrolytes inside
norflaksatsin, 400mg. Orally 2 times a day for 3 days, orciprofloxacin. Children designate
trimetroprim / sulfametaksazol.
Severe diarrhea with common symptoms hospitalization.
Diarrhea is considered chronic if it lasts for more than three weeks. In chronic diarrhea,
especially after returning from India and China, to suspect protozoal infektsiyu - amebiasis and
giardiasis.
Prevention of intestinal infections is:
Drink only boiled water or industrial made water.
Boil the water for 10 minutes.
Do not eat raw vegetables and fruits.
Do not eat raw shellfish, raw meat, dairy products, milk, cream, ice cream, cheese.
Often use disposable paper towels and wipes.
Malaria prevention and treatment are carried out according to the WHO and national committees
to combat malaria.
Chloroquine is still effective for the most common three-day malaria, malaria is particularly
dangerous during pregnancy, in children up to 5 years, and immunodeficiencies.
A vaccine against malaria has not been created, so the main directions of prevention - a
protection against mosquito bites and the appointment of antimalarial drugs.
24
Mandatory immunization- according to the WHO, before traveling to endemic areas
necessarily only immunization against yellow fever. Immunized certificate is issued by WHO. Yellow
fever - viral infection of transmission intensively. Like malaria, it is prevalent mainly in tropical
countries. Carriers of the pathogen - mosquitoes. Vaccination against yellow fever are required before
going to the central Africa and northern South America.The vaccine is administered once. Immunity
lasts at during 10 years.
The effectiveness of vaccination against cholera is low, so the WHO does not consider it
to mandatory. She is assuming that necessarily in Pakistan and the Pitcairn Island, but only for entering
their endemic areas.The vaccine is administered twice, with an interval of 7-28 days. Children under 5
and pregnant women immunized witha tion is not carried out.
Voluntary immunization optional travel, if during the forthcoming visit of a high risk of
infectious diseases, such as hepatitis A and B, typhoid or typhoid fever, Japanese encephalitis,
meningococcal disease, rabies or plague.
Vaccination against hepatitis A is carried out in three stages, the pre-determined level of antibodies
to AT. If a little time before leaving and the traveler does not have time to complete a full course of
immunization, enter and immunoglobulin that provides passive immunitet for 3-6 months.
Immunization is not carried out for children up to 8 years. Hepatitis B is most common in South-east
Asia, South America, immunizations to recommend that you in these countries for a long time,
especially health care workers. The vaccine is administered, if serum anti-HBc Ag antibody class G.
Vaccination is carried out in three stages: a second dose of the vaccine is administered in a month, and
the third - six months after the first.
Immunization against typhoid is recommended before traveling to developing countries in
Asia, Africa, Central and South America, and southern Europe.There are two vaccines: for p / c and a
new administration - oral, duration of post-vaccination immunity after a full course of immuneization
(4 capsules) - 5 years.
Japanese encephalitis is a transmissible infection, spread it are mosquitoes. In endemic regions
very common, usually in the summer. Susceptibility to the disease is high. Very often infected with
walks near pig farms and rice fields. Mortality - 20-40%. Vaccine against Japanese encephalitis often
Callsyvaet anaphylaxis, so the main measure of prevention - a protection against mosquitoes.
Meningococcal disease has several clinical forms, the most dangerous meningococcal and
meningococcemia, which often lead to death. Meningococcal disease is common in some countries in
Asia and Africa, the incidence rises in drought. Immunization is recommended exploring the
Kathmandu Valley in Nepal and over pilgrimage to Mecca.
Immunization against rabies conducted persons working with animals in endemic areas.When
visiting endemic areas after any bite or scratch, animals, and animal saliva in contact with the skin is
washed immediately with soap and water and apply to GPs. If the risk of rabies is high, the immunized
conduct even after being bitten previously vaccinated.
Immunization against plague recommended working in the centers in the field of medical and skim
employees. Adult vaccine is given in two stages, children - in three stages. Booster vaccinations every
l year.
When traveling by air with travelers may experience jet lag syndrome.Jet lag syndrome is manifested
by fatigue, against BHIman, insomnia, anxiety, are also possible loss of appetite, headache, dizziness,
blurred vision.
The fact whether the traveler will develop jet lag syndrome, the following factors.
Endogenous: age, health, capacity for acclimatization and mental state. Endogenous: noise and
vibration, humidity, comfortable cabin, overeating, smoking and alcohol abuse, etc.
Tips: before the flight should sleep well in advance to get together and come to the airport.In
flight should: drink orange juice and mineral water, avoid coffee and alcohol, eat moderately, the flight
is at night, how much sleep,
During the flight the better to keep his feet elevated, occasionally walk through the cabin, during the
stops to do physical exercises, wipe face governmental wetwipes.Try to get some sleep after arriving
1-2 h, and then take a walk, go to bed at the usual time. Traveling by air should not be in the following
25
cases: SARS, respiratory diseases, Heavy Wishing heart failure, severe anemia, pregnancy, starting
from the 28th week, acute psychosis in history, the first month after myocardial infarction, the first two
weeks after a stroke, after a large surgery, brain tumor, recent skull fracture, recent surgery on the
eyes, severe or poorly controlled hypertension and epilepsy.
Motion sickness- the movement in space receptors perceive the semicircular canals of the inner ear, in
individuals prone to motion sickness, the sensitivity of these receptors is increased, it decreases with
age, children often get motion sickness than adults.The first symptom of motion sickness - pale in
children - lethargy, silence. In the future, nausea, vomiting, head ofenvironment, weakness,
drowsiness. Prevention- before and during the trip to avoid the wave oftions. Children need to calm
down. During the trip, it is better to lie and not to read, before and during the trip takes a little to eat,
but do not overeat.
Treatment- when rocking effective scopolamine, H1-blockers, and
phenothiazines, these include prohloperazin, promethazine and Tietilperazin. Travakalm and
Benatsin- the combination of drugs scopolamine.
Altitude sickness- mountain climbing - it is a serious test even for young and healthy people. Osonit
especially dangerous for people with heart and lung. The risk depends on the height and speed of
ascent, air temperature, and physical fitness person. Allocate following forms of altitude sickness:
acute mountain sickness (mild to severe), pulmonary edema, cerebral edema.The clinical picture develops in the first 8 - 24h. Observed discharges a headache in the forehead, worse in the morning
and in the supine position, malaise, weakness, loss of appetite, nausea, and insomnia.
In severe cases, there are swelling, shortness of breath, vomiting, dry cough, dizziness, and
neurological symptoms.Treatment - Immediate descent below 2000 m above sea level, oxygen
inhalation, dexamethasone, 4 mg. PO / IM every 6 hours. Prevention: acclimatization and lessefief
climb - from 3000m, the rate of ascent should be no more 300m/sut, stop for 2-3 days at intermediate
altitudes. Limitation of Acetazolamide, 250 mg orally every 8 hours, start taking one day before ascent
and continue during 3-6 days.
Travel medical kit- going on a long journey, it is useful to take a medical kit, it should include the
following items:
Tools and materials:plaster, sterile and non-sterile and sterile cotton bandages, thermometer, tweezers
and scissors, flashlight, a few safety pins.
For topical application: arenovated with antifungal, antiseptic cream, insect repellent containing
diethyltoluamide, the proceeds from the common cold (spray or drops), 20% solution of aluminum
sulfate in aerosols - inactivate poisons animals and prevent their absorption, antiseptic tablets,
sunscreen .
Medicines: antibakterial funds - norfloxacin 400mg tablets to, trimetroprim / sulfamethoxazole (for
children), antacids (heartburn and dyspepsia), antimalarials when traveling in endemic areas,
acetazolamide when traveling in the mountains, tinidazole, metronidazole 2g or , 2.4 g with amebiasis
and giardiasis, laxatives, loperamide for diarrhea, with motion sickness (promethazine) for fever and
pain (paracetamol), sleep disturbances (temazepam), means of rehydration (tours)-these are all means
prescription is .
The script for the role-play:
Patient: For you to receive a woman came 28 years old, 1 pregnancy, 28 notweeks. She will travel to
Egypt as tourists. She worried if she could go and she was concerned that she might not survive a
flight from aircrafts. Before pregnancy, she had not endured a trip to airbus.
The problem of the patient at this time: the fear of traveling by plane.
Behavior during the consultation: restless.
Inspection: The skin of normal color, slimy pink.Respiratory and cardiovascular system without
features. Stomach increased through pregnancy, standing height uterus corresponds to the period of
pregnancy. Heartbeating fetus is normal.
BP -110/70 mm.Hg. APulse - 100 beats per minute (the experience).The liver and spleen can not
palpate because of pregnancy. Stool and urine output but PME.
Learning point of view:
1.
Establish psychological contact.
26
2. Give advice (which she can fly the plane up to 36 weeks). Calm downoit patient.
3.
Determine the tactics of appointments on the trip to Egypt as Egipet is an endemic area
(schistomoz - she should not go swimming in the irrigation canals and natural water bodies,
drinking water out of them and move them to wade. Pathogen-worming., Intermediate hosts,
molluscs, final owners - people infected proicoming off when bathing or washing clothes,
especially in standing water).
Handout:
Students dealt with the content of the theme lists, examples of laboratory and instrumental
studies.
Equipment Workshop:
1. Table with the data of the family.
2. Educational and scientific literature containing data on the impact of the factors riska
3. Health education booklets
4. Templates laboratory and instrumental studies.
Independent work and self-education.
Topic:"Medicine for travelers.The change of climate and time zones. Altitude sickness. Travel medical
kit. "
1.Independent oversight of patients while receiving outpatient and development of communication
with travellers.
2. The development of skills in time service calls to your home.
3. Prepare and deliver a presentation on the subject of clinical studies at the morning conference atthe
Department of polyclinics.
4. Improving skills in interpreting medical history, physical and laboratory-instrumental methods.
Teaching practice during the lesson.
Supervision of patients.
Number of hours - 1 hour.
Quiz
1. The value of travel medicine in GP
2. The concept of their consultation
3. The main causes of morbidity travelers
4. Explanation of jet lag and climate
5. The concept of altitude sickness and motion sickness
6. What is included in a set of road?
Practical lesson number 5.
Topic: " Differential diagnostics in GP's work. Diagnosis suggested. Most dangerous diseases.
Diagnostic mistakes. Mimicking diseases. Mental disturbances and simulation. Principles of
teaching the topic "- 6.7 hours.
Justification of the theme:
Features of general practice - a large number of subjects and the limited laboratory capacity and
institutionalrumentalnoy diagnosis.Given this, the doctor should be able to use concise and clear
differential and diagnostic schemes: this will avoid many mistakes in his career.
The purpose of teaching:
Teach GPs on establishing a preliminary diagnosis, brief differential diagnostic schemes, highlight the
problems of the most dangerous diseases, disease-imitators, mental disorders and simulation.
27
Learning objectives:
1. Consider the characteristics of the establishment of a presumptive diagnosis.
2. Teach GPs recognize and differentiate the most dangerousany ill.
3. Discuss the problems of diagnostic errors in their professional activities.
4. Educate GPs on disease simulators, mental disorders and simulations.
Anticipated results
Conducting this training allows student to correctly navigate the challenges of establishing a
presumptive diagnosis, recognize and differentiate the most dangerous diseases, disease simulators,
mental disorders and simulation, to avoid diagnostic errors, make the right decisions in their work as a
GP or family doctor.
GPs should know:
1. Establishing a presumptive diagnosis.
2. The general scheme of differential diagnosis.
3. A list of the most dangerous diseases.
4. List of diseases imitators.
5. Detection of mental disorders and malingering.
GPs should be able to:
1. Data analysis and history of complaints to determine a preliminary diagnosis patient.
2. Assume and properly elect their tactics at the most dangerously ill.
3. Correct differential diagnosis in primary Health Care.
4. Avoid diagnostic errors.
5. Recognize disease-simulators, personality disorders and simulation.
GPs should do:
1. Competently carry out inspection of the patient to establish a preliminary diagram forecasts.
2. To fill out the patient card.
3. Make a differential diagnosis.
4. Assign the necessary examination and treatment of the patient, but to interpret thennye.
5. Correctly choose their tactics in the most dangerous diseases, diseases of the simulators, found
disorders and simulation.
The list of skills that GPs should possess after completing studies on the subject
1. Generalization of the complaint data, medical history and examination of the patient.
2. Filling the necessary medical documentation.
3. Prescribing for patients.
4. Definition of tactics in the most dangerous diseases, diseases of the simulators, the detection of
psychiatric drug and simulation.
Place of activity:
1.Training themed room.
2.Reception rooms of GPs.
The course is taught
The structure of employment
1.Checking the initial level of preparedness of students to engage in "Differential Diagnostic of stick in
the practice of GPs. Presumptive diagnosis.The most dangerous diseases. Diagnostic errors. Disease
simulators. Psychic violations and simulation. "
2.Decision analysis and situational problems.
3. Supervision of patients with the most dangerous diseases, disease simulators, mental disorders.
28
4. Clinical analysis of patients with the most dangerous diseases, disease simulators, mental violateny
and simulation.
5. Role-playing game to assess knowledge on training.
The course is taught:
Time
8.30-9.30
Content
Report on subordinators
examined by patients in
the
clinic
and
the
challenges at home.
9.30-10.30 Admission
Each student is receiving
outpatients under patients
with
GPs,
control of the followed by a discussion
teacher.
of patients examined in the
audience.
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
Activity
Morning
conference.
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory
and
instrumental
studies,
preliminary
studyconsuming and final
clinical
diagnoses.Aboutthe
determining further tactics.
Break.
Study skills.
Theoretical
analysis of
topic.
Student
under
the
supervision of a teacher
must complete a minimum
of two skills.
Checking the initial level
the of
preparedness
of
students
using
the
'braingovoy
storm
".Solution
with
case
problems using counseling
skills.
Materials
Lesson time
Hospital records of 1:00
patients
The
patient, 1:00
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1:00
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Folders with case 80 minutes
studies, educational
boards,
posters
appropriate subject
classes.
On practical training and theoretical part, consistently addresses the establishment of a
presumptive diagnosis, differential diagnosis, according to the most dangerous diseases, disease
simulators, mental disorders and simulation.
DIFFERENTIAL DIAGNOSIS IN PRACTICE GP
The basis of the modern medical profession on three progressive methodological principle of
mental activity in clinical diagnosis:

Syndromic diagnosis principle
29

Diagnostic algorithm

The principle of optimal diagnostic usefulness.
What is a clinical syndrome? V.A.Germanova by definition, is a group of clinical symptoms,
among which are clearly defined, not only space-time, but the cause and effect, the essential, the
pathogenetic link. Mental operations are performed in the doctor's strict compliance with the following
terms and conditions of:

First, only those symptoms and the range of diseases that make this leading syndrome
(syndromic principle activity);

Second, extremely reliable diagnosis is based on a minimum of features, detected at a
minimum of medical research (the principle of optimal diagnostic feasibility);

Third, mental operations have symptoms of the disease are made with a clear
instruction that allows each stage of thinking differential diagnosis of similar diseases, which in the
last stage leads to a definite diagnosis (diagnostic algorithm).
In practice, detection of symptoms conceptualized, and in the differential diagnosis in a group
of clinically similar diseases doctor comes to the diagnosis.
The general scheme of the differential diagnosis includes five questions that should answer the
doctor, faced with various complaints:

The most likely reason (possible diagnosis)

The most dangerous diseases

Sources misdiagnosis

Is not the cause of complaints is one of the seven diseases pretenders?

Can there be mental disorders and simulation?
Assuming a particular disease, the physician is guided by the data history, clinical features, by
how the disease is spread. For this, he should know where it is found, remember the peculiarities
course of disease.
A general practitioner, are constantly faced with widespread diseases, should always remember
and diseases relatively rare but dangerous: cancer, meningoencephalitis, septicemia, endocarditis, HIV
infection, myocardial infarction, unstable angina, arrhythmia, asthma, mental illness and traumatic
brain injury.
Diagnostic errors usually occur when doctors overlooked detail. So, we should not forget that
cause headache and fatigue may be adversely affected environment.Careful examination is particularly
important in the diagnosis of urinary tract infections. It can manifest in children - fever of unknown
origin, pregnancy - back pain in the elderly - malaise. In addition, the clinical picture which is diverse
and for which there is no pathognomonic symptoms, it - so-called diseases of imitators or pretenders.
Diagnosis of these seven major pretenders is difficult:
1.
Depression
2.
Diabetes mellitus
3.
Side effects of drugs and toxic
4.
Anemia
5.
Thyroid diseases
6.
Diseases of the spine
7.
Urinary infection
Other diseases, the simulators are given in the book "Handbook of general practitioner,"
Dzh.Merta, 1998, p.111.
The general practitioner should be subtle psychologist. Often vague complaints- only reason for
seeking medical attention, but the real reason is low self-esteem, family conflict, etc. GP must tactfully
ascertain the nature of family relationships, explain the cause of anxiety or depressed mood.
Handout:
Students dealt with the content of the theme lists, examples of laboratory and instrumental
studies.
30
Equipment Workshop:
1.Tables listing the most dangerous diseases, disease-imitators, mental disorders and
Simulayatsii.
2.Educational and scientific literature containing data on classes.
3. Role-play scenario.
4.Templates laboratory and instrumental studies.
Independent work and self-education.
Topic: "The differential diagnosis in the practice of GPs. Presumptive diagnosis. The most
dangerous Zaboletion.Diagnostic errors. Diseasesofimitatry.Mental and simulation. "
1.Independent oversight of patients while receiving outpatient and mastering
skillsmentationestablisha presumptive diagnosis, differential diagnosis, according to the most
dangerous diseases, disease simulators, mental disorders and simulation.
2.The development of skills in time service calls to your home.
3.Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference onthe basis ofgenderiklinicheskoy department.
4.Improving skills in interpreting medical history, physical and laboratoryAthorne and
instrumental data.
Teaching practice during the lesson.
Supervision of patients.
Number of hours - 1 hour.
Test questions:
1.The role of establishing a preliminary diagnosis in the management case.
2.You know what the most dangerous diseases?
3.Do you know the general scheme of the differential diagnosis?
4.What is disease-pretender?
5.You know what the seven major diseases-pretenders?
6.The main causes of anxiety in the patient.
7.What is a phobia?
8.What is the ability to give the patient to share their problems?
9.List the most common complaints of a general nature.
10.What are the characteristics of professional activity of a general rightktiki?
REFERENCES
Summary
1. Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
2. Ички касалликлар, Камолов Н.Н., 1991
3. Внутренние болезни, том 1 Мухин Н.А. М.: ГЭОТАР - Медиа,2009
4. Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
More
1. Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
2. Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3. Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
4. Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т.,
2010.
5. Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С.,
2010. Т.
6. Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
31
7. Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАРМедиа, 2007.
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/cgibin/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
32
CARDIOLOGY
CONTENTS TOPICS CASE STUDIES
The references
№
Themes of workshops
Chest pain. Diseases that present with chest pain. They are more
dangerous diseases that present with chest pain. Differential diagnosis
of NDCs, coronary angina, PICS. Tactics GPs. Indications for referral
to a specialist or hospitalization ofprofiled section.The principles of
treatment, follow-up, monitoring and rehabilitation in RHU or family
1 policlinics. Definition of disability.
Topics for independent work:
The physiological function of the heart muscle. The etiology and
pathogenesis, classificationand treatment standards of NDCs, CHD.
Practical skills: ECG interpretation and analysis in different types of
angina and PICS.
Chest pain. Differential diagnosis of coronary heart disease,
myocarditis and myocardial degeneration.Tactics GPs. Indications for
referral to a specialist detailing profile department. The principles of
treatment, follow-up, monitoring and rehabilitation in RHU or family
policlinics. The principles of prevention. Definition of
disability.Principles of teaching the topic.
2
Topics for independent work:
The physiological function of the heart muscle. The etiology and
pathogenesis, classification and treatment standards myocarditis and
myocardial dystrophy.
Practical skills: ECG interpretation and analysis with myocarditis and
myocardial dystrophy.
Chest pain. Differential diagnosis of osteoarthritis of the spine,
intercostal neuralgia, chest injuries, herpes.Tactics GPs. Indications for
referral to a specialist or hospitalization of the profile department.The
principles of treatment, follow-up, monitoring and rehabilitation in
RHU or family policlinics. The principles of prevention. Definition of
3
disability. Principles of teaching tools.
Topics for independent work:
Etiopathogenesis, clinical osteoarthritis, spondylosis, Titse syndrome,
ankylosing spondylitis. Standards of treatment.
Practical Skills: Interpretation of tests, X-rays of the thoracic spine.
Heartbeat. Differential diagnosis of arrhythmias tachycardia,
respiratory arrhythmia, extrasystoles. Tactics GPs. Indications of
direction to a specialist or hospitalization profile department.When
treatment dispensary monitoring, control and rehabilitation in rural
health units or family policlinics. Principles of prevention. Definition
4 of disability.
Topics for independent work:
The physiological function of the heart muscle. Normal ECG.The
etiology and pathogenesis, classification arrhythmias. Classification of
antiarrhythmic drugs.
Practical skills: ECG interpretation.
Heartbeat. Differential diagnosis of heart with completely insufficient
5-6
blood circulation, anemia, hyperthyroidism.Tactics of GPs.Indications
33
7
8
for referral to a specialist or hospitalization profile department.The
principles of treatment, follow-up, monitoring and rehabilitation
inaloviyah
RHU
or
family
policlinics.
Principles
of
prevention.Determination of ability to work hazards. Principles of
teaching the topic..
Topics for independent work:
Etiopathogenesis, clinical heart failure, anemia, goitus. Modern
classification of CHF. Standard treatment.
Practical Skills: Interpretation of tests, ECG and echocardiography.
Hypertension. Differential diagnosis of hypertension with
hemodynamic hypertension (atherosclerosis, coarctation of the aorta,
aortic valveinsufficiency, congestive hypertension, complete AV
block).Tactics of GPs. Principles of follow-up, monitoring and
rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of teaching topics.
Topics for independent work:
The etiology and pathogenesis of hypertension and symptomatic
arterial hypertension. Classification HD and symptomatic
hypertension. Methods of investigation patients with hypertension.
Classification of antihypertensive drugs.
Practical Skills: Interpretation of tests, chest X-ray, ECG, fundus,
echocardiography, ultrasound, writing of drugs for the treatment of
hypertension.
Hypertension. Differential diagnosis of hyperpertonic disease with
cerebral hypertension (traumatic brain injury, vertebral-basilar
syndrome, arachnoiditis, encephalitis, brain tumors). Tactics of GPs.
Principles of follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of prevention. Principles of teaching
topics.
Topics for independent work:
Etiology, pathogenesis, risk factors of hypertension and symptomatic
hypertension.
Practical Skills: Interpretation of tests, chest X-ray, ECG, fundus,
echocardiography, ultrasound, writing of drugs for the treatment of
hypertension.
34
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH CHEST PAIN
Purpose: Teach students syndromal addressing patients with chest pain, as well as the principles of
their management in primary health care in the qualifying characteristics of GPs.
Key learning objectives:

To teach students the problem associated with pain in the chest;

Giving students a timely diagnosis when there is a problem associated with chest pain.

To teach students to differentiate the disease, accompanied with pain in the chest.

Improve the knowledge, skills, and practical skills in solving problems of patients with
chest pain (information gathering, problem identification and physical examination, as well as
the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU and FP.
What the student needs to knowto solve the problems of patients with chest pain:
№
1
2
3
4
The list of knowledge
The list of diseases that present with chest pain
A list of the most dangerous diseases that present with
chest pain
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
5
A list of studies requiring in RHU or FP (3-1 category)
6
The list of research areas requiring outside RHU or FP
(3.2-category)
7
Key points (criteria) diagnosis, occurring with chest
pain
8
Classification of CHD
9
Symptoms of internal organs
10
Indicators of blood sugar.
Lipid profile
11
Treatment policy
35
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must list.
Student should know signs of heart,
lung,
liver,
spleen,
stomach,
duodenum
the student should know:
- Normal levels of blood sugar both
fasting after exercise
- Indicators of impaired fasting
glucose
- Normal lipid profile
- Indicators dislipidemia
The student must know the
techniques and principles of
treatment (including non-drug)
12
13
The principles of primary, secondary and tertiary
prevention
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The principles of clinical examination and rehabilitation The student must list the main
of disorders that occur with chest pain in a rural health
activities for clinical examination
units or FP (4-category)
and rehabilitation
That the student should be able to solve the problems of patients with chest pain:
№
List of skills
Basic level
1.
Student should be able to ask questions of
rational concise questions that really helps to set the
probable diagnosis.
2. The student must be able to specifically identify
and assess the patient's complaints.
3. The student must be able to analyze medical
Ask the patient and his relatives
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics
of their development.
4. The student must be able to analyze life history:
the identification of risk factors, the health of parents
and family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient,
based on an objective approach
Measure blood pressure.
1.
Student should be able to hold tonometry with
the incremental principle.
1.
The student must be able to conduct a survey of
the spine with the incremental principle.
2.
The student must be able to identify signs or
Rate spine (inspection and palpation,
symptoms:
including functional tests)
- Pathological lordosis and kyphosis
- Curvature of the spine
- Functional disorders
-Characteristic of osteochondrosis
The student must be able to identify features:
- Characteristic shingles rash.
An inspection of the skin
The student must be able to detect the presence of
cold, moist and pale skin
The student must be able to detect:
Explore the pulse of the carotid, radial
- The presence or absence of a pulse
and femoral arteries
The student must be able to evaluate the properties of
the radial artery.
The student must be able to detect:
Palpate the chest
- Local tender points in joints sternocostal.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and
- Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
36
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and - If the heart murmur, be able to identify their
auscultation of heart and vascular system. epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
Student should be able to conduct surface and deep
palpation of the abdomen
The student must be able to identify features:
Conduct palpation, percussion of the
- Acute abdomen
abdomen
- Hepatomegaly, splenomegaly.
The student must be able to assess:
- All available structures in the abdomen
The student must be able to detect:
Inspect the limb
- Swelling
-Varicose veins of the extremities
The student must be able to identify features:
Calculate the index weight / body
- Underweight
- Increased weight.
1. The student must be able to evaluate sensitive
area with the step and identify the principle
characteristics:
- Sensory disturbances (analgesia hypalgesia,
gipostezii, anesthesia, parastezii, dysesthesia, etc.).
2. The student must be able to evaluate reflexes
(neurological hammer) and identify features:
Conduct a neurological examination.
- Hyperreflexia
- Hyporeflexia
- Areflexia
3. The student must be able to assess motor function
and symptoms violateniya
4. Student should be able to point out the symptoms
of spinal lesions.
Student should be able to hold ophthalmoscopy with
the principle of step and look of the eye, and to
Hold ophthalmoscopy
identify features:
- Arteriovenous Crossings
Student should be able to palpate the breast and detect
Inspect the mammary gland
entities (nodes).
The student must be able to identify features:
- Impaired fasting glucose
Interpret the clinical and biochemical
- Impaired glucose tolerance.
- Dislipidemia
The student must be able to identify features:
Interpret the X-ray picture of light
- Pneumonia
- Pneumothorax
37
ECG and decrypt it.
Differentiate disease accompanied with
chest pain
Give non-medical advice
Provide prehospital care
Hold the pleural puncture
Rational use of medicines in the
treatment of diseases that occur with pain
in the chest.
Conduct monitoring and surveillance of
patients
- Pleurisy
- Lung cancer and tuberculosis
1. The student must be able to record the ECG with
the incremental principle.
2. Student should be able to decipher the results of
the ECG and identify signs:
- Myocardial ischemia
- MI
- Hypertrophy of the heart.
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
Student should be able to provide prehospital care in
case of emergency.
The student must be able to conduct the pleural
puncture technique for spontaneous pneumothorax.
1. The student should be able to choose products
with proven effectiveness.
2. When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control:
- The level of glucose in the blood
- The level of the BP.
- The level of blood lipids
Practical class № 1
Topic: " Chest pain. Diseases with chest pain. The most dangerous illnesses, running from chest
pain. Differential diagnosis of NDCs, coronary angina, PICS. Tactics GPs. Indications for
referral to a specialist to whom the hospitalization profile department. The principles of
treatment, monitoring, control and rehabilitation in RHU or family policlinics. Definition of
disability. Principles of teaching tools"- 6.7 hours.
Justification of the theme: Pain in the chest is one of the most common causes of rotating the patient
for medical help. Although the possible causes of chest pain are many, to moments accurate diagnosis
of any chest pain should be seen by a GP as the pain supposedly cardiogenetic origin on the one hand
and the need to avoid the most dangerous diseases on the other. In this situation, the force of a general
practitioner (GP) should be directed first before the exclusion of the most dangerous diseases, such as
myocardial infarction, pulmonary embolism, spontaneous pneumothorax culated, dissecting aortic
aneurysm, etc. After you have removed the above condition, GPs must avenue of conduct differential
diagnosis of chest pain. This syndrome occurs, including in neurocirculatory dystonia (NCD) and
ischemic heart disease (angina), which are widely distributed in thepopulation. Of GPs requires a deep
knowledge of diagnosis, care and the exact place of the dislocation in this group of patients to be
38
treated in a rural health units, or FP, or directionandlysedin specialhospitals.These circumstances are
the mainaniem to include this subject in the training of GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options for different variants of the NDC, angina, coronary heart disease, as well as the principles of
their management in primary care, provided the requirements of "Qualification characteristics of a
general practitioner".
Learning objectives:
1.Consider options for the clinical diagnosis of various NDCs.
2.Consider different variants of the diagnosis of angina (stable angina - 4 FC and unstable angina).
3.Discuss these clinical-laboratory and instrumental data for NDCs, different variants of angina.
4.Make a differential diagnosis NDCs, angina.
5.Identify the main diagnostic criteria for NDCs, angina.
6.Discuss the indications for surgical treatment of coronary artery disease.
7.Discuss issues in the tactics of qualifying characteristics of GPs
8.Discuss the principles of treatment (non-drug and drug).
9.Discuss the principles of management, supervision and monitoring of patients in a rural health
units or a family policlinics.
10. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
11.Demonstrate patients with NDCs and angina.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiated by clinical
and laboratory data of instrumental studies NDCs, angina. Set prelight sensitivity diagnosis and
determine the future tactics of the patient.
GPs should know:
1. The list of diseases that present with chest pain.
2. A list of the most dangerous diseases that present with chest pain
3. Etiology, pathogenesis, and classification of NDCs, CHD angina.
4. Clinical manifestations of NDC, stable and unstable angina.
2. Differential diagnosis of various types of NDCs, angina.
3. Pharmacodynamics of drugs used in the treatment of angina and the NDC.
4. Indications for surgical treatment for angina.
5. Principles of follow-up and monitoring of patients with coronary artery disease with angina
pectoris.
6. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints for different NDCs and angina.
1. Diagnose, differentiate NDCs, angina clinic and laboratory - instrumental studies;
2. ECG recording technique and decipher it.
3. Choose products with proven efficacy
4. Advise on non-medicated treatments.
5. To monitor the RHU or in family policlinics.
GPs should do:
1.Competently prescribe treatment for patients with NDCs, angina, depending on the course.
2.To fill out the medical history of a patient with NDCs, angina.
3.Assign the required survey plan for NDCs, angina.
4.Interpret the results of the ECG in patients with NDCs, angina.
39
5. Prescribe treatment for patients with NDCs, angina.
6. Appoint a medical examination, the primary and secondary prevention with the NDC, angina.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with NDCs, angina and PICS.
2. Interpretation of ECG at NDC, angina, and PICS.
3. Writing of drugs for the treatment of patients with NDCs, angina.
Place of activity:
1. Training themed room.
2. Cabinet ECG
3. Cabinet GPs.
The course is taught
The structure of the lessons:
Checking the initial level of preparedness of students to engage in: Check initial level of preparedness
of students for employment: "The pain in chest. Of diseases that present with chest pain. The most
dangerous diseases that present with chest pain. Differential diagnosis of NDCs, coronary angina,
PICS. Tactics of GPs. Indications for onboard to a specialist or hospitalization profile department. The
principles of treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of teaching topics."
1. Clarification time with GPs at NDCs, angina.
2. Decision analysis and situational problems.
3. Clinical analysis of supervised patients. Demonstration of patients.
4. Service calls to your home.
5. Report on the results of calls served on the house.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
40
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients
12.2012.40.
12.4014.00
Study skills.
Student
under
the
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students with the use of
the method “rotation”.
Students handed out
ECG, they need to
analyze, decipher and
treatment. Address the
situation of main tasks
on the topic.
Patient or volunteer.
20 minutes
Table, corresponding 30 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
research,
case
studies.
The theoretical part includes:
NDC has a functional nature and is characterized by disorders of mostly CV system. In
adolescents and young NDC often caused physical mismatch of development and the formation of
neuroendocrine regulation of autonomic functions. Individuals of all ages develop NCD may promote
fatigue in the outcome of acute and chronic infectious diseases and intoxication, lack of sleep, fatigue,
improper diet, sex, physical activity (lack of exercise or physical overload). A number of patients have
a family history of value vasomotor sympathological reactions. Clinical manifestations usually consist
of the symptoms of neurosis state (weakness, fatigue, sleep disorders, irritability) and functional
circulatory disorders, the predominant character of which is divided into three types of NCD: cardiac,
anti-hypertensive and hypertensive.
Cardiac type NDC establish the absence of significant changes in blood pressure on the
complaints of palpitations, irregular heart area, and sometimes shortness of breath on exertion and
objective abnormalities in the activity of the heart - the tendency to tachycardia, severe respiratory
arrhythmia, presence of supraventricular arrhythmia, paroxysmal tachycardia, inadequate load changes
cardiac output or others, sometimes marked ECG changes in the form of high-voltage or reduced T
wave.
Hypotensive type NDC manifested symptoms of chronic vascular disease (a systolic blood
pressure below 100 mm Hg.). Which is based mostly lies hypotension veins, arteries hypotension. The
majority of patients with reduced cardiac index increased peripheric vascular resistance (only about
25% of the increased cardiac output is determined). A number of patients is determined by reducing
the sympathy and optical activity. The most common complaints are fatigue, muscle weakness,
headache (provoked hunger), sensitivity to cold hands and feet, the tendency to orthostatic disorder
properties. Most patients asthenic physique, pale skin, hands often cold, wet hands, orthostasis, usually
tachycardia and decreased pulse AD.
Hypertensive type NDC characterized transient increases in blood pressure, which is almost half
of the patients may not be combined with changes in health and first time curves detected during a
physical examination. In some cases the complaints of headache, palpitations, fatigue. This type of
NDC and practcally coincides with the state, defined as a border hypertension (see Arterial
hypertension).
Treatment is directed primarily to the underlying disease (neurosis, pathological menopause,
etc.), also includes the pathogenetic therapy (sedation, if necessary, anticholinergics, adrenergic
blockers), and symptomatic of the application - hypotenzsive, antiarrhythmics, etc. In all cases showed
normal work and rest, ensuring full sleep, exercise (swimming). Using physiotherapy, balneotherapy,
sanatorium-spa treatment.
Emergency treatment of autonomic crises begin with parenteral administration of 10 mg
Seduxenum. When adrenergic stroke shown beta-blockers (e.g., parenteralor oral), and in patients with
severe diastolic blood pressure rise as alpha-blockers (phentolamine, thropaphen).When cholinergic
41
crisis subcutaneously injected atropine, platifillin, and the concomitant rise in blood pressure
expressed, excitement stomach-gangleron.
Angina -sudden attacks of chest pain due to lack of blood supply to the myocardium - the
clinical form of ischemic heart disease. For angina pain is always differs with following features: 1) is
in the nature of attack, that is, has a clear-cut time of occurrence and cessation, remission, and 2) there
is, under certain conditions, 3) begins to fade em or completely terminated under the influence of
nitroglycerin (1 to - 3 minutes after sublingual administration). This conditions singing in angina
attack: most - walking (pain when accelerating movement when climbing a hill, with a sharp head
wind, walking after a meal or with a heavy load). Pain, the origin of which is not clear, there may be
variations in atypical CHD. Stable angina qualify the so-called functional class (FC).
CHD to include individuals with stable angina attacks are rare, only caused excessive physical
exertion. If the attacks stable angina arise under normal loads, but not always, this is dated angina FC
II, and in the case of attacks with small (household) loads - to FC III. FC IV fixed in patients with
seizures at the lowest load, and sometimes the lack of them.
The basis of any stage of diagnosis of angina is properly constructed and carefully conducted
races demand patient. In unclear cases a exercise test (bicycle stress test) in order tohide an existing
phenomenons of coronary insufficiency.Tactics of diagnosis determines the sequence of the following
schematic solution main issues: coronary (angina) whether the nature of the pain, whether there are
signs of preinfarction angina unrelated whether the present aggravation of coronary artery disease in
the sample with extracardiac influence (related) diseases? Only convincing argumented negative
answer to the first three questions is entitled to search for a different reason (source) pain: detecting the
patient another disease as the source of his pain can not exclude the presence of his time and stroke as
a manifestation of coronary heart disease.
Outpatient treatment of various options angina. Cupping: quiet, preferringlight sensitivity
sitting position of the patient, sublingual nitroglycerin tablets or 1 1 - 2 drops of 1% solution of a
sugar, re-taking the drug with no effect after 2 - 3 minutes; valokordin - 30 - 40 drops into a sedative
to, treatment of opportunistic diseases, especially of the digestive system, prevention of
atherosclerosis, the preservation and the gradual expansion of the limits of physical activity (including
the functionality of the patient).
Treatment in interictal period: rare angina (FC 1) - nitrate (nitrosorbid 10 - 20 mg per dose) in
anticipation of heavy loads.Angina FCII requires continuous use (years!) blockers, beta-adrenergic
receptors (propranolol, obzidan, etc.) of their individual dose (10 to 40 - 60 mg for 1 dose), it is
desirable reception 4, not 3 times a day (at the present time, there were sustained release formulations
), and last at least 3 - 4 hours before going to bed, while the heart rate should be reduced to 60 - 70 in 1
min (not being counted on ECG performed alone, but only in the active stateof hurt!). Nitrates
(nitromazin, trinitrolong, etc.) should be used systematically, and to stop the attacks (stabilization of
course) - just before the loads (tour of the city, emotional stress, etc. nitrosorbid take 10 mg of 4 - 6
times a day ( effect of the drug lasted for 2.5 - 3 hours); Nitrolime ointment applied to the skin every 4
- 6 hours (valid for 4 - 5 hours), including just before going to sleep.
When angina FC II and above - stopping antianginal drugs (singularity of beta-blockers - the
phenomenon of "impact"!) even for a short period is not justified and therefore appropriate.Work is
also treatment of opportunistic diseases - hypertension, diseases of the GI tract etc.
Prognosis in the absence of complications is relatively favorable. Employability is retained, but
with a work requiring considerable physical effort. At higher grades of angina should provdit selective
coronary angiography to address the issue of surgical treatment. All patients with angina for follow-up
and secondary prevention of CHD.
Handout
Students dealt with the content and lists the name of the definition of pathology topics, examples
of analyzes for different diseases, differential - diagnostic criteria.
Equipment Workshop:
42
1. Table: Classification and diagnostic criteria for NDCs, angina, and coronary artery disease PICS.
2. Patterns of ECG, laboratory and instrumental studies at NDCs, angina, and coronary artery disease
PICS.
3. Tables: differential treatmentNDC, CHD angina, PICS.
4. ECG machine.
Independent work and self-education
Topic: Physiological functions of the heart muscle. The etiology and pathogenesis, classification and
treatment standards NDC, CHD, myocarditis and myocardiodystrophy.
1. Independent work with literature in the library and at home.
2. Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference chair.
3. The development of the interpretation of ECG, echocardiography, laboratory data.
4. Service calls at home.
Teaching practice during the lesson.
Supervision of patients with NDC, CHD, PICS.
The number of hours -1.5 hours.
Quiz
1. The etiology and pathogenesis of NDCs, CHD.
2. Classification and diagnostic criteria for NDC.
3. Outpatient treatment of patients with NDC and tactics of GPs in different types of NCD.
4. Differential diagnosis of NCD with stable angina pectoris.
5. Classification of angina and tactics GPs in different types of flow angina.
6. Standards for the treatment of various variants of angina in the hospital, FP and RHU.
7. Primary and secondary prevention of CHD.
8. Principles of follow-up and monitoring of patients with coronary artery disease with angina
pectoris.
Practical lesson № 2
Topic: "Chest pain. Differential diagnosis of coronary heart disease, myocarditis and
myocardiodystrophy.Tactics GPs.Indications for referral to a specialist or hospitalization in the
profile department. The principles of treatment, follow-up, monitoring and rehabilitation in
RHU or family policlinics. Definition of disability.Principles of Teaching Tools"- 6.7 hours.
JustificationTopics: Heart diseasesare one of the common causes of chest pain. Among the causes of
cardiac origin th CHD plays a special role because of chest pain is often the only symptom in this
disease, and has the characteristics. However, chest pain seen with myocarditis and myocardial
dystrophy. These most frequently observed among the working population. Recent years, the number
of patients with the above listed diseases are increasing. Of GPs requires a deep knowledge of
diagnosis, health-care, and details of where the dislocation in this group of patients to be treated in a
rural health units or a family policlinics, or in the direction of specialization and hospitals.These
circumstances are the basis for the inclusion of this subject in the program of GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options for different variants of the angina pectoris, myocarditis and myocardial dystrophy, as well as
the principles of their management in primary care, provided the requirements of "Qualification
characteristics of a general practitioner".
Learning objectives:
1. Consider the timely and early detection of different variants of the angina (stable or
unstable), myocarditis and myocardial dystrophy.
43
2. Discuss these clinical - laboratory and instrumental data for angina, myocarditis and
myocardial dystrophy.
3. Make a differential diagnosis of angina, myocarditis and myocardial dystrophy.
4. Identify the main diagnostic criteria for angina, myocarditis and myocardial dystrophy.
5. Discuss questions about tactics in the qualifying characteristics of GPs
6. The principles of treatment (non-drug and drug).
7. Principles of management, follow-up and monitoring of patients with coronary heart
disease, myocarditis and myocardiodystrophy in RHU or family policlinics.
8. The principles of primary, secondary and tertiary prevention in these diseases.
9. Demonstrate patients with angina pectoris, myocarditis or myocardiodystrophy.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiate the
clinic to the laboratory and instrumental studies of angina, myocarditis and myocardial dystrophy,
establish a preliminary diagnosis and determine the future tactics of the patient.
GPs should know:
1. Etiology, pathogenesis, and classification of angina, myocarditis and myocardial dystrophy,
2. Clinical symptoms and syndromes for angina pectoris, myocarditis and myocardial
dystrophy.
3. Differential diagnosis of various types of angina pectoris, myocarditis and myocardial
dystrophy.
4. Pharmacodynamics of drugs used in the treatment of angina pectoris, myocarditis and
myocardial dystrophy.
5. Principles of follow-up and monitoring of patients with coronary heart disease, myocarditis
and miokardistrofiey.
6. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints for different types of angina, myocarditis and
myocardial dystrophy.
2. Diagnose, differentiate angina, myocarditis and myocardial dystrophy the clinic and
laboratory - instrumental studies.
3. Rational use of medicines
4. Advise on non-drug methods of treatment, as well as healthy living
5. ECG recording technique and interpretation of it.
GPs should do:
1. Competently prescribe treatment to patients with angina pectoris, myocarditis and
myocardial dystrophy, depending on the course.
2. To fill out the medical history of the patient with angina pectoris, myocarditis, and
myocardiodystrophy.
3. Assign the required survey plan for angina, myocarditis and myocardial dystrophy.
4. Interpret the results of the ECG in patients with angina pectoris, myocarditis, and
myocardiodystrophy.
5. Prescribe treatment in patients with angina pectoris, myocarditis, and myocardiodystrophy
caused by various conditions.
6. Appoint a medical examination, to carry out prevention of angina pectoris, myocarditis and
myocardial dystrophy in a rural health units, or family policlinics.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with angina pectoris, myocarditis, and miokardiodistrofiey.
44
2. ECG interpretation in angina pectoris, myocarditis and myocardiodystrophy.
3. Writing of drugs for the treatment of patients with angina pectoris, myocarditis, and
miokardiodistrofiey.
Place of activity:
1. Training themed room.
2. Cabinet ECG
3. Cabinet GPs.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "The pain in chest.
Differential diagnostics CHD, myocarditis and myocardial dystrophy. Tactics GPs. Indications
for referral to a narrow specialcare professional or hospitalization profile department.The
principles of treatment, follow-up, control and to rehabilitation in RHU or family policlinics.
Principles of prevention.Definition of disability. Principles imparted and topics".
2. Clarification tactics GPs angina, myocarditis and myocardial dystrophy.
3. Decision analysis and situational problems.
4. Clinical analysis of supervised patients. Demonstration ill.
5. Service calls to your home.
6. Report on the results of calls served on the house.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
45
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
12.4014.00
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students with the use of
the method, "a swarm
of bees."On thequestion
of students on the topic
ofadoption.Students
ECG, they need to
analyze, decipher and
give
aconclusion.Decision
problems on the topic.
Table, corresponding 80 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
research,
case
studies.
The theoretical part includes:
Myocarditis- an inflammatory disease of the heart muscle. Distinguish between primary and
secondary myocarditis. Primary myocarditis often cause various pathogens (bacteria, viruses, fungi,
protozoa, helmints). Depending on the type of pathogen are specific and nonspecific myocarditis. Less
frequent loss of the heart muscle as a result of exposure to radiation, toxic substances, injury. In
addition, myocarditis develops with collagenosis (systemic lupus erythematosus, rheumatoid arthritis,
dermatomyositis), rheumatism, stopryh pneumonia, drug disease. Myocarditis under specified
conditions or not mandatory symptom.
The etiological classification of myocarditis.
6. Viral myocarditis.
Etiofactory viruses: Coxsackie A and B, polio, mumps, measles, rubella, influenza (A & B),
dengue fever, chickenpox, shingles, herpes simplex virus, Epstein-Barr virus, HIV, cytomegalovirus.
1. Bacterial myocarditis.
Etiofaktory specific and non-specific pathogens: rheumatic fever, scarlet fever, typhus and
typhoid fever, salmonellosis, meningococcal disease, tuberculosis, syphilis, brucellosis, etc.
1. Fungal myocarditis (frequent pathogen Cryptococcus neoformans).
2. Myocarditis caused by protozoan diseases: Lyme disease, toxoplasmosis, chlamidiaze.
3. Myocarditis with helminths (trichinosis, echinococcosis).
4. Radiation myocarditis.
5. Toxic myocarditis.
6. Posttraumatic myocarditis.
7. Allergic myocarditis (medicinal and parasitic origin).
8. Myocarditis with collagenosis.
Allocate a specific form of severe myocarditis - idiopathic myocarditis Abramov-Fiedler
(pseudocoronary variant of myocarditis).
Pathological anatomy and pathogenesis. Under the influence of the antigen is either diffuse lesion
parenhimy - muscle cells and interstitial or focal lesions of the interstitial connective tissue. Allergic
and immuneprocesses are developed onto the antigen, which has a close antigenic structure of
myocardial cells. Infiltration of inflammatory cells is dependent on the nature of inflammation
(infectious or immune inflammation). Diffuse changes myocardial lesions may be accompanied by
cardiac conduction system.
Diagnosis of myocarditis.
Based on the presence of clinical symptoms of heart disease and the results of additional research
methods.
5. Peripheral symptoms include pallor, cyanosis of the lips, fever.
6. Symptoms of the cardiovascular system:
a) pain symptoms (long blunt, stabbing pains in the heart of the lack of effect of nitrates);
46
b) objective signs of heart disease: the weakening of the apical impulse, expanding the
boundaries of the heart, diastolic gallop rhythm or (and) systolic murmur, voiceless heart sounds,
blood pressure reduction, the violation rate and rhythm of cardiac activity;
c) signs of cardiovascular disease by left ventricular or type (s) for the type of right ventricular
(shortness of breath, swelling of the neck veins, rales over the lungs, liver enlargement, swelling
in the legs);
3. Communication with the disease and the availability etiofaktorom prodromal period.
4. These additional methods of research supporting heart disease:
 ECG: transient ST-segment changes and tooth T;
 Echocardiography and X-ray of the heart - increase the size of the heart;
 acute phase reactant: accelerated ESR, eosinophilia, neutrophilic leukocytosis, an increase
of sialic acid, fibrinogen, positive C-reactive protein, an increase disproteinemia globulin
fraction, increased cardiac isoenzymes.
Clinical forms of myocarditis flow:
Acute, subacute, chronic.
Diagnostic criteria for myocarditis
1. Sinus tachycardia.
2. I weakening tone.
3. Dysrhythmia, including gallop.
4. ECG changes: slow atrioventricular conduction, impaired repolarization (ST-T).
5. Cardiomegaly.
6. Increased aspartate aminotransferase (AST).
7. Congestive heart failure.
Complications of myocarditis:
 congestive heart failure (cardiac asthma, pulmonary edema);
 paroxysmal arrhythmias in heart failure;
 atrioventricular block with heart failure;
 pericarditis;
 development of dilated cardiomyopathy;
The most common complications are idiopathic myocarditis Abramov-Fiedler (atrial
fibrillation, thromboembolic syndrome, progressive cardiac failure).
The differential diagnosis of myocarditis.
The differential diagnosis of myocarditis is carried out with organic and functional lesions of the heart:
1. rheumatic myocarditis;
2. allergic myocarditis;
3. myocarditis in collagenosas;
4. cardiomyopathies;
5. pericarditis;
6. myocardial dystrophy (with endocrinopathy, anemia, and climacteric alcoholic
cardiomyopathy);
7. myocardial infarction or angina;
8. cardioneurosis;
9. myxoma of the left atrium or ventricle;
10. endocarditis different etiologies;
11. aneurysm ventricular
12. congenital heart disease.
Treatment of myocarditis.
Diet table number 10 to Pevsner, bed rest before the disappearance of pain andsigns of heart failure.
Etiotropic treatment applied at a known etiology. Rheumatic myocarditis and use - salicylates,
sometimes prednisolone, in allergic myocarditis against the early phase of opisthorchiasis after
47
preparatory pathogenetic therapy etiotropic praziquantel treatment, systemic lupus erithmatosus - used
prednisolone or prednisone combination with cyclophosphamide (metatrexat). Radiation myocarditis
treated with prednisolone. Symptomatic treatment includes correction of cardiovascular disease,
Prophylaxy and treatment of arrhythmias, metabolic therapy (Riboxin, Panangin, Parmidin etc.),
sanitation of foci of infection.
Outcomes: recovery, development myocardiac cardiosclerosis with jetlag or (and) heart failure, the
development of dilated cardiomyopathy.
Clinical examination. Patients with a history of myocardit seen by a cardiologist or physician, the
frequenc depends on the severity of the disease, presence of concomitant diseases.The survey includes
about the blood, echocardiography and ECG, other research and advice on the testimony. Performs
primary and secondary prevention of myocarditis.
4. The term "myocardial" means the disease occurs as a result of myocardial violation its
metabolism (and energy), which leads to a lack of contractile and other functions of the heart.The
concept of "myocardial degeneration" was introduced by GF Lang (1936),which brought together
for the term disease of the heart muscle is not inflammatory and coronary nature revealed by earlier
different terms: cardiomyopathy, "myocardosis", "myodegeneration heart", etc.
Etiologic agent of the disease include vitamin deficiency diseases (beriberi, scurvy, rickets,
pellagra), anemia (acute and chronic), endocrine and metabolic disorders (diabetes mellitus,
hyperthyroidism, hypothyroidism, Adrenocortical insufficiency, pheochromocytoma, obesity,
abnormal menopause) , infection (acute and chronic), endogenous intoxication (kidney and liver
failure, cancer intoxication, Mts. suppurative processes), exogenous intoxication: a) acute
(barbiturates, cardiac glycosides, amitriptyline, dichloroethane, etc.), b) chronic (nicotine , alcohol),
and c) professional (lead, benzene, carbon disulfide), physical stress (acute and Mts.) dysmetabolic
influence (fermentopathy, hemochromatosis, eating disorders), physical agents (ionizing radiation,
vibration, trauma gr. cells, weightlessness, high-frequency currents, etc.), neuromuscular disease
(myasthenia gravis, myotonic dystrophy), neurogenic effects (stress, sympathicotonia) postnatal
influences.
A drift myocardiodystrophy divided into acute, chronic and myocardiodystrphy..
Diagnosis of myocardial dystrophy
The clinical picture of myocardial diverse - from latent flow to the severe stage of heart failure.
Acute myocardial dystrophy develops in its acute congestion due to physical stress, a sudden
increase in blood pressure in a large, or pulmonary circulation (hypertensive crisis, acute nephritis,
PE).
In the early stages of chronic course myocardiodystrophy no clinical illness. Only with the
development of heart failure patients begin to complain of shortness of breath, palpitations on exertion,
fatigue, decreased working ability, appear not pleasant, and more in the heart, which, as a rule, has the
character of Cardiology. However, for some myocardiodystrophy such menopausal pain may resemble
angina, which requires differential diagnostics with CAD. Myocardial can cause heart rhythm
disturbances, feelings of outages, attacks the heartbeats. Along with the complaint, and marked
expansion of the boundaries of the heart due to hypertrophy and dilatation, muted tones, gallop,
systolic murmur at the apex and at Botkin, usually poor conductors, soft and variable tone. Clinical
picture myocardiodystrophy nonspecific, it is very similar to that of myocarditis and cardiosclerosis
myocarditis and atherosclerotic origin. On that these diseases first step is to conduct differential
diagnosis.
Classification of clinical stages myocardiodystrophy
Stage
Ineurofunctional
Clinical symptoms
ECG changes
Circulation
pattern
Subjectively: transient, unfounded, Shortening the interval P- Hyperdynamic
stitching or drawing pains in Q, udlenenenny QT,
region. heart palpitations, feeling kosovoskhodyaschy
48
short of breath, fatigue, headaches, segment ST, spiky T
poor sleep, irritability, sweating.
wave
OBJECTIVE: wet cold hands, the
normal limits of the heart, sonorous
tones, weak systolic murmur at the
apex of the heart, tachycardia, a
moderate increase in blood pressure
II-falselySigns of left ventricular Hypodynamic
structural
hypertrophy,
(organic phase
intraventricular block
change)
compensation
IIA corresponds NC Art.
Flattening and inversion
period
of the T wave, segment
depression
ST,
arrhythmia.
period
of IIB corresponds NC Art.
decompensation
III-metabolic
Dystrophic stage corresponds NC
The same as in the II-Art. Hypodynamic
forms of heart
Usually
more
failure
pronounced
The basic method of ECG diagnosis of myocardial dystrophy research. When the ECG and
myocardial dystrophy basically end portion of ventricular complex (ST segmentand T wave).Often
there is a segment depression ST, which has a bottom-up nature of the T wave is positive and is
combined with a sinus tachycardia. For myocardial degeneration due to digitalis toxicity characteristic
navicular segment depression ST, combining with negative T waves and shortening the interval Q-T,
sinus bradycardia, arrhythmia and conduction band. In some forms of myocardial dystrophy, for
example when pheochromacytome may appear deep negative T wave. In myocardiodystrophy can be
determined QRS voltage is not expressed, especially with obesity and myxedema, but thyrotoxicosis
voltage is often elevated and cardiac slows internal conductivity, extended interval Q-T, there is a
violation of intraventricular conduction.
For diff. diagnosis of coronary artery disease with myocardial dystrophy myocarditis conducted ECG
studies with pharmacological tests (used potassium, B-blockers, B-agonists).
Alcohol myocardial
Quite often the cause of cardiomegaly and is the result of prolonged use of a large amount of
alcoholic beverages.
Clinical forms of alcohol myocardiodystrophy
1. The classical form of all manifestations of chronic alcoholism, liver enlargement, false
angina, especially at night, shortness of breath, palpitations, irregular, deterioration occurs
2-3 days after ingestion of large amounts of alcohol.
2. Pseudoischemic form: more pain in the heart, low-grade fever, cardiomegaly, arrhythmias,
clinical NC.
3. Arrhythmic form manifests MA, extrasystoles, paroxysmal tachycardia, dyspnea, and
cardiomegaly.
Clinical stage and alcohol myocardiodystrophy
I stage. (Initial) lasts about 10 years, the clinic reminds NDC.
II stage. Develops in patients with alcohol abuse for over 10 years. Complaint: shortness of breath,
cough, swelling in nogah. Observed acrocyanosis, puffy face, swelling, congestion in the small circle.
Heart borders enlarged HN in both directions, the tones are deaf, sometimes gallop rhythm,
arrhythmia, the increase of the liver. ECG LVH. Vnutrizheludochkovoy block, T wave changes, etc.
IIIstage. Meets dystrohpic stage CHF.
49
Treatment of patients with myocardial dystrophy.
Begins with the treatment of the disease, which was the cause of myocardial dystrophy.
Eliminate the causes arising dystrophy infarction - no smoking and alcohol, elimination of physical
and emotional exertion. Patient treatment depends on the severity of heart failure. Treatment of
patients and myocardio-electrolyte disturbances are reduced due to the correction of the
violations.When myocardiodystrophy due to increased adrenergic effects on the heart, showing the use
of B-blockers. Used drugs stimulate the metabolic processes myocardium (riboksin, inosine, vitamin
B, Anabolic steroids).With the development of heart failure shows the use of cardiac glycosides. When
alteration heart rate prescribed antiarrhythmic heart.
Indications for cardiac transplantation. Heart transplantation is the only effective treatment for
most patients with end-stage heart failure. Many heart transplant can not only extend the life of the
patient, but partially, and sometimes fully restore disabled patients.
Primary prevention of myocardial dystrophy focused on early treatment and prevention of
diseases and injuries which may cause myocardial dystrophy.
Necessary to promote a healthy lifestyle, not smoking or drinking and controlled physical
training and sports.
Secondary prevention is reduced to timely complete treatment of anemia, endocrine
diseasestions, acute and chronic infections and intoxications. Remediation of chronic foci of infection
can not only predupredit myocardiodystrophy progression, but also to regress dystrophic process.
Clinical examination by a cardiologist to be people with chronic diseases proceeding with
myocardial dystrophy myocardiodystrophic cardiosclerosis (neuroendocrine disorders, anemia, chronic
toxicity), the physician determines the activities to rehabilitation.
Definition of disability depends on the nature of the underlying disease, flow, stage of disease
and complications.
Handout
Students dealt with the content and lists the name of the definition of pathology topics, examples
of analyzes for different diseases, differential - diagnostic criteria.
Equipment Workshop:
1. Table: Classification and diagnostic criteria forcoronary heart disease, myocarditis and myocardial
dystrophy
3. Tables: differential treatmentof CHD, myocarditis and myocardial dystrophy.
Independent work and self-education
Topic: Physiological functions of the heart muscle. The etiology and pathogenesis, classification and
treatment standards CHD, myocarditis and myocardiodystrophy.
1. Independent work with literature in the library and at home.
2. Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference chair.
3. The development of the interpretation of ECG, echocardiography, laboratory data.
4. Service calls at home.
Teaching practice during the lesson.
Supervision of patients with coronary heart disease, myocarditis and myocardiodystrophy
The number of hours -1.5 hours.
50
Quiz
 The etiology and pathogenesis of coronary heart disease, myocarditis and myocardial
dystrophy.
 Outpatient treatment of patients with coronary artery disease and tactics GPs.
 Primary and secondary prevention of CHD.
 Classification of cardiomyopathies. Change the configuration of the heart with
cardiomyopathyiyah.
 Features cardiomegaly with myocardial dystrophy.
 Clinic and diagnosis of alcoholic myocardial dystrophy.
 Standard Treatment Guidelines myocardiodystrophy depending on the etiology.
 Indications for cardiac transplantation.
 Classification of myocarditis.
 Diagnostic criteria for myocarditis.
 The principles of treatment of myocarditis.
 Indications for referral to a specialist in CHD.
 Clinical examination of patients with coronary heart disease, myocarditis and
myocardiodystrophy.
Practical lesson № 3
Topic: «Chest pain. Differential diagnosis of osteoarthritis of the spine, intercostalneuralgia
tion, chest injuries, shingles. Tactics of GPs. Indications for referral to a specialist or hospital in
the profile department. The principles of treatment, outpatient observation, control and
rehabilitation in RHU or family policlinics. Principles of prevention. Determination working
ability. Principles of teaching the topics »-6.7 hours.
Justification topic: Defining a tactic of patients with chest pain caused by various diseases (pathology
of the spine, chest, shoulder girdle muscles, shingles), for the primary care physician is a difficult task,
since GPs will have to decide on the definition, be treated in a rural health units or a family policlinics,
or referral to specialized hospitals.These circumstances are the basis for the inclusion of this subject in
the training of GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options for pain in the chest associated with the pathology of the spine, anterior chest, shoulder girdle
muscles, herpes zoster, and the principles of their management in primary care, provided the
requirements of «qualifying characteristics of a general practitioner. "
Learning objectives:
1.
Consider diagnosis of chest pain associated with the pathology of the spine, anterior chest wall,
muscles of the shoulder girdle.
2.
Demonstrate patients with chest pain associated with the pathology of the spine, anterior chest
wall, muscles of the shoulder girdle.
3.
Discuss the differential treatment (non-pharmacological and pharmacological), pain in the chest
associated with the pathology of the spine, anterior chest wall, muscles of the shoulder girdle.
4.
Discuss questions about tactics in the qualifying characteristics of GPs with pain in the chest
associated with the pathology of the spine, anterior chest wall, muscles of the shoulder girdle.
5.
Principles of management, supervision and monitoring in RHU or family policlinics.
6.
The principles of primary, secondary and tertiary prevention in these diseases.
7.
Discuss the indications for determining disability of patients with chest pain associated with the
pathology of the spine, anterior chest wall, muscles of the shoulder girdle.
Expected results
51
Conducting this training gives the opportunity to study in a timely and properly diagnose conditions
associated with the pathology of the spine, anterior chest wall, muscles of the shoulder girdle and
shingles, as well as to determine the future tactics of the patient.
GPs should know:
1. The mechanism of pain in the chest associated with the pathology of the spine, anterior chest
wall, muscles of the shoulder girdle.
2. Clinical manifestations of chest pain.
3. Differential diagnosis of chest pain associated with the pathology of the spine, anterior chest
wall, muscles of the shoulder girdle.
4. Indications for hospitalization of patients with pathology of the spine, anterior chest, shoulder
girdle muscles, herpes zoster in the profile department.
5. Of drugs used in the treatment of chest pain associated with the pathology of the spine, anterior
chest, shoulder girdle muscles, shingles.
6. Non-drug treatments.
7. Principles of management, supervision and monitoring of patients in rural health units or a
family policlinics.
8. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints of patients with chest pain associated with spinal
pathology, anterior chest wall, muscles of the shoulder belt, the mediastinum.
2. Diagnose, to differentiate on clinical data and laboratory and instrumental studies of chest
pain associated with the pathology of the spine, anterior chest, shoulder girdle muscles,
mediastinum.
3. Determine the ability to work in patients with chest pain associated with the pathology of
the spine, anterior chest, shoulder girdle muscles, mediastinum.
4. The principles of treatment strategy for pain in the chest associated with the pathology of
the spine, anterior chest, shoulder girdle muscles, mediastinum.
5. Advise on non-drug methods of treatment, as well as healthy living
GPs should do:
1. Competently carry out inspection of the patient for the diagnosis of diseases associated with
chest pain associated with the pathology of the spine, anterior chest, shoulder girdle muscles,
shingles.
2. Patient card to fill out the patient with chest pain associated with the pathology of the spine,
anterior chest, shoulder girdle muscles, shingles.
3. Assign the required survey plan for pain in the chest associated with the pathology of the spine,
anterior chest wall, muscles of the shoulder girdle.
4. Interpret the results of the ECG in patients with chest pain associated with the pathology of the
spine, anterior chest wall, muscles of the shoulder girdle.
5. Prescribe medication and perform clinical examination of patients with chest pain associated
with the pathology of the spine, anterior chest, shoulder girdle muscles, shingles.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with chest pain associated with the pathology of vertebrateika, anterior
chest, shoulder girdle muscles, mediastinum
2. Data interpretation of laboratory and instrumental studies at pains in the chest, shoulders denied.
Place of activity:
1. Training themed room.
2. Cabinet ECG
3. Cabinet GPs.
52
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students for employment: "Thepain in my
chest.Differential diagnosis of osteoarthritis of the spine, intercostal neuralgia, chest injuries, herpes.
Tactics GPs. Indications for referral toa specialist or hospitalization profile department. The principles
of treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles and
prevention. Definition of disability. Principles of teaching topics. "
1. Decision analysis and situational problems.
2. Supervision of patients with diseases of the spine, chest trauma and herpes.
3. Clinical analysis of supervised patients. Demonstration of patients.
4. Service calls to your home.
5. Report on the results of calls served on the house.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness
topic.
students. The training
using the "round of the
table". Students given
ECG,
they
must
analyze, explain and
give a conclusion.
53
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 30 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
research,
case
studies.
Decision of problems
on the topic.
The theoretical part includes:
Diseases of the spine. A common cause of chest pain patients who are treated in the clinic, is a
osteochondrosis and herniated discs in the cervical and thoracic spine. Pain with these diseases is dull,
aching in nature, can be localized in any part of the chest, including the thoracic. Enhanced with a deep
breath.
Diseases of the spine, shoulder joints
Osteochondrosis of the cervical or thoracic vertebrae with intervertebral disk herniation and prolapse it
is in the spinal canal.
Traumatic injuries of the spine or shoulder joints.
Primary or metastatic tumors of the spine.
Gross deformities of the spine (kyphosis, scoliosis) or deformation of the ribs, the sternum is a
precondition for the emergence of the axon, muscle pain, seen the detection herpes zoster, which is the
source of pain in the chest. In breathing or absence of respiratory movements of the chest with one
hand indicate lung, pleura, diaphragm, or serious injury to the ribs and intercostal muscles.
Palpation of the chest in conjunction with the data history allows the physician to identify these
diseases of the musculoskeletal system and the peripheral nervous system. Palpation reveals fractured
ribs. Effective strong pressure on the cross-sectional area of the sternum and back ends of the ribs,
which can give a local pain at the fracture edges or other pathological processes.At the thoracic or
cervical radiculitis strong pressure on the head can cause new or worsening pain in the corresponding
neural cortex.
Carefully and deliberately should be palpated muscle formations chest, with the help of which
reveal a pathology of a group of muscles. Sore intercostal muscles as revealed by deep breathing,
coughing, with sharp bends and torso. Soreness of the major and minor pectoral muscle appears when
abduction hands behind his back, determined tonus muscles.
Syndrome for musculo-fascial or costovertebral pain (not visceral) is characterized as follows.
Constant localization.
Unconditional relationship of pain with pressure of the groups of muscles and posture.
The low intensity of pain, the lack of "common symptoms" of the chronic course or clear
conditionality in acute injuries.
Clear evidence palpation that identify pathology, local pain (limited) palpation of relevant muscle
groups, muscular hypertonicity, the presence of trigger zones.
Reduction or disappearance of pain with local agents (mustard, pepper patch, massage, acupuncture,
electrophoresis, infiltration zones pain novocaine, hydrocortisone).
For radicular pain syndrome, including intercostal neuralgia, characterized by the following.
Acute onset or aggravation of chronic course.
The preferential localization of pain in the area of the corresponding nerve.
Clear link pain with spinal movements.
Neurological symptoms of cervical or breast sciatica.
Sharp local pain in places where the nerves.
Tactics GPs.Outpatient treatment.Spine immobilization (bed with hard mattress), heat, analgesics and
kinetics- the basic triad of therapeutic techniques that allow in many cases to arrest worsening pain.
Showing locally irritants - rubbing. Manual therapy. Widely apply traction, massage, physical therapy,
physiotherapy, blockade. Important role in aftercare and prevention of exacerbations is spa treatment.
In the case of long intense pain, despiteafull-ing conservative treatment (3-4 months.), The patient
should be offered admission. Absolute indications for surgery arise paralyzing sciatica, caused by the
pressure of cauda equina drive.
Shingles are caused by reactivation of the virus varicella-zoster, is in cerebrospinal ganglia in patients
with a history of chicken pox. The reason for the reactivation of the virus most cases is unknown, it is
often observed in immunodeficiency, such as leukemia and lymphoma, as well as irradiation vertebra,
54
tumors of the spine and spinalmarrow. The disease occurs at any age, even in infants if they were
infected with varicella-zostervirusin utero. Diagnosis is based on clinical chartsins.
Clinic:The disease begins with radicular pain and hyperesthesia in the area of innervation structure
ganglion.After a few days in the area of innervation of one or two adjacent spinal roots rash. Rash
Chacala presented papules located on infiltration contrary and hyperemic base. Papules quickly turn
into vesicles and blisters, and they in turn to pustules. Then form crusts that to 10-14 th days of the
disease begin to separate, leaving areas of hypopigmentation. Defeat usually unilateral. Can affect any
part of the body, but most often the rash is localized in the area of innervation intercostal and
trigeminal nerves. An increase in morbidity and regional lymph nodes. Complications: 1.Common:
postherpetic neuralgia (in 70-80% of patients are treated within a year, the rest takes years),
blepharitis, keratitis, uveitis. 2. Less frequent, peripheral paresis of the muscles. 3. Raremeningoencephafalit.
Treatment: Local: You should explain to the patient that the excessive use of local resources can lead
to secondary bacterial infection. Calamine lotion to reduce the pain, but their removal is very painful,
noetomu to reduce pain better use of lotions. Frigid water. Very effective film-forming agents with
menthol.
General treatment: aspirin, paracetamol, or acetaminophen with codeine. Acyclovir orally (800 mg 5
times daily for 7 days, start taking should not later than 72 hours from the onset of the rash) reduces
the duration disease and risk infecting others. Instead acyclovir sometimes take corticosteroids
(Prednizolon inward week 1 - 50 mg / day Week 2 - 25 mg / day Week 3 - 12.5 mg / day).
Handout
Students distributed sheets with the content and the topic title, the definition of disease,
examples of analyzes for different diseases, differential - diagnostic criteria. The following is a list of
references and tontrolnye questions.
Equipment Workshop:
1.Tables: clinical manifestations of diseases associated with chest pain associated with pathology
nozvonochnika, anterior chest wall, muscles of the shoulder girdle.
2. Data templates laboratory and instrumental studies for pain in the chest caused by a
pathologicaliey spine, anterior chest, shoulder girdle muscles
Independent work and self-education
Topic: Etiopathogenesis, clinical osteoarthritis, spondylosis, Tietze syndrome.
1. Independent work with literature in the Bible,and edema at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference
department.
3. The development of the interpretation of ECG, echocardiography, X-ray images of laboratory
tests were performed.
4. Service calls at home.
Teaching practice during the lesson.
Supervision of patients with osteochondrosis, spondylosis.
The number of hours -1.5 hours.
Quiz
1. Differential diagnosis of chest pain associated with the pathology of the spine.
2. Differential diagnosis of chest pain associated with the pathology of the anterior chest wall.
3. Differential diagnosis of chest pain associated with the pathology of the shoulder girdle muscles.
4. Differential diagnosis of chest pain associated with shingles.
5. Tactics GP with pain in the chest associated with the pathology of the spine and the muscles of
the chest.
55
6. Indications for referral to a specialist and hospitalization profile department.
7. The principles of treatment of patients with diseases of the spine, muscles of the chest wall
shingles.
8. Principles of supervision, management, and monitoring in a rural health units, or family
policlinics.
9. Definition of disability in patients with pathology of the spine, anterior chest wall, muscles of
the shoulder girdle.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS
WITH PALPITATION
Purpose: Teach students syndromal addressing patients with palpitations, as well as the principles of
their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

Giving students a solution to the problem with the heartbeat.

Giving students a timely diagnosis when there is a problem associated with the heartbeat.

To teach students to differentiate the disease, accompanied with palpitation.

Improve the knowledge, skills, and practical skills in solving problems of patients with
palpitations (information gathering, problem identification and physical examination, as well as
the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU and FP.
What the student needs to know to solve the problems of patients with palpitations:
№
The list of knowledge
Basic level
The student should know at
The list of diseases that occur with the heartbeat
least 10 of the most common
diseases
A list of the most dangerous diseases that present with
The student should know at
palpitations
least five diseases
The list of states that require management in a rural
According to the characteristics
health units or FP (1 category)
of the GP qualifying
The list of states that require a specialist consultation or According to the characteristics
hospitalization (category 2)
of the GP qualifying
According to the characteristics
A list of studies requiring in RHU or FP (3-1 category)
of the GP qualifying
The list of research areas requiring outside RHU or FP
According to the characteristics
(3.2-category)
of the GP qualifying
A student must know features
Key points (criteria) diagnosis, occurring with the
and symptoms of each disease,
heartbeat
and the criteria for their
diagnosis.
Classification of CHD
The student must list.
Tax classification
The student must list.
Classification of arrhythmias and conduction
The student must list.
The student should know the
Symptoms of internal organs
signs of defeat
56
The student must list the major
manifestations
the student should know:
Indicators of laboratory results
- Normal values and their
changes in pathology.
The student must know the
Treatment policy
techniques and principles of
treatment (including non-drug).
The student must know the
Antiarrhythmics
classification of antiarrhythmic
drugs
The student should know the
The principles of primary, secondary and tertiary
basic activities required for
prevention
primary, secondary and tertiary
prevention
The principles of clinical examination and rehabilitation The student must list the main
of disorders that occur with the heartbeat in RHU or SP activities
for
clinical
(4-category)
examination and rehabilitation
Signs of heart failure
That the student should be able to solve problems of patientswithpalpitations:
№
List of skills
Basic level
1.
Student should be able to ask
questions of rational concise questions
that really helps to set the probable
diagnosis.
2. The student must be able to specifically
identify and assess the patient's
complaints.
3. The student must be able to analyze
Ask the patient and his relatives
medical history: the beginning of the
disease, the first symptoms, the causal
relationship and the dynamics of their
development.
4. The student must be able to analyze
life history: the identification of risk
factors, the health of parents and family
members.
The student must be able to identify
unmanaged and uncontrolled risk factors as
Identify risk factors
on questioning patient, based on an objective
approach
Measure blood pressure.
Student should be able to hold tonometry with
the incremental principle.
The student must be able to detect the
An inspection of the skin
presence of cold, moist and pale skin
The student must be able to identify signs or
An inspection of the oral cavity and
symptoms:
pharyngoscope
- Tonsillitis
- Pharyngitis
57
The student must be able to detect:
- The presence or absence of a pulse
The student must be able to evaluate the
properties of the radial artery.
The student must be able to assess:
- A tour of the chest
- Voice trembling
Conduct palpation, percussion and
- Change of lung sounds and their meaning
auscultation of breath.
- The types of breathing
- The presence of breath sounds and
wheezing
The student must be able to identify:
- Cardiac impulse
Palpation of the heart to hold
- Systolic and diastolic tremor
The student must be able to evaluate the
apical impulse.
The student must be able to identify:
- The boundaries of the relative and absolute
dullness of heart
- The boundaries of the vascular bundle
- The diameter of the heart
Conduct percussion heart
And waist-configuration of the heart.
The student must be able to identify:
- Signs of hypertrophy of the heart
- Mitral configuration
-Aortic configuration
The student must be able to identify:
- Easing I and II Tone
- I gain tone at the top
- Accent II tone of the aorta or pulmonary
artery
Conduct cardiac auscultation
- Systolic and diastolic murmur, and to
identify their epicenter
Be able to differentiate functional from
organic heart sounds.
- Pericardial friction noise
The student must be able to identify features:
Conduct palpation, percussion of the - Hepatomegaly
abdomen
The student must be able to assess:
- All available structures in the abdomen
The student should see the limbs and body,
and to be able to detect:
- Local or generalized edema. Fingers should
be able to put pressure on the rearsurface of
Inspect the limb
the foot nuyu and discover:
- There is a pit or not.
Should pay attention to the condition of the
veins of the lower limb
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
58
Explore the pulse of the carotid, radial
and femoral arteries
Calculate the index weight / body
Hold ophthalmoscopy
Interpret the clinical and biochemical
ECG and decrypt it.
Differentiate disease accompanied with
palpitation
Give non-medical advice
Provide prehospital care
Rational use of medicines in the
treatment of diseases occurring in a
heartbeat
Conduct monitoring and surveillance of
patients in a rural health units or SP
goiter
The student must be able to identify features:
- Underweight
- Increased weight.
Student should be able to hold
ophthalmoscopy with the principle of step and
look of the eye, and to identify features:
- Arteriovenous crossings
The student must be able to identify signs of
shifts from the norm
3. The student must be able to record the
ECG with the incremental principle.
4. Student should be able to decipher the
results of the ECG and identify signs:
- Arrhythmias
- Conduction disturbances
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory
and instrumental investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
Student should be able to provide prehospital
care in urgent situations, which are
accompanied with rhythm disturbances.
3. The student should be able to choose
products with proven effectiveness.
4. When choosing drug student should be
able to evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out
monitoring and control:
- The level of glucose in the blood
- The level of the BP.
- The level of blood lipids
Practice session № 4
Topic: "Arrhytmias. Differential diagnosis of arrhythmias: sinus tachycardia, respiratory
arrhythmia, extrasystole. Tactics GPs. Indications for referral to a specialist or hospitalization of
profiled section.The principles of treatment, dispensary o nsecond monitor, control and
rehabilitation in rural health units or family policlinics. Principles of prevention. Definition of
disability. Principles of Teaching Tools"-6.7 hours.
Justification of the theme: The reason most of the heart associated with various disorders arrhythmias
and conduction. The identified patient cardiac arrhythmia has set a number of GPs tasks requiring
59
sometimes numerical solution. A wide variety of causes and forms to determine the complexity of
diagnosis and timely cazaniyaandassistance.This fact is the basis for the inclusion of this subject in the
program of training GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options rhythm disturbances caused by various diseases, as well as the principles of their management
in primary care, provided the requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Consider the diagnosis and differential diagnosisof arrhythmias: sinus tachycardia, respiratory
arrhythmia, extrasystoles.
2. Demonstrate patients with arrhythmias: sinus tachycardia, respiratory arrhythmia, extrasystoles.
3. Discuss the results of clinical, laboratory and instrumental studies of patients with narusheniyami
rhythm (sinus tachycardia, respiratory arrhythmia, extrasystoles).
4. Make a differential diagnosisof sinus tachycardia, respiratory arrhythmia, arrhythmia.
5. Educate GPs provide differentiated treatment of patients withsinus tachycardia, respiratory
arrhythmia, extrasystoles.
6. Discuss questions about tactics in the qualifying characteristics of GPs.
7. The principles of treatment (non-drug and drug).
8. Principles of management, follow-up and monitoring of patients in conditionsiyah RHU or
family policlinics.
9. The principles of primary, secondary and tertiary prevention in data consistsyaniyah.
Anticipated results
Conducting this training allows the learner time and correctly diagnose, differentiate according to
clinical and ECG various types of cardiac arrhythmias, to establish a preliminary diagnosis and
determine the future tactics of the patient.
GPs should know:
1. The mechanism and causes of sinus tachycardia, respiratory arrhythmia, arrhythmia.
2. Clinical manifestations of sinus tachycardia, respiratory arrhythmia, arrhythmia.
3. ECG signs of sinus tachycardia, respiratory arrhythmia, arrhythmia.
4. Differential diagnosis of arrhythmias.
5. Antiarrhythmic drugs, their pharmacodynamics and dosage.
6. Principles of follow-up and monitoring in RHU or family policlinics.
7. The principles of primary, secondary and tertiary prevention in these states.
GPs should be able to:
1. Diagnose, differentiated according to clinical and ECG sinus tachycardia, respiratory
arrhythmia, arrhythmia.
2. Choose the right medication for the treatment of arrhythmias.
3. Advise on non-drug methods of treatment, as well as healthy living
4. ECG recording technique and decipher it.
GPs should do:
1. Data analysis of complaints and medical history to diagnosesinus tachycardia, respiratory
arrhythmia, arrhythmia.
2. Establish diagnosis and differential diagnosis ofsinus tachycardia, respiratory arrhythmia,
arrhythmia.
60
3. Interpret the results of the ECG in patients withsinus tachycardia, respiratory arrhythmia,
extrasystoles.
4. Prescribe medication and perform clinical examination of patients with cardiac arrhythmias.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with cardiac arrhythmias.
2. Interpret ECG sinus tachycardia, respiratory arrhythmia, arrhythmia.
Place of activity:
1. Training themed room.
2. Cabinet ECG
3. Cabinet GPs.
The course is taught.
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Heartbeat.Differential
Diagnosticstickofarrhythmias: sinus tachycardia, respiratory arrhythmia, extrasystoles.Tactics
GPs. Indications onthe board to a specialist or hospitalization profile department. The
principles of treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of prevention. Determination trudospindividuality. Principles of teaching topics.
"Explanation of the diagnosis and differential diagnosis of sinus tachycardia, respiratory
arrhythmia, arrhythmia.
2. Decision analysis and situational problems.
3. Supervision of patients with cardiac arrhythmias.
4. Clinical analysis of supervised patients. Demonstration of a patient with a drug rhythm.
5. Service calls to your home.
6. Report on the results of calls served on the house.
Contents classes
Time
8.309.30
9.3010.30
10.3011.30.
11.3012.15.
12.20-
Events
Morning
conference.
Content
Report
on
subordinators
examined by patients in the
clinic and the challenges at
home.
Admission
Each student is receiving
outpatients
patients with GPs, followed by
under control a discussion of patients
of the teacher. examined in the audience.
Service calls at Examination of patients at
home.
home, medical history, a
complete inspection of the
patient, data analysis and
laboratory and instrumental
studies, and preliminary study
of
a
definitive
clinical
diagnosis. Defining the further
tactics.
Break.
Study skills.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and
Laboratory
data,
hospital
records of patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and
Laboratory
data,
hospital
records of patients
Student under the supervision Patient or volunteer. 20 minutes
61
12.40.
12.4014.00
of a teacher must complete a
minimum of two skills.
Theoretical
Checking the initial level of
analysis of the preparedness of students with
topic.
the
use
of
the
method"brainstorming."Polling
stationat
thedents
on
classes.Address the situationof
ion tasks on the topic.
Whiteboard,
a 30 minutes
folder with ECG,
case studies and
tables,
corresponding to a
subject class.
In the theoretical part of the practical training consistently treat certain arrhythmias, classification,
differential diagnosis of arrhythmias, clinical and ECG - diagnosis of sinus tachycardia, respiratory
arrhythmia, arrhythmia.
Cardiac arrhythmia- any heart rate, which is not a regular sinus rhythm, normal frequency
and electric impulse conduction disturbances on various parts of the conduction system of the heart.
Sinus arrhythmia- is a consequence of the irregular sinus node, resulting ina number equal
education in it to the excitation pulse. This causes the black following periods of acceleration and
deceleration rate. About sinus arrhythmia say in cases where the distance between RR QRS complexes
are not identical, the difference Duration ofthe shortest and longest RR interval exceeds 10% of the
average distance of RR (P-P).Respiratory and non-respiratory distinguish sinus arrhythmia, do not
depend on breathing.With respiratory arrhythmia during inhalation increases heart rate and distance
RR decreases gradually. During expiration the opposite. Sinus respiratory arrhythmia often with sinus
bradycardia. At ECG: P wave, PQ interval and QRS complex and the T wave is usually not changed,
only the act of breathing in sync with the extended distance and shortening RR. Sinus respiratory
arrhythmia is usually seen in healthy people, especially children and young adults, patients with the
NDC, and occasionally in patients with CVD. Non-respiratory sinus arrhythmia is most common in
patients with coronary artery disease, acute myocarditis, myocardial infarction, heart tumors, digitalis
intoxication, drugs, etc.
Paroxysmal supraventricular tachycardia-suddenly begins and ends as abruptly increased
frequency of heart attack up to 140-250 per minute while maintaining mostly of aregular rhythm.
Sinoatrial, atrioventricular atrial and supraventricular tachycardia. ECG signs: the presence before
each QRS complex reduced, deformed, two-phase or negative P wave, normal unmodified ventricular
complexes QRS, like QRS, recorded before an attack of paroxysmal tachycardia, and in some cases, a
deterioration of atrioventricular conduction with the development of atrioventricular block or I II
degree.
ECG signs of paroxysmal tachycardia atrioventricular connection: 1. Presence in leads II, III,
and aVF negative P wave, QRS complexes located behind or merging with them and recorded the
ECG, 2. normal unmodified (not broadened and deformed) ventricular complexes QRS, like QRS,
recorded before an attack of paroxysmal tachycardia (except in relatively rare cases of ventricular
aberration).
Beats- is primarily stimulation of the heart or of its departments that occurs under the influence
of ectopic focus pathological impulse. ECG signs of atrial extrasystoles: premature appearance of P
wave followed by a complex QRS; deformation or change in the polarity of P wave beats, the presence
of unchanged extrasystolic complex QRS, similar in form to the usual normal QRST complexes of
sinus origin, the presence of atrial extrasystoles after incomplete compensatory pause.
ECG signs of beats of atrioventricular connection: the extraordinary appearance of premature
unchanged ECG QRS complex ventricular sinus origin, a negative P wave in leads II, III, and aVF
after extrasystolic QRS complex or absence of P wave (the merger of P and QRS); presence of
incomplete compensatory pause.
Ventricular arrhythmias- premature ventricular excitation and contraction caused by
heterotrophic automaticity in one of them.The mechanism of ventricular arrhythmia mechanisms are
re-entry and postdepolarization in ectopic foci branches bundle of His and the Purkinje fibers.
62
ECG signs of ventricular extrasystoles: premature extraordinary appearance on the ECG QRS
complex ventricular changed without prior P wave and a significant expansion and deformation
extrasystolic complex QRS; arrangement of RS-T segment and T wave beats discordant to QRS; with
left ventricular arrythmia main prong of the QRS complex in the I and in V5-V6 leads downwards, and
III and V1-V2 leads upward.
Beats can be single and paired, if registered two consecutive sistoly extracted, as well as group
or beats – i.e. following in succession, one after the other.A group of 5 or more ekstrasitable can be
defined as an attack of ectopic tachycardia. There is also allorythmic beats, i.e. alternating with
ordinary complexes in the correct sequence. Beats that follow each new complex, characterized as
bigimeny, groups of 3 complexes, separated by pauses (two more complex and one premature beat, or
one regular set and two beats) - trigimenia, a group of four complexes - quadrigimeniya etc . Correct
sequence of complexes with regular cargoppoy extrasystoles is defined as a group allodromy.
Beats can be monotopic, coming from one ectopic focus, and politopics caused by operation of
several education centers extrasystoles. Frequent politop and groups of curves atrial beats may precede
the development of atrial fibrillation or atrial tachycardia.Classification of ventricular arrhythmias by
Lown:
I. Monotopic less than 30 beats in 1 hour.
II. Monotopic beats more than 30 to 1 hour.
III. Politopical extrasystole.
IV. A-coupled extrasystole.
IV. B-group beats.
V. Premature beat R-T.
With early premature ventricular extraordinary R wave superimposed on the T wave preceding
obviousRedņevs ventricular complex (beats type "R on T"), or separated from it no more than 0.04
seconds.Politopical, group and pannie ventricular extrasystoles in patients with severe organic changes
in the myocardium in certain conditions can provoke the development of ventricular tachycardia and
ventricular fibrillation, and are therefore a risk factor for sudden arrhythmic death, which requires a
general practitioner necessarily the direction of the patient in hospital. In this respect, the left
ventricular extrasystoles profile less favorable than the right ventricle.
Handout:
Students distributed lists containing the names of topics, list of diseases associated with rhythm
disturbances, arrhythmias classification, diagnostic criteria, examples of ECG data.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Electrocardiograms for different types of arrhythmias.
3. Table: Classification of arrhythmias and anti-arrhythmic drugs, schemes of various
arrhythmias.
4. Dummy with various arrhythmias.
5. ECG machine.
Independent work and self-education.
Topic: Physiological functions of the heart muscle. Classification of antiarrhythmic drugs (Field
work).
1. Independent work with literature in the libraryke, at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference by the
department.
3. The development of the interpretation of ECG, echocardiography, laboratory study data.
4. Service calls to your home.
Teaching practice during the lesson.
Supervision of patients with supraventricular arrhythmias.
63
The number of hours -1.5 hours.
Quiz
1. Differential diagnosis of sinus tachycardia, respiratory arrhythmia, arrhythmia.
2. Clinical and ECG - diagnosis of sinus tachycardia.
3. Clinical and ECG - diagnosis of respiratory arrhythmia.
4. Differential diagnosis supraventricular arrythmia.
5. Differential diagnosis of ventricular arrhythmia.
6. Differentiated treatment sinus tachycardia, respiratory arrhythmia.
7. Differentiated treatment arrythmia.
8. The principles of treatment of patients with sinus tachycardia, respiratory arrhythmia,
extrasystoles.
9. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
10. The principles of primary, secondary and tertiary prevention in these states.
Practice session № 5-6
Topic: "Arrhytmias. Differential diagnosis of heart at circulatory adequacy, anemia,
hyperthyroidism. Tactics of GPs. Indications for referral to a specialist at hospitalization profile
department. The principles of treatment, control and rehabilitation in RHU or family policlinics.
Principles of prevention. Definition of disability. Principles of Teaching Tools "-6.7 hours.
Justification of the theme:The cause palpitations can be many diseases of the heart, especially in
heart is not enough.This syndrome is also characterized by increased features gland (hyperthyroidism),
and anemia in this downturn to the general practitioner (GP) should be directed to the diagnosis of
diseases that caused arrhythmias, to provide medical assistance and monitoring in rural health units or
family policlinics. These circumstances are the basis for the inclusion of this subject in the training of
GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options rhythm disturbances caused by various diseases including circulatory failure, anemia,
thyrotoxicosis, and the principles of their management in primary care, provided the requirements of
"Qualification Specifications GP’
Learning objectives:
1. Consider the diagnosis and differential diagnosis ofarrhythmias in heart failure, anemia,
hyperthyroidism.
2. Demonstrate patients with arrhythmiasin heart failure, anemia, hyperthyroidism.
3. Discuss the results of clinical, laboratory and instrumental studies of patients with narusheniyami
rate (circulatory failure, anemia, hyperthyroidism).
4. Make a differential diagnosis of arrhythmias in heart failure, anemia, hyperthyroidism.
5. Educate GPs provide differentiated treatment of patients with arrhythmiasin heart failure,
anemia, hyperthyroidism.
1. Principles of management, follow-up and monitoring of patients with arrhythmias in heart
failure, anemia, conditions hyperthyroidism RHU or family policlinics.
2. The principles of primary, secondary and tertiary prevention in these diseases.
Anticipated results
64
Conducting this training allows the learner time and correctly diagnose, differentiate according to
clinical and ECG various types of cardiac arrhythmias in heart failure, anemia, thyrotoxicosis, to
establish a preliminary diagnosis and determine the future tactics of the patient.
GPs should know:
1.
The mechanism of arrhythmias in heart failure, anemia, hyperthyroidism.
2.
Clinical manifestations of heart failure, anemia, hyperthyroidism.
3.
Differential diagnosis of heart failure, anemia, hyperthyroidism.
4.
Medicinal products used arrhythmias in heart failure, anemia, hyperthyroidism.
5.
Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
6.
The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1.
Diagnose, differentiate arrhythmias in heart failure, anemia, hyperthyroidism.
2.
Choose the right medication for the treatment of patients with arrhythmias in heart failure,
anemia, hyperthyroidism.
3.
Advise on non-drug methods of treatment, as well as healthy living
4.
ECG recording technique and decipher it.
GPs should do:
1. Data analysis of complaints and medical history to diagnose and rhythm of heart failure, anemia,
hyperthyroidism.
2. Establish diagnosis and differential diagnosis ofarrhythmias in heart failure, anemia,
hyperthyroidism.
3. Interpret the results of the ECG in patients witharrhythmias in heart failure, anemia,
hyperthyroidism.
4. Prescribe medication and perform clinical examination of patients with heart failure, anemia,
hyperthyroidism.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with heart failure, anemia, hyperthyroidism.
2. Interpret ECG heart failure, anemia, hyperthyroidism.
Place of activity:
1. Training themed room.
2. Cabinet ECG
3. Cabinet GPs.
The course is taught.
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in arrhythmia. Differential
dandagnostic heart circulatory failure, anemia, hyperthyroidism. Tactics GPs.
 Definition of disability. Principles of teaching about the "Explanation of diagnosis and
differential diagnosis of sinus tachycardia, respiratory arrhythmia, arrhythmia.
 Decision analysis and situational problems.
 Supervision of patients with sinus tachycardia, respiratory arrhythmia, extrasystoles.
 Clinical analysis of supervised patients. Demonstration of a patient with violation rhythm.
 Service calls to your home.
 Report on the results of calls served on the house.
65
Contents classes
Time
8.30-9.30
9.30-10.30
10.3011.30.
11.3012.15.
12.2012.40.
12.40-14.00
Lesson
time
Morning
Report on subordinators examined by Hospital records of 1 hour
conference.
patients in the clinic and the patients
challenges at home.
Admission
Each student is receiving patients The
patient, 1 hour
outpatients
with GPs, followed by a discussion phonendoscopes,
under control of patients examined in the audience. tonometer.Clinical
of
the
and
Laboratory
teacher.
data,
hospital
records of patients.
Service calls Examination of patients at home, The
patient, 1 hour
at home.
medical
history,
a
complete phonendoscopes,
inspection of the patient, data tonometer. Clinical
analysis
and
laboratory
and and
Laboratory
instrumental studies, and preliminary data,
hospital
study of a definitive clinical records of patients
diagnosis. Defining the further
tactics.
Break.
Events
Content
Study skills.
Student under the supervision of a
teacher must complete a minimum of
two skills.
Theoretical
Checking the initial level of
analysis of preparedness of students using the
the topic.
method of the "brainhowling
storm".Polling
station
at
the
classes.Students Sectional ECG, they
must analyze, explain and give a
conclusion. Decision situradiative
problems on the topic.
Materials
Patient
volunteer.
or 20 minutes
Whiteboard,
a 30 minutes
folder with ECG,
case studies and
tables,
corresponding to a
subject class.
In the theoretical part of the practical training consistently treat certain arrhythmias,
classification, and differential diagnosis clique heart circulatory failure, anemia, hyperthyroidism.
Chronic heart failure
Symptoms within different for different forms and stages of heart failure. Clinical forms:
1. Congestive left ventricular failure is characteristic of mitral for heavy CHD, especially in patients
with hypertension. Symptoms: shortness of breath, orthopnea, symptoms of pulmonary congestion
auscultative (dry rales below the shoulder blades, migrating rales) and X-ray, cardiac asthma and
pulmonary edema, secondary pulmonary hypertension, tachycardia.
2. Left ventricular ejection failure characteristic aortic defect, coronary heart disease,
arterialhypertension. Implication: cerebrovascular insufficiency (dizziness, blackouts, fainting), crown
insufficiency and echocardiographic signs of low output. In severe cases, can Cheyne - Stokes,
alternating pulse (rare), presystolic gallop rhythm (abnormal tone IV), clinical signs of congestive left
ventricular failure. In the terminal stage can added right ventricular failure.
3. Congestive right ventricular failure characteristic of the mitral and tricuspid blemish pericarditis.
Normally attached to congestive left ventricular failure. Implication: swelling neck veins, high venous
pressure, liver enlargement, swelling - abdominal and peripheral.
66
4. Right ventricular failure emission characteristic of pulmonary artery stenosis, pulmonary
hypertension . Radiologically diagnosed and mostly (depleted peripheral pulmonary vessels). May
show other signs of this form: shortness of breath with a strictly defined threshold • exercise, right
ventricular hypertrophy - palpation, then the ECG signs of the type "Downloading pressure" (high R
wave and reduce the T wave in the right precordial leads). In severe cases, the gray color of the skin.
5. Nical form of dystrophy. Typically, end-stage right heart failure. Options: a) cacheccy b) swelling
and dystrophic with degenerative changes of the skin ( shine, smoothness of the picture, sagging),
edema - common or limited mobility, hypoalbuminemia, in the most severe cases - anasarca)
uncorrected salt depletion.
Stage of development and the severity of congestive heart failure. Of the many signs of heart
failure, enumerated in the description of a stage, you need to select a few, each of which is sufficient to
determine the specific hundred. Stage I: CH subjective symptoms at moderate or heavy loads. Phase II
A: 1) expression of subjective symptoms of heart failure at low loads, and 2) orthopnea, and 3) asthma,
4) rentgenographic, in some cases - and electrocardiographic signs of secondary pulmonary
hypertension, 5) re-occurrence of edema, 6) again increased liver 7) cardiomegaly with no other
recognized this stage, 8) atrial fibrillation without other signs of this stage. Stage II B: 1) repeated
episodes of cardiac asthma, 2) Consistent peripheral edema, and 3) significant abdominal swelling permanent or re-emerging, and 4) a persistent increase in the liver, which in the course of treatment
can be reduced, but there is a larger, 5) atriomegaly; 6) cardiomegaly in combination with at least one
of the signs of the previous stage, and 7) atrial fibrillation in combination with at least one of the signs
of the previous stage. Stage III, the terminal: 1) heavy subjective disorder with minimal exertion or at
rest, 2) repeated during the week episodes of cardiac asthma, 3) degenerative changes of the organs
and tissues.
In chronic heart failure edema develop gradually, symmetrically localized predominantly in the
feet and legs, as well as in bed patients on the back, in the tissues of the lumbar and sacral
domains.The material is cold to the touch, cyanotic, its elasticity is reduced, especially for long
duration of edema. Cardiac edema moderately dense, leaving a hole when pressed with your finger,
mix with the change of gender body. Edema is usually preceded by a more or less prolonged period of
apnea. Often, swelling of the skin and subcutaneous tissue is accompanied ascites, hydrothorax
(predominantly right-sided). As a rule, there are other symptoms of heart failure - swollen neck veins,
shortness of breath, liver enlargement. In the study of the heart is determined directly by the signs of
its destruction (sizing, availability aritmy, heart murmurs, etc.).
Cardiac edema may be the same composition of urine, but urine often reflects the so-called
"Decent kidney."In this case, the urine is ocinuriya, usually less than one per thousand, a sufficient
proportion, moderate changes in the sediment.
Anemia can lead to heart failure with high cardiac output.
Circulatory failure (CF) - 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 CF, which manifestation in minutes and
hours, and chronic HF, which is formed during the period of several weeks to several years. Except
mth, isolated heart failure associated with cardiac and vascular insufficiency, in which the fore in the
mechanism of impaired circulation acts predominantly vascular component.
Hyperthyroidism occurs everywhere.Onibolee often the disease occurs between the ages of 20
and 50 years, more often in women than in men.
Causes: Graves' disease, toxic thyroid adenoma, subacute granulomatous thyroiditis (thyroiditis
Kerwin), receipt thyreodit hormones from outside.
Clinic: irritability, anxiety, weight loss despite a good appetite, palpitations, heat intolerance,
sleep disturbances, low-grade temperature of the body, we are muscular weakness, diarrhea, sweating,
especially palms, female menstrual cycle. On examination revealed a warm wet hands, melky tremor,
increasing the size of the thyroid, atrophy and weakness of the proximal muscles, wide eye slitit,
exophthalmos, eye disease. Leading to changes in clinical hyperthyroidism are CVS. Patients
concerned heartbeat, in some cases, stabbing pain in the heart without irradiation, shortness of breath
67
shortness of breath reminiscent NDC ("unsatisfactory breath "). A number of patients are often visible
carotid pulse, raised apex beat, tachycardia (heart rate over 90 beats per minute). BP is usually normal
in mild disease. In the laste follows depending on the severity of increased systolic and diastolic blood
pressure is lowered. When auscultation heart sounds loud, often at the top of the tone I boosted. In
some cases, there is an emphasis II tone of the pulmonary criterion. In the third left intercostal space,
at the edge of the sternum and the apex of the heart auscultated systolic functional noise, worse after
exercise.With progressionof the issues arising, systolic murmur becomes permanent, and can rough
listens over the entire atrial area.Some patients may experience rhythm: sinus (breathing), arrhythmia,
extrasystoles. Atrial fibrillation, which arose in the early paroxysmal in nature. As the disease
progresses it may become permanent. Sometimes called observed circulatory failure I or II, which
after in the appearance of is progressing rapidly. However, the main changes were observed in the
systemic circulation (increasing dramatically and compacted nery, there is peripheral edema, ascites,
hydrothorax, less anasarca). Congestion in the pulmonary shelter is rare.
Treatment of cardiac edema.
Treatment of the underlying disease, the pathogenetic therapy of individual syndromes
arrhythmias, AV block, congestive heart failure (given that the cardiosclerosis tolerance of
myocardium to cardiac glycosides are usually reduced).
Treatment. Regime and diet: stage I - compliance work and rest, moderate physical exercises of
(but not a sport!). In the more severe stages of physical activity should be limited, intermittent
appointed bed, half bed mode. Diet - a complete, easily digestible, rich in proteins, and potassium. Diet
number 10 does not meet these requirements. She should choose diet number 5, preferably – rich men
to fruit, cottage cheese and sour cream.With tendency to fluid retention and hypertension shown
moderate restriction of salt.With massive edema can be assigned to a short-term strict salt-free diet.
Long-term (more than 1-2 weeks.) The use of diet number 10, especially in combination with saluretic
therapy, can lead to dangerous salt depletion. Effective fasting days during which used monotonous,
easily digestible, poor sodium chloride food (rice, block-rice, etc. days).
Drug therapy is not the same in different forms, manifestations and the origin of HF. It should
be on the face of limited physical activity. In chronic heart failure adequate drug therapy should be
constant - unjustified cancellation of its often lead to decompensation.
Cardiac glycosides are shown mainly in congestive heart failure and atrial fibrillation. They
contraindicated in obstructive hypertrophic cardiomyopathy, severe hypo-and hyperkalemia,
hypercalcemia, atrioventricular block, syndrome WPW, sick sinus syndrome, ventricular extrasystoles
(frequent, politopical) and allodromy, as well as ventricular tachycardia.With reduced eliminp eration
of cardiac glycosides (renal failure, advanced age) to reduce the maintenance dose of 2-3 times and, if
possible, corresponds with the view of serum creatinine or glycoside.
Cardiac glycosides are assigned to levels close to the maximum tolerated, with stable heart
failure - a poststantly. Initially (2-3 days) loading dose is given, then a daily dose 1.5-2 times.In the
subsequent maintenance dose specified depending on the individual patient's response, to that part
about the pulse was maintained at the level of 52-68 in 1 min at rest and no more than 90-100 in 1
minute after the minimum load.In expanding motoring maintenance dose is increased. When
symptoms of glycoside and intoxication, overdose (bradycardia or threat - the rapid decrease in pulse
rate to 60 in 1 minute or less, nausea, vomiting, and the appearance of ventricular premature beats Politopical, paired with a frequency greater than or 5-6 in 1 minute, atrioventricular block etc.) the
treatment of cardiac glycosides should be stopped immediately, not limited dose reduction. Digoxin
assigned 2 times a day in pill form to 0.00025 g or parenterally by 0.5-1.5 ml of 0.025% solution
(saturated absorption period), followed by 0.25-0.75 mg (maintenance dose) per day. Instead of
digoxin may have less stable effect celanid izolanid or tablets to 0.00025 gor drops of 10-25 drops of
0.05% solution and Lantosidum 15-20 drops 2-3 times a day. About tablet digoxin tablets celanida 1.52 match or 16-20 drops celanida and Lantosidum. Application of the most active and the heart
digitoxin (0.1 mg tablets) requires special care (with the danger of toxic effects of cardiac arrest may
persist after the drug up to 2-4 weeks). Selection of dosage of cardiac glycoside etc, should be done in
a hospital.Parenteral administration of short-acting drugs (stanzantin, corglycone) is conducted in the
68
first days of treatment of the most severe patients with a subsequent transition to oral treatment. 0.05%
solution of strophanthin by 0.25-1 ml or 0.06% solution corglycone 0,5-1 ml administered mainly drip
into a vein with isotonic sodium chloride solution or with 5-10% glucose solution.
Diuretics are shown not only in edema, liver enlargement, clear stagnant changes in the lungs,
but also in the hidden fluid retention, one sign of which is the reductionof dyspnea tion in response to a
test giving a diuretic. Assigned in the lowest effective dose, usually after treatment with cardiac
glycosides. Massive diuretic therapy begins in bed rest. Individual treatment regimens fulfilled and
corrected during treatment. More effective is usually intermittent treatment when drug administered 23 times a week and rarely or short (2-4 days) courses. In most cases, a diuretics deficiency, if taken on
an empty stomach, and if the day of their admission assigned unloading diet. The effectiveness of
therapy in addition to increasing the daily urine output, toe swelling and weight loss shows clever
solution dyspnea and some reduction in the size of the liver. In severe abdominal swelling
(hydrothorax, but only with massive ascites) evacuation of the liquid may be mechanical
(puncture).The major complications of diuretic therapy include hypokalemia, hyponatremia,
hypocalcemia (loop diuretics) hypochloremic alkalosis, dehydration and hypovolemia, sometimes with
the formation and progression phlebothrombosis. Rarely (mostly in longlight sensitivity massive
treatment of certain drugs, particularly thiazide derivatives, ethacrynic acid) having hyperglycemia,
hyperuricemia, and other side of manifestation. Hydrochlorthiazide (hypothiazide) used in tablets of,
025 gor preferably in the triampura (tablets containing 12.5 mg and 25 mg dichlorthiazida potassiumsparing diuretic triamterene).These preparaty administered at a dose of 1 tablet 1-2 times a week to 1-2
tablets 2 times a day for the first 2-5 days, then 1-2 tablets 1-3 times a week or daily. Loop diuretic
furosemide (Lasix) in tablets of 0.04 g or parenterally (2 mL of 1%was happening laeiksa races) is
forced diuresis, which lasts up to 4-6 hours massive (more than 5-8 tablets per week) treatment reduces
the diuretic effect and hypokalemia. When light sensitivity maintenance therapy should have limited
furosemide on half a tablet (0.02 g) to 2-3 times a week - alone or in conjunction with a triampur.
Quick action and proper furosemide initial extrarenal effect of redistribution of blood from the
pulmonary emptying make particularly valuable centuries intravenous dose to 0.04 - 0.08 gin case of
emergency (cardiac asthma and pulmonary edema). Klopamid (brinaldiks) of 0.02 g for the diuretic
effect of furosemide is inferior, but it is better tolerated (diuretics speed sufferedsharp to days).
Appointed by 10-20 mg of 1-2 times a day to 1 time of 10-15 days. Hypotensive effect is more
pronounced than that of other diuretics, treatment is not accompanied Klopamid. Ethacrynic acid
(Uregei) tablets 0.05 g usedan isolated, or potassium-sparing diuretics in doses of 1 tablet 1-2 times a
week to 2-3 tablets in the morning after eating short courses of 2-4 days with intervals 2.3
days.Diakarb (fonurit) tablets of0.25 g administered every other day or a short (2 - 3 days) courses;
shown only cardiopulmonary failure, hypercapnia.
Peripheral vasodilators prescribed in more severe cases, the lack of effectiveness of the
glycosides and diuretics alone or in conjunction with preparations of these groups.In sharp stenosis
(mitral, aortic), and systolic blood pressure of 100 mmHg. and below them should not be used.
Advantage DNA venous dilators - nitrates (nitrosorbid 0.01 g, etc.) in high doses reduces the pressure
on the complement of the ventricles ("preload") and are effective in congestive failure. Predominantly
arteriolar dilator apressin (hydralazine) to 0,025 g per tablet appoint 2-3 tablets 3-4 times a day, and
calcium antagonist fenigidin (nifedipine, korinfar) tablets of 0.01 g administered to reduce afterload in
hypertensive heart failure; they can be useful for moderate heart failure in patients with aortic or mitral
insufficiency. Potent vasodilators universal venuloarteriolar steps: prazosin administered from 2 to 10
mg / day (0.5-1 mg first dose, treatment short course), a daily dose of captopril was 0,075-0,15 The
combined use of venules and arterioles-dilators-indicated for severe, refractory cardiac glycosides and
diuretic CH with significant dilation of the left ventricle, as well as in hypertensive heart failure.
Effective treatment of the combined action of vasodilators associated with reduced volume of the left
ventricle and the restoration of sensitivity to glycosides and diuretics.
When treating patients with CHF are widely used ACE inhibitors reduce the formation of
angiotensin II and tensine causes marked dilation of the arteries and veins. And there is no tachycardia
in response to system vazodilation. Reduction in preload (end-diastolic volume of the left ventricle)
69
and afterload (total peripheral resismentation) on the heart can reduce his systolic and diastolic
function.
Almost all ACE inhibitors (except phosphinopril) removed by the kidneys, so the presence of
CRF is necessary to reduce the optimal dose of 2 - 3 times and by careful control of the level of serum
creatinine and proteinuria. In patients with CHF average therapeutic doses are: for Capote (captopril)
75 mg per day in three divided doses (25 mg per dose), enalapril 10 to 20 mg per day in two divided
doses, lisinopril 10 to 20 mg per day for 1 admission , ramipril 5 mg daily in 1 reception, perindopril 4
mg 1 time a day, cilazapril 2.5 -5.0 1 mg once a day, benazepril 10 to 20 mg per day in 1-2 reception.
To date, ACE inhibitors-the only group of drugs that can improve patients' life expectancy with
CFH II-III functional class that justifies the more widely used in clinical practice in combination with
diuretics and cardiac glycosides.
In recent years, great importance is the introduction into clinical practice for the treatment of
CFH receptor blockers angiotenzin II. In various tissues (adrenals, heart, kidneys, brain, uterus)
identified two main subtypes of angiotensin II - ATI and ATII. Angiotensin II receptor antagonists is
recommended, with no effect on applicationtion of ACE inhibitors or intolerances.For the treatment of
chronic HF antagonist used ATI-losartan (25-50 mg 1 time in aduck)
In the pathogenesis of chronic HF activation plays an important role sympathoadrenal system.
In the last rode began to discuss the possibility of applying for the treatment of chronic HF betaadrenergic blockers.
Question of the use of beta-blockers in the treatment of chronic HF finally solved and we must
be careful, because they may worsen myocardial contractility.
Potassium supplements prescribed for the treatment of cardiac glycosides, diuretics and steroid
hormones. They must be used when singinginlenii ventricular extra systoles, ECG signs of
hypokalemia, with a refractory cardiac glycosides tachycardia, flatulence in severely ill. The most
useful, though not always sufficient, the potassium required by the appropriate diet (prunes, dried
apricots, apricot, apricot, peach, plum juice with pulp, etc.). All right tolerated, but are low in
potassium and panangin asparcam (into meaningful to 6 tablets per day). Potassium chloride is usually
poorly tolerated; appointed interior only in 10% solution of 1 tablespoon 2-4 times a day after meals
with milk, kitty Lem, fruit juice. Receiving potassium inside, stop with abdominal pain (threat
ulceration and perforation of the stomach wall of the small intestine).Intake of potassium into the
intracellular space Spown intramuscular injection of insulin in small (4-6 units) doses. Potassiumsparing antagonist spironolactone (veroshpiron, Aldactone) tablets to 0,025 g appoint 3-4 tablets in
less severe and up to 10-12 pills a day - in more severe cases resistant to therapy, has mild diuretic self,
manifested in the2 -5-day treatment.Causes moderate acidosis. With prolonged treatment possible
reversible gynecomastia.
In dystrophic stage / injected albumin, used essentiale, anabolic steroids, retabolil (1 ml of 5%
solution of 1 in 10-20 days) or fenobolin (1 ml of 2.5% solutionra 1 every 7-15 days ) in the
muscle.These drugs are contraindicated in prostate, fibrous mastopathy neoplasms.The evacuation of
fluid from the pleural cavity or pericardial cavity is an indication for immediate hospitalization
operation.
Infusion therapy is rarely required in patients with chronic heart failure, disruption of water and
electrolyte balance and complex redistribution of blood volume (CBV). It requires special care even
very small amounts are not comparable with diuresis and lack of BCC. It should be taken with the
threat of a dangerous hypervolemia, circulatory overload of the heart, extra-and intravascular fluid
overload, intracellular hydration (the danger of glucose) and hydropenias (the danger of concentrated
hyperosmolar solutions, sodium chloride, diuretics), as well as imbalances and intracellularcontent of
potassium and other electrolytes.The result of these violations can be a cerebral edema, pulmonary
edema, and other with life-threatening complications and sudden death. Fluid therapy should be
carried out according to strict indications, differentiated, desirable - immediately after the forced
diuresis, under the supervisionof staff.
70
To limit the emotional stress is prescribed tranquilizers - sibazon (diazepam) to 0,005 g or
nozepam (tazepam) of 0.01 g.When insomnia is prescribed nitrazepam (radedorm) at 0.005-0.01 g per
night.
Metabolic therapy aims - to improve the metabolic processes in the myocardium and the
formation of its energy. Recommended following dosage formulations:

multivitamin complexes (Duovit, Oligovit, Undevit, Dekamevit)

anabolic steroid means: retabolil, pyridoxal phosphate, lipoic acid, cocarboxylase, Riboxin,
fosfaden, cytochrome C (cyto-mak), Neoton.
Due to the activation of lipid peroxidation in CFH appropriate use of antioxidants (vitamin E).
Vitamin E is assigned to 0.2 ml 2-3 times a day for a month or / m 1.0 ml of 10% oil solution for 20
days.
Employability: the ability to easily work from home with CFH II-degree, at III-disabled.
Disability issues are resolved individually.
Prevention: avoid fact provoking underlying disease. Dyspanserization for systematic
monitoring and treatment of the underlying disease.
The principles of treatment of hyperthyroidism.
Investigate the cause of hyperthyroidism, radioactive iodine, antithyroid drugs (carbimazole,
propylthiouracil) Other facilities: β-blockers, lithium carbonate, saturated solution of potassium iodide;
Surgery.
Handout:
Students distributed lists containing the names of topics, list of diseases associated with rhythm
disturbances, arrhythmias classification, diagnostic criteria, examples of ECG data.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Electrocardiogram with heart failure, anemia, hyperthyroidism with jetlag.
3. Table: Classification of heart failure, arrhythmias and antiarrhythmic drugs scheme
examination of patients with heart failure, anemia, hyperthyroidism.
4. Dummy with various arrhythmias.
5. ECG machine.
Independent work and self-education.
Topic: Etiopathogenesis, clinicalheart failure, anemia, hyperthyroidism.Modern classification of CF.
Standard treatment.
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference by the
department.
3. The development of the interpretation of ECG, echocardiography, laboratory studies any data.
4. Service calls to your home.
Teaching practice during the lesson.
Supervision of patients with cardiac arrhythmias in heart failure, anemia, hyperthyroidism.
The number of hours -1.5 hours.
Quiz
 Differential diagnosis of blood circulation. Differential diagnosis of failure for anemia,
hyperthyroidism. Clinical and ECG - diagnosis of heart failure.
 Clinical and ECG - diagnosis of anemia, hyperthyroidism.
 Differentiated treatmentarrhythmias depending on the etiology.
 Principles of treatment of treatment of patients withheart failure, anemia, hyperthyroidism.
 Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
71
 The principles of primary, secondary and tertiary prevention in these diseases.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS WITH ARTERIAL
HYPERTENSION (AH)
Purpose:6-7 courses teach students syndromal addressing patients with hypertension, as well as the
principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with hypertension;

Giving students a timely diagnosis when there is a problem associated with hypertension.

To teach students to differentiate the disease, accompanied with hypertension.

Improve the knowledge, skills, and practical skills in solving problems of patients with
hypertension (information gathering, problem identification and physical examination, as well
as the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHUs and SP;
What the studentneeds to know to solve the problems of patients with hypertension:
№
The list of knowledge
The list of diseases that occur with hypertension
A list of the most dangerous diseases that occur with
hypertension
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
hypertension
Classification of hypertension (in degree, the risk of
cardiovascular events and stage)
Symptoms of internal organs
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and rehabilitation
72
Basic level
The student should know at least
10 of the most common diseases
The student should know at least
five diseases
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must provide.
The student must list the symptoms
of
The student must know the
principles of non-medical and
medical treatment of diseases
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
of disorders that occur with hypertension in a rural
health units or FP (4-category)
activities for clinical examination
and rehabilitation
That the student should be able to solve problems of patients with hypertension:
№
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the
probable diagnosis.
The student must be able to specifically identify
and assess the patient's complaints.
The student must be able to analyze medical
Ask the patient and his relatives
history: the beginning of the disease, the first
symptoms, the causal relationship and the
dynamics of their development.
The student must be able to analyze life history:
the identification of risk factors, the health of
parents and family members.
The student must be able to identify unmanaged
Identify risk factors
and uncontrolled risk factors as on questioning
patient, based on an objective approach
Measure blood pressure.
2.
Student should be able to hold tonometry
with the incremental principle.
The student must be able to detect the presence of:
- Pale
An inspection of the skin
- Cyanosis,
-The presence of rash, acne, striae
The student must be able to assess the
An inspection of the subcutaneous fat
proportionality of the distribution
The student must be able to identify:
- The presence of a person lunoobraznogo
General inspection
- Puffiness
- Swelling of the neck veins
- Pulsation of the abdominal aorta
The student must be able to detect:
Explore the pulse of the carotid, radial
- The presence or absence of a pulse
and femoral arteries
The student must be able to evaluate the
properties of the radial artery.
The student must be able to identify:
Conduct auscultation of breath.
- Moist rales
The student must be able to identify features:
- Left ventricular hypertrophy
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and
- If the heart murmur, be able to identify their
auscultation of heart and vascular system.
epicenter, and the relation to the phase of the
cardiac activity (systolic or diastolic murmur);
- To be able to differentiate functional from
organic heart sounds.
73
Conduct palpation, percussion liver
Conduct percussion and palpation of the
kidneys.
Conduct auscultation over the renal
arteries
Hold ophthalmoscopy
Conduct a neurological examination.
Calculate the index weight / body
Interpret the clinical and biochemical
ECG and decrypt it.
Differentiate disease accompanied with
hypertension
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
hypertension.
The student must be able to identify features:
- Acute abdomen
- Hepatomegaly
the student should be able to:
- Test for tapping the lumbar region
- Palpation to evaluate the properties of the
kidneys
The student must be able to detect the presence
of:
-Systolic murmur.
Student should be able to hold ophthalmoscopy
with the principle of step and look of the eye, and
to identify features:
- Arteriovenous crossings
The student must be able to identify features:
- Peripheral paresis or paralysis
- Central paresis or paralysis.
The student must be able to evaluate reflexes
(with neurological hammer) and identify features:
- Hyperreflexia
- Hyporeflexia
- Areflexia
The student must be able to assess motor function
and signs of
The student must be able to identify features:
- Underweight
- Increased weight.
The student must be able to identify features:
- Increase or decrease in performance from the
norm.
The student must be able to record the ECG with
the incremental principle.
Student should be able to decipher the results of
the ECG and identify signs:
- Myocardial ischemia
- MI
- Left ventricular hypertrophy.
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory and
instrumental investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products
with proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
74
- Eligibility
- Economy.
Student should be able to carry out monitoring
and control:
Conduct monitoring and surveillance of
- The level of glucose in the blood
patients
- The level of the BP.
- The level of blood lipids
Practice session № 7
Topic: "Hypertension. Differential diagnosis of hypertension with hemodynamic AH
(atherosclerosis, coarctation of the aorta, aortic valve insufficiency, congestive hypertension,
complete AV block). Tactics GPs. Principles of follow-up, monitoring and rehabilitation in RHU
or family policlinics. Principles of prevention. Principles of teaching topics. "
JustificationThread: In case of hypertension GPs should diagnose not only the hypertoniyu, but he
needed to determine the cause of health care.If Diagnostic AH GPs have to solve the question of
defining groups of patients to be treated in a rural health units or a family policlinics, or referral to
specializedhospitals nye.These and other circumstances are the basis for the inclusion of the subject in
a program GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis of symptomatic arterial hypertension, as well
as the principles of management of patients in primary care,provided the requirements of
"Qualification characteristics of a general practitioner"
Learning objectives:
1. Consider the differential diagnosis of symptomatic (renal parenchymal, endocrine,
hemodynamic, cerebral) arterial hypertension
2. Demonstrate patients with symptomatic (renal parenchymal, endocrine, hemodynamic,
cerebral) arterial hypertension.
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in rural health
units or a family policlinics.
6. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
GPs should know:
1. The mechanism of occurrence of symptomatic arterial hypertension.
2. Clinical manifestations of symptomatic arterial hypertension.
3. Symptomatic diagnosis of hypertension.
4. Differential diagnosis of various options of symptomatic arterial hypertension.
5. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
6. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Diagnose, differentiate symptomatic arterial hypertension (renal parenchymal, endocrine,
hemodynamic, cerebral).
2. Advise on non-medicated treatments.
3. To monitor the RHU or in family policlinics.
GPs should do:
75
1. Competently carry out inspection of the patient for the diagnosis of diseases associated with
hypertension.
2. To fill out the medical history of patients with symptomatic arterial hypertension (renal
parenchymal, endocrine, hemodynamic, cerebral)
3. Interpret the results of the ECG in patients with symptomatic arterial hypertension.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with patients with symptomatic arterial hypertension (parenchymal
renal, endocrine, hemodynamic, cerebral)
2. Data interpretation of laboratory and instrumental studies in symptomatic arterial hypertension.
Place of activity:
1. Training themed room.
1. Cabinet ECG
2. Hospital wards.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Hypertension. Differential
diagnosis of hypertension with hemodynamic hypertension (atherosclerosis, coarctation of the
aorta, aortic valve insufficiency accuracy, long-term hypertension, complete AV block).Tactics
GPs.Principles of follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of prevention. Principles of teaching topics. "
2. Decision analysis and situational problems.
3. Supervision of patients with symptomatic arterial hypertension.
4. Clinical analysis of supervised patients. Demonstration illth.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
76
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
12.2012.40.
12.4014.00
Study skills.
Student
under
the
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness
topic.
students.On thequestion
of students on training
with examplesequation
method
"rotation".
Students
distributed
ECG
that
Study
Options to analyze,
explain
and
give
conclude. Solution to
the case tasks on the
topic.
Patient or volunteer.
20 minutes
Whiteboard, a folder 30 minutes
with ECG, case
studies and tables,
corresponding to a
subject class.
The theoretical part includes:
Atherosclerosis- a disease of the arteries chronic large and medium caliber (elastic and
muscular-elastic type), characterized by a deposition and accumulation in the intima of atherogenic
plasma apoprotein B-containing lipoproteins, followed by reactive proliferation of connective tissue
and the formation of plaque.
Clinical features of hypertension in the elderly (sclerotic AH).
- Age> 60 years;
- AH in atherosclerosis is caused by hardening of the aorta and its main branches;
- Insulated or disproportionate increase in systolic pressure;
- The disease is relatively easy to carry, has non-malignant flow;
- Cistolicheskoe blood pressure> 160 mmHg, diastolic blood pressure <90 mm Hg;
Accent II tone of the aorta, rough systolic murmur with a metallic shade of the aorta, which
is well done in the interscapular space.
As a "hypertensive" first come to the doctor, many patients with aortic coarctation (men 3-4
times faster). When coarctation aortic patients live an average of 33 years of age with aortic over a
short distance below the discharge of the left subclavian artery, although sometimes stricture above
aorta.Vessel diameter mismatch volume with age becomes more and more significant hypertension
develops the upper body, increases blood circulation through collateral pectoral and intercostal
arteries, according to the latest moves in the shelter abdomenal aorta but retrograde. Increased blood
pressure can be detected by clinical examination of life as subjective disorders yet. In this case,
hypertension is a very stable th beginning with a significant increase in diastolic blood pressure
increases after any stress, bad inferior to medication therapy. Important diagnostic feature of
coarctation of the aorta pump is noise. Most often it is not limited to the phase of systole, takes part or
all of diastole, auscultated over the top of the heart and in the folds muscular area of the carotid
subclavian artery. Maximum noise is in paravertebral zone on the left. Helps in the diagnosis of AD
detection asymmetry in her arms: high blood pressure on the hands-150/90-250/150 mm Hg, and the
legs reduced (normally on their feet by 15-20mm. Hg Higher than on the hands). The shoulder belt is
developed better than legs and pelvic muscles. Radiographically noted the absence of aortic arch on
the left contour heart enhanced aortic edges due to the pressure of the collateral arteries. Diagnosis is
refined by aortography.
With systolic hypertension and diastolic blood pressure occurs aortic insufficiency and patent
ductus arteriosus (BP 190/30-160/0 mm Hg).Clinically appears reinforced contraction of heart,
pulsation in the neck and head, dizziness, pain in various areas of the heart, dyspnea later, suffocation
and other complaints related to increasing left ventricular failure. Pallor of the skin, "dance" carotid
77
and other large arteries, a symptom of Musset, capillary pulse Quincke. Apical push strengthened
shifted to the left and down; auscultated protodiastolic noise on the aorta or V point decreases, soft
tone, dual tone on the arteries Traube and dual noise Duroziez, ECG - hypertrophy of the left ventricle.
Hypertension occurs in congestive heart failure in 5% of cases. Its development increased tone
of the arterioles, secondary aldosteronism, and ischemia hypervolume kidney.The special features of
congestive hypertension include: rare occurrence of crises, Just noticeable changes in the fundus, no
hypertensive malignant syndrome.
III degree AV block (Full). At the level of the AV node is completely stopped conducting
impulses. Ventricles are reduced separately.Ventricular defined figures pacemaker replacement of AV
connections,but usually not more than 40-50 per min. Patients complain of weakness, dizziness,
darkening of the brief fainting, pain in the heart. Determined by slowing heart rate, cardiac
auscultation, bradycardia, regular rhythm of the heart. Iusually tone deaf, but the time on from time to
time (the coincidence of atrial and ventricular), there is a "gun-tone" Strazhesko. Systolic BP may life
improved. Complete AV block may be acute (transient) or chronic (persistent). On ECG:QRS
complexes are not widened. If the cardiac conduction system completely below the AV node,
developing stem AV block III degree (level bundle branch block), or the so-called distal threefascular
blockade (level bundle-branch block). Source replacement rate is usually located in one of the
branches of the beam calcium. Course of the excitation wave abruptly disrupted and widened QRS
complex deformed. RR interval isthe same with chachtatoy 30-40 in 1min or less. The number of P
wave normal, the interval P-P one and lie in wait with rate 60-80 bpm. In 1 minute. Chronic distal AV
block III degrees in half the cases are caused by sclerotic and degenerative pathways - bilateral
idiopathic fibrosis feet (Lenegre disease) occurs mainly in young and middle age, and Loew's disease a progressive sclerosis and calcification of the membranous part and upper part of the ventricular
muscle septum.
The principles of treatment of hypertension in the elderly.
According to the MS Kuszakowski (1995), in first place in the treatment of hypertension in the elderly
follows deliver calcium from the subclass dihydropyridines (nifedipine 40mg/sut and its analogues).
They have a mild diureticsgical action, active, and in the form of low-renin hypertension, maintain
renal and cerebral blood flow, increase the compliance of the walls artery. It is very effective and easy
to use calcium antagonist II generation prolonged release is radipine- 2.5-10mg / day.
Preferred destination of thiazide diuretics in small doses, especially hydrochlorothiazide- 12.5-25mg /
day.With hypokalemia best given potassium-sparing diuretics, potassium supplements and not orcom
applybinirovannnye preparations containing a thiazide and potassium-sparing diuretic.Older diuretics
may mustacheugubit bladder dysfunction (eg, incontinence).
Angina pectoris and contraindications to diuretics blockers administered in small doses
before.With isolated systolic hypertension, ACE inhibitors are effective and calcium antagonists.Α1blockers should be used with great cautious, because they can cause orthostatic hypotension with
cerebral ischemia. In patients with congestive cardiovascular failure, when blood pressure is back on
the use of diuretics, the most effective and safe prazosin.
Symptomatic treatment for other AH shall take account of the underlying disease, with a number of
surgical disease (coarctation of the aorta, the heart and parkas, etc.).
Handout
Students dealt with the content and lists the name of the definition of pathology topics flowing
with symptomatic hypertension, examples of analyzes for different diseases, socio-differential
diagnostic criteria.The following is a list of references and control questions.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Electrocardiogram in hypertension.
3. Table: Classification of symptomatic arterial hypertension.
78
Independent work and self-education
Topic: etiology, pathogenesis of hypertension and hemodynamic classification of antihypertensive
drugs.
1. Independent work with literature in the library and at home.
2. Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference chair.
3. The development of the interpretation of ECG, echocardiography, laboratory data.
Teaching practice during the lesson.
Examination of patients with symptomatic arterial hypertension.
The number of hours -1 hour.
Quiz
1. The differential diagnosis of hemodynamic hypertension.
2. The diagnostic features of sclerotic hypertension.
3. Clinical features of hypertension in coarctation of the aorta.
4. Diagnosis of hypertension in aortic insufficiency.
5. The mechanism of occurrence of hypertensive heart failure.
6. Tactics GPs with hemodynamic hypertension.
7. Indications for hospitalization in symptomatic hypertension.
8. Differentiated treatment depending on the disease.
9. Definition of disability.
Practice session № 8
Topic: "Hypertension. Differential diagnosis of hypertension with cerebral AH (traumatic brain
injury, vertebral-basilar syndrome, arachnoiditis, encephalitis, brain tumors).Tactics of GPs.
Principles of follow-up, monitoring and rehabilitation in rural health units or family policlinics.
Principles of prevention. Principles of teaching topics. "
JustificationThread: In case of hypertension GPs should diagnose not only the hypertension, but he
needed to determine the cause of health care. If diagnostic AH GPs have to solve the question of
defining groups of patients to be treated in a rural health units or a family policlinics, or referral to
specialized hospitals .These and other circumstances are the basis for the inclusion of the subject in a
program training GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis of cerebral hypertension, as well as
principles of management of patients in primary care, provided the requirements of "Qualification
characteristics of a general practitioner"
Learning objectives:
1. Consider the differential diagnosis of cerebral hypertension.
2. Demonstrate patients with cerebral hypertension.
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in rural health
units or a family policlinics.
6. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
79
Conducting this training allows student time and correctly diagnose and differentiate on clinical data of
laboratory and instrumental studies of cerebral hypertension, establish a preliminary diagnosis and
determine the future tactics of the patient.
GPs should know:
1. The mechanism of cerebral hypertension.
2. Clinical manifestations of cerebral hypertension.
3. Symptomatic diagnosis of hypertension.
4. Differential diagnosis of various options of symptomatic hypertension.
5. The principles of treatment (drug and non-drug) for these diseases.
6. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1.
Diagnose, differentiate cerebral hypertension (traumatic brain injury, vertebralbasilar syndrome, arachnoiditis, encephalitis, brain tumors).
2.
Choose products with proven efficacy
3.
Advise on non-medicated treatments.
4.
To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient for the diagnosis of diseases associated with
hypertension.
2. To fill out the medical history of patients with cerebral hypertension (traumatic brain injury,
vertebral-basilar syndrome, arachnoiditis, encephalitis, brain tumors).
3. Interpret the results of the ECG in patients with cerebral hypertension (traumatic brain injury,
vertebral-basilar syndrome, arachnoiditis, encephalitis, brain tumors).
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with hypertensive patients with cerebral (brain injury, vertebral-basilar
syndrome, arachnoiditis, encephalitis, brain tumors).
2. Data interpretation of laboratory and instrumental studies in symptomatic hypertension.
Place of activity:
1.
Training themed room.
2.
Cabinet ECG
3.
Cabinet GPs.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Hypertension. The
differential diagnosis of hypertension with cerebral hypertension (traumatic brain injury,
vertebral-basilar syndrome, arachnoiditis, encephalitis, brain tumors).Tactics GPs. Principles of
follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of teaching topics. "
2. Decision analysis and situational problems.
Supervision of patients with cerebral hypertension.
1. Clinical analysis of supervised patients. Demonstration of patients.
Contents classes
Time
8.30-9.30
Events
Morning
Content
Materials
Lesson time
Report on subordinators Hospital records of 1 hour
80
conference.
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness
topic.
students.On thequestion
of students on training
using
the
"snowCove."Students
distributetsya ECG that
students must analyze,
explain
and
give
aconclusion.Decision
situradiative problems
on the topic.
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Whiteboard, a folder 30 minutes
with ECG, case
studies and tables,
corresponding to a
subject class.
The theoretical part includes:
In some cases, the differential diagnosis is difficult HD and brain tumor with secondary
hypertensive syndrome. Headache, changes in the fundus in the form of dead optic nerve, increased
internal pressure observed in cerebral form HD ("pseudotumorous form") but can be life due to a
tumor.
The various forms of the blood pressure increase, sympathetic-adrenal paroxysms resistant to
hypertension, may lead encephalitis, polymielitis, regional intracranial inflammation, as well as
contusion and concussion.
Centrogenic characterized by paroxysmal hypertension increase in blood pressure, accompanied by
severe headaches, dizziness, vegetative various manifestations of epileptic syndrome.In history, a
reference to perenesinnye cranial trauma, encephalitis. The long course of the disease can be identified
behaviors, movement disorders and sensitive areas of the pathology oftdelnyh cranial nerves.
81
In diagnostics, together with the therapist must participate neurologist, a neurosurgeon, an
ophthalmologist. Exclusive brain tumors to define the field of view, to make the studytion fundus. Use
methods of specialized study: rentgenografiyu skull, EEG, CT, pneumoencephalography, angiography
of cerebral vessels.
Handout
Students distributed sheets with the content and determine the topic title pathology, proceeding
with symptomatic arterial hypertension, examples of analyzes for different diseases, Differential-diagnostic criteria.The following is a list of references and control questions.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Table: Classification of symptomatic arterial hypertension.
Independent work and self-education
Topic: etiology, pathogenesis of cerebral hypertension.
1. Independent work with literature in the library and at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference
department.
3. The development of the interpretation of ECG, EEG, skull X-ray, laboratory data.
Teaching practice during the lesson.
Supervision of patients with symptomatic arterial hypertension.
The number of hours -1 hour.
Quiz
1. The differential diagnosis of cerebral hypertension.
2. Tactics GPs with cerebral hypertension.
3. Indications for hospitalization for symptomatic arterial hypertension.
4. Differentiated treatment depending on the disease.
5. Definition of disability.
References:
Main
1) Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2) Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3) Ички касалликлар, Камолов Н.Н., 1991
4) Внутренние болезни, том 1 Мухин Н.А. М.: ГЭОТАР - Медиа,2009
5) Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
6) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
1) Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
2) Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
3) Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
4) Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
5) Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С., 2010. Т.
6) Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
7) Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
8) Диагностика болезней внутренних органов. Окороков А.Н. 2005.
9) Лечение болезней внутренних органов. Окороков А.Н. 2005.
10) Дифференциальный диагноз внутренних болезней. Виноградов А.В. М.: Медицинское
информационное агенство, 2009.
11) Внутренние болезни: учебник.- в 2-х т. (1т) Под ред. Мартынова и др. М.: ГЭОТАР - Медиа,
2005:
82
12) Внутренние болезни: учебник.- в 2-х т. (2 т.)
Медиа, 2005:
Под ред. Мартынова и др. М.: ГЭОТАР -
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/cgibin/mbook,http://www.intute.ac.uk/medicine/
83
PULMONOLOGY
CONTENT THAT CASE STUDIES
№
Themes of workshops
Literature, practical
skills
Cough with phlegm. Diseases that occur cough. The most dangerous
diseases that present with cough. Differential diagnosis of acute
respiratory infections, viral respiratory infections, acute bronchitis and
pneumonia.Tactics of GPs.Indications for referral to a specialist or
hospital in the profile department. Principles Treatment, monitoring,
control in rural health units or a family policlinics. Principles of
2.1
prevention.
Topics for independent work:
Etiology, classification of pneumonia, acute bronchitis, research
methods, complications.
Practical skills:
Interpretation of tests, X-rays.
Cough with phlegm.Differential diagnosis of chronic bronhit (CB) and
bronchiectasis (BE). Tactics GPs.Indications for referral to a specialist
or hospitalstion in the profile department.The principles of treatment,
follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of prevention. Definition of disability.
3
Topics for independent work:
Etiology, pathogenesis, classification of bronchitis, BE, clinical signs,
methods, complications.
Practical skills:
Interpretation of tests, X-rays.
"Shortness of breath and choking." Diseases that present with
shortness of breath or asthma. The most dangerous diseases that present
with shortness of breath or asthma. Differential diagnosis of asthma,
emphysema, pneumosclerosis. Chronic respiratory failure.Tactics GPs.
Indications for referral to a specialist or hospital in the profile
department. The principles of treatment, monitoring, control and
rehabilitation in RHU or family policlinics. Principles of prevention.
4-5 Principles of Teaching Tools "
Topics for independent work:
Classification, pathogenesis, clinical features of asthma, emphysema,
pneumosclerosis, respiratory failure. Pharmacodynamics of drugs used
in treatment of asthma
Practical skills:
Interpretation of tests, x-ray, ultrasound, ECG, drugs for the treatment
of bronchial asthma and heart.
"The differential diagnosis of cor pulmonale. Clinical
managementofpatients with xpical cor pulmonale disease.Indications for
referral to a specialist or hospital in the profile department. The
principles of treatment, outpatient observations, control and
6
rehabilitation in RHU or family policlinics. Principles of prevention.
Definition working ability. Principles of Teaching Tools"
III (1-10)
Topics for independent work:
Classification, pathogenesis, clinical features of asthma, emphysema,
84
pneumosclerosis, respiratory failure. Pharmacodynamics of drugs used
in asthma treatment.
Practical skills:
Interpretation of tests, x-ray, ultrasound, ECG, drugs for the treatment
of bronchial asthma.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH COUGH
Purpose: Teach students syndromal address with cough, and the principles of their management in
primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with the cough.

Giving students a timely diagnosis when there is a problem associated with cough.

To teach students to differentiate the disease, accompanied with cough.

Improve the knowledge, skills, and practical skills in solving problems of patients with
cough (information gathering, problem identification and physical examination, as well as the
ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to knowto solve the problems of patients with cough:
№
The list of knowledge
The list of diseases that occur with coughing
A list of the most dangerous diseases that present with
cough
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with a cough
Signs of cardiac asthma or pulmonary edema
Symptoms of asthma
Symptoms of heart failure
Signs of respiratory distress
Symptoms of internal organs
85
Basic level
The student should know at least
10 of the most common diseases
The student should know at least
five diseases
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must list the symptoms
The student must list the symptoms
Student should know
manifestations
Student should know
manifestations
The student should know the
symptoms of defeat
Student should knowlevels of peak
The principle of "traffic light"
expiratory flow (PEF), depending
on the color of the traffic light
the student should know:
Indicators of laboratory results
- Normal values and their changes
in pathology.
The student must know the
Treatment policy
techniques and principles of
treatment (including non-drug).
The principles of primary, secondary and tertiary
The student should know the basic
prevention
activities required for primary,
secondary and tertiary prevention
The principles of clinical examination and rehabilitation The student must list the main
of disorders that occur with coughing in RHU or FP (4- activities for clinical examination
category)
and rehabilitation
That the student should be ableto solve problems of patients with cough:
№
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the
probable diagnosis.
The student must be able to specifically identify
and assess the patient's complaints.
The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the
dynamics of their development.
The student must be able to analyze life history:
the identification of risk factors, the health of
parents and family members.
The student must be able to identify unmanaged
and uncontrolled risk factors as on questioning
patient, based on an objective approach
Student should be able to hold tonometry with the
incremental principle.
The student must be able to detect the presence of:
- Pale
- Cyanosis,
- Icterus,
- The presence of rash
The student must be able to detect:
- The presence or absence of a pulse
The student must be able to evaluate the properties
of the radial artery.
the student should be able to:
- To evaluate the chest and
- Assess voice trembling
- To estimate the elasticity of the chest
Ask the patient and his relatives
Identify risk factors
Measure blood pressure.
An inspection of the skin
Explore the pulse of the carotid, radial
and femoral arteries
Palpate the chest
86
the student should be able to:
detect the change in lung sounds and interpret
them
the student should be able to:
assess vesicular and bronchial breathing, and if
Conduct auscultation respiratory
there is abnormal noise or wheezing, interpret
them.
The student must be able to identify:
- Cardiac impulse
Palpation of the heart to hold
- Systolic and diastolic tremor
The student must be able to evaluate the apical
impulse.
The student must be able to identify:
- The boundaries of the relative and absolute
dullness of heart
- The boundaries of the vascular bundle
- The diameter of the heart
Conduct percussion heart
And waist-configuration of the heart.
The student must be able to identify:
- Signs of hypertrophy of the heart
- Mitral configuration
-Aortic configuration
The student must be able to identify:
- Easing I and II Tone
- I gain tone at the top
- Accent II tone of the aorta or pulmonary artery
Conduct cardiac auscultation
- Systolic and diastolic murmur, and to identify
their epicenter
Be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
Student should be able to conduct surface and
Conduct palpation, percussion of the deep palpation of the abdomen
abdomen
The student must be able to identify features:
- Hepatomegaly, splenomegaly.
The student should see the limbs and body, and to
be able to detect:
- Local or generalized edema. Fingers should be
Inspect the limb
able to put pressure on the dorsum of the foot and
updaruzhit:
- There is a pit or not.
The student must be able to detect:
To inspect the bones and joints
- The presence of the articular syndrome
Student should be able to inspect and palpate the
thyroid gland and identify signs of increase, and
Examine the thyroid gland.
depending on the size of the thyroid gland to
distinguish the degree of goiter
Student should be able to inspect the throat with
Examination of the throat
the principle of step and identify signs of angina.
The student must be able to identify features:
Calculate the index weight / body
- Underweight
Conduct percussion respiratory
87
- Increased weight.
Student should be able to hold a peak flow meter
Conduct a peak flow
with the principle of incremental
A student must:
- Know how to use tables and graphs of normal
PFM values depending on sex, age and height of
the patient.
Interpret the results of peak flow
- Be able to calculate the percentage of PFM on
proper values depending on sex, age and height of
the patient.
- Be able to analyze and predict the results
Student should be able to hold ophthalmoscopy
Hold ophthalmoscopy
with the principle of step and look of the eye
The student must be able to identify signs of shifts
Interpret the clinical and biochemical
from the norm
The student must be able to identify features:
- Pneumonia
Interpret the X-ray picture of light
- Pneumothorax
- Pleurisy
- Lung cancer and tuberculosis
5. The student must be able to record the ECG
with the incremental principle.
6. Student should be able to decipher the results
of the ECG and identify signs:
ECG and decrypt it.
- Myocardial ischemia
- MI
- Hypertrophy of the heart.
-Arrhythmias and conduction
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory and
Differentiated disease, accompanied with instrumental investigations).
cough
The student must be able to differentiate asthma
from cardiac asthma, based on 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-management
Give non-medical advice
- Advise on diet
- Advise on healthy living
Student should be able to provide prehospital care
in asthma attacks, spontaneous pneumothorax,
Provide prehospital care
cardiac asthma or pulmonary edema and
myocardial infarction.
The student must be able to conduct the pleural
Hold the pleural puncture
puncture technique for spontaneous pneumothorax.
The student should be able to choose products
Rational use of medicines in the with proven effectiveness.
treatment of diseases that occur with When choosing drug student should be able to
coughing
evaluate:
Effectiveness
88
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control:
Conduct monitoring and surveillance of - The level of glucose in the blood
patients
- The level of the BP.
- The level of blood lipids
- PFM
Practice session № 1-2
Topic: "The cough with expectoration. Diseases that occur with cough. The most dangerous
illness, running from coughing. Differential diagnosis of acute respiratory infections, viral
respiratory infections, acute bronchitis and pneumoniation.Tactics GPs. Indications for referral
to a specialist or hospitalization separated profiledetermination. The principles of treatment,
monitoring, control iniyah RHU or family policlinics. Principles of Prevention "- 6.7 hours.
Justification Thread: Cough is one of the most frequent causes of treatment for ME patients help.
Although the potential causes of coughing a lot, up to accurate diagnosis GPs should avoid in the first
place the most dangerous diseases. But, in general practice most patients present with bronchitis,
pneumonia, acute respiratory disease, SARS, where cough is one of the main manifestations of these
diseasestions.In this situation, the force of a general practitioner (GP) should be directed to the
diagnosis of cough due to various diseases. In case of cough GPs should diagnostician structed ARI,
ARI, bronchitis, pneumonia, and he needed to determine the reasons behind the disease is to provide
medical care and refine locations of this group of patients.
The aim of teaching: Getting GPs on timely diagnosis and differential diagnosis cough.Clinical
features, as well as principles of management of patients in primary care healthcare under the
requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Teach RHU diagnostics - bronchitis, pneumonia, clinical features, depending on the etiology
and stage.
2. Teach GP diagnosis and differential diagnosis of diseases in which there is a cough.
3. GPs familiarize with the list of communicable and non-communicable diseases associated with
cough and be treated in the FCP (FP) or specialized hospitals.
4. Discuss questions about tactics in the qualifying characteristics of GPs
5. The principles of treatment (non-drug and drug).
6. Principles of management, follow-up and monitoring of patients in a rural health units or a
family policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
Anticipated results.
Conducting this training allows student to correctly differentiate the state, accompanied by a
cough (ARI, ARI, acute bronchitis, pneumonia), and the targeted selection of tactics GPs.
GPs should know:
1.
The list of diseases that occur with coughing.
2.
A list of the most dangerous diseases that present with cough
3.
Clinical manifestations of acute respiratory infections, viral respiratory infections, bronchitis,
pneumonia (especially current).
89
4.
Differential diagnosis of cough.
5.
Principles of supervision and management of patients in a rural health units or a family
policlinics.
6. The principles of prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints for diagnosis occurring cough.
2. Diagnose, differentiate the clinic, laboratory studies, radiographs different types of cough.
3. Advise on non-medicated treatments.
GPs should do:
1. Data analysis of complaints and medical history to diagnose the disease.
2. To inspect a patient with infectious diseases, accompanied by coughing.
3. Establish diagnosis and differential diagnosis of infectious diseases, accompanied by cough
4. Interpret the test results, the data of laboratory-instrumental studies in patients with bronchitis,
pneumonia, acute respiratory disease, SARS.
5.
For a list of diseases of pulmonary infiltrate and be further examination and / or treatment in
specialized units.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with acute respiratory infections, viral respiratory infections,
bronchitis and pneumonia
2. Data interpretation of laboratory and instrumental studies in patients with acute respiratory
infections, viral respiratory infections, bronchitis and pneumonia, accompanied by a cough.
Place of activity:
1. Training themed room.
2. Roentgen study.
3. Hospital wards.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Cough with expectoration of
diseases that occur cough.The most dangerous diseases that avenueswell with cough. Differential
diagnosis of acute respiratory infections, viral respiratory infections, acute bronchitis, and pneumonia.
Tactics GPs. Indications for referral to a specialist or hospitalization profiletion department.The
principles of treatment, monitoring, control in a rural health units, or family policlinics. Principles of
prevention. "
2. Clarification of diagnosis and differential diagnosis of infectious diseases that are accompanied by
pulmonary infiltrates.
3. Decision analysis and situational problems.
4. Supervision of patients with diseases that are accompanied by a cough with expectoration.
5. Clinical analysis of supervised patients.
6. Problem-based learning based on the analysis of the clinical situation. Discussing thematic patient.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Materials
Lesson time
Report on subordinators Hospital records of 1 hour
examined by patients in patients
the clinic and the
90
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students with the use of
the method "Tour the
gallery."
Students
ECG, the student must
analyze,
and
the
conclusion. A decision
on a
task on the
subject
and
roleplaying.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
research,
case
studies.
On practical training in the theoretical part series discusses the clinical features diagnosis of
cough.
Infections: pneumonia various etiologies (causative agents of acute pneumonia should first identify all
types of pneumococci and streptococci - and staphylococci, gram-negative bacteria - Escherichia coli,
Pfeiffer coli, Proteus, Pseudomonas aeruginosa) - widely used in the hospital, causing nosocomial
pneumonia Gram-negative rods Legionella in the water, Klebsiella (pneumonia Friedlander), viral
pneumonia (influenza, adenovirus, cytomegalovirus), viral-bacterial pneumonia, mycoplasma, ICP in
patients with severe impaired cellular immunity, especially in AIDS, pneumonia caused by fungi,
rickettsia, chlamydia, etc.).Emphasize the need to increase atypical pathogens: Chlamydia, Legionella,
Mycoplasma.
Basic principles of treatment of acute pneumonia
The choice of antibiotics is directly related to the type of pathogen establishment and
refinement of its sensitivity.
I. Pneumococci.
Therefore, in recent years have become widely used beta-lactamase inhibitor - sulbactam and
Claudiacleon acid.They come in combination with ampicillin and amoxicillin. The combination of
91
ampicillin with sulbaktamom - unazin, 1.5-3 g per day for 3-4 hours.Combination klaulon acid
amokitsillinom - amoxicillin.
Second-line drugs - cephalosporins
First generation: cefazolin (Kefzol) to 4-6g per os cephalexin, 1-2 grams per day.These drugs are high
active against staphylococci, streptococci, Escherichia coli, Klebsiella, destroyed most of the betalactamase.
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 the
action of beta-lactamases.
Third generation: Claforan - 3-6 grams a day; dardum (tsefaperazon) - 2-4 grams per day 2 times
intravenously; Fortum - 3 g per day for 3 doses, only parenterally, Rocephin (ceftriaxone) - 1-2 g daily
(one dose) intravenously or intramuscularly.
The preparation of the third generation + sulbactam: sulperadon (tsefaperazen) - 2-4 grams per
day in 2 divided doses intravenously or intramuscularly.
Third-line - macrolides:erythromycin - 200 mg 2-3 times a day intravenously (up to 1 g per day), per
os 250-500 mg 4 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 - to 20 million units, semi-synthetic penicillins
(oxacillin, methicillin), second row: Lincomycin - 500 mg 3 times a day, aminoglycosides: gentamicin
- 80 mg three times a day, kanamycin - 500 mg 3 times night.
III. Escherichia coli, Pseudomonas aeruginosa, Proteus (nosocomial infection): semi-synthetic
penicillins, aminoglycosides, chloramphenicol to 1 g per day.
IV. Klebsiella (pneumobaccillus): aminoglycosides in combination with chloramphenicol or
tetracycline (doksatsiklina hydrochloride), prolonged scheme - the first day of 200 mg (100 mg 2 times
a day), then 100 mg 1 time a 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 saline solution 2-3 times a day).
Fluoroquinolones.Drugs in this group can be attributed to antibiotics and stone. Along with
cephalosporins are widely used in the treatment of bacterial infections. Ftorhinolones have the
advantage over many other antibiotics: well penetrate into the cells, are active against gram-positive
and gram-negative, anaerobic bacteria, they are sensitive Haemophilus influenzae, Streptococcus,
Staphylococcus.
Use in the clinic: ciprofloxacin (tsiprolet, Tsiprobay) at 250-500 mg 2 times a day for 7-10
days, 200 mg intravenously 2 times a day for 1-2 weeks, ofloxacin (tarevid) 200-400 mg 2 times a day
(more active against Staphylococcus aureus).
VII. Fungi: amphotericin B (daily dose - 250 U / kg intravenously every other day or two
times a week for 4-8 weeks).
VIII. Virus - interferon.
Tactics GPs with acute pneumonia - hospitalization.
Handout
Students distributed lists containing the topic title, the list of diseases associated with cough,
examples of laboratory and instrumental studies
Equipment practice session.
14. Patterns of laboratory and instrumental studies.
15. Tables: clinical manifestations ARI, ARI, pneumonia, bronchitis
Independent work and self-education.
92
Topic: "The cough with expectoration. Differential diagnosis of acute respiratory infections, viral
respiratory infections, acute bronchitis, and pneumonia. Tactics GPs'
 Independent oversight of case patients during the supervision and development of skills in the
diagnosis differential diagnosis of viral respiratory infections, acute respiratory infections,
bronchitis, pneumonia.
 Prepare and deliver a presentation on the subject of training sessions on clinical research
conferences in the department, CHO, student research conferences, etc.
 Improving skills on data interpretation radiographs, laboratory data ARI, ARI, bronchitis,
pneumonia
 Improving skills to treat ARI, ARI, bronchitis, pneumonia
Teaching practice during the lesson.
Supervision of patients with diseasesthe respiratory system.
Number of hours - 1 hour.
Quiz
 Classification of ARI, ARI, bronchitis, pneumonia
 Clinical features of viral respiratory infections, acute respiratory infections,
bronchitis, pneumonia.
 Differential diagnosis of viral respiratory infections, acute respiratory infections,
bronchitis, pneumonia
 The etiology and pathogenesis of viral respiratory infections, acute respiratory
infections, bronchitis, pneumonia
 The main clinical and laboratory studies to diagnose and.
 Features of treatment of ARI, acute respiratory infections, bronchitis, pneumonia
Practical lesson number 3.
Topic: "The cough with expectoration. Differential diagnosis of chronic bronchitis (CB) and
bronchoectatic disease (BED).Tactics GPs.Indications for referral to a specialist or hospitalstion
in the profile department.The principles of treatment, follow-up, monitoring and rehabilitation
in RHU or family policlinics. Principles of prevention. Definition of disability.Principles of
teaching the topic. "- 6.7 hours.
JustificationTopics: The majority of patients with chronic lung disease (CLD) in the group that
includes chronic bronchitis (CB) bronchoectasic disease (BED), seek medical attention. In this
situation, general practitioners (GPs) is sent to diagnose chronic lung disease caused by various
diseases. In case of chronic lung disease GPs should diagnose the disease, and he needed to determine
the cause ofthe disease condition for medical treatment and refining locations of this group of patients.
The aim of teaching:Getting GPs on timely diagnosis and differential diagnosis. Chronic lung disease
(chronic bronchitis and BED).Clinical features, as well as principles of management of patients in
primary care healthcare underthe requirements of "Qualification characteristics of a
general practitioner"
Learning objectives:
1.
Teach RHU diagnostics - CB and BED, clinical features, depending on the etiology and
the stage.
2.
Teach GP diagnosis and differential diagnosis of diseases in which there is a cough with
phlegm.
3.
GPs familiarize with the list of diseases associated with cough with phlegm and being
treated in the FCP (FP) or specialized hospitals.
4. Discuss questions about tactics in the qualifying characteristics of GPs
93
5. The principles of treatment (non-drug and drug).
6.
Principles of management, follow-up and monitoring of patients in a rural health units or
a family policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
Anticipated results.
Conducting this training allows student to correctly differentiate the state, accompanied by
breathlessness and suffocation (CB, BED), the clinical and laboratory data of instrumental studies and
thus to establish a preliminary diagnosis of the patient.
GPs should know:
1. Clinical manifestations of chronic bronchitis, Bab.
2. Differential diagnosis of these.
3. Key points (test) diagnostics.
4. Signs of respiratory distress.
5. The principles of treatment (drug and non-drug) for the diseases.
6. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Data analysis and history of complaints to diagnose diseases occurring with shortness of
breath and asthma.
 Diagnose, differentiate the clinic, laboratory studies, radiographs of these different kinds of
diseases.
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 Conduct monitoring.
GPs should do:
 Data analysis of complaints and medical history to diagnose the disease.
 To inspect a patient with chronic lung disease, accompanied by breathlessness and suffocation
 Establish diagnosis and differential diagnosis of chronic lung disease accompanied by
shortness of breath and asthma.
 Interpret the test results, the data of laboratory-instrumental studies in patients with chronic
lung disease
 For a list of diseases with chronic lung disease and to be further examination and / or treatment
in specialized units.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with chronic lung disease, accompanied by breathlessness and
suffocation
2. Data interpretation of laboratory and instrumental studies in patients with chronic lung disease,
accompanied by breathlessness and suffocation
3. To monitor the RHU or in family policlinics.
Place of activity:
1. Training themed room.
2. Roentgen study.
3. GP office
94
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "Shortness of breath, choking.
For diseases that present with shortness of breath or asthma.The most dangerous diseases, the present
with shortness of breath or asthma. Differential diagnosis of chronic bronchitis (CB) and
bronchiectasis (BED).Tactics GPs. Indications for referral to a specialist or hospital in the profile
department.The principles of treatment, follow-up, monitoring and rehabilitation in RHU or family
policlinics.Principles of prevention. Definition of disability. Principles of teaching topics.
"Clarification of diagnosis and differential. diagnosis of CLD, accompaniedby breathlessness and
suffocation.

Decision analysis and situational problems.

Supervision of patients with diseases that are accompanied by breathlessness and suffocation

Clinical analysis of supervised patients.

Problem-based learning based on the analysis of the clinical situation. Discussing thematic
patient.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students with Setting up
forthe method of the
"Tour the gallery."A
95
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
decision on a task on research,
the subject and role- studies.
playing.
case
On practical training in the theoretical part series discusses the clinical features of COPD
diagnosis.
Chronic obstructive pulmonary disease (COPD) - a term with duplicate content.
First, COPD - is a collective term that covers 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 death rates, they
develop faster irreversible obstructive changes thefunction of breathing and all of the known
symptoms of COPD. It is believed that reflects the demographics of COPD prevalence of smoking.
Most often (70%) where COPD is COB, about 1% of the EL (because a1-antitrypsin deficiency), the
remaining percentage accounted for severe asthma. COB allocation as a separate nosological form is
crucial from the point of early diagnosis and treatment under reversible component of airway
obstruction, ie when the disease has not yet lost its identity and there is a real possibility of inhibition
of disease progression by affecting the reversible component of airflow obstruction.
The first sign that patients usually go to the doctor, is ancough and shortness of breath, wheezing
sometimes accompanied with expectoration. These symptoms are most pronounced in the morning. At
an even earlier symptoms that to 40-50 years of life, is a cough. By this time in the cold with beginning
to have episodes of reflex respiratory infection, does not bind to the first one disease. Shortness of
breath, initially perceived by load, there are on average 10 years after the occurrence of cough.
Sputum production in a small number (rarely more than 60 ml / day) in the morning, has a
slimy character and becomes purulent only during infectious episodes, which are usually regarded as
an exacerbation.
Results of the physical examination of patients with COB depends on the severity of
bronchialstruction, the severity of lung hyperinflation and physique. As the disease progresses to
coughing of connecting wheezing, most notable for accelerated expiration.Often auscultation revealed
dry rales. Shortness of breath may vary very widely: from a sense of lack of air at standard physical
exercise to severe respiratory failure. With progression bronchial obstruction and hyperinflation of the
lungs increase the size of anteroposterior chest. Limited mobility of the diaphragm, auscultation
picture changes: reduced the severity of wheezing, prolonged exhalation.
Sensitivity of physical techniques to determine the severity of COPD is low.Among the
classical symptoms include wheezing breath and elongate expiration (> 5 sec), which may indicate
bronchial obstruction.
Thus, the development and progression of COPD occurs in times of risk factors, characterizing the
slow gradual onset.The first (the earliest) COPD is a sign of a cough.
Physical examination in patients with COPD is not enough for a diagnosis of the disease, it provides a
benchmark for the future direction of the diagnostic studies using instrumental and laboratory methods
of vector. Conventionally all diagnostic methods can be divided into methods required minimum, the
Executive all patients (complete blood count, urine, sputum, chest radiography, the study of respiratory
function (ERF), ECG), and additional methods used for special indications.
For daily clinical work with patients with COB addition to routine clinical tests should follow the ERF
study(FEV1, forced vital capacity or VC), test with bronchodilators (b2-agonists and cholinolitics),
chest X-ray.The remaining methods are recommended for special indications, depending on the
severity of illness and nature of its progression.
In everyday practice, patients with COB apply tests bronchodilators (b-agonists and / or cholinolitics),
which to some extent the ability to fast regression of bronchial obstruction, in other words, a
"reversible" component obstruction.The increase in FEV1 during the test by more than 15% from
baseline values are commonly characterized as a reversed obstruction.
1. Smoking cessation and limitation of external risk factors.
96
2. Patient education.
3. Bronchodilatory therapy.
4. Mucoregulatory therapy.
5. Antiinfective therapy.
6. Correction of respiratory failure.
7. Rehabilitation therapy.
In forming the strategy and tactics of treatment of patients with COPD is crucial to allocate two
regimens: treatment without exacerbation (maintenance therapy) and treatment of COPD exacerbations
Handout
Students distributed lists containing the topic title, the list of diseases associated with
breathlessness and suffocation, examples of laboratory and instrumental studies
Equipment practice session.
2. Patterns of laboratory and instrumental studies.
3. Tables: clinical manifestations of COPD
Independent work and self-education.
Topic: etiology, classification of CLD, clinical signs, methods, complications.
1. Independent oversight of case patients while on duty and the development of skills in the
diagnosis differential diagnosis of COPD.
2. Mastering skills while on duty at the clinic.
3. Prepare and deliver a presentation on the subject of training sessions on clinical research
conferences in the department, CHO, student research conferences, etc.
4. Improving skills on data interpretation radiographs, laboratory data CLD.
5. Improve skills for the treatment of CLD
Teaching practice during the lesson.
Supervision of patients with diseasesthe respiratory system.
Number of hours - 1 hour.
Quiz
 Classification of chronic lung disease
 Clinical features of CLD.
 Differential diagnosis of CLD.
 The etiology and pathogenesis of chronic lung disease.
 The main clinical and laboratory investigations for the diagnosis of CLD.
 What radiographic changes identified CLD?
 Features of treatment of CLD.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH SHORTNESS OF BREATH OR CHOKING
Purpose: Teach students syndromal addressing patients with shortness of breath or choking, as well
as the principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:
 To teach students the problem associated with shortness of breath or asthma.
 Giving students a timely diagnosis when there is a problem associated with wheezing or asthma.
 To teach students to differentiate the disease, accompanied with shortness of breath or asthma.
97
 Improve the knowledge, skills, and practical skills in solving problems of patients with shortness of
breath or dyspnea (gathering information, identifying problems and physical examination, as well as
the ability to reasonably prescribe laboratory and instrumental methods of investigation);
 Giving students a reasonably choose tactics;
 To teach students to exercise reasonable medical and preventive measures and surveillance in RHU
and FP
What the student needs to knowto solve the problems of patients with shortness of breath or
choking:
№
The list of knowledge
The list of diseases that present with shortness of breath
or choking
A list of the most dangerous diseases that present with
shortness of breath or choking
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
Basic level
The student should know at least
10 of the most common diseases
The student should know at least
five diseases
According to the characteristics of
the GP qualifying
According to the characteristics of
the GP qualifying
According to the characteristics of
A list of studies requiring in RHU or FP (3-1 category)
the GP qualifying
The list of research areas requiring outside RHU or FP
According to the characteristics of
(3.2-category)
the GP qualifying
A student must know features and
Key points (criteria) diagnosis, occurring with shortness
symptoms of each disease, and the
of breath or choking
criteria for their diagnosis.
Signs of cardiac asthma or pulmonary edema
The student must list the symptoms
Symptoms of asthma
The student must list the symptoms
Student should know
Symptoms of heart failure
manifestations
Student should know
Signs of respiratory distress
manifestations
The student should know the
Symptoms of internal organs
symptoms of defeat
Student should knowlevels of peak
The principle of "traffic light"
expiratory flow (PEF), depending
on the color of the traffic light
the student should know:
Indicators of laboratory results
- Normal values and their changes
in pathology.
The student must know the
Treatment policy
techniques and principles of
treatment (including non-drug).
The principles of primary, secondary and tertiary
The student should know the basic
prevention
activities required for 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 examination
choking under RHU or FP (4-category)
and rehabilitation
98
That the student should be ableto solve problems of patients with shortness of breath or choking:
№
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the
probable diagnosis.
The student must be able to specifically identify
and assess the patient's complaints.
The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the
dynamics of their development.
The student must be able to analyze life history:
the identification of risk factors, the health of
parents and family members.
The student must be able to identify unmanaged
and uncontrolled risk factors as on questioning
patient, based on an objective approach
Student should be able to hold tonometry with the
incremental principle.
The student must be able to detect the presence of:
-Pale
- Cyanosis,
- Icterus,
-The presence of rash
The student must be able to detect:
- The presence or absence of a pulse
The student must be able to evaluate the properties
of the radial artery.
the student should be able to:
- To evaluate the chest and
- Assess voice trembling
- To estimate the elasticity of the chest
the student should be able to:
detect the change in lung sounds and interpret
them
the student should be able to:
assess vesicular and bronchial breathing, and if
there is abnormal noise or wheezing, interpret
them.
The student must be able to identify:
- Cardiac impulse
- Systolic and diastolic tremor
The student must be able to evaluate the apical
impulse.
The student must be able to identify:
- The boundaries of the relative and absolute
dullness of heart
- The boundaries of the vascular bundle
- The diameter of the heart
And waist-configuration of the heart.
Ask the patient and his relatives
Identify risk factors
Measure blood pressure.
An inspection of the skin
Explore the pulse of the carotid, radial
and femoral arteries
Palpate the chest
Conduct percussion respiratory
Conduct auscultation respiratory
Palpation of the heart to hold
Conduct percussion heart
99
The student must be able to identify:
- Signs of hypertrophy of the heart
- Mitral configuration
-Aortic configuration
The student must be able to identify:
- Easing I and II Tone
- I gain tone at the top
- Accent II tone of the aorta or pulmonary artery
Conduct cardiac auscultation
- Systolic and diastolic murmur, and to identify
their epicenter
Be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
Student should be able to conduct surface and
Conduct palpation, percussion of the deep palpation of the abdomen
abdomen
The student must be able to identify features:
- Hepatomegaly, splenomegaly.
The student should see the limbs and body, and to
be able to detect:
- Local or generalized edema. Fingers should be
Inspect the limb
able to put pressure on the dorsum of the foot and
updaruzhit:
- There is a pit or not.
The student must be able to detect:
To inspect the bones and joints
- The presence of the articular syndrome
Student should be able to inspect and palpate the
thyroid gland and identify signs of increase, and
Examine the thyroid gland.
depending on the size of the thyroid gland to
distinguish the degree of goiter
Student should be able to inspect the throat with
Examination of the throat
the principle of step and identify signs of angina.
The student must be able to identify features:
Calculate the index weight / body
- Underweight
- Increased weight.
Student should be able to hold a peak flow meter
Conduct a peak flow
with the principle of incremental
A student must:
- Know how to use tables and graphs of normal
PFM values depending on sex, age and height of
the patient.
Interpret the results of peak flow
- Be able to calculate the percentage of PFM on
proper values depending on sex, age and height of
the patient.
- Be able to analyze and predict the results
Student should be able to hold ophthalmoscopy
Hold ophthalmoscopy
with the principle of step and look of the eye
The student must be able to identify signs of shifts
Interpret the clinical and biochemical
from the norm
The student must be able to identify features:
Interpret the X-ray picture of light
- Pneumonia
- Pneumothorax
100
ECG and decrypt it.
Differentiated disease, accompanied with
shortness of breath or choking
Give non-medical advice
Provide prehospital care
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
- Pleurisy
- Lung cancer and tuberculosis
The student must be able to record the ECG with
the incremental principle.
Student should be able to decipher the results of
the ECG and identify signs:
- Myocardial ischemia
- MI
- Hypertrophy of the heart.
-Arrhythmias and conduction
The student must be able to differentiate the
disease on the basis of the distinctive features
(history, physical examination and laboratory and
instrumental investigations).
The student must be able to differentiate asthma
from cardiac asthma, based on 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-management
- Advise on diet
- Advise on healthy living
Student should be able to provide prehospital care
in asthma attacks, spontaneous pneumothorax,
cardiac asthma or pulmonary edema and
myocardial infarction.
The student must be able to conduct the pleural
puncture technique for spontaneous pneumothorax.
The student should be able to choose products
with proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control:
- The level of glucose in the blood
- The level of the BP.
- The level of blood lipids
- PFM
Practice session № 4-5
Topic: "Shortness of breath, choking. "Shortness of breath, choking. Diseases that present with
shortness of breath or asthma. Greater than dangerous diseases that present with shortness of
breath or asthma. Differential diagnosis of bronchial asthma, emphysema, pneumosclerosis.
Chronic respiratory failure. Tactics GPs. Referral to a specialist or hospitalization profile
department. Principles Treatment, follow-up, monitoring and rehabilitation in RHU or family
policlinics. Principles of prevention.Principles of Teaching Tools "- 6.7 hours.
101
Justification Thread: Shortness of breath or choking is the most frequent symbolptomam
broncho-pulmonary diseases. Especially, they are most common in chronic obstructive pulmonary
disease (COPD).This group includes emphysema (EL), some form of bronchial asthma (BA).
Reduction in quality of life associated with the increase of irreversible airflow obstruction (usually
non-atopic asthma), pneumosclerosis are the main cause of Heads of treatment of patients with
medical care. In this situation, the force of a general practitioner (GP) should be directed to the
diagnosis of COPD is caused by various diseases. In the case of COPD, GPs should diagnose the
disease and he needs to determine the cause ofthe diseases accompanied for medical care and refine
locations of this group of patients.
The aim of teaching: GettingGPs on timely diagnosis and differential diagnosis COPD (chronic
obstructive bronchitis (COB), emphysema (EL)), some forms of bronchial asthma (BA).Clinical
features, as well as principles of management of patients in primary care, provided the requirements of
"Qualification characteristics of a general practitioner"
Learning objectives:
 Consider the timely and early detection of COPD.
 Discuss these clinical - laboratory and instrumental data in COPD.
 Make a differential diagnosis between the COB, the EL and BA.
 Learn how to analyze and predict the results of peak flow.
 Identify key diagnostic criteria
 Discuss questions about tactics in the qualifying characteristics of GPs
 The principles of treatment (non-drug and drug).
 Principles of management, follow-up and monitoring of patients in a rural health units or a
family policlinics.
 The principles of primary, secondary and tertiary prevention in these diseases.
 Demonstrate patients with COPD.
Anticipated results.
Conducting this training allows student to correctly differentiate the state, accompanied by
breathlessness and suffocation (emphysema (EL), some form of bronchial asthma (BA) with an
increase of irreversible airflow obstruction (usually non-atopic asthma), pulmonary fibrosis) in the
clinic and to the laboratory and instrumental studies and, thereby establish a preliminary diagnosis of
the patient.
GPs should know:
8. Clinical manifestations of asthma, Al and pneumosclerosis.
9. Differential diagnosis of these.
10. Signs of respiratory distress.
11. The principles of treatment (drug and non-drug) for the diseases.
12. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
13. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints to diagnose diseases occurring with shortness of breath
and asthma.
2. Diagnose, differentiate the clinic, laboratory studies, radiographs different types of COPD.
3. Conduct a peak flow
4. Interpret the results of peak flow:
- Proper use of tables and diagrams of normal PFM values depending on sex, age and height of
the patient.
102
- Be able to calculate the percentage of PFM on proper values depending on sex, age and height
of the patient.
- Be able to analyze and predict the results
5. Choose products with proven efficacy
6. Advise on non-medicated treatments.
7. To monitor the RHU or in family policlinics.
GPs should do:
1. Data analysis of complaints and medical history to diagnose the disease.
2. To inspect a patient with COPD, accompanied by breathlessness and suffocation
3. Establish diagnosis and differential diagnosis of COPD accompanied by shortness of breath
and asthma.
4. Interpret the test results, the data of laboratory and instrumental studies in patients with
COPD
5. See the list of diseases in patients with COPD and to be further examination and / or
treatment in specialized units.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with COPD, accompanied by breathlessness and suffocation
2. Data interpretation of laboratory and instrumental studies in patients with COPD,
accompanied by shortness of breath and asthma.
3. Analyze and forecast the results of PEFR.
4. To monitor the RHU or in family policlinics.
Place of activity:
1. Training themed room.
2. Roentgen study.
3. Cabinet GPs.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "Shortness of breath,
choking. Differential diagnosis of asthma, emphysema, pneumosclerosis. Chronic
respiratory failure. Tactics GPs.Indications for referral to a specialist or hospital in the
profile department.The principles of treatment, dispansernogo monitoring, control and
rehabilitation in RHU or family policlinics. Principles of prevention.Principles of
teaching topics. "Explanation of the diagnosis and differential diagnosis of COPD,
accompanied by breathlessness and suffocation
 Decision analysis and situational problems.
 Supervision of patients with diseases that are accompanied by breathlessness and
suffocation
 Clinical analysis of supervised patients.
 Problem-based learning based on the analysis of the clinical situation. Thematic analysis
of the patient.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
9.30-10.30 Admission
Content
Materials
Lesson time
Report on subordinators Hospital records of 1 hour
examined by patients in patients
the clinic and the
challenges at home.
Each
student
is The
patient, 1 hour
103
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
Service calls at Examination of patients
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
Break.
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Study skills.
Patient or volunteer.
Student
under
the
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students with the use of
the method "Tour the
gallery."A decision on a
task on the subject and
role-playing on the
subject
and
roleplaying.
20 minutes
Table, corresponding 80 minutes
to a subject class, a
folder with ECG,
laboratory
and
instrumental
data
research,
case
studies.
On practical training in the theoretical part series discusses the clinical features of COPD
diagnosis.
Chronic obstructive pulmonary disease (COPD) - a term with duplicate content.
First, COPD - is a collective term that covers a group of chronic illness 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 form of
bronchial asthma (BA) with an increase of irreversible airflow obstruction.
Second, as a distinct disease COPD (nosological form) is the final stage ofthe flow progressive COB
AL, BA, ie the stage at which the disease progresses is lost due to the reversible component of airway
obstruction and disease, leading to COPD, lose their individuality. Which attitudes to match, and the
International Classification of Diseases, 10th Revision (ICD-10), it marked the rubric J.44.8 chronic
obstructive bronchitis not otherwise specified, included in the adjusted COPD.
Thus, in patients with COPD, there are at least two main features are fundamentally different
from their HP - diffuse damage the respiratory system, and progressive respiratory failure on
obstructive type.
Chronic obstructive pulmonary disease (COPD) are the leading causes of morbidity and
mortality in the adult population.
COPD is a chronic inflammatory process appears with a primary lesiontion of the distal airways.For
this category of patients is characterized by reduction in peak expiratory flow rate and lessdleniya
gradual deterioration of pulmonary gas exchange function, which reflects the irreversible airway
104
obstruction.Biomarkers of chronic inflammation in COPD is involved with increased neutrophils
activity mielopeperoxidase, elastase, an imbalance in the systems of proteolysis-antiproteoliz-oxidants
and antioxidants.The main clinical manifestations of COPD are cough varying degree, the allocation to
the company can and dyspnea.COPD refers to a group of diseases multigenetic.
Externally and internally the etiological factors of COPD (risk factors) are divided according
to importance.
Handout
Students distributed lists containing the topic title, the list of diseases associated with
breathlessness and suffocation, examples of laboratory and instrumental studies
Equipment practice session.
1. Patterns of laboratory and instrumental studies.
2. Tables: clinical manifestations of COPD
3. Peak flow meter.
Independent work and self-education.
Topic: etiology, classification of COPD, clinical signs, methods, complications.
1. Independent oversight of case patients while on duty and the development of skills in the
diagnosis differential diagnosis of COPD.
2. Mastering skills while on duty at the clinic.
3. Prepare and deliver a presentation on the subject of training sessions on clinical research
conferences in the department, CHO, student research conferences, etc.
4. Improving skills on data interpretation radiographs, laboratory data COPD.
5. Improve skills for the treatment of COPD
Teaching practice during the lesson.
Supervision of patients with diseasesthe respiratory system.
Number of hours - 1 hour.
Quiz
1. Classification of COPD
2. Clinical course of COPD.
3. Differential diagnosis of emphysema, pneumosclerosis, CB and CRF.
4. The etiology and pathogenesis of COPD.
5. The main clinical and laboratory studies to diagnose with these diseases.
6. What radiographic changes detected COPD?
7. Features of treatment of COPD?
Practical lesson № 6.
Topic: "Shortness of breath, choking. Differential diagnosis of cor pulmonale. Clinical
management of patients with apical cor pulmonale disease.Indications for referral to a specialist
or hospitalization of the profiled department.The principles of treatment, outpatient, control
and rehabilitation in RHU or family policlinics. Principles of prevention. Definition of
disability.Principles of Teaching Tools"-6.7 hours.
JustificationTopics: Cor pulmonale disease is the endpoint of many diseases of the bronchopulmonary system, particularly COPD. Therefore, the efforts of GPs should be directed
tomennuyutimelydiagnosis and prevention of COPD is caused by various diseases.In the case of
COPD, GPs should diagnose the disease, and he needed to identify the reasons behind the disease is to
provide medical care and utopianchneniya locations of this group of patients.
105
The aim of teaching: Getting GPs on timely diagnosis and differential diagnosis of cor pulmonale
disease, as well as the principles of management of patients in primary care, provided the requirements
of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Teach GPs diagnosis of diseases associated with cor pulmonale disease.
2. Educate GPs emergency care for acute and subacute cor pulmonale.
3. Educate GPs tactics of the patient with chronic cor pulmonale disease.
4. Teach self-management of patients with chronic cor pulmonale disease.
5.
Familiarize GPs with indications for treatment of hospitalized patients with chronic cor
pulmonale disease.
6. Educate GPs determine disability of patients with chronic cor pulmonale disease.
7. Discuss questions about tactics in the qualifying characteristics of GPs
8. The principles of treatment (non-drug and drug).
9. Principles of management, follow-up and monitoring of patients in a rural health units or a
family policlinics.
10. The principles of primary, secondary and tertiary prevention in these diseases.
11. Demonstrate patients with cor pulmonale disease.
Anticipated results.
Conducting this training gives the opportunity to study in a timely and correct diagnosis and to
differentiate on clinical and laboratory data of instrumental studies diseases associated with cor
pulmonale disease, establish a preliminary diagnosis and determine whether to continue the tactics of
the patient, indications for hospitalization, outpatient observation and outpatient treatment, to resolve
issues prevention and determining disability.
GPs should know:
1. Clinical manifestations of diseases associated with cor pulmonale disease;
2. Acute care, and differentiated treatment of diseases involving acute and chronic cor
pulmonale disease.
3. GPs tactics in acute and chronic cor pulmonale.
4. The tactics of the patient with chronic cor pulmonale disease.
5. Indications for hospitalization.
6. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
7. The principles of primary, secondary and tertiary prevention of cor pulmonale.
8. Definition of disability.
GPs should be able to:
1. Data analysis and history of complaints for the diagnosis of diseases associated with cor
pulmonale disease.
2. Diagnose, differentiated by the clinic to laboratory and instrumental studies diseases associated
with cor pulmonale disease.
3. To provide emergency assistance in cases involving cor pulmonale disease.
4. An outpatient treatment of patients with chronic cor pulmonale disease.
5. Determine the ability to work in patients with chronic cor pulmonale disease.
GPs should do:
1. Conduct a survey of patients with diseases that are accompanied by cor pulmonale disease.
2. To fill out the medical history of a patient with cor pulmonale disease.
3. Assign the desired plan of examination of patients with cor pulmonale disease.
106
4. Interpret the test results, the data of laboratory-instrumental studies in patients with diseases
associated with cor pulmonale disease.
5. Provide emergency care to patients with acute and subacute cor pulmonale disease.
6. Prescribe treatment for patients with chronic cor pulmonale disease caused by various
etiological factors.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with diseases that are accompanied by cor pulmonale disease.
2. Interpretation of analyzes of laboratory and instrumental studies, X-rays of patients with
diseases that are accompanied by cor pulmonale disease.
3. Billing drugs depending on the etiology of cor pulmonale.
4.To monitor the RHU or in family policlinics.
Place of activity:
1. Training themed room.
2. Cabinet GPs.
The course is taught.
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Differential diagnostics of cor
pulmonale. Clinical management of patients with chronic cor pulmonale disease. Outpatient treatment.
Indications for hospitalization.Definition of disability. Prevention. Principles of teaching about the
"Explanation of tactics GPs in cases involving suffocation.
2. Decision analysis and situational problems.
3. Supervision of patients with bronchoobstructive syndrome.
4. Clinical analysis of supervised patients.
5. Service calls at home. Report results calls served.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
107
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients
12.15.
12.2012.40.
Study skills.
Student
under
the Patient or volunteer. 20 minutes
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial Table, corresponding 80 minutes
14.00
analysis of the level of preparedness to a subject class, a
topic.
students.
On
the folder with ECG,
question of students on laboratory
and
training
with instrumental
data
application method eat research,
case
"round table."Students studies.
case studies on the
subject, they have to
analyze and give an
opinion.
On practical training in the theoretical part of the differential diagnosis considered
successively diseases that are characterized by the development of cor pulmonale.
Cor pulmonale - is hypertrophy and dilation, or only the right ventricle dilatation resulting from high
blood pressure in pulmonary circulation, which developed as a result of diseases of the bronchi and
lungs, chest wall deformity, or primary pulmonary artery lesion. (WHO 1961).
Right ventricular hypertrophy and dilatation with changes from primary heart disease, or birth
defects do not belong to the concept of cor pulmonale disease.
Recently, clinicians have observed that hypertrophy and dilatation of the right ventricle are already late
manifestations of cor pulmonale disease, when it can not be rational to treat these patients, so it was an
offer a new definition of cor pulmonale disease:
"Cor pulmonale - a set of hemodynamic 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 stageshows right ventricular hypertrophy and progressive heart failure. "
ETIOLOGY of cor pulmonale
Cor pulmonale disease is the result of three groups:
1. Bronchus and lung disease, primarily affecting the flow of air and the alveoli.This group consists of
disease (chronic obstructive bronchitis, pulmonary fibrosis of any etiology, pneumoconiosis,
tuberculosis, not in itself, as posttuberculosis outcomes, SLE sarcoidosis Beck (Boeck), fibrosing
alveolitis (enpre-and exogenous) and others). Cause of pulmonary middtsa in 80% of cases.
2. Disease, primarily affects the chest, diaphragm and the restriction of their mobility spine
(kyphoscoliosis, multiple rib injury, Pickwick syndrome in obesity, ankylosing spondylitis, pleural
suppuration after suffering pleurisy, etc.)
3. Disease primarily affecting the pulmonary vessels (primary 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 cor pulmonale disease in 20% of
cases. That's why they say that, depending on the etiology are three forms of cor pulmonale:
1. Bronchopulmonary
2. Thorax-diaphragmal
3. Vascular
Regulations quantities characterizing the hemodynamics of the pulmonary circulation.
Ratio
normal
Systolic pulmonary artery pressure
15-30 mm Hg
Diastolic pressure in the pulmonary artery
3-15 mm Hg
Mean pulmonary artery pressure
7-19 mm Hg
108
Total lung resistance
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 cor pulmonale disease is pulmonary hypertension. Since the most
common cor pulmonale develops with bronchopulmonary diseases, then it'll start. All diseases,
particularly chronic bronchitis on the constructive, above all, lead to respiratory (lung) disease.
Pulmonary failure - it is a condition in which the disturbed normal gas composition.
There are 3 stages of pulmonary disease.
Ratio
first stage
The second stage
The third stage
gas composition
no changes
hypoxemia (decreased partial hypoxemia
and
pressure of oxygen in the blood), hypercapnia
with
but combined with normocapnia metabolic acidosis
(45 mm Hg)
Arterial hypoxemia is at the heart of the pathogenesis is the basis for chronic diseases of the
heart, particularly in chronic obstructive bronchitis.
All these diseases lead to respiratory failure. Arterial hypoxemia will alveolar simultaneously
due to the development of hypoxia fibrosis, emphysema increases intraalveolar partial pressure.In the
non-respiratory arterial hypoxemia impaired lung function - begin secreted biological active substance
properties, which have not only bronhospasticheskim but vasospastic effect. Simultaneously when it is
a violation of the vascular arhitetonictothe lungs - the vessels of the dying, and so part of the
expanding Arterial hypoxemia leads to the tissue hypoxia.
The second stage of pathogenesis: arterial hypoxemia will lead to the restructuring of central
hemodynamics - interalia increasing the number of circulating blood, polycythemia, poliglobulii,
increased blood viscosity. Alveolar hypoxemic hypoxia lead to vasoconstriction by reflex, reflex with
which reflex called the Euler-Liestranda.Alveolar hypoxia led to hypoxemic vasoconstriction,
increased intra-arterial pressure, which leads to increased hydrostatic pressure in the capillaries.
Violate non-respiratory lung function results in the release of serotonin, histamine, prostaglandins,
catecholaminov, but most importantly, in terms of tissue hypoxia and alveolar interstitium starts to
develop in more angiotensin converting enzyme. Is the main body which produce this enzyme. It
converts angiotensin 1 to angiotensin 2. Hypoxemic vasoconstriction selection of BAS in central
hemodynamics lead not just to increased pressure in the pulmonary artery, but persistent increase it
(above 30 mmHg), that is, to the development of pulmonary hypertension. If the prospect of the
processes going on, if the underlying disease is not treated, it is natural to the vessels in the pulmonary
artery dies due pneumosclerosis, firmness and pressure increases in the pulmonary
artery.Simultaneously resistant secondary pulmonary hypertension will result revealed that shunts
between the pulmonary artery and bronchial arteries and non-oxiginated blood enters the systemic
circulation on bronchial veins and also contributes to the work of the right ventricle.
Thus, the third stage - the persistent pulmonary hypertension, the development of vein grafts, which
amplified work of the right ventricle.The right ventricle is not powerful in itself, and it is rapidly
developing hypertrophy with elements dilyatp eration.
Fourth stage - hypertrophy or dilatation of the right ventricle. Right ventricular myocardial
dystrophy budet also contribute as tissue hypoxia.
So, arterial hypoxemia led to secondary pulmonary hypertension and right ventricular
hypertrophy, dilatation and its development predominantly right ventricular heart failure.
The pathogenesis of cor pulmonale disease at torakodiafragmalnoy form in this form is dominant due
to hypoventilation kyphoscoliosis lung, pleural suppuration, deformations ofthe spine, or obesity
109
which rises high aperture. Hypoventilation of lungs, primarily lead to restrictive type of respiratory
failure in the presence of which is caused by obstructive chronic cor pulmonale.A further mechanism
is the same - the restrictive type of respiratory failure leads to arterial hypoxemia, alveolar hypoxemia,
etc.
The pathogenesis of pulmonary vascular heart in shape is that thrombosis main branches of the
pulmonary arteries, the blood supply decreases dramatically lung tissue, because along with
thrombosis of the main branches are reflex constriction of branches. In addition, the vascular form,
particularly in primary pulmonary hypertension, cor pulmonale disease contribute to the development
of humoral pronounced shift, there is a noticeable increase in the number sertonina, prostaglandins,
catecholamine excretion convertase, angiotensin-converting enzyme.
CLASSIFICATION OF COR PULMONALE.
Uniform classification of cor pulmonale disease does not exist, but the first international classification
mainly etiological (WHO, 1960):

Bronchocor pulmonale

Thorax-diaphragmal

Vascular
Proposed domestic classification of cor pulmonale, which provides for the division of cor pulmonale
rate of development:

acute

subacute

chronic
Acute cor pulmonaledevelops within a few hours, days, minutes maximum. Subacute cor pulmonale
develops within a few weeks or months.Chronic cor pulmonale develops over several years (5-20
years).
This classification provides for compensation, but the acute lung decompensated heart always, that is
friction immediate assistance. Subacute compensated and decompensated can mainly on right
ventricular type. Chronic cor pulmonale can be compensated, subcompensated, decompensated.
On the genesis of acute cor pulmonale develops in the vascular and bronchopulmonary forms.
Underacute and chronic cor pulmonale may be vascular, bronchopulmonary, thoraxdiaphragmal.
Acute cor pulmonale develops primarily:
 embolism - not only for thromboembolism, but also for gas, tumor, fat, etc.
 with pneumothorax (especially valves)
 In attacks of asthma (especially in asthmatic status - a qualitatively new state of patients with
bronchial asthma, a complete blockade of β 2-adrenergic receptors, and acute cor pulmonale
disease);
 acute pneumonia drain
 total sided pleurisy
A practical example of subacute cor pulmonale disease is recurrent thromboembolism of
small branches of the pulmonary arteries, bronchial asthma attacks. A classicexample is the
lymphangitis, especially chorionepithelioma, in peripheral lung cancer. Thoraxdiaphragmal form
develops in the central hypoventilation or peripheral origin - myasthenia gravis, botulism, polio etc.
To delineate what stage cor pulmonale of stage respiratory failure becomes a hundred heart
failure has been proposed another classification. Pulmonary middtse divided into three stages:
 hidden latent failure- lung function is - reduced to 40%, but no change in the gas composition
of the blood, that is, this stage is characterized by respiratory failure 1-2 stages.
 Stage severe pulmonary disease- the development of hypoxemia, hypercapnia, but no signs
offailure in the middle periphery.Have shortness of breath at rest, which is not abouttnesti to heart
disease.
 stage cor pulmonale varying degrees(swelling of the limbs, increased stomach, etc.).
Chronic cor pulmonale in terms of respiratory failure, arterial oxygen saturation, right ventricular
hypertrophy and heart failure is divided into four stages:
110
Pulmonary insufficiency I degree - VC / KZHEL reduced to 20%, the gas composition was not
affected. Hypertrophy of the right ventricular missing on ECG, echocardiography but hypertrophy.
Failure circulation at this stage no.
Pulmonary insufficiency II degree - VC / KZHEL to 40% oxygen saturation of 80%, there are the
first indirect evidence of right ventricular hypertrophy, circulatory failure + / -, then there is only
dyspnea at rest.
Pulmonary insufficiency III degree - VC / KZHEL less than 40% saturation of the arterial blood to
50%, showing signs of right ventricular hypertrophy on the ECG as direct evidence.Circulatory
failure II.
Pulmonary insufficiency IV degree. Oxygen saturation less than 50%, right ventricular hypertrophy
with dilatation, insufficient circulation II B (dystrophy, refractory).
Clinic acute cor pulmonale
The most common cause of a pulmonary embolism, acute of thorax increase internal pressure due to
bronchial asthma. Precapillary arterial hypertension in acute cor pulmonale, as in valar form of chronic
cor pulmonale disease is accompanied by increased pulmonary resistancetion. Next is the rapid
development of dilatation of the right ventricle. Acute right ventricular failure manifested expression
dyspnea passing in inspiratory gasp nature rapidly increasing cyanosis, chest pain once personal, shock
or collapse. Rapidly increasing size of the liver, there is swelling in the legs, ascites, epigastric
pulsation, tachycardia (120-140), breathing hard, in some places a weakened vesicular; moist rales
variegated especially in the lower lung. Important in the development of acute cor pulmonale disease
have additional methods especially ECG sharp deviation electric right axis (R 3> R 2> R 1, S 1> S 2> S 3),
there is P-pulmonale- pointed the P wave, in two, three standard leads. Right bundle branch block,
complete or incomplete, the inversion of ST (more lift), S in the first abduction deep, Q in the third
abduction deep.These symptoms can and in acute myocardial infarction rear degree NKI.
Emergency treatment depends on the cause by acute cor pulmonale. If PE was then prescribe
painkillers, fibrinolytic and anticoagulant drugs (heparin, fibrinolysin, streptodekaza, streptokinase),
up to surgery.
When asthmatic status - high doses of corticosteroids intravenously broncholitic drugs through a
bronchoscope, the translation of mechanical ventilation and bronchial lavage. If this is not done then
the patient absorption.
When valvular pneumothorax - surgical treatment.When the drain along with the treatment of
pneumonia antibiotic necessarily prescribe diuretics and cardiac glycosides.
CLINIC OF CHRONIC COR PULMONALE
Patients concerned about shortness of breath, which depends on the nature of the pathological
process in the lungs, such as respiratory insufficiency (obstructive, restrictive, mixed).In obstructive
apnea processes and the vector character with unchanged respiratory rate, in restrictive processes
expiratory duration decreases, and breathing rate increases.An objective study, along with the main
features of appears cyanosis, often diffuse, warm because of the conservation of peripheral blood
current, in contrast to patients with heart failure. Some patients with cyanosis expressed so that the
skin etc,and shall havea cast-iron color.Swollen neck veins, edema of the lower extremities, ascites.
Pulse teaching, expanding the boundaries of the heart to the right and then to the left, the tones are deaf
by emphysema, the focus of the second tone of the pulmonary artery. Cystolic noise at the xiphoid
process by dilatation of the right ventricle and the relative failure of the right three flap valve. In some
cases with severe heart failure, diastolic murmur can be heard on the pulmonary artery - the noiseGraham Still, that is linked tothe relative failure of pulmonary valve. Over light percussion boxed,
vesicular breathing, tough. In the bottom of affairs lung congestion, wet wheezing.On palpation the
abdomen - liver enlargement (one of the reliable, but no early signs of cor pulmonale disease, as the
liver can be displaced by emphysema). Symptom severity depending on the stage.
The first stage: in the background of the main disease increased dyspnea, cyanosis appears due
acrocyanosis, but the right border of the heart is not enlarged, the liver was not enlarged, the lungs
Physical findings depend on the underlying disease.
111
The second stage - shortness of breath goes in asthma, with breathing difficulties, cyanosis becomes
diffusenym of objective research data: there is a ripple in the epigastric region, the tones are deaf, the
emphasis of the second tone of the pulmonary artery is not constant.The liver was not enlarged, can be
opuschena.
The third stage - joining signs of right heart failure – increase right border of cardiac dullness, enlarged
liver. Persistent swelling in the lower code.
Fourth stage - shortness of breath at rest, forced position, often joined rhythm disturbances type
Cheyne-Stokes.Swelling permanent, untreatable, weak pulse frequent, beef heart, deaf, systolic
murmur at the xiphoid process. In light weight rales. Significant liver is not reduced by the action of
glycosides and diuretics as developing fibrosis. Patients are constantly dreaming.
Diagnosis thoraxdiaphragmal heart often difficult, we must always bear in mind the possibility
of its development completely in kyphoscoliosis, ankylosing spondylitis, etc.The most important
feature is the early appearance of cyanosis, and replace increased breathlessness without asthma.
Pickwick syndrome characterized by a triad of symptoms – obesity. The validity expressed cyanosis.
The syndrome was first described by Dickens in "Pondeath Pickwick Papers." Associated with
traumatic brain injury, obesity is accompanied by thirst, bulimia, hypertension.
Chronic cor pulmonale with primary pulmonary hypertension, a disease called Aerza
(described in 1901). Polietiologic disease, no clear origin, mainly women suffer from 20 to 40 years.
Pathomorphologic studies have found that in primary pulmonary hyperstrain precapillary intimal
thickening of the arteries, the arteries that is marked thickening of the muscular type of media, and
develops fibrinoid necrosis with subsequent sclerosis and the rapid development of pulmonary
hypertension. Symptoms diversity usually complaints of weakness, fatigue, pain in the heart or in the
joints, a third of patients may appear vertigo, Raynaud's syndrome. And further increases dyspnea,
which is the sign which indicates that the primary pulmonary hypertension unstable transition in the
final stage. Increases rapidly cyanosis, which is expressed to the stations fine cast shade becomes
permanent, grow rapidly swelling.The diagnosis of primary pulmonary hypertension is established by
exclusion. In these patients, the entire clinic is progressing without a background in the form of
obstructive or restrictive of breath.Echocardiography pressure pulmonary artery reaches maximum
numbers.Treatment ineffective, die of thromboembolus.
Additional methods of cor pulmonale, chronic lung process - leukocytosis, increasing the number of
red blood cells (polycytemia associated with increased erythropoiesis due to arterial hypoxemia).
Radiographic data: there are very late. One of the early symptoms is a bulging of the pulmonary artery
trunk on the radiograph. Pulmonary arterial often smoothing waist heart, and the heart of many doctors
take a mitral configuration of the heart.
ECG appear indirect and direct signs of right ventricular hypertrophy:
1. Deviation of the electrical axis of the heart to the right -R 3> R 2> R 1, S 1> S 2> S3,the angle of pain
above 120 degrees.The most basic indirect sign - is increasing the interval R wave in V1 is greater
than 7 mm.
2. Direct indicators - right bundle branch block, R-wave amplitudein V1 to 10 mm when fully right
bundle branch block.The observed negative T wave offset lower teeth contours in the third, standard
lead, V1-V3.
Of great importance is spirography that identifies the type and degree of respiratory retarded. On the
ECG signs of right ventricular hypertrophy appear very late, and if there are only a deviation of the
dielectric element axis to the right, are already talking about severe hypertrophy.The most basic
diagnostics - is dopplerocardiography, echocardiography - an increase of the right heart, increasing the
pressure in the pulmonary artery.
PRINCIPLES OF TREATMENT OF COR PULMONALE
Treatment of cor pulmonale disease is to treat the underlying disease. During exacerbation of
chronic obstructive diseases and prescribes bronchodilators, expectorants. At Pickwick syndrome obesity treatment etc.
112
Reduce the pressure in the pulmonary artery calcium channel blockers (nifedipine, verapamil),
peripheral vazodilatatory reduces preload (nitrates, korvaton, sodium nitroprusside).Greatest value has
nitroprussid sodium in combination with inhibitors of angiotensin-converting enzyme.Nitroprussid 50100 mg / in, Capoten 25 mg 2-3 times a day, or enalapril 10 mg per day.Used as treatment of
prostaglandins E, antiserotonin drugs, etc. But these drugs are effective only at the beginning.
Treatment of heart failure: diuretics, glycosides, oxygen.
Anticoagulant, antiplatelet therapy - heparin, Trental, etc. Due to tissue hypoxia rapidly
evolving myocardial so designed cardioprotectors (potassium orotate, Panangin, riboksin). Very
carefully prescribed glycosides.
PREVENTION.
Primary - prevention of chronic bronchitis. Secondary - treatment of chronic bronchitis.
Handout
Students distributed lists containing the names of topics, examples of laboratory and
instrumental examinations, chest X-ray.
Equipment practice session.
1. Patterns of laboratory and instrumental studies in cor pulmonale.
2. Radiographs of the chest.
3.Table: Clinical manifestations of diseases involving acute, subacute and chronic cor pulmonale,
these laboratory and instrumental studies in cor pulmonale, cor pulmonale disease classification.
Independent work and self-education.
Topics for independent work: etiology, clinical features, methods of research, treatment principles cor
pulmonale. Pharmacodynamics of drugs in the treatment of cor pulmonale.
1. Independent oversight of patients while receiving outpatient and development navykov
diagnostic differential diagnosis and differential therapy of diseases that manifest cor pulmonale
disease.
2. The development of skills.
3. Prepare and deliver a presentation on the subject of clinical studies at the morning conference by
the department.
4. Improving skills on data interpretation radiographs, laboratory data for sabolevaniyah manifested
cor pulmonale disease.
Teaching practice during the lesson.
Supervision of patients with cor pulmonale disease.
Hours - 1.5 hours.
Quiz
1.Classification of cor pulmonale.
2.Differential diagnosis of cor pulmonale.
3.Emergency treatment of acute and subacute cor pulmonale.
4.Clinical management of patients with chronic cor pulmonale.
5.Outpatient treatment of patients with chronic cor pulmonale.
6.Indications for hospitalization.
7.Definition of disability in patients with chronic cor pulmonale.
8. Prevention.
9. Principles of supervision, management, and monitoring in a rural health units, or family policlinics.
REFERENCES
Main:
113
1) Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2) Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3) Ички касалликлар, Камолов Н.Н., 1991
4) Внутренние болезни, том 1 Мухин Н.А. М.: ГЭОТАР - Медиа,2009
5) Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
6) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С., 2010. Т.
Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
8) Диагностика болезней внутренних органов. Окороков А.Н. 2005.
9) Лечение болезней внутренних органов. Окороков А.Н. 2005.
10) Дифференциальный диагноз внутренних болезней. Виноградов А.В. М.: Медицинское
информационное агенство, 2009.
11) Внутренние болезни: учебник.- в 2-х т. (1т) Под ред. Мартынова и др. М.: ГЭОТАР - Медиа,
2005:
12) Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005
13) http://www.lib.uiowa.edu/hardin/md/index.html,http://dir.rusmedserv.c,http://www.medlinks.ru/,http://w
ww.kosmix.com/,http://www.medpoisk.ru/,http://www.tripdatabase.com/,h
ttp://www.klinrek.ru/cgibin/mbook,http://www.intute.ac.uk/medicine/
14) http://elibrary.ru
http://www.freebooks4doctors.com/
http://www.medscape.com/
http://www.meducation.net/ http://www.thecochranelibrary.com
1)
2)
3)
4)
5)
6)
7)
114
GASTROENTEROLOGY
Content of the material
CONTENT THAT CASE STUDIES
№
1
2
3
4
Topic name practice session
The references
Dyspepsia (heartburn, nausea, vomiting). Differential diagnosis
Dyskinesia biliary and cholecystitis.Tactics GPs. Indications for direction
to a specialist or hospitalization profile department. Treatment,
monitoring, control and rehabilitation in rural health units or family
policlinics. Principles of prevention. Principles of teaching topics.
Topics for independent work: etiology, pathogenesis, mechanism of
dyspepsy, nausea, heartburn, vomiting. Etiopathogenesis dyskinesia,
biliary and cholecystitis. Factors influencing the dyspepsia.
Practical skills:
EFGDS interpretation, medical imaging and analysis of the stomach.
Dyspepsia (heartburn, nausea, vomiting). Differential diagnosis stick
gastritis, duodenitis and peptic ulcer disease.Tactics GPs. Indications for
referral to a specialist, hospitalization profile department.The principles
of treatment, monitoring, control and rehabilitation in RHU or family
policlinics. Principles of prophylaxy. Principles of teaching topics.
Topics for independent work:
.
The etiology and pathogenesis of dyspepsia, the mechanism of heartburn,
nausea, vomiting. Risk factors for the development of gastritis,
duodenitis, ulcer disease, clinical manifestations, clinical and laboratory
criteria, complications, treatment.
Practical skills:
EFGDS interpretation, medical imaging and analysis of the stomach.
Dyspepsia (heartburn, nausea, vomiting). Differential diagnosis
postcholecystectomic syndrome and diseases of operated stomach.Tactics
GPs. Indications for a referral to a specialist or admission to a profile of
the division.The principles of treatment, dispansery monitoring, control
and rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of teaching subjects. "
Topics
for
independent
work:
etiology,
pathogenesis
postcholecystectomic syndrome and diseases of operated stomach.
Clinical manifestations of postcholecystectomic syndrome and diseases of
operated stomach, clinical and laboratory criteria, complications,
treatment.
Practical skills:
EFGDS interpretation, medical imaging and analysis of the stomach.
Medications used in postcholecystectomic syndrome and disease of the
operated stomach.
Abdominal pain. Differential diagnosis of diseases of the with pain epi-,
meso-and hypogastral areas.Tactics GPs. Indications for the direction of
to specialist. The principles of treatment, follow-up, monitoring and
rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of teaching topics.
Topics for independent work:
Etiology of colitis, pathogenesis, mechanism of pain, the clinical
manifestations of the disease, clinical and laboratory criteria,
115
5
6-7
8
9
complications.
Practical skills:
Interpretation
of
tests,
x-ray
of
the
intestine,
esophagogastroduodenoscopy, colonoscopy.
Abdominal pain. Differential diagnosis of chronic cholecystitis and
chronic pancreatitis. Tactics GPs. Indications for referral to a specialist or
hospital in a probtion department. The principles of treatment, follow-up,
control and rehabilitation in RHU or family policlinics. Principles of
prevention. Principles of teaching topics.
Topics for independent work: Ethiopatogenesis pancreatitis, classification
pancreatitis. Diagnostic tests pancreatic.
Practical skills: Interpreting ultrasound, cholecystography, laboratory
analysis blood. Writing of the drugs used in chronic cholecystitis and
chronic pancreatitis.
Diarrhea. Differential diagnosis of infectious and noninfectious diarrhea
etiology. Hypovitaminosis. Tactics GPs. Indications for referral to a
specialist or to whom hospitalization profile department. Principles of
treatment, follow-up, monitoring and rehabilitation in RHU or family
policlinics. Principles of prevention. Principles of teaching topics.
Topics for independent work:
The etiology and pathogenesis of diarrhea. Etiology Pathogenesis
hypovitaminosis.Treatment for inflammatory diseases of intestines.
Practical Skills: Interpretation of tests, x-ray bowel, sigmoidoscopy,
colonoscopy.
Constipation. Differential diagnosis of irritable bowel, senile
constipation and colon cancer. Tactics GPs. Indications for the specialist.
The principles of treatment, follow-up, monitoring and rehabilitation in
RHU or family policlinics. Principles of prevention. Principles of
teaching topics.
Topics for independent work:
The etiology and pathogenesis of constipation. Clinic for constipation of
various etiologies.
Practical skills:
Interpretation EFGDS, gastrointestinal radiography, ultrasound and
laboratory analyzes.Writing of the drugs used for constipation.
Hepatomegaly. Differential diagnosis of acute and chronic hepatitis and
alcoholic liver disease. Tactics GPs. Indications for referral to a specialist
or to whom hospitalization profile department. Principles of treatment,
follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of prevention.Principles of teaching topics.
Topics for independent work:
Etiology
and
patogenesis
acute
and
chronic
hepatitis.
Pharmacodynamics of medications used in hepatitis and alcoholic liver
disease.
Practical skills:
Interpretation of the gastrointestinal tract radiography, ultrasonography of
the liver and spleen, and laboratory tests. Writing of the drugs used in
hepatitisumax, alcoholic liver disease.
,
Summary:
1,2,3,4,5,6,7,8,9.
Supplementary
$n$ & 1 & 2 &
3&4&5&
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH DYSPEPSIA
116
Purpose: Teach students syndromal addressing patients with dyspepsia, and the principles of their
management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with dyspepsia.

Giving students a timely diagnosis when there is a problem related to dyspepsia.

To teach students to differentiate the disease, accompanied with dyspepsia.

Improve the knowledge, skills, and practical skills in solving problems of patients with
dyspepsia (information gathering, problem identification and physical examination, as well as
the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to know to solve the problems of patients with dyspepsia:
№
The list of knowledge
The list of diseases that occur with dyspepsia
A list of the most dangerous diseases that occur with
dyspepsia
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation or
hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
abdominal pain
The nature and location of the pain
Signs of acute abdomen
Symptoms of internal organs
Indicators of laboratory results
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and rehabilitation
117
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must know the
characteristic location of the pain in
diseases of the abdominal cavity
The student must list the symptoms.
Student should know signs of heart,
lung,
liver,
spleen,
stomach,
duodenum, Bowel and kidneys
the student should know:
- Normal values and their changes in
pathology.
The student must know the
techniques and principles of
treatment (including non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
of disorders that occur with dyspepsia in a rural health
units or FP (4-category)
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with dyspepsia:
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the
probable diagnosis.
The student must be able to specifically identify and
assess the patient's complaints.
The student must be able to analyze medical history:
Ask the patient and his relatives
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents
and family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient,
based on an objective approach
The student must be able to identify:
- Liver palms
General inspection
-Gynecomastia
- Cachexia.
The student should be able to appreciate the
Examination of the mouth
language.
The student must be able to detect the presence of:
- Pale
- Icterus,
An inspection of the skin
-The presence of rash
- Seal
- Teleangiectasy.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and - Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and - If the heart murmur, be able to identify their
auscultation of heart and vascular system. epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
General inspection of the abdomen
The student must be able to detect the presence of:
118
-Ascites
-Flatulence
-Spider veins
- Venous collaterals
the student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
Conduct surface abdominal palpation
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To carry out the test Shchetkina-Blumberg
the student should be able to:
Hold deep abdominal palpation
- To evaluate all available structures in the abdomen
the student should be able to:
Conduct percussion liver
- Define the boundaries of the liver Kurlov
the student should be able to:
Conduct palpation of the liver and gall
- To evaluate the properties of the liver and gall
bladder
bladder.
the student should be able to:
Conduct percussion and palpation of the
- Test for tapping the lumbar region
kidneys.
- Palpation to evaluate the properties of the kidneys
The student must be able to identify features:
Calculate the index weight / body
- Underweight
- Increased weight.
1. The student must be able to evaluate sensitive
area with the step and identify the principle
characteristics:
- Sensory disturbances (analgesia hypalgesia,
gipostezii, anesthesia, parastezii, dysesthesia, etc.).
2. The student must be able to evaluate reflexes (C
usesaniem neurological hammer) and identify
Conduct a neurological examination.
features:
- Hyperreflexia
- Hyporeflexia
- Areflexia
3. The student must be able to assess motor function
and symptoms violateniya
4. Student should be able to point out the symptoms
of spinal lesions may RSA.
Student should be able to conduct rectal
Conduct a rectal examination
examination with the incremental principle.
Student should be able to conduct gynecological
Conduct gynecological examination
examinations including step principle.
The student must be able to identify features:
Interpret the clinical and biochemical
- Increase or decrease in performance from the norm.
1. The student must be able to record the ECG
with the incremental principle.
2. Student should be able to decipher the results of
ECG and decrypt it.
the ECG and identify signs:
- MI
- LV hypertrophy
119
The student must be able to differentiate the disease
Differentiate disease accompanied with on the basis of the distinctive features (history,
dyspepsia
physical examination and laboratory and
instrumental investigations)
the student should be able to:
- Educate patients on self-management
Give non-medical advice
- Advise on diet
- Advise on healthy living
1. The student should be able to choose products
with proven effectiveness.
2. When choosing drug student should be able to
Rational use of medicines in the
evaluate:
treatment of diseases that occur with
Effectiveness
dyspepsia
safety
- Eligibility
- Economy.
Conduct monitoring and surveillance of Student should be able to carry out monitoring and
patients
control states in RHU and SP.
Practical class № 1
Theme: "Dyspepsia (indigestion, nausea, vomiting). Differential diagnosis of biliary dyskinesia
and cholecystitis.Tactics GPs. Indications for referral to a specialist or hospitalization of profiled
section.The principles of treatment, monitoring, control and rehabilitation in RHU or family
policlinics. Prevention. Principles of Teaching Tools "- 6.7 hours.
Justification of the theme: Patients complaining of indigestion for the first time to seek treatment by
means of a general practitioner. In this situation, the force of a general practitioner (GP) is directed to
the diagnosis of these complaints are various diseases, to provide medical care in the FCP (FP), or in
the direction of specializationcialized hospitals.These circumstances are the basis for the inclusion of
this subject in the program GPs.
The purpose of teaching:
Teach GP diagnosis and differential diagnosis, conduct best option treatment strategy in dyspepsia,
caused by various diseases, as well as the principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Consider diagnosis of dyspepsia.
2. Demonstrate patients with dyspepsia.
3. Discuss the results of clinical, laboratory and instrumental studies in dyspepsia.
4. Make a differential diagnosis of dyspepsia.
5. Discuss questions about the tactics of management of patients with dyspepsia in the qualifying
characteristics of GPs
6. The principles of treatment (non-drug and drug).
7. Principles of management, follow-up and monitoring of patients with dyspepsia in a rural
health units or family policlinics.
8. The principles of primary, secondary and tertiary prevention of diseases involving dyspepsia.
120
Anticipated results
Conducting this training will enable the learner in a timely and correct diagnosis, to
differentiate on clinical and laboratory data of instrumental studies the diseases that are accompanied
by dyspepsia, as well as the diagnosis, to make a differential diagnosis and determine the future tactics
of the patient.
GPs should know:
1. The mechanism and causes of dyspepsia.
2. Clinical manifestations of dyspepsia.
3. Diagnosis of dyspepsia.
4. Differential diagnosis of dyspepsia.
5. The principles of treatment (drug and non-drug) for the diseases accompanied by dyspepsia.
6. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
7. The principles of primary, secondary and tertiary prevention of diseases involving dyspepsia.
GPs should be able to:
1. Data analysis and history of complaints for the diagnosis of dyspepsia.
2. Diagnose, to differentiate on clinical, laboratory and instrumental studies different types of
dyspepsia.
3. Choose the right treatment strategy for specific dyspepsia.
4. Choose products with proven efficacy
5. Advise on non-medicated treatments.
6. To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of patients with dyspepsia.
2. To fill out the medical history of patients with dyspepsia.
3. Assign the required survey plan for dyspepsia.
4. Interpret the results of instrumental studies of patients with dyspepsia.
5. Prescribe medication and perform clinical examination of patients with dyspepsia, due to
various diseases.
Place of activity:
1. Training themed office clinic.
2. GPs in the clinic office.
The course is taught
The structure of the lessons:
1.
Checking the initial level of preparedness of students to engage in "dyspepsia (heartburn,
nausea, vomiting). Differential diagnosis of biliary dyskinesia and cholecystitis.Tactics GPs.
Indications for direction to a specialist or hospitalization profile department.The principles of
treatment, observation, Rehabilitation in rural health units or family policlinics. Principles of
prevention.Principles of teaching subjects. "
2.
Explanation of the diagnosis and differential diagnosis of dyspepsia data.
3.
Decision analysis and situational problems.
4.
Supervision of patients with dyspepsia.
5.
Clinical analysis of supervised patients.
6.
Role-playing game to assess knowledge on training.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Materials
Lesson time
Report on subordinators Hospital records of 1 hour
examined by patients in patients
121
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the source
14.00
analysis of the level of preparedness
topic.
Students using the
"Knob on the middle of
the table" and
solution case studies.
Students
distributed
situational
task on this topic and
they
must analyze and give
Conclusion
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Situational
tasks
table, corresponding
to a subject class,
educational boards.
80 minutes
When parsing the theme focuses on the following points.
Hypertonic-hyperkinetic biliary dyskinesia occurs with paroxysmal pain in the right upper
quadrant aching or cramping in nature, reminiscent of the attacks of gallstone colic with bois useful,
but usually less intense and easily stoped antispasmodic.Pain can irradistructed in the right shoulder
blade, arm, may be accompanied by nausea, sweating, pallor, and sometimes headache,
palpitation.During an attack of stomach pain is usually not intense, determined slight tenderness in the
gallbladder.
Hypotonic-hypokinetic form of biliary dyskinesia is also apparent in the main pain in the right
upper quadrant. However, these low-intensity pain, are dull, oppressive or bursting character, often
lengthy. There may be a bitter taste in the mouth, nausea. The diagnosis helps cholecystography,
ultrasound, duodenal probing.
Acute cholecystitis begins suddenly with pain in the right upper quadrant, pain often radiating
to the right films of shoulder.Sometimes movement, deep breathing can increase the pain. When
purulent cholecystitis or flegmanous temperature may rise. Seizures are usually accompanied by
122
nausea, repeated vomiting, flatulence, delayed stool. Become positive symptoms Ortner, Zakharyin,
Obraztsova-Murphy, Vasilenko, frenikus-symptom, symptoms of peritoneal irritation. Jaundice is
usually not observed or it is insignificant. In acute coldholding etsistite duodenal sounding
contraindicated.
Severe general condition, the patient, fever, chills, tachycardia, sharp pain in the right upper
quadrant, the presence of neutrophilic leukocytosis with a significant shift, increased ESR allow
suspected abscess sludge gangrenous cholecystitis.The diagnosis helps ultrasound.
Patients with chronic cholecystitis usually feel dull, aching pain in the right hypochondrium,
permanent or occur 1-3 hours after abundant and rich food. Pain radiating up to the right shoulder
blade. Often there dyspepsia: a feeling of bitterness and metallic taste in the mouth, frequent belching
insspirit, nausea, bloating, impaired bowel movements, alternating constipation and diarrhea.Part of
the positive symptoms, George Musso, Grekova-Ortner, Murphy, Vasilenko. Diagnostic importance
are data duodenal sensing cholecystography, ultrasound of the gallbladder.
Handout:
Students distributed lists containing the names of topics, definitions of dyspepsia, indigestion
classification, the list of diseases associated with dyspepsia, case studies, laboratory results.
Equipment Workshop:
 Patterns of laboratory and instrumental studies in dyspepsia, radiographs of the gallbladder.
 Tables: clinical manifestations of disease with dyspepsia.
Independent work and self-education.
Topic: Themes for independent work:
Etiology and pathogenesis of dyspepsia mechanism of nausea, heartburn, vomiting. Etiopathogenesis
dyskinesis with biliary and cholecystitis. Factors affecting the development of dyspepsia.(Field work)
1.
Independent work with literature in the library, at home.
2.
Prepare and deliver a presentation on the subject of clinical studies at the conference in the
clinic.
3.
Mastering the interpretation of laboratory and instrumental studies.
4.
Service call at home.
Teaching practice during the class
Supervision of patients with dyspepsia.
Number of hours - 1 hour.
Quiz
1. Etiology of dyspepsia.
2. Clinic dyspepsia.
3. Diagnosis of dyspepsia.
4. Differential diagnosis of dyspepsia.
5. Assigning ambulatory treatment of dyspepsia.
6. Principles of management, supervision and monitoring of patients with dyspepsia in a rural
health units or FP
Practical lesson № 2
Theme: "Dyspepsia (indigestion, nausea, vomiting). Differential diagnosis of gastritis, duodenitis
and peptic ulcers.Tactics GPs. Indications for referral to a specialist or hospitalization profile
fine determination.The principles of treatment, monitoring, control and rehabilitation in RHU
or family policlinics. Prophylaxy principles.Principles of teaching subjects". - 6.7 hours.
123
Justification of the theme: Patients complaining of belching, heartburn, nausea, vomiting, pain in the
epigastritis are common in medical practice in primary care. In this situation, the force of a general
practitioner (GP) is directed to the diagnosis of diseases for medical care in a RHU (FP) or the
direction ofthe bathrooms in the specialized hospitals.These and other circumstances are the basis for
the inclusion of this subject in the training of GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options for stomach indigestion, as well as principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
.
Tasks Study:
1. Consider diagnosis of gastric dyspepsia.
2. Consider diagnosis of gastritis and duodenitis, peptic ulcer disease.
3. Demonstrate patients with gastric dyspepsia.
4.
Discuss the results of clinical, laboratory and instrumental studies with gastric dyspepsia.
5. Make a differential diagnosis of gastric dyspepsia.
6. Discuss questions about tactics in the qualifying characteristics of GPs
7. Discuss the principles of treatment (non-drug and drug).
8.
Discuss the principles of management, supervision and monitoring of patients in rural
health units or family policlinics.
9. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting the lesson allows students time and correctly diagnose and differentiate on clinical
data of laboratory and instrumental studies gastric dyspepsia.
GPs should know:
1.
Mechanism and cause of gastric dyspepsia.
2.
Clinical manifestations of gastric dyspepsia.
3.
Diagnosis of gastric dyspepsia.
4.
Differential diagnosis of gastric dyspepsia.
5.
Of drugs used in the treatment of gastric dyspepsia their pharmacodynamics and dosage.
6.
3- and 4-component treatment of peptic and duodenal ulcers
7.
Principles of supervision and monitoring of patients with gastric dyspepsia in RHU or family
policlinics.
8.
The principles of primary, secondary and tertiary prevention of diseases that occur with gastric
dyspepsia.
GPs should be able to:
1.
Data analysis and history of complaints in the diagnosis of gastric dyspepsia.
2.
Diagnose, to differentiate on clinical, laboratory and instrumental studies different
types of gastric dyspepsia.
3.
Choose products with proven efficacy
4.
Advise on non-medicated treatments.
5.
To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient with gastric dyspepsia.
2. To fill out the medical history of a patient with gastric dyspepsia.
3. Assign the required survey plan with gastric dyspepsia.
124
4. Interpret the results of instrumental studies of patients with gastric dyspepsia.
5. Prescribe medication and perform clinical examination of patients with gastric dyspepsia
caused by various diseases.
The list of skills that GPs should possess after completing studies on the subject
 Examination of patients with gastric dyspepsia.
 The interpretation of laboratory and instrumental studies with gastric dyspepsia.
Place of activity:
 Training themed room.
 Classrooms GP clinics.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "dyspepsia (heartburn,
nausea, vomiting). Difdifferential diagnosis of gastritis, duodenitis and peptic ulcer
disease.Tactics GPs. Indications for referral to a specialist or hospitalization of the profile
department. The principles of treatment, monitoring, control and rehabilitation in RHU or
family policlinics. Principles of prevention. Principles of teaching subjects. "Explanation of the
diagnosis and differential diagnosis of gastric dyspepsia.
 Decision analysis and situational problems.
 Supervision of patients with gastric dyspepsia.
 Clinical analysis of supervised patients.
 Thematic analysis of the patient.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
125
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
12.40.
12.4014.00
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students using the
"snowball" and the
decision of problem
situational.Students
case studies on the
subject, they have to
analyze, and then give
an opinion.
Situational
80 minutes
tasks,
tables,
corresponding to a
subject classes
When parsing the theme focuses on the following aspects:
Dyspepsia - a generic term for the symptoms caused by indigestion, which refer patients to
gastroenterology practitioners clinics and hospitals.
Dyspepsia includes the following symptoms: nausea, heartburn, belching, unpleasant
sensationsof epigastric and in the lower parts of the chest, fullness or heaviness in the epigastrium,
flatulence.At the heart of yellowudochnoy dyspepsia is a violation of its secretion and motor function.
Dyspeptic syndrome accompanies practically all diseases of the digestive system, the main of
which are as follows: non-ulcer dyspepsia, overeating, smoking, gastro, etc., reflux esophagitis, hiatal
hernia, esophageal dysmotility, peptic ulcer and 12 duodenal ulcer, cancer of the esophagus , stomach,
pancreas, liver disease, biliary tract and pancreas, inflammatory disease of the gastrointestinal tract:
gastritis, giardiasis, Crohn's disease, irritable bowel syndrome, variants of coronary heart disease,
alcohol use, adverse drug effects and toxicity.
During prolonged and severe dyspepsia to establish its reasons for making the following
laboratory and instrumental studies: complete blood count, fecal occult blood, analysis of gastric juice
if necessary with histamine test, stress ECG - sample ultrasound abdominal radiography and biliary
tract bubble EFGDS with mucosal biopsy, retrograde holetsistopankreatografiya, esophageal
manometer, a tumor marker, carcinoembryonic antigen embriogenalny for suspected colon cancer, Afetoprotein - with suspected cancer of the liver.
It must be emphasized that the leading role in the diagnosis of various forms of dyspepsia is a
correct assessment of anamnestic data and posistemny patient survey.
Heartburn and burping air, acid are the most common painful symptoms in patients
gastroenterolocal. We must always remember that they are not necessarily a manifestation of the state
of hyperacidity observed even in cancer patients with deep Achilles (lactic acid, bile, pancreatic juice).
Discomfort epigastric may accompany diseases of the chest, retroperitoneum, spine, and in these cases
timely ECG and X-ray examination to avoid rough diagnostic errors.
Handout
Students distributed lists containing the names of topics, definitions of gastric dyspepsia, gastric
dyspepsia types, the list of diseases associated with gastric dyspepsia, case studies, laboratory results,
examples of analyzes of gastric juice, EGDFS, radiographic images.
Equipment practice session
 Templates laboratory and instrumental data of gastric dyspepsia.
 Tables: clinical manifestations of disease, accompanied by gastric dyspepsia.
Independent work and self-education.
Topics for independent work:
126
The etiology and pathogenesis of dyspepsia, the mechanism of heartburn, nausea, vomiting. Risk
factors for the development of gastritis, duodenitis, ulcers, clinical presentation, clinical and
laboratory criteria, complications, treatment (Field work)
 Independent work with literature in the library, at home.
 Prepare and deliver a presentation on the subject of clinical studies at the morning conference
in the clinic.
 Mastering the interpretation of laboratory and instrumental studies.
 Service call at home.
Teaching practice during the class
Supervision of patients with gastric dyspepsia.
Hours - 1:00
Quiz
1.The etiology of gastritis.
2.Clinic gastritis.
3.Classification of gastritis.
4.Diagnosis of gastritis.
5.Differential diagnosis of gastritis.
6.Etiology duodenitis.
7.Clinic duodenitis.
8. The classification of duodenitis.
9. Diagnosis duodenitis.
10. Differential diagnosis of duodenitis.
11. The etiology of peptic ulcer.
12. Ulcer clinic.
13. Classification of peptic ulcer disease.
14. Diagnosis of peptic ulcer disease.
15. Differential diagnosis of peptic ulcer disease.
16. Principles of management and monitoring of patients with gastritis, peptic and duodenal ulcers.
Practical lesson № 3
Theme:
"Dyspepsia
(indigestion,
nausea,
vomiting).
Differential
diagnosis
of
postcholecystectomy syndrome and operated stomach illness. Tactics GPs. Indications for a
specialist or hospitalization profile department. The principles of treatment, follow-up,
monitoring and rehabilitation RHU or family policlinics. Principles of prevention. Principles of
teaching subjects. " - 6.7 hours.
Justification of the theme: Most patients with postcholecystectomy syndrome, a disease of the
operated stomach, first seek medical help general practitioners (GPs). In this situation, diagnose
diseases for medical care in the FCP (FP) in the direction of specialized hospitals.These and other
circumstances are the basis for the inclusion of this subject in the program.
The purpose of teaching: Teach GPs choosing the best option for treatment policy
postcholecystectomy syndrome, diseases of the operated stomach and the principles of management of
patients in primary care, provided the requirements of "Qualification characteristics of a general
practitioner"
Tasks Study:
1. Consider diagnosis postcholecystectomy syndrome
2. Consider diagnosing the disease operated stomach
3. Demonstrate patients with postcholecystectomy syndrome, a disease of the operated stomach
127
4. Discuss the results of clinical, laboratory and instrumental studies at postcholecystectomy
syndrome, diseases of the operated stomach
5. Make a differential diagnosis of postcholecystectomy syndrome, diseases of operated stomach.
6. Discuss questions about tactics in the qualifying characteristics of GPs
7. Discuss the principles of treatment (non-drug and drug).
8. Discuss the principles of management, supervision and monitoring of patients in a rural health
units or a family policlinics.
9.Discuss the principles of primary, secondary and tertiary prevention in these states.
Expected results
Conducting this training will enable time and correctly diagnose and differentiate on clinical
data of laboratory and instrumental studies postcholecystectomy syndrome, a disease of the operated
stomach.
GPs should know:
1. The mechanism and causes of postcholecystectomy syndrome, diseases of the operated
stomach
2. Clinical manifestations of postcholecystectomy syndrome, diseases of the operated stomach
3. Postcholecystectomy syndrome diagnosis, disease operated stomach
4. Differential diagnosis of postcholecystectomy syndrome, diseases of the operated stomach
5. Of drugs used in the treatment of postcholecystectomy syndrome, diseases of the operated
stomach, their pharmacodynamics and dosage.
7. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
8. The principles of primary, secondary and tertiary prevention in these states.
GPs should be able to:
1. Data analysis and history of complaints in the diagnosis of postcholecystectomy syndrome,
diseases of the operated stomach
2. Diagnose, to differentiate on clinical and laboratory research tool postcholecystectomy
syndrome, a disease of the operated stomach.
3. Choose products with proven efficacy
4. Advise on non-medicated treatments.
5. To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient with postcholecystectomy syndrome, a
disease of the operated stomach.
2. To fill out the medical history of a patient with postcholecystectomy syndrome, a disease of
the operated stomach.
3. Assign the required survey plan with postcholecystectomy syndrome, a disease of the
operated stomach.
4. Interpret the results of instrumental studies of patients with postcholecystectomy syndrome,
diseases of operated stomach.
5. Prescribe medication and perform clinical examination of patients with postcholecystectomy
syndrome, a disease of the operated stomach.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with postcholecystectomy syndrome, a disease of the operated
stomach.
2. The interpretation of laboratory and instrumental studies at postcholecystectomy syndrome,
diseases of the operated stomach.
128
Place of activity:
 Training themed room.
 Classrooms GP clinics.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "dyspepsia (heartburn,
nausea, vomiting). Differential diagnosis and postcholecystectomy syndrome and diseases of
operated stomach.Tactics GPs. Indications for referral to a specialist or hospital in the profile
department. The principles of treatment, follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of prevention.Principles of teaching subjects. "Explanation of the
diagnosis and differential diagnosis of these data becomes diseases.
 Decision analysis and situational problems.
 Supervision of patients with postcholecystectomy syndrome, a disease of the operated stomach.
 Clinical analysis of supervised patients.
 Service calls at home.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students
using
the
"round table" and the
129
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Case studies, tables, 80 minutes
and relevant topic
classes
decision
situational
original
problem.
Students case studies
on the subject, they
should analyze and give
an opinion.
When parsing the theme focuses on the following points lessons:
Common diseases that occur after surgical removal of the gall bladder and related operations
are: 1) the lack of gall bladder syndrome, and 2) the cystic duct stump syndrome, and 3) cholangitis
and constrictive papillitis.
Clinic postcholecystectomy syndrome is characterized by dull pain in the right upper quadrant,
repeated attacks of biliary colic (the formation of stones), the symptoms of cholangitis.The diagnosis
can be confirmed by cholegraphy, retrograde cholangiopancreatography.There may be symptoms of
cholestasis and with prepossession of inflammation - symtoms cholangitis. Often marked diarrhea and
intestinal upset second properties, especially with abundant use of fatty foods and sent
messages.Treatment is similar to treatment of dyskinesia ways and cholecystitis, with the presence of
stones and strictures reoperation.
There are early and late disease operated stomach. These include: Dumping syndrome, hypoglycemic
syndrome, afferent loop syndrome, peptic ulcer of anastomosis. Prix dempinga syndrome usually 1015 minutes after eating (especially sweet and dairy foods) suddenly appear severe weakness, sweating,
hypotension, tachycardia, headache, rapid heartbeat, severe muscle hypotonia, appears continuous
insurmountable desire to lie down. Sometimes abdominal pain cutting nature, rumbling, culminating
diarrhea. Tachycardia, hypotension, in the blood of hypoglycemia. Condition improves after meals.
When afferent loop syndrome can be a pain in the epigastric region, in the right upper quadrant, the
abundance of vomiting, bringing relief. Because of the simple vomiting after eating, patients limit
themselves to food.
Handout:
Students distributed lists containing the names of threads, the list of diseases associated with
gastric dyspepsia, case studies, laboratory results.
Equipment practice session
1. Templates laboratory and instrumental data postcholecystectomy syndrome, diseases of the
operated stomach.
2. Tables: clinical manifestations of disease, accompanied with postcholecystectomy syndrome,
diseases of the operated stomach.
Independent work and self-education.
Topics for independent work:
1. The etiology and pathogenesis of dyspepsia, the mechanism of heartburn, nausea, vomiting. Risk
factors in gastritis development, duodenitis, ulcers, clinical presentation, clinical and laboratory
criteria, complications, treatment.
2. Independent work with literature in the library, at home.
3. Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference in the clinic.
4. Mastering the interpretation of laboratory and instrumental studies.
5. Service calls to your home.
6. Homework on the choice of drug for pain in the abdomen.
7. Clinical case. Patient K., 34 years old, came to the reception complaining of severe cramping,
accompanied by severe weakness, palpitations, enhanced flow separation.According to the patient, due
130
to the improved-being 2 days ago stopped taking ranitidine, who had appointed her to the doctor about
the disease of 12 duodenal ulcer.
Teaching practice during the class
Supervision of patients with gastric dyspepsia.
Number of hours - 1 hour.
Quiz
1. Etiology postcholecystectomy syndrome, diseases of operated stomach.
2. Postcholecystectomy syndrome clinic, operated stomach illness
3. Postcholecystectomy syndrome diagnosis, disease operated stomach
4. Differential diagnosis of postcholecystectomy syndrome, disease operated stomach
5. Clinical supervision and management of postcholecystectomy syndrome, diseases of the stomach
operated in RHU or family policlinics.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH ABDOMINAL PAIN
Purpose: Teach students syndromal addressing patients with abdominal pain, as well as the principles
of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with abdominal pain.

Giving students a timely diagnosis when there is a problem associated with abdominal
pain.

To teach students to differentiate the disease, accompanied with abdominal pain.

Improve the knowledge, skills, and practical skills in solving problems of patients with
abdominal pain (information gathering, problem identification and physical examination, as
well as the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to knowto solve the problems of patients with abdominal pain:
№
The list of knowledge
The list of diseases that occur with abdominal pain
A list of the most dangerous diseases that present with
abdominal pain
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
131
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
abdominal pain
The nature and location of the pain
Signs of acute abdomen
Symptoms of internal organs
Indicators of laboratory results
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with abdominal
pain in a rural health units or FP (4-category)
symptoms of each disease, and the
criteria for their diagnosis.
The student must know the
characteristic location of the pain in
diseases of the abdominal cavity
The student must list the symptoms.
Student should know signs of heart,
lung,
liver,
spleen,
stomach,
duodenum, Bowel and kidneys
the student should know:
- Normal values and their changes in
pathology.
The student must know the techniques
and principles of treatment (including
non-drug)
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with abdominal pain:
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the probable
diagnosis.
The student must be able to specifically identify and
assess the patient's complaints.
The student must be able to analyze medical history:
Ask the patient and his relatives
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents and
family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient,
based on an objective approach
The student must be able to identify:
- Liver palms
General inspection
-Gynecomastia
- Cachexia.
Examination of the mouth
The student should be able to appreciate the language.
The student must be able to detect the presence of:
- Pale
- Icterus,
An inspection of the skin
-The presence of rash
- Seal
- Teleangiectasy.
132
Conduct palpation, percussion
auscultation of breath.
and
Conduct palpation, percussion and
auscultation of heart and vascular system.
General inspection of the abdomen
Conduct surface abdominal palpation
Hold deep abdominal palpation
Conduct percussion liver
Conduct palpation of the liver and gall
bladder
Conduct percussion and palpation of the
kidneys.
Calculate the index weight / body
Conduct a neurological examination.
The student must be able to assess:
- A tour of the chest
- Voice trembling
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
- If the heart murmur, be able to identify their
epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
-Ascites
-Flatulence
-Spider veins
- Venous collaterals
- Injuries and bruises
the student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To test Shchetkina-Blumberg
the student should be able to:
- To evaluate all available structures in the abdomen
the student should be able to:
- Define the boundaries of the liver Kurlov
the student should be able to:
- To evaluate the properties of the liver and gall
bladder.
the student should be able to:
- Test for tapping the lumbar region
- Palpation to evaluate the properties of the kidneys
The student must be able to identify features:
- Underweight
- Increased weight.
The student must be able to evaluate sensitive area
with the step and identify the principle
characteristics:
- Sensory disturbances (analgesia hypalgesia,
hypesthesia, anesthesia, parastezii, dysesthesia, etc.).
The student must be able to evaluate reflexes (with
neurological hammer) and identify features:
- Hyperreflexia
- Hyporeflexia
133
Conduct a rectal examination
Interpret the clinical and biochemical
ECG and decrypt it.
Differentiated disease, accompanied with
abdominal pain
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
abdominal pain.
Conduct monitoring and surveillance of
patients
- Areflexia
The student must be able to assess motor function and
signs
4. Student should be able to point out the symptoms
of spinal lesions.
Student should be able to conduct rectal examination
with the incremental principle.
The student must be able to identify features:
- Increase or decrease in performance from the norm.
The student must be able to record the ECG with the
incremental principle.
Student should be able to decipher the results of the
ECG and identify signs:
- MI
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control states in RHU and FP.
Practice session № 4
Topic: «Abdominal pain. Differential diagnosis of diseases that occur with pain epi-, meso-and
hypogastric areas. Tactics GPs. Indications for referral to a specialist or hospital in the profile
department. The principles of treatment, follow-up, monitoring and reabilitation eration in a
rural health units or family policlinics. Principles of prevention. Principles of teaching subjects.
"- 6.7 hours.
JustificationTopics: Most patients with functional and inflammatory bowel disease, accompanied by
abdominal pain in the epi-, meso-, gipogastric areas for the first time to seek medical helps to a general
practitioner (GP).In this situation, the force sent to GPs for diagnosis of diseases medical conditions
RHU (FP) or referral to a specialized hospital.These and other are the basis for the inclusion of this
subject in the training of GPs.
Goal of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options for functional bowel disease, as well as principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
134
Tasks to Study:
1. Consider diagnosis of abdominal pain in functional bowel disease.
2. Consider diagnosis of colitis.
3. Demonstrate patients with abdominal pain in functional bowel disease.
4.
Discuss these clinical-laboratory and instrumental studies with abdominal pain in
functional bowel disease.
5. Make a differential diagnosis of abdominal pain in functional bowel disease.
6. Discuss questions about tactics in the qualifying characteristics of GPs
7. Discuss the principles of treatment (non-drug and drug).
8.
Discuss the principles of management, supervision and monitoring of patients in rural
health units or family policlinics.
9.
Discuss the principles of primary, secondary and tertiary prevention in functional bowel
disease.
Anticipated results
Conducting the lesson allows students time and correctly diagnose and differentiate on clinical
data of laboratory and instrumental studies of abdominal pain in functional diseases of the stomach
GPs should know:
1. Mechanism and cause of abdominal pain in functional bowel disease.
2. Clinical manifestations of abdominal pain in functional bowel disease.
3. Diagnosis of abdominal pain in functional bowel disease.
4. Differential diagnosis of abdominal pain in functional bowel disease.
5. The principles of treatment (drug and non-drug) in functional bowel disease.
6. Principles of management and monitoring of patients with functional bowel disease in a
rural health units, or family policlinics.
7. The principles of primary, secondary and tertiary prevention in functional bowel disease.
GPs should be able to:
 Data analysis and history of complaints in the diagnosis of abdominal pain in functional bowel
diseases
 Diagnose, to differentiate on clinical, laboratory and instrumental studies of abdominal pain in
functional bowel diseases
 Choose drugs with proven efficacy in functional bowel disorders.
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient with abdominal pain in functional bowel
disease.
2. To fill out the medical history of a patient with abdominal pain in functional bowel disease.
3. Assign the desired plan of inspection of patient with abdominal pain in functional bowel
disease.
4. Interpret the results of instrumental studies of patients with abdominal pain in functional
bowel disease.
5. Prescribe medication and perform clinical examination of patients with abdominal pain in
functional bowel disease.
The list of skills that GPs should possess after completing studies on the subject
 Examination of patients with abdominal pain.
 Data interpretation of laboratory and instrumental studies in patients with abdominal pain.
135
The course is taught
The structure of the lessons:
1.
Checking the initial level of preparedness of students to engage in "pain in the abdomen.
Differential diagnostic diseases that occur with pain in epi-, meso-and hypogastric areas.
Tactics GPs. Indications for referral to a specialist or hospital in the profile department. The
principles of treatment, monitoring, control and rehabilitation in RHU or family policlinics.
Principles of prevention.Principles of teaching subjects. "
2. Decision analysis and situational problems.
3. Supervision of patients with abdominal pain in functional bowel disease.
4. Clinical analysis of supervised patients.
5. Role-playing game for evaluation sessions on lessons
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students
using
a
"brainstorming" and the
decision
situational
original
problem.
Students case studies
on the subject, they
136
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Case studies, tables, 80 minutes
and relevant topic
classes
should analyze and give
an opinion
When parsing the theme focuses on the following aspects: the most common functional
disorders of the digestive tract can be identified stomach syndrome, aerophagia, habitual constipation,
irritable bowel syndrome, and biliary dyskinesia.
Habitual constipation- prolonged disturbance of bowel movements (stools less than 1 time in 2
days, the amount of feces is less than 100 vg, the lack of a feeling of complete emptying) is not
associated with organic diseases. Habitual saporia is 10-12% of all diseases of the intestine.
Fecal usually delayed in the left half of the colon (sigma restum). Often violated reflex from a
vial of the rectum, stimulating peristalsis. By the development of intestinal constipation cause a
number of factors, primarily psychogenic factors. They are frequently observed in depression in
patients with than separately, atherosclerosis of cerebral vessels, cyclothymia.
On palpation the abdomen can be felt painless, dense sometimes uneven (stool)
sigmaprominent intestine.Sigmoidoscopy and radiography in functional sporesandnot any organic
changes are not detected. For the diagnosis has a duration of constipation with no tendency to a sharp
increase and good condition of the patient, as well as dietary and occupational history.
Treatment involves removal of the neurotic condition, adjust the work, the appointment of a
rational diet and laxatives stimulate defecation reflex - taking a glass of cold water on an empty
stomach, a large breakfast, a comfortable posture during defecation (on cards - "eagle pose"), selfhypnosis, pectin containing foods.
Irritated thick intestine (colon primary dyskinesia) - continuous or intermittent bowel
dysfunction (mainly motor), not due to organic disease and is characterized by pain, disruption of
normal bowel movements, and sometimes an increased secretion of mucus.
Etiologic basis of the disease is a neurosis, and depression in men predominates,
hypochondriasis, psychasthenia and women - the hysterical reaction, phobia, paranoid withstanding,
and hyperreactivity. All patients have dystonia vegetative part of the nervous system.
The clinical picture in the foreground are the "intestinal" complaints, particularly pain and
disorderproperties of the chair, often accompanied by increased production of intestinal mucus.Of pain
varies from feeling the pressure in the lower abdomen, like colic, pain lasting from a few minutes to
several days, with periodic amplification.The pain is localized in the lower quadrant of the abdomen,
but sometimes spreads to the entire intestine, radiating to the back, left side of the chest, often
accompanied by rumbling, feeling swelling, bloating.Ishechnuyu colicrarely totake for liver, kidney, or
linked with duodenal ulcer. Pain usually occur after stress or after taking certain foods. Violation of the
chair often seen constipation, less constipation.
Sigmoidoscopy and irrigoscopy difficult because of irritation and spasm of the sigmoid colon.
The final diagnosis can be made only after the exclusion of organic disease, intestinal
dysbiosis, allergic enterocolitis.
Treatment is based on the elimination and prevention of neuroses, diet, depending on the nature
of changes in stool: constipation - food rich in fiber, with diarrhea - easily digestible foods with
restriction of carbohydrates, fiber.
Handout
Students distributed lists containing the names of topics definition of abdominal pain in
functional bowel diseases, the list of diseases associated with pain in abdomen, case studies, laboratory
results, differential diagnostic criteria.The following are questions to control and references.
Equipment Workshop:
1.
Templates laboratory and instrumental data of patients with abdominal pain in functional
bowel disease.
137
Independent work and self-education.
Topics for independent work:
Etiology of colitis, pathogenesis, mechanism of pain, the clinical manifestations of the disease, clinical
and laboratory criteria, complications.
Number of hours - 3 hours.
 Independent work with literature in the library, at home.
 Prepare and deliver a presentation on the subject of clinical studies at the morning conference
in the clinic.
 Mastering the interpretation of laboratory and instrumental studies.
 Service calls at home.
Teaching practice during the class
Supervision of patients with abdominal pain
The number of hours -1 hour
Quiz
1.
2.
3.
4.
5.
6.
7.
8.
The etiology of functional bowel disease.
Clinic functional bowel disease.
Diagnosis of abdominal pain in functional bowel disease.
Differential diagnosis of abdominal pain.
Etiology of colitis.
Clinic colitis.
Diagnosis of colitis.
Differential diagnosis of colitis.
Practice session № 5
Topic: "Abdominal pain. Differential diagnosis of chronic cholecystitis and chronic pancreatitis.
Tactics GPs. Indications for referral to a specialist or hospitalization profile determination.The
principles of treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics.
Principles of prevention. Principles of Teaching Tools "- 6.7 hours.
Justification of the theme: Among patients seeking treatment for abdominal pain with no small
proportion of patients with lesionsof the gallbladder, and pancreas.In this situation, the force of a
general practitioner (GP) is directed to the early diagnosiss and health care in the FCP (FP), referral to
specialized hospitals.These and other circumstances constitute grounds on this subject in the training
of GPs.
The purpose of teaching: Teach GPs choosing the best option treatment strategy for chronic
cholecystitis and pancreatitis, the differential diagnosis, as well as the principles of management of
patients in primary care, provided the requirements of "Qualification characteristics of a general
practitioner."
Tasks Study:
1.
Consider diagnosis of chronic cholecystitis and pancreatitis.
2.
Demonstrate patients with chronic cholecystitis and pancreatitis.
3.
Discuss the results of clinical, laboratory and instrumental studies in chronic
cholecystitis and pancreatitis.
4.
Make a differential diagnosis of chronic cholecystitis and pancreatitis.
5.
Discuss issues in the tactics of qualifying characteristics of GPs
6.
Discuss the principles of treatment (non-drug and drug).
138
7.
Discuss the principles of management, supervision and monitoring of patients in rural
health units or a family policlinics.
8.
Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic
to the laboratory and instrumental studies of chronic cholecystitis and pancreatitis
GPs should know:
2. The mechanism and causes of chronic cholecystitis and pancreatitis
3. Clinical manifestations of chronic cholecystitis and pancreatitis
4. Diagnosis of chronic cholecystitis and pancreatitis
5. Differential diagnosis of chronic cholecystitis and pancreatitis
6. Tactics GPs.
7. The principles of treatment (drug and non-drug) for these diseases.
8. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
9. The principles of primary, secondary and tertiary prevention in these diseases.
GPs shouldbe able to:
 Data analysis and history of complaints in the diagnosis of chronic cholecystitis and
pancreatitis
 Diagnose, to differentiate on clinical and laboratory research tool chronic cholecystitis and
pancreatitis
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient with chronic cholecystitis and pancreatitis
2. To fill out the medical history of a patient with chronic cholecystitis and pancreatitis
3. Interpret the results of instrumental studies of patients with chronic cholecystitis and
pancreatitis
4. Prescribe medication and perform clinical examination of patients with chronic
cholecystitis and pancreatitis
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with chronic cholecystitis and pancreatitis
2. The interpretation of laboratory and instrumental studies in chronic cholecystitis and
pancreatitis
Place of activity:
 Cabinet GPs.
 Training themed room.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "pain in the abdomen.
Differential diagnostics of cholecystitis and chronic pancreatitis. Tactics GPs. Indications for
referral to a narrow specialist hospitalization profile department.The principles of treatment,
follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of teaching subjects. "Explanation of the diagnostics and differential diagnosis of the
data in these diseases.
139
 Decision analysis and situational problems.
 Supervision of patients with pancreatitis
 Clinical analysis of supervised patients.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis. Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students
using
the
"round table" and the
decision
situational
original
problem.
Students case studies
on the subject, they
should analyze and give
an opinion
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Case studies, tables, 80 minutes
and relevant topic
classes
When parsing the theme focuses on the following points lessons:
The clinical picture
Pain syndrome - a leading sign. With the localization of inflammation in the pancreas head pain
is felt mainly in the epigastrium to the right, in the right upper quadrant, radiating to the area 6.9
thoracic vertebrae. When involved in the inflammatory process of the body of the pancreas pain
localized in gastric episodes, with the defeat of the tail in the left upper quadrant, with pain radiating to
140
the left and up from 6 to 1 thoracic lumbar vertebraeminute.In total lesion of the pancreas pain is
localized in the entire upper half of the abdomen and is the nature of shingles.
Treatment program in chronic pancreatitis
1. Etiological treatment. 2. Treatment during pronounced exacerbation of chronic pancreatitis a) - pain relief, b) - the suppression of pancreatic secretion, c) - Inhibiting the enzyme pancreatic
cancer d) - antibacterial anti-inflammatory treatment, e) - reduction of hypertension in the pancreatic
duct, e ) - the fight against intoxication, dehydration, electrolyte disorders, vascular insufficiency
3. Health food. 4. Correction foreign and endocrine pancreatic function. 5. Stimulation of reparative
processes in the pancreas. 6. Correction of immunological disorders. 7. Normalisation of gastric
secretion of the liver, biliary tract,bowel 8. Sanatorium- spa treatments. 9. Physical therapy.
Handout:
Students distributed lists containing the names of threads, the list of diseases associated with
abdominal pain, case studies, and laboratory results.
Equipment practice session
1. Templates laboratory and instrumental data in chronic cholecystitis and chronic pancreatitis.
2. Tables: clinical manifestations of disease, accompanied by abdominal pain
Independent work and self-education.
Topic: The clinical manifestation of chronic cholecystitis and chronic pancreatitis, clinical and
laboratory criteria, complications, treatment (Field work)
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the subject of clinical studies on the morning of the
conference.
3. Mastering the interpretation of laboratory and instrumental methods.
Teaching practice during the class
Supervision of patients with abdominal pain
Number of hours - 1 hour.
Quiz
1. The etiology of chronic cholecystitisand chronic pancreatitis
2. Clinic for chronic cholecystitisand chronic pancreatitis
3. Diagnosis of chronic cholecystitisand chronic pancreatitis
4. Differential diagnosis of chronic cholecystitisand chronic pancreatitis
5. Treatment of chronic cholecystitisand chronic pancreatitis
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING
STUDENTS TO APPROACH TO THE PROBLEM OF PATIENTS
WITH DIARRHEA
Purpose: Teach undergraduate courses syndromal addressing patients with diarrhea, as well as the
principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with diarrhea.

Giving students a timely diagnosis when there is a problem associated with diarrhea.

To teach students to differentiate the disease, accompanied with diarrhea.

Improve the knowledge, skills, and practical skills in solving problems of patients with
diarrhea (information gathering, problem identification and physical examination, as well as
the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;
141

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to know to solve the problems of patients with diarrhea:
№
The list of knowledge
The list of diseases that occur with diarrhea
A list of the most dangerous diseases that occur with
diarrhea
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
abdominal pain
Stool
Symptoms of dehydration
Signs of acute abdomen
Symptoms of internal organs
Indicators of laboratory results
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with diarrhea in a
rural health units or FP (4-category)
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must know the
characteristic change chairs.
The student must list the signs
The student must list the symptoms.
Student should know signs of heart,
lung,
liver,
spleen,
stomach,
duodenum, Bowel and kidneys
the student should know:
- Normal values and their changes in
pathology.
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve the problems of patients with diarrhea:
List of skills
Ask the patient and his relatives
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the probable
diagnosis.
The student must be able to specifically identify and
assess the patient's complaints.
The student must be able to analyze medical history:
142
Identify risk factors
General inspection
Examination of the mouth
An inspection of the skin
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents and
family members.
The student must be able to identify unmanaged and
uncontrolled risk factors as on questioning patient,
based on an objective approach
The student must be able to identify:
- Liver palms
-Gynecomastia
- Cachexia.
The student should be able to appreciate the language.
The student must be able to detect the presence of:
- Pale
- Icterus
-The presence of rash
The student should be able to estimate the elasticity of
the skin and detect signs of dehydration.
Assess the subcutaneous fat.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and - Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and - If the heart murmur, be able to identify their
auscultation of heart sosudistoyistemy
epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
General inspection of the abdomen
-Ascites
-Flatulence
the student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
Conduct surface abdominal palpation
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To carry out the test Shchetkina-Blumberg
the student should be able to:
Hold deep abdominal palpation
- To evaluate the properties of the intestine
- To evaluate all available structures in the abdomen
Conduct percussion liver
the student should be able to:
143
Conduct palpation of the liver and gall
bladder
Conduct percussion and palpation of the
kidneys.
Examine the thyroid gland.
Calculate the index weight / body
Conduct a neurological examination.
Conduct a rectal examination
Interpret the clinical and biochemical
Differentiated disease, accompanied with
diarrhea
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
diarrhea.
Conduct monitoring and surveillance of
patients
- Define the boundaries of the liver Kurlov
the student should be able to:
- To evaluate the properties of the liver and gall
bladder.
the student should be able to:
- Test for tapping the lumbar region
- Palpation to evaluate the properties of the kidneys
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 must be able to identify features:
- Underweight
- Increased weight.
The student must be able to evaluate sensitive area
with the step and identify the principle
characteristics:
- Sensory disturbances (analgesia hypalgesia,
gipostezii, anesthesia, parastezii, dysesthesia, etc.).
The student must be able to evaluate reflexes (with
neurological hammer) and identify features:
- Hyperreflexia
- Hyporeflexia
- Areflexia
The student must be able to assess motor function and
signs of
Student should be able to point out the symptoms of
spinal cord lesions.
Student should be able to conduct rectal examination
with the incremental principle.
The student must be able to identify features:
- Increase or decrease in performance from the norm.
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control states in RHU and FP.
144
Practice session № 6-7
Theme: "Diarrhea. Differential diagnosis of diarrhea, infectious and noninfectious etiologies.
Hypovitaminosis.Tactics GPs. Indications for referral to a specialist or hospital in the profile of
the division.The principles of treatment, follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of prevention. Principles of teaching tools. "- 6.7 hours
Justification of the theme: Often in the practice of primary care patients with the syndrome occur
diarrhea. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of
diarrhea caused by various diseases, to provide medical care in the FCP (FP) or, or in the direction of
the induced specialized hospitals.These circumstances are the basis for the inclusion of this subject in
the program prepared GPs.
GoalTeaching: Teaching GPs choosing the best option for treatment policy diarrheal diseases, as well
as the principles of management of patients in primary care, provided the requirements of
"Qualification Specifications GP"
TasksStudy:
1. Consider the issues of diagnosis and hyperosmolar hypersecretory diarrhea
2. Consider diagnosis of hyper-and hypokinetic diarrhea
3. Demonstrate patients with diarrhea
4. Discuss these clinical-laboratory and instrumental studies at diarrhea.
5. Make a differential diagnosis of diseases, leading to diarrhea.
6. Discuss questions about tactics in the qualifying characteristics of GPs
7. Discuss the principles of treatment (non-drug and drug).
8. Discuss the principles of management, supervision and monitoring of patients in rural health units or
a family policlinics.
9. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting the lesson allows students time and correctly diagnose and differentiate on clinical data of
laboratory and instrumental studies diseases associated with diarrhea.
GPs should know:
 Mechanism and cause of the diarrhea.
 Clinical manifestations of diarrhea.
 Diagnosis of diarrhea.
 Differential diagnosis of diarrhea.
 The principles of treatment (drug and non-drug) for these diseases, accompanied by Diarios.
 Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
 The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Data analysis and history of complaints in the diagnosis of diarrhea.
 Diagnose, to differentiate on clinical, laboratory and instrumental studies of diarrhea.
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
145
GPs should do:
1. Competently carry out inspection of the patient with diarrhea.
2. To fill out the medical history of a patient with diarrhea.
3. Assign the desired plan of inspection of patient with diarrhea.
4. Interpret the results of instrumental studies of patients with diarrhea.
5. Prescribe medication and perform clinical examination of patients with diarrhea.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with diarrhea.
2. Data interpretation of laboratory and instrumental studies in patients with diarrhea.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Diarrhea. Differential
diagnosis of diarrhea and infectious and noninfectious etiologies. Hypovitaminosis. Tactics
GPs. Indications for referral to a specialist or hospital in the profile department. The principles
of treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles
of prevention. Principles of teaching subjects. "
2. Decision analysis and situational problems.
3. Supervision of patients with diseases, diarrheal
4. Clinical analysis of supervised patients.
5. Service calls at home.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
146
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
12.4014.00
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students using the
"rotation" and the
decision siation
problem. Distributed
case studies on the
subject, they have to
analyze and give an
opinion.
Case studies, tables,
and relevant topic
classes
80 minutes
When parsing the theme focuses on the following points.
Violation of passage of intestinal contents and motor function of the intestine in chronic
enteritis most often manifested by diarrhea. In the development of diarrhea involves four mechanisms:
intestinal hypersecretion, increased osmotic pressure in the intestine, the intestinal hyperexudation,
impaired intestinal. Intestinal motility disorders are of great importance in the development of
diarrhea. In most of the patients with diarrheas acceleration transit of intestinal contents is not due to
increased intestinal peristaltic activity, and the weakening of motor skills, particularly of the distal
small intestine.Rectosigmoid department acts as a sort of a functional sphincter, diarrhea relaxes,
begins failure, termination or weakening segmented cuts leads to the fact that cal passively moves in
the large intestine, without resistance, which in normal conditions are showing their bowel movements
are segmented, stirreding the content and form "fecal pole '.However, in some patients, the diarrhea
may be due tolight sensitivity and a significant increase in motor function of the intestine.
Intermittent diarrhea is one of the most constant symptoms of chronic intestinal minute.This
term refers to an increase in stool frequency (more than 3 times a day) with the release of large
amounts of liquid consistency and more feces than usual for this individual intestine.
Hypersecretion due to impaired intestinal electrolyte transport in the intestine.Most tipical
example secretory diarrhea is cholera. Secretory diarrhea characterized water chair polifecaly,
steatorrhea due to fatty acids with long-chain, high losses of sodium, potassium, chloride with feces,
metabolic acidosis, high pH of feces.
The increase in osmotic pressure in the intestine occurs in the following cases: 1) violation of the
digestion and absorption of carbohydrates, 2) malabsorption syndrome, and 3) an increased inflow into
the gut of osmotically active substances (salt softeners, sorbitol).Osmotic diarrhea is characterized by
liquid, polifecaly, increased fecal concentrations of short chain fatty acids and lactic acid, minor fecal
loss of electrolytes, low pH of feces.
Acceleration of transit of intestinal contents occurs when: hormonal and pharmacological stimulation
of transit (serotonin, prostaglandins, secretin, pancreozymin, gastrin) neurostimulation of gene transit
acceleration evacuation activity of the intestine, increasing intracolonic pressure. Increasing the speed
of transit through intestine more common in functional diarrhea and is characterized by frequent rare
chair, sometimes with mucus, mostly in the morning or after a meal, are often observed cramping
abdominal pain
Treatment of diarrhea: health food - diet 4b (with a high content of protein and fat
physiological norm), gluten-free diet, recovery eubioz intestine, enzymes, adsorbents, astringents,
enveloping, excess organic acid binding agents, the means to slow peristaltics; antisecretory drugs.
Handout
Students distributed lists containing the names of threads, the list of diseases associated with diarrhea,
case studies, laboratory results.
Equipment Workshop:
Templates laboratory and instrumental data of patients with diarrhea.
147
Independent work and self-education.
Topics for independent work:
The etiology and pathogenesis of diarrhea. Etiology Pathogenesis hypovitaminosis. Treatment for
inflammatory diseases of intestines (Field work).
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference at
polyclinics.
3. Mastering the interpretation of laboratory and instrumental methods.
4. Service calls at home.
Teaching practice during the class
Supervision of patients with diarrhea
The number of hours -1 hour.
Quiz
1.
2.
3.
4.
5.
The etiology of diseases associated with diarrhea.
Clinic diseases associated diarrhea.
Diagnosis of diseases associated with diarrhea.
Differential diagnosis of diseases associated with diarrhea.
Principles of follow-up and monitoring of patients, accompanied by diarrhea, or RHU in the
family policlinics.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS
WITH CONSTIPATION
Purpose: Teach students syndromal addressing patients with constipation, as well as the principles of
their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

Giving students a solution to the problem with constipation.

Giving students a timely diagnosis when there is a problem associated with constipation.

To teach students to differentiate the disease, accompanied with constipation.

Improve the knowledge, skills, and practical skills in solving problems of patients with
constipation (information gathering, problem identification and physical examination, as well
as the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to know to solve the problems of patients with constipation:
№
The list of knowledge
The list of diseases that occur with constipation
A list of the most dangerous diseases that occur with
constipation
The list of states that require management in a rural
148
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
constipation
Stool
Symptoms of internal organs
Indicators of laboratory results
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with constipation
in a rural health units or FP (4-category)
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must know the
characteristic change chairs.
Student should know signs of heart,
lung,
liver,
spleen,
stomach,
duodenum, bowel and kidneys
the student should know:
- Normal values and their changes in
pathology.
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with constipation:
List of skills
Ask the patient and his relatives
Identify risk factors
General inspection
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the probable
diagnosis.
The student must be able to specifically identify and
assess the patient's complaints.
The student must be able to analyze medical history:
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents and
family members.
The student must be able to identify unmanaged and
uncontrolled risk factors as on questioning patient,
based on an objective approach
The student must be able to identify:
- Liver palms
- Gynecomastia
- Cachexia.
149
Examination of the mouth
An inspection of the skin
The student should be able to appreciate the language.
The student must be able to detect the presence of:
- Pale
- Icterus,
-The presence of rash
The student should be able to estimate the elasticity of
the skin and detect signs of dehydration.
Assess the subcutaneous fat.
General inspection of the abdomen
Conduct surface abdominal palpation
Hold deep abdominal palpation
Conduct percussion liver
Conduct palpation of the liver and gall
bladder
Conduct percussion and palpation of the
kidneys.
Examine the thyroid gland.
Calculate the index weight / body
Conduct a rectal examination
Interpret the clinical and biochemical
Differentiated disease, accompanied with
constipation
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur
constipation.
The student must be able to detect the presence of:
-Ascites
-Flatulence
the student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To test Shchetkina-Blumberg
the student should be able to:
- To evaluate the properties of the intestine
- To evaluate all available structures in the abdomen
the student should be able to:
- Define the boundaries of the liver Kurlov
the student should be able to:
- To evaluate the properties of the liver and gall
bladder.
the student should be able to:
- Test for tapping the lumbar region
- Palpation to evaluate the properties of the kidneys
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 must be able to identify features:
- Underweight
- Increased weight.
Student should be able to conduct rectal examination
with the incremental principle.
The student must be able to identify features:
- Increase or decrease in performance from the norm.
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
150
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Conduct monitoring and surveillance of Student should be able to carry out monitoring and
patients
control states in RHU and FP.
Practice session № 8
Topic: "Constipation. Differential diagnosis of irritable bowel syndrome, constipation, old age
and is determined at the colon.Tactics GPs. Indications for referral to a narrow specialist and
students or hospitalization profile department. The principles of treatment, follow-up,
monitoring and rehabilitation in RHU or family policlinics. Principles of prevention. Principles
of Teaching Tools "- 6.7 hours.
JustificationTopics
Patients with complaints of constipation often first seek medical help from a doctor in general practice.
In this situation, the force of a general practitioner (GP) is directed to the diagnosis of constipation due
to different diseases, to provide medical care in the FCP (FP), or referral to specialized stationary.
These circumstances are the basis for the inclusion of this subject in programmu training GPs.
The purpose of teaching: Teach GPs on timely diagnosis and differential diagnosis, selection of the
optimal treatment strategy options for constipation caused by various diseases, as well as principles of
management of patients in primary care, provided the requirements of "Qualification
characteristics of a general practitioner."
Learning objectives:
 Consider diagnosis of constipation.
 Consider diagnosis of irritable bowel syndrome, colitis, colon cancer, diverticulosis, dolichocolon.
 Demonstrate patients with constipation.
 Discuss these clinical and laboratory research tool for saporia.
 Make a differential diagnosis for constipation.
 Discuss questions about tactics in the qualifying characteristics of GPs
 Discuss the principles of treatment (non-drug and drug).
 Discuss the principles of management, supervision and monitoring of patients in rural health units
or a family policlinics.
 Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting this training will allow students time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies diseases associated with constipation.
GPs should know:
 Mechanism and cause constipation.
 Clinical manifestations of constipation.
 Diagnosis of constipation.
 Differential diagnosis of constipation.
 The principles of treatment (drug and non-drug) for data.
 Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
151
 The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Data analysis and history of complaints in the diagnosis of constipation.
2. Diagnose, to differentiate on clinical and laboratory instrumentation investigatediyam constipation.
3. Choose the right medication for the treatment of constipation.
4. Advise on non-medicated treatments.
5. To monitor the RHU or in family policlinics.
GPs should do:
1. Competently carry out inspection of the patient with constipation.
2. To fill out the medical history of a patient with saporia.
3. Assign the desired plan of inspection of patient with constipation.
4. Interpret the results of instrumental studies of patients with constipations.
5. Prescribe medication and perform clinical examination of patients with constipation.
The list of skills that GPs should possess after completing studies on the subject
1. Examination of patients with constipation.
2. Data interpretation of laboratory and instrumental studies in patients with westernproof operation.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Constipation. Differential
diagnosis of irritable bowel, constipation, senile and colon tumors.Tactics GPs. Indications for a
specialist or hospitalization profile department.The principles of treatment, follow-up, monitoring
and rehabilitation in RHU or family policlinics. Principles of prevention. Principles of Teaching"
2. Decision analysis and situational problems
3. Supervision of patients with diseases that are accompanied by constipation.
4. Clinical analysis of supervised patients.
5. Service calls to your home.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
152
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
of a definitive clinical
diagnosis. Defining the
further tactics.
11.3012.15.
12.2012.40.
12.4014.00
Break.
Study skills.
Student
under
the
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students with Setting up
forthe method of
"snowballs". Students
pazdayutsya case
studies on the subject,
they have to analyze
and give an opinion.
Patient or volunteer.
20 minutes
Case studies, tables,
and relevant topic
classes
80 minutes
When parsing the theme you must pay attention to the following aspects.
Constipation - difficulty is the selection of a small number of dense feces. Rare stool, feeling
of incomplete defecation, defecation less accurate because the soft stool every 2-3 days - a variant of
the norm, and a tight chair several times a day should be considered as constipation.
Functional constipation.There are three types of functional constipation, simple constipation,
constipation hypokinesia bowel constipation without intestinal hypomotility (irritable bowel
syndrome). The most common simple constipation, caused by poor diet, lack of exercise, are served in
the urge to defecate tion, poor working conditions, unusual food during long trips.The constant urge to
defecate suppression leads to dyskinesia - a state where increased threshold to stretch vials rectum.
Hypokinesia intestine is usually observed in young people. Constipation usually begins, in childhood
or adolescence, increases after birth, a strict diet in order to lose weight or operations.After
examination and exclusion of organic causes of constipation give advice ondiet and changed healthy
living
Acquired megacolon main reasons: the abolition of laxatives after prolonged use, hypotireoz,
systemic scleroderma.vClinic: characteristic expression of bloating, with rectal examination extension vials rectum and lower tone sphincter anus; ergography reveals expansion of the colon,
which is filled with fecel masses.Practical advice: should exclude organic causes of constipation, give
advice on nutrition and healthy living and should not be long-term use drugs weaklight sensitivity,
with constipation, emitting dark blood should be suspected colon cancer, hemorrhoids are
characterized by the selection of bright red blood, can cause constipation hypokalemia in patients
taking diuretics.
Colon cancer. Usually men older than 50 years, mortality rates as high as 60% due to late
diagnostics, and in 70% of cases the tumor is localized in the rectum. Risk factors: ulcerative colitis
family polyposis colon, villous adenoma of the colon.Clinic: an admixture of blood and mucus,
constipation, and sometimes diarrhea, feeling of incomplete emptying of the bowel, abdominal
discomfort or cramping pain, discomfort in the back passage, anemia.
With the years the frequency of bowel diverticulosis (people over 40). It is characterized by educated
an deat multiple diverticula in the descending colon.The cause of the disease is a rare fiber intake.
Clinic: bowel diverticulosis often asymptomatic, sometimes observed or alternating constipation and
its with diarrhea, pain in the hypogastrium, mostly on the left. Patients complain of pain on palpation
of the left iliac region, bleeding, sometimes massive, can join the symptoms of "acute
abdomen."Complications: abscess, perforation of a diverticulum, peritonitis, intestinal permeability,
153
fistulas. In the blood leukocytosis, increased ESR. For diagnosis should helpful sigmoidoscopy,
colonoscopy, barium enema.
Chronic colitis- a chronic inflammation of the colon. Clinic: Constipation and diarrhea, typical
symptom of insufficient bowel movements, false urge to defecate, abdominal pain, flatulence,
anorexia, a feeling of bitterness in the mouth, polyhypovitaminosis, anemia.
Treatment: mechanical light diet, split meals, broad spectrum antibiotics, sulfa drugs, drugs
bifida and lyophilized cultures of E. coli, with the express flatulence prescribe charcoal.
Handout
Students distributed lists containing the names of topics list of diseases associated with constipation,
case studies, laboratory results.
Equipment Workshop:
1. Templates laboratory and instrumental data of patients with constipation
Independent work and self-education.
Topics for independent work:
The etiology and pathogenesis of constipation. Clinic constipation these different. Epidemiology.
(Field work).
Practical skills:
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the subject of clinical studies at the morning conference at
polyclinicsIke.
3. Mastering the interpretation of laboratory and instrumental methods.
4. Service calls at home.
Teaching practice during the class
Supervision of patients with constipation.
Number of hours, 1 hour.
Quiz
1. The etiology of constipation.
2. Clinic constipation.
3. Clinic of irritable bowel syndrome, colitis, colon tumors, diverticulosis, dolichocolon.
4. Diagnosis of constipation.
5. Differential diagnosis of constipation.
6. The etiology of irritable bowel syndrome, colitis, colon cancer, diverticulosis, dolichocolon.
8. Diagnosis of irritable bowel syndrome, colitis, colon cancer, diverticulosis, dolichocolon.
9. Differential diagnosis of irritable bowel syndrome, colitis, colon cancer, diverticulosis,
dolichocolon.
10. Differential diagnosis of constipation.
11. Principles of supervision and monitoring of patients in rural health units or family policlinics.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS WITH HEPATOMEGALY
Purpose: Teach students syndromal addressing patients with hepatomegaly, as well as the principles
of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

To teach students the problem associated with hepatomegaly.
154

Giving students a timely diagnosis when there is a problem associated with
hepatomegaly.

To teach students to differentiate the disease, accompanied with hepatomegaly.

Improve the knowledge, skills, and practical skills in solving problems of patients with
hepatomegaly (information gathering, problem identification and physical examination, as well
as the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU or family policlinics.
What the student needs to know to solve the problems of patients with hepatomegaly:
№
The list of knowledge
The list of diseases that occur with hepatomegaly
A list of the most dangerous diseases that occur with
hepatomegaly
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, occurring with
hepatomegaly
Routes of transmission of hepatitis viruses
Symptoms of liver disease and organ
Indicators of laboratory results
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with
hepatomegaly in a rural health units or SP (4-category)
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student must know the
mechanism of transmission
The student should know the signs of
defeat
the student should know:
- Normal values and their changes in
pathology.
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with hepatomegaly:
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the probable
Ask the patient and his relatives
diagnosis.
The student must be able to specifically identify and
155
assess the patient's complaints.
The student must be able to analyze medical history:
the beginning of the disease, the first symptoms, the
causal relationship and the dynamics of their
development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents and
family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient,
based on an objective approach
The student must be able to identify:
- Liver palms
General inspection
- Gynecomastia
- Cachexia.
Examination of the mouth
The student should be able to appreciate the language.
The student must be able to detect the presence of:
- Pale
- Icterus,
An inspection of the skin
-The presence of rash
- Seal
- Teleangiectasy.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and - Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the right gastric
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and - If the heart murmur, be able to identify their
auscultation of heart and vascular system. epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
-Ascites
-Flatulence
General inspection of the abdomen
-Spider veins
- Venous collaterals
- Injuries and bruises
the student should be able to:
- To identify sensitive points
- To evaluate the presence of tension in the muscles
Conduct surface abdominal palpation
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
Hold deep abdominal palpation
the student should be able to:
156
Conduct percussion liver
Conduct palpation of the liver and gall
bladder
Hold spleen palpation
Inspect the limb
Calculate the index weight / body
Interpret the clinical and biochemical
ECG and decrypt it.
Differentiate disease accompanied with
hepatomegaly
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
hepatomegaly
Conduct monitoring and surveillance of
patients
- To evaluate all available structures in the abdomen
the student should be able to:
- Define the boundaries of the liver Kurlov
the student should be able to:
- To evaluate the properties of the liver and gall
bladder.
the student should be able to:
- Identify splenomegaly
The student should see the limbs and body, and to be
able to detect:
- Generalized edema. Fingers should be able to put
pressure on the dorsum of the foot and updaruzhit:
- There is a pit or not.
The student must be able to identify features:
- Underweight
- Increased weight.
The student must be able to identify features:
- Increase or decrease in performance from the norm.
The student must be able to record the ECG with the
incremental principle.
Student should be able to decipher the results of the
ECG and identify signs:
- MI
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
control states in RHU and FP.
Practice session № 9
Topic:"Hepatomegaly.Differential diagnosis of acute and chronic hepatitis, andlkogolnoy liver
disease.Tactics GPs. Indications for referral to a specialist or hospital in the profile of
theTdivision.The principles of treatment, follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of prevention. Principles of teaching topics. "- 6.7 hours
JustificationTopics: The majority of patients with hepatomegaly seek medical helpschyu.In this
situation, the force of a general practitioner (GP) is directed to the diagnosis of diseases (acute and
chronic hepatitis - bolezn hepatitis, hepatitis: B, C, alcoholic liver diseaseor), accompanied by
157
hepatomegaly.In the case of diagnosis of hepatomegaly GPs have to solve the problem of defining a
group of patients is to beaschih treatment in RHU or family policlinics, or referral to specialized
stationary.These and other circumstances are the basis for the inclusion of this subject in the training of
GPs.
GoalTeaching: Teach GP diagnosis and differential diagnosis, conduct best option for treatment
policy hepatomegaly caused by various infectious diseases, and alcoholic liver disease, as well as
principles of management of patients in primary care, provided the requirements of "Qualification
Specifications GP"
Tasks Study:
1. Consider diagnosis of hepatomegaly in acute and chronic liver diseases.
2. Consider diagnosis of infective hepatitis, hepatitis B, C, chronic hepatitis
3. Demonstrate patients with hepatomegaly with these diseases.
4. Discuss the results of clinical, laboratory and instrumental studies with hepatomegaly
5. Make a differential diagnosis of diseases - infectious disease, hepatitis B, C, chronic hepatitis
6. Discuss questions about tactics in the qualifying characteristics of GPs
7. Discuss the principles of treatment (non-drug and drug).
8. Discuss the principles of management, supervision and monitoring of patients in rural health
units or family policlinics.
9. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Anticipated results
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies diseases associated gepatomagaliyami, set the correct initial
diagnosis, to make a differential diagnosis and determine the future tactics of the patient.
GPs should know:
1. The mechanism and causes of hepatomegaly
2. Clinical manifestations of hepatomegaly
3. Diagnosis of hepatomegaly
4. Differential diagnosis of hepatomegaly
5. The principles of treatment (drug and non-drug) for the diseases.
6. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Data analysis and history of complaints to diagnose hepatomegaly
 Diagnose, to differentiate on clinical, laboratory and instrumental studies different kinds of
hepatomegaly
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Competently carry out inspection of the patient with hepatomegaly
 To fill out the medical history of a patient with hepatomegaly
 Assign the required survey plan for hepatomegaly
 Interpret the results of instrumental studies of patients with hepatomegaly
158

Prescribe medication and perform clinical examination of patients with hepatomegaly caused
by various diseases
The list of skills that GPs should possess after completing studies on the subject
 Examination of patients with hepatomegaly.
 The interpretation of laboratory and instrumental studies with hepatomegaly.
Place of activity:
 Training themed office clinic.
 Cabinet GPs.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "hepatomegaly. Differential
diagnostics of acute and chronic hepatitis, alcoholic liver disease.Tactics GPs. Indications for
referral to a specialist or hospitalization profile department.The principles of treatment, followup, control and rehabilitation in RHU or family policlinics. Principles of prevention. Principles
of teaching topics. "
 Explanation of the diagnosis and differential diagnosis data hepatomegaly.
 Decision analysis and situational problems.
 Supervision of patients with hepatomegaly.
 Clinical analysis of supervised patients.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
159
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
12.4014.00
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students to studyuse of
the method of "tour of
the gallery."Students
dealt withituatsionnye
tasks on the subject,
they have to analyze
and give an opinion
Case studies, tables,
and relevant topic
classes
80 minutes
When parsing the theme you must pay attention to the following aspects.
Chronic hepatitis - an inflammatory disease of the liver, accompanied by growth of connective
tissue in the portal tracts without the formation of false lobules. Among the etiological factors of
chronic hepatitis and viral infection that is a leader. In our practice we recommend using GP
classification proposed association of hepatologists in 1994 (Los Angeles).
Clinical hepatitis ambiguous, which is, on the one hand, extremely high compensatory capacity
of the liver, on the other - the involvement in the pathological process of adjacent organs and the body
as a whole.
Characteristic syndromes: asthenovegetative, dyspeptic syndrome, jaundice, cytolytic,
mesenchymal-inflammatory, cholestatic, hemorrhagic syndrome, hypersplenism.
Diagnosis of chronic hepatitis B in a clinic, in addition to a thorough analysis of complaints,
medical history and examination, including lab tests the patient.
Laboratory studies in outpatient conditions usually include: determining the level of prothrombin,
the level of fibrinogen, albumin and albumin-globulin factor correction, sediment samples (thymol and
sulemovaya), the level of cholesterol, immunoassays (IgM, IgG and IgA, IgE).
Instrumental methods usually require referral to the specialized agencies, and include:
radiohepatography, liver scan, endoscopic retrograde cholangiography, ultrasonography of the liver,
liver biopsy.
Thus, the diagnostic algorithm for all types of hepatitis consists of three phases:
 The first stage - focused catanamnesis and detection of clinical signs of liver
(hepatomegaly, jaundice, telangiectasias - "spider veins"), laboratory diagnosis: a study of
bilirubin, ALT and AST, lactate dehydrogenase, sublimate and thymol, and the protein
spectrum of blood, identification of specific antigens.
 The second stage - Instrumental: liver ultrasound, radiohepatography, laparoscopy
 The third (the most important step) - morphological study of the liver using light optical,
immunological and electron microscopic analysis.
Cirrhosis (from French kirros - red) - diffuse process characterized by fibrosis and
reorganization of the architectonics of the liver, leading to the formation of structurally abnormal
nodes.
Currently, the international gastroenterology committee recommended in clinical hepatology
following classification cirrhosis:
Classification of liver cirrhosis (Los Andzhelec, 1994.)
Etiology: viral, alcoholic, autoimmune, metabolic, deficience of alfa-antitripsin, cholestogenic
(primary, secondary), cryptogenic.
On morphology: portal, postnecrotic, posthepatitic, metabolic, biliary, small nodular.
Diagnosis of cirrhosis of the liver, as well as chronic hepatitis is thus a key to identify the
clinical and biochemical syndrome and your use of these imaging studies. Need to consider that
hepatomegaly is more common biliary cirrhosis, and in these cases the predominant cholestatic
syndrome (hyperbilirubinemia, increased alkaline phosphatase in the blood, jaundice, itching, and
others).With portal cirrhosis hepatomegaly observed in the early stages of the disease with last
blowing decrease its size and appearance of splenomegaly.Dominated by other signs of portal
hypertension (telangiectasias, varicose veins, splenomegaly, ascites, etc.). Jaundice may be absent.
160
Differential diagnosis of hepatomegaly with hepatitis and cirrhosis of the liver is performed with a
variety of liver diseases that are accompanied by an increase in its size, but in general practice they are
much rarer.
Handout
Students distributed lists containing the names of threads determining hepatomegaly, the list of
diseases associated with hepatomegaly, case studies, laboratory results.
Equipment Workshop:
1. Templates laboratory and instrumental data of patients with gepatomegalis
2. Table: symptomatic hepatomegaly
Independent work and self-education.
Topics for independent work:
"Etiology and pathogenesis of acute and chronic hepatitis. Pharmacodynamics of drugs in hepatitis
and alcoholic liver disease "(Field work).
1. Independent work with literature in the library, at home
2. Prepare and deliver a presentation on the topic at the morning session of the conference hospital.
3. Mastering the interpretation of laboratory and instrumental Methods.
4. Tour of duty in the department schedule.
Quiz
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hepatomegaly etiology of acute and chronic hepatitis
Clinic hepatomegaly, in acute and chronic hepatitis
Diagnosis of Hepatomegaly in acute and chronic hepatitis
Differential diagnosis of hepatomegaly in acute and chronic hepatitis.
Etiopathogenesis of alcoholic liver disease
Clinic hepatomegaly, alcoholic liver disease
Diagnosis hepatomegaly in alcoholic liver disease
Differential diagnosis of hepatomegaly in alcoholic liver disease
Clinical examination of patients with hepatomegaly
References.
Main
1) Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2) Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3) Ички касалликлар, Камолов Н.Н., 1991
4) Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
5) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional
Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С., 2010. Т.
Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
8) Диагностика болезней внутренних органов. Окороков А.Н. 2005.
9) Лечение болезней внутренних органов. Окороков А.Н. 2005.
1)
2)
3)
4)
5)
6)
7)
161
10) Дифференциальный диагноз внутренних болезней. Виноградов А.В. М.: Медицинское
информационное агенство, 2009.
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http://elibrary.ru http://www.freebooks4doctors.com/ http://www.medscape.com/ http://www.meducation.net/
http://www.thecochranelibrary.com
162
RHEUMATOLOGY
CONTENT THAT CASE STUDIES
The references
№
Topic name practice session
1
Joint syndrome. Diseases that present with articular syndrome. Most
dangerous diseases that present with articular syndrome. The differential
diagnosis of infectious arthritis.Tactics GPs. Indications for referral to a
specialists or hospitalization profile department. The principles of treatment,
dispansery monitoring, control and rehabilitationin in RHU or family
policlinics. Principles of prevention.Definition of disability. Principles of
teaching the topic.
Topics for independent work:
Diagnostic criteria for rheumatism, rheumatoid arthritis and infection.
Practical skills:
Interpretation of tests, X-rays.
Joint syndrome "Differential diagnosis of osteoarthritis and gout.Tactics
GPs. Indications for referral to a specialist or hospitalization ofprofiled
section.The principles of treatment, follow-up, monitoring and
rehabilitationandlitatsii in RHU or family policlinics. Principles of
prevention.Determination trudosposobnosti.Principles of Teaching Tools
Topics for independent work:
Diagnostic criteria for seronegative spondylarthritis.
Practical Skills: Interpretation of tests, x-rays.
Fever of unknown origin. Nature, types of fevers, survey design with dashing.
Tactics GPs. Indications for referral to a specialist or hospitalization in the
profile department. Treatment principles, follow-up, monitoring and
rehabilitation in rural health units or family policlinics. Principles of
prevention.Principles of teaching.
Topics for independent work:
Diagnostic criteria of fever of unknown origin
Practical Skills: Interpretation of tests, x-rays.
Differential diagnosis of fever in infectious diseases (bacterial, viral). GPs
tactics depending on the disease. Indications for referral to a specialist or
hospital in the profile department. Treatment, follow-up, monitoring and
rehabilitation in rural health units or family policlinics. Principles of
prevention. Principles of teaching tools.
Topics for independent work:
Diagnostic criteria for fever noncommunicable diseases
Practical Skills: Interpretation of tests, x-rays.
Differential diagnosis of fever in rheumatic diseases and malignant
neoplasms. Tactics GPs.Of the show for a referral to a specialist or hospital in
the profile department.The principles of treatment, monitoring, control and
rehabilitation in RHU or family policlinics. Principles of prevention. Principles
of teaching topics.
Topics for independent work:
Diagnostic criteria of fever in infectious diseases
Practical Skills: Interpretation of tests, x-rays.
2
3
163
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS WITH ARTICULAR SYNDROME
Purpose: Teach students syndromal addressing patients with articular syndrome, and the principles of
their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

Train students in solving problems related to articular syndrome;

Giving students a timely diagnosis when there is a problem related to the articular
syndrome.

To teach students to differentiate the disease, accompanied by articular syndrome.

Improve the knowledge, skills, and practical skills in solving problems of patients with
articular syndrome (information gathering, problem identification and physical examination, as
well as the ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

Giving students a reasonable exercise of health care measures and surveillance in RHUs
and FP;
What the student needs to know to solve the problems of patients with articular syndrome:
№
1
2
3
4
The list of knowledge
The list of diseases that occur with joint syndrome
A list of the most dangerous diseases that occur with
joint syndrome
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
5
A list of studies requiring in RHU or FP (3-1 category)
6
The list of research areas requiring outside RHU or FP
(3.2-category)
7
Signs joint syndrome
8
Symptoms of internal organs
7
Key points (criteria) diagnosis occurring articular
syndrome.
8
Treatment policy
9
The principles of primary, secondary and tertiary
prevention
10
The principles of clinical examination and
164
Basic level
The student should know at least 30
of the most common diseases
The student should know at least 10
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
The student should know the
symptoms of joint inflammation and
destruction of ligaments and articular
syndrome in particular diseases.
The student should know the signs
poliserozita, heart disease, lung,
kidney, gastrointestinal tract, etc.
The student must know the distinctive
features of each disease, and
diagnostic criteria.
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
rehabilitation of disorders that occur with joint
syndrome in a rural health units or SP (4-category)
activities for clinical examination and
rehabilitation.
That the student should be able to solve the problems of patients with articular syndrome:
№
1
2
3
4
5
List of skills
Basic level
Student should be able to ask questions of rational
concise questions that really helps to set the probable
diagnosis.
The student must be able to specifically identify and
assess the patient's complaints.
Ask the patient and his relatives
The student must be able to analyze medical history: the
beginning of the disease, the first symptoms, the causal
relationship and the dynamics of their development.
The student must be able to analyze life history: the
identification of risk factors, the health of parents and
family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient, based
on an objective approach
Identify the main problem, that is, the Student should be able to approve the signs of the
presence of articular syndrome
affected joint
Student should be able to conduct joint inspection
technique of step with the principle.
The student must be able to identify features:
- Defiguration
- Deformations
- Swelling
- Congestion
Hyperthermia,
An inspection and palpation of the - Contractures
joints
- Crepitations
- Ankylosis
And functional disorders in the joint
- The presence of free fluid
3. The student must be able to determine:
- Arthralgia
- Monoarthritis
- Oligoarthritis
- Fever
1.
Student should be able to hold the spine
examination technique with the step principle.
2.
The student must be able to identify signs or
symptoms:
Rate spine (inspection and palpation,
- Pathological lordosis and kyphosis
including functional tests) (step)
- Curvature of the spine
- Functional disorders
- Schober
- Otto
- "Chin-sternum"
165
6
7
8
9
10
11
12
13
14
15
16
- Forest
- Kushelevsky
-Characteristic of degenerative disc disease, herniated
disc
The student must be able to identify signs or symptoms:
Evaluate muscle strength
- Atorfii regional muscle
- Hypo-or hyperkinesia muscles
An inspection of the oral cavity and The student must be able to identify signs or symptoms:
pharyngoscope (step)
- Tonsillitis
- Stomatitis
Take a swab from the throat for
bacteriological examination
The student must be able to identify features:
- Psoriasis
- Keratoderma
An inspection of the skin
- Annular erythema
- Lupus butterfly
- Induration and thickening of the skin
The student must be able to identify features:
- Chancre
An inspection of the penis (step)
- Abnormal discharge from the urethra
- Balanitis
The student must be able to identify features:
Conduct a rectal examination (step)
- Prostatitis
1.The student must be able to identify features:
- Organ damage.
2. Based on physical examination the student should be
able to identify clinical symptom characterizing
An
inspection,
palpation
and systematic destruction and against this background the
auscultation of organs and systems
signs involved in the pathological process of the
musculoskeletal system: bones and joints and muscular
system.
3. The student must be able to identify systemic
inflammation syndrome.
The student must be able to identify features:
- Underweight
Calculate the index weight / body
- Increased weight
The student must be able to reasonably assign research
methods, and to identify deviations from the norm.
The student must be able to identify features:
- Osteoporosis
- Joint space narrowing
- Uzurations (erosion)
Interpret the X-ray image of the joints,
- Osteophytosis
lungs
- Characteristic of diseases that occur with joint
syndrome
- Tuberculous lung disease
Interpret the clinical and biochemical
Differentiated disease, accompanied The student must be able to differentiate the disease on
166
by articular syndrome
17
18
the basis of the distinctive features (history, physical
examination and laboratory and instrumental
investigations)
The student should be able to choose products with
proven effectiveness.
Rational use of medicines in the When choosing drug student should be able to evaluate:
treatment of diseases that occur with
Effectiveness
joint syndrome
safety
- Eligibility
- Economy.
Student should be able to carry out monitoring and
Conduct monitoring and surveillance
control symptoms of disease activity in a rural health
of patients with articular syndrome
unit.
Practical class № 1
Topic: "The articular syndrome. Diseases that present with articular syndrome. The most
dangerous diseases that occur with articular syndrome.The differential diagnosis of rheumatism
and reumathoid arthritis and infectious arthritis. Tactics GPs. Indications for referral to a
specialist or hospital in the profile department. The principles of treatment, follow-up,
monitoring and rehabilitation and orientation of RHU or in family policlinics. Principles of
prevention. Definition of disability. Principles teaching the topics. "
Justification of the theme: A big proportion of arthritis and arthralgia in the overall structure diseases
of the musculoskeletal system for the interest in a wide range of doctors to the problem. Patients with
arthritis and artralgy seek treatment in medical institutions of primary health care. In this situation, the
force of a general practitioner (GP) is directed to the diagnosis diseases that caused arthritis and
arthralgia, to address the issue areas for consultation and hospitalization, as well as for treatment in a
rural health units, or family policlinics. These circumstances are the basis for the inclusion of this
subject in the training of GPs.
The aim of teaching : Getting GPs on timely diagnosis and differential diagnosis of arthritis and
arthralgia, and the principles of management of patients in primary care, provided the requirements of
"Qualification characteristics of a general practitioner"
Learning objectives:
1.
Teach GPs - diagnosis and differential diagnosis of arthritis and arthralgia, clinical
features, depending on the etiology.
2. Discuss the issues of diagnosis and differential diagnosis of infectious arthritis.
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5.
Discuss the principles of management, supervision and monitoring of patients in rural
health units or a family policlinics.
6.
Discuss the principles of primary, secondary and tertiary prevention in these diseases
involving articular syndrome.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies rheumatism, rheumatoid arthritis, infectious arthritis,
167
accompanied by arthritis and arthralgias; ustanovit diagnosis and determine the future tactics of the
patient.
GPs should know:
1.
The list of diseases that occur articular syndrome.
2.
A list of the most dangerous diseases that present with articular syndrome.
3.
Clinical manifestations of arthritis and arthralgia, especially the flow, depending on the
etiology.
4.
Differential diagnosis of infectious arthritis.
5.
The principles of treatment (medical and nonmedical) rheumatism, rheumatoid arthritis and
infectious arthritis.
6.
Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
7.
The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Diagnose, differentiated by the clinic to laboratory and instrumental studies diseases associated
with arthritis and arthralgia.
2. Choose products with proven efficacy
3. Advise on non-medicated treatments.
4. To monitor the RHU or in family policlinics.
GPs should do:
 Data analysis of complaints and medical history for the diagnosis of rheumatic fever, rheumatoid
arthritis and infectious
 To inspect a patient with the above diseases soprovozhdayuschimisya arthritis or arthralgia.
 Establish diagnosis and differential diagnosis of arthritis or artralgiyah.
 Interpret the test results, the data of laboratory-instrumental studies in patients with arthritisor
arthralgia itami.
 Prescribe treatment for patients with arthritis caused by various etiological factors.
 For a list of arthritis and arthralgia and subject further examination and / or treatment in
specialalizirovannyh offices.
 The list of skills that GPs should possess after completing studies on the subject
 Conduct a survey of patients with arthritis.
 Interpretation of analyzes of laboratory and instrumental studies of patients with artritium.
 Billing drugs depending on the etiology of artritium and arthralgias.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with arthritis.
2. Interpretation of analyzes of laboratory and instrumental studies of patients with arthritis.
3. Billing drugs depending on the etiology of arthritis and arthralgia.
Place of activity:
 Training themed room.
 Hospital rooms in the rheumatology department.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "articular syndrome.
Disease, the catonrye occur articular syndrome.The most dangerous diseases that present with
articular syndrome. The differential diagnosis of rheumatism and rheumatoid arthritis, and
infectious arthritis. Tactics GPs. Indications for referral to a narrow and specialized
168





hospitalization profile department.The principles of treatment, follow-up, monitoring and
rehabilitation in RHU or family policlinics. Principles of prevention. Definition of disability.
Principles of teaching the topics. "
Clarification of diagnosis, differential diagnosis and tactics GPs arthritis and arthralgia.
Decision analysis and situational problems.
Supervision of patients with arthritis and arthralgia.
Clinical analysis of case-patients.
Role play on sessions.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students with the useof
the method "Tour the
gallery."A decision on a
task on the subject and
role-playing.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and
instrumental
studies, case studies.
On practical training in the theoretical part series includes: the characteristics of the articular
syndrome in rheumatism and rheumatoid arthritis.
Rheumatoid arthritis.Reference points in the diagnosis of rheumatic fever are: association with
streptococcal infection (1-2 weeks), polyarthritis with norazheniem large and medium joints, volatile
169
nature of joint damage, lasting hours, days, weeks, with no residual effects in them, regression of the
inflammatory process in the joints in 3 - 5 days, sometimes even without treatment, the simultaneous
development of carditis, chorea, erythema annulare, subcutaneous rheumatoid nodules, good effect of
antirheumatic therapy to small diagnostic criteria include fever, increased erythrocyte sedimentation
rate, acute phase reactant, titer antistreptolysin O.
The general practitioner should be aware that in recent years with rheumatism have noted cases
of chronic persistent flow with 2.3 lesions of joints and even one joint to the presence of proliferative
changes reminding beginning rheumatoid arthritis.Unlike the latter, the lack of morning stiffness,
symmetry, the lack of rheumatoid factor in the blood. Acute inflammation of the joints and involves
the so-called palindromic rheumatism unclear origin,the distinguishing feature of which are repeated
attacks of arthritis at irregular intervals, often in men of middle aged and elderly.This usually affect
one or how many joints (usually the knee, wrist and then the small joints of the hands). Duration of
attack varies from several hours to several days, characterized by sharp pain and swelling of
periarticular tissues, and complete reversibility of the process. In the blood the eosinophilia,
lymphocytosis.
Rheumatoid arthritis. It is a chronic systemic autoimmune inflammatory disease of
connective tissue, mainly affecting the joints of the type of erosive and destructive progressive
polyarthritis.
General practitioner to probe the patient and pay attention when inspecting it on the following
diagnostic criteria: morning stiffness in the joints, joint swelling lasting more than six weeks, bilateral
symmetrical lesion of joints of the hands ("fin Walrus"), the rapid development of regional atrophy of
the muscles, the presence of pain-free , mobile, rheumatoid nodules, lesions of the internal organs
(pleurisy, gastritis, liver enlargement, myocarditis, pericarditis, renal amyloidosis, polyserozitis etc.),
an increase of alpha-1 and 2, and gamma-globulin in the blood, the presence of rheumatoid factor in
serum or synovial membrane (reaction Voler-Rose, latex test), increased C-reactive protein, reduced
the number of T-lymphocytes, T-suppressor function, disimmunoglobulinemia expressed cell count in
the synovial fluid, biopsy: histological changes in the synovial membrane (proliferation synovial,
lymphoid and plasma cells, hypertrophy, necrosis).
Newer diagnostic features: continuous low-grade temperature of the body, the total weight loss,
persistent increase in ESR. Radiographically: juxta-articular, epiphyseal osteoporosis, narrowing of the
joint slit whether uzuration, persistent inflammatory changes in the joints of the development of the
deformation and contractures. It can be assigned only if the following criteria: involvement in more
than one quarter of all the joints in addition to the defeat of the small joints of the hands and feet, a
typical joint damage brushes with defiguratsiey or at least swelling intercostals spaces and the typical
radiographic changes in at least one joint.
In 10% of cases there is joint and visceral form of the disease, characterized aggresivity rapidly
progressive course, almost constant activity.In this variant of the disease the general practitioner
usually has to send the patient to the hospital due to unsuccessful outpatient treatment.
Infectious arthritis.
Arthrempyesis develops with hematogenous germs into the joint of the primary foci of
infection.Often affects one major joint in the background of fever, chills, regional limphadenitis.
About sword sharp pain and swelling of the joint, the skin over it turns red, the function is
broken.Puncture turbid purulent synovial fluid, which is dominated by neutrophils.
Gonorrheal arthritis usually localized in the knee and ankle joints are usually affected one
joint. May be migratory polyarthralgia, preceded by a high rate ofeture with chills.The joint swells,
becomes hot to the touch. Formed early contractures and muscle atrophy with the development
deficitandfiguration joint. Joint damage still accompanied by the development achillo-bursitov,
tenosynovitis, calcaneal exostosis, atrophy. In synovial fluid can be detected, white blood cell count 50 to 150h109/ l.
When Brucella arthritis affects one or more of the peripheral joints and spine. Possible
arthralgia (generalized), arthritis, periarthritis, bursitis, sacroiliitis, spondylitis, spondylitis compared to
other manifestations of the disease: an undulating fever, chills, hepatosplenomegaly,
170
lymphadenopathy, nerve damage, leukopenia, lymphocytosis, a moderate increase in ESR. In the
diagnosis of relevant epidemic anamnesis, a positive reaction Wright-Heddlsona, skin testing with
brucellosis antigen reaction (Burne).
Syphilitic arthritis pain is manifested especially pronounced at night.The skin over the joint is
pale, stretched. Palpation of the joint is not painful, its function is preserved, Wasserman positive floor.
Lyme disease endemic infectious disease caused by Borrelia, transmitted. Characteristic
symptom - ring erythema migrans in combination with recurrent mono-or oligoarthritis, accompanied
by fever, arthralgia, headache, rigidity of the neck muscles.Possible complications such as arthritis of
small joints, meningitis, myocarditis, pericarditis, conduction disturbances, hitting, cranial and
peripheral nerves, as well as the identity lymphocytoma earlobe or nipple of the breast. Diagnostics
consists of detection to the spirochete Borrelia IgG-antibody titer of 1:80 or higher, as well as the
planting of synovial fluid.
Tuberculous arthritis.With him there is loss of peripheral joints and spine. Most often the process is
localized in one joint (knee, hip, ankle, wrist). Has developed gradually: there are moderate local pain,
swelling and joint effusion, amrofiya muscles. Externally joint pale, have light hyperthermia
defiguration, effusion. In later stages, the formation of a fistula. Radiographically defined focal
alteration of bone trabeculae, degradation and melting of ends of bones and their displacement,
subluxations. In the diagnosis of clinical features included: epidemic anamnesis detection of
tuberculosis lesions in other organs, a positive tuberculin skin test, the changes in X-ray, biopsy tissue,
synovial fluid culture results
An example of an RPG:
Patient 40 years old, complained of pain in the joints, stiffness in the morning, recurrent fevers
arela, the appearance of subcutaneous site in the right elbow, general weakness.History of joint pain
with rest whists 5-6. She was treated irregularly. She is married and has no children (ovarian
dysfunction).
Inspection: OBJECTIVE: state of relatively satisfactory, low power, there is a moderate strain
in areas 2 and 3 fingers mezhfalangovyh joints of both hands, the rest of the joints are no changes.BP
110/70 mm.Hg pulse 80 beats per minute. Cardiac sounds are rhythmic. In the lungs, vesicular
breathing. Abdomen soft, painless, the liver does not increaseichena, in the right elbow - subcutaneous
node 2.1 cm, round shape.
Patient's problem:
1) Lack of full treatment: a hospital, clinic, nursing home.
2) The desire to have children.
Tactics of GPs:
1) Psychological contact with the patient.
2) Determine history (chronic tonsillitis, otitis media, etc.).
3) Causes of irregular treatment.
4) Set: common urine analysis, X-ray joints of the hands, latex test, reaction Vaaler-Rose.
With a group to discuss the actions of the student performing the role of "patient." Then discuss
what the survey needs to be doneenthis patient.Answer must first student, who plays "doctor", then
answer esuppl students about the group.At the end of the game is necessary to evaluate the analytical
abilities of each student st.
The practical part of training - Supervision of sick students - performed under the supervision
of a teacher at the Department of Rheumatology.
To prepare thematic bypass 3.2 patients with pathology of the joints, with the presence of a
history of sufficient minimum surveys: common blood and urine tests, blood tests for rheumatoid
factor, CRP, seromucoid, sialic, sublimate sample ASO, ASK, ASG, uric acid , x-rays of the joints and
organs of thoracic cage. During rounds fixed attention on the characteristics of complaints of patients,
depending on the nature of joints damaging, pain, swelling, limitation of movement in the joints,
which points to the destruction of joints, what time of day worries and pain with which it is associated.
The attention to the sequence of history-taking, depending on the nature of joint damage.
171
Physical examinations aimed at identifying the nature of the affected joint, restriction of joint
movement, the presence of swelling, local temperature, redness.
Handout
Students distributed lists containing the names of topics, definitions of arthritis and arthralgia,
rheumatism classifications, with case studies on class, with laboratory studies, X-rays of the joints.
Equipment practice session
 Patterns of laboratory and instrumental studies.
 Table: Clinical manifestations of arthritis and arthralgia.
Independent work and self-education.
Topic: Diagnostic criteria for rheumatism, rheumatoid arthritis. Criteria for the diagnosis of
rheumatic fever. (Outauditorium work).
 Independent work with literature in the library, at home.
 Prepare and deliver a presentation on the topic at the morning session of the conference at the
Department of Clinical
 Mastering the interpretation of laboratory and instrumental studies.
 Tour of duty in the department schedule. The development of skills in eezhurstv clinic.
Teaching practice during the lesson.
 Supervision of patients with arthritis and arthralgia.
 The number of hours -1 hour.
Quiz






Especially arthritis and rheumatism arthralgia.
Especially arthritis and arthralgia in rheumatoid arthritis.
Differential diagnosis of joint syndrome.
Classification of rheumatism and rheumatoid arthritis
The course and diagnosis of these diseases
Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
Practical lesson № 2
Topic:"The differential diagnosis of osteoarthritis and gout. Tactics GPs. Indications for referral
to a specialist or hospital in the profile department. The principles of treatment, outpatient
Observed of, control and rehabilitation in RHU or family policlinics. Principles of prevention.
Determination working ability. Principles of Teaching Tools"- 6.7 hours.
Justification of the theme:A big proportion of arthritis and arthralgia in the overall structurere
diseases of the musculoskeletal system for the interest in a wide range of doctors to the
problem.Patients with arthritis and artralgiyami seek treatment in medical institutionsof primary health
care.In this situation, the force of a general practitioner (GP) is directed to the diagnosis diseases that
caused arthritis and arthralgia, to address the issue areas for consultation and hospitalization, as well as
for treatment in a rural health units, or family policlinics. These circumstances are the basis for the
inclusion of this subject in the training of GPs.
The aim of teaching: Getting GPs on timely diagnosis and differential diagnosis of osteoarthritis and
gout,as well as principles of management of patients in primary care, provided the requirements of
"Qualification characteristics of a general practice."
.
172
Learning objectives:
1.
Teach GP-diagnosis and differential diagnosis of arthritis and arthralgia, clinical features,
depending on the etiology.
2. Discuss questions about tactics in the qualifying characteristics of GPs
3. Discuss the principles of treatment (non-drug and drug).
4.
Discuss the principles of management, supervision and monitoring of patients with
osteoarthritis and gout in a rural health units, or family policlinics.
5. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiate the
clinic to the laboratory and instrumental studies osteoarthritis and gout, accompanied by arthritis and
arthralgias; ustanovit diagnosis and determine the future tactics of the patient.
GPs should know:
1. Clinical manifestations of arthritis and arthralgia, especially the flow, depending on the
etiology.
2. Differential diagnosis of arthritis and arthralgia.
3. The principles of treatment (drug and non-drug) for osteoarthritis and gout.
4. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
5. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Diagnose, differentiated by the clinic to laboratory and instrumental studies diseases associated with
arthritis and arthralgia.
 Choose products with proven effectiveness.
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Data analysis of complaints and medical history for the diagnosis of osteoarthritis and gout
 To inspect a patient with the above diseases, accompanied by arthritis or arthralgia.
 Establish diagnosis and differential diagnosis of arthritis or arthralgia.
 Interpret the test results, the data of laboratory and instrumental studies in patients with arthritis
and arthralgia.
 Prescribe treatment for patients with arthritis caused by various etiological factors.
 For a list of arthritis and arthralgia and subject further examination and / or treatment in
specialized units.
The list of skills that GPs should possess after completing studies on the subject
1.
Conduct a survey of patients with arthritis.
2.
Interpretation of analyzes of laboratory and instrumental studies of patients with
osteoarthritis and gout.
3.
Billing drugs depending on the etiology of arthritis and arthralgia.
Place of activity:
 Training themed room.
 Hospital rooms in the rheumatology department.
The course is taught
173
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "Differential diagnosis of
osteoosteoarthritis and gout.Tactics GPs. Indications for referral to a specialist or hospital in
the profile department. The principles of treatment, dispanseption monitoring, control and
rehabilitation in RHU or family policlinics. Principles of prevention. Definition of
disability.Principles of teachingsubjects. "Clarification of diagnosis, differential diagnosis and
tactics GPs.
 Decision analysis and situational problems.
 Supervision of patients with arthritis and arthralgia.
 Clinical analysis of case-patients.
 Role play on sessions.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students with the useof
the method
"brainstorming."A
decision on a task on
the subject and roleplaying.
174
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and instrumental
studies, case studies.
On practical training in the theoretical part series includes: the characteristics of the articular
syndrome in osteoarthritis and gout.
Deforming osteoarthritis (primary and secondary OAD).
The most common abnormality of the joints in the practice of general practitioners. This
degenerative joint disease contrib-dystrophic nature, with the destruction of articular cartilage and
underlying bone proliferation tissue. In this disease, the joints involved in the process, searching most
stress: the major joints of the extremities, spine, and distal interphalangeal joints acid parts (Fig.8).
DOA are the primary causes of the discrepancy between the mechanical stress on the articular
cartilage, family history, etc.
Secondary DOA begins in pre-modified cartilage due to congenital disorders of static
structure and Hip Dysplasia endured arthritis, injuries, fractures, also causes are endocrine diseases
(diabetes, acromegaly), metabolic disorders (hemochromatosis, ochronosis, gout).
Diagnostic criteria:
- Pain in the joints at the end of the day, and (or) in the first half of the night;
- Increase in pain after the mechanical stress on the joint, occasionally - a symptom of "blockade" of
the joint;
- Deformation of the joint by bone growths, including Heberden's nodes;
- X-ray data: kistovidnaya alteration of bone structure, joint space narrowing, osteosclerosis of the
articular surface, osteophytosis.
Spondylosis, osteochondrosis, spondiloartrosis is degenerative joints of the spine, a common
condition in the patient practice.These include pathology as fibro-cartilaginous intervertebral discs
(spondylosis or osteochondrosis) and synovial intervertebral joints (spondiloartrosis).
Spondylosis deformans. As practice shows, usually in the lumbar and cervical spines. Perhaps
asymptomatic, but are more common local pain in the spine, strengthening load, stay in a forced
position, may limit the mobility of the spine.Often shows tenderness effleurage spine palpation or
spinous processes. Rehn characterized rentgenologic data - availability of secondary bone growths on
the edges of the vertebral bodies (osteophytes or exostosis). Because of this, emphasizes the "waist" of
vertebrae. With no loss spondylosis samykayuschih plates, intervertebral space is not restricted.
Intervertebral osteochondrosis- degenerative - dystrophic disease of the intervertebral
discs,accompanied by their deformation, reduced height and separation. Greater than often low back
pain localized in the lower-cervical, thoracic and upper-lower-lumbar spine.
Perhaps the presence of three groups of clinical syndromes: a neurotic, muscular and vascular.
Neurotic manifestations may be in the form of neuralgia, radiculitis, cervicalgia, lumbalgia or
lumbago, radicular pain, vegetative-trophic disorders. Muscular syndrome is pain and contracture
paravertebral and pectoral muscles.Vascular syndrome characterized by feeling sick chill, color change
to covers limbs, presence of edema and paresthesias in the extremities. On radiographs indicated triad
signs: reducing the height of the intervertebral disks, seal and flattening of the subchondral layer of the
vertebral bodies (subchondral sclerosis), the presence of a horizontally elongated edge overgrowth osteophytes.
Spondylarthrosis- degenerative - dystrophic lesion synovial intervertebral and costo-transverse
joints. The clinic depends on the location of the process. Symptoms can be local or distant. Presence of
pain in the cervical-thoracic or lumbar spine, increases after exercise, a prolonged stay in the same
position. Revealed tenderness in paravertebspectral points.A significant proportion of patients also
expressed spondylarthrosis vegetative neurodystrophic and vascular syndromes (migraine attacks,
vertebrobasilar insufficiency, sympatalgia, neuralgia, false angina, sciatica, lumbago). Spine on
radiographs determined narrowing of the joint gaps, subchondral osteosclerosis, marginal bone
growths on the edges of the joint surfaces, the elongation and deformationation articular processes.
Microcrystallic arthritis.
The main difference in this group of diseases is the paroxysmal nature of the articular
syndrome, with which the general practitioner is usually found when called to the patient's home or at
a reception in the clinic.
175
Gout- a chronic disease that results from a violation of urine acid metabolism, characterized by
elevated levels of uric acid and urate deposition in tissues, which is manifested recurrent acute arthritis
and the formation of tophi (gouty nodes).
For the diagnosis of gout, the following criteria:
- A typical attack of arthritis, with the defeat of the first metatarsophalangeal joint of the big toe;
- Two typical attack with damage to other joints;
- Arthritic nodules;
A positive therapeutic effect of colchicine;
- Hyperuricemia.
The absolute sign of gout - detection of urate crystals in synovial fluid or tissue. Symptoms:
arthritis attack duration no more than 2 weeks, a preferential loss of male gender, obesity, urolithiasis.
Distinguish the following stages of gouty arthritis:
Stage I - large cysts in the subchondral bone, and in the deeper layers, sometimes sealing of
soft tissue;
Stage II - large cyst near the joint and minor erosion of the joint, permanent sealing of soft tissue
sometimes with calcifications (9 years);
Stage III - large erosion by at least one third of the articular surface, osteolysis epiphysis, sealing soft
tissue deposition of lime (10-15 years).
Diagnosis is based on the Rome criteria (1963):
- Increase of uric acid more than 0.42 mmol / l in men and 0.36 mmol / l in women - tophi.
- Sodium urate crystals in synovial fluid or tissue under the microscope and chemical study.
- Acute gouty arthritis, occurs suddenly with a complete clinical re-mission in 1-2 weeks.
Chondrocalcinosis (pseudogout)- a disease that is associated with deposition in articular
cartilage and synovial tissues of microcrystals of calcium salts, belongs to a group of pyrophosphate
arthropathy.
Criteria for diagnosis:
- Acute pgout-like arthritis (especially the knee and wrist joints);
- R-evidence of calcification of the cartilage;
- Identification of single crystals of calcium salts in synovial fluid and cartilage;
- That one of the factors that often accompanied by the development of chondrocalcinosis
(especially in combination with arthritis), advanced age of the patients, the disease Konovalov-Wilson,
joint laxity, neurotrophic arthropathy, hypothyroidism, gout, prolonged corticosteroid therapy.
guidance on family chondrocalcinosis.
Handout
Students distributed lists containing the names of topics, definitions of arthritis and arthralgia,
rheumatism classifications, with case studies on class, with laboratory studies, X-rays of the joints.
Equipment practice session
1. Patterns of laboratory and instrumental studies.
2. Table: Clinical manifestations of arthritis and arthralgia.
Independent work and self-education.
Topic: Diagnostic criteria for osteoarthritis and gout (Extracurricular workthat). Number of hours - 2
hours.
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the topic at the morning session of the conference at the
Department of Clinical
3. Mastering the interpretation of laboratory and instrumental studies.
4. Tour of duty in the department schedule. The development of skills in eezhurstv clinic.
Teaching practice during the lesson.
176
Supervision of patients with arthritis and arthralgia.
The number of hours -1 hour.
Quiz




Especially arthritis and arthralgia in reactive arthritis.
Classification of osteoarthritis and gout
Especially arthritis and arthralgia osteoarthritis and gout.
Differential diagnosis of joint syndrome.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS WITH FEVER
Purpose: Teach students syndromal addressing patients with a fever, and the principles of their
activities in primary health care in the qualifying characteristics of GPs
Key learning objectives:

Train students in solving the problems associated with fever.

Giving students a timely diagnosis when there is a problem associated with a fever.

To teach students to differentiate the disease, accompanied with fever.

Improve the knowledge, skills, and practical skills in solving problems of patients with
fever (information gathering, problem identification and physical examination, as well as the
ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU and FP.
What the student needs to know to solve the problems of patients with fever:
The list of knowledge
Basic level
The student should know at least 10
The list of diseases that occur with fever
of the most common diseases
A list of the most dangerous diseases that occur with The student should know at least five
fever
diseases
The list of diseases that can occur fever of unknown The student should know at least 10
origin
of the most common diseases
The list of states that require management in a rural
According to the characteristics of the
health units or FP (1 category)
GP qualifying
The list of states that require a specialist consultation or According to the characteristics of the
hospitalization (category 2)
GP qualifying
According to the characteristics of the
A list of studies requiring in RHU or FP (3-1 category)
GP qualifying
The list of research areas requiring outside RHU or FP According to the characteristics of the
(3.2-category)
GP qualifying
Student should know in which cases
show:
- Subfebrile
Types of fevers
- A moderate increase
- High
- Excessive
- Hyperpyretic body temperature.
177
Stud ent must know in which cases
show:
- Ongoing
Types of temperature curves, depending on the nature
- Laxative (remitting)
of the daily temperature fluctuations.
- Intermittent
- Hectic
- Reverse type
- Irregular fever.
Student should know in which cases
show:
Shape of the temperature curve
- Return
- Undulating fever
Methods for measuring the temperature
The student must list
A student must know features and
Key points (criteria) diagnosis, occurring with fever
symptoms of each disease, and the
criteria for their diagnosis.
The student should know the
Symptoms of internal organs and systems
symptoms of defeat
The student must know the
Elements of rash
characteristics of primary and
secondary elements
The student must know the techniques
Treatment policy
and principles of treatment (including
non-drug).
The principles of primary, secondary and tertiary
The student should know the basic
prevention
activities required for primary,
secondary and tertiary prevention
The principles of clinical examination and The student must list the main
rehabilitation of disorders that occur with fever in a activities for clinical examination and
rural health units or FP (4-category)
rehabilitation
That the student should be able to solve problems of patients with fever:
List of skills
Ask the patient and his relatives
Identify risk factors
Measure blood pressure.
Basic level

Student should be able to ask questions of
rational concise questions that really helps to set the
probable diagnosis.
 The student must be able to specifically identify
and assess the patient's complaints.

The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics
of their development.
 The student must be able to analyze life history:
the identification of risk factors, the health of parents
and family members.
The student must be able to identify unmanaged and
uncontrolled risk factors as on questioning patient,
based on an objective approach
Student should be able to hold tonometry with the
178
incremental principle.
The student must be able to detect the presence of:
- Pale
An inspection of the skin
- Cyanosis,
- Icterus,
-The presence of rash
Student should be able to describe in detail the
Describe the elements of rash
elements of skin lesions
The student must be able to explain to patients the
Measure the temperature of the body
rule of measurement.
The student must be able to evaluate the lymph nodes
Conduct palpation of lymph nodes
and detect signs of increasing and changing the
properties.
The student must be able to detect:
Explore the pulse of the carotid, radial
- The presence or absence of a pulse
and femoral arteries, as well as the
The student must be able to evaluate the properties of
superficial temporal artery
the radial artery.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and - Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify:
- Cardiac impulse
Palpation of the heart to hold
- Systolic and diastolic tremor
The student must be able to evaluate the apical
impulse.
The student must be able to identify:
- The boundaries of the relative and absolute dullness
of heart
- The boundaries of the vascular bundle
- The diameter of the heart
Conduct percussion heart
And waist-configuration of the heart.
The student must be able to identify:
- Signs of hypertrophy of the heart
- Mitral configuration
-Aortic configuration
The student must be able to identify:
- Easing I and II Tone
- I gain tone at the top
- Accent II tone of the aorta or pulmonary artery
Conduct cardiac auscultation
- Systolic and diastolic murmur, and to identify their
epicenter
Be able to differentiate functional from organic heart
sounds.
- Pericardial friction noise
The student must be able to detect the presence of:
An inspection, palpation, percussion, -Ascites
belly
the student should be able to:
- To identify sensitive points
179
- To evaluate the presence of tension in the muscles
of the abdominal wall
- To identify the presence of enlarged organs or
tumor formation.
- To test Shchetkina-Blumberg.
the student should be able to:
- To evaluate all available structures in the abdomen.
the student should be able to:
- Define the boundaries of the liver Kurlov and
identify signs of hepatomegaly.
the student should be able to:
- To evaluate the properties of the liver and gall
bladder.
the student should be able to:
- To evaluate the properties of the spleen and identify
signs of splenomegaly.
the student should be able to:
Conduct percussion and palpation of the
- Test for tapping the lumbar region
kidneys.
- Palpation to evaluate the properties of the kidneys
The student should see the limbs and body, and to be
able to detect:
Inspect the limb
- Local or generalized edema. Fingers should be able
to put pressure on the dorsum of the foot
- There is a pit or not.
The student must be able to detect:
To inspect the bones and joints
- The presence of the articular syndrome
Student should be able to inspect and palpate the
thyroid gland and identify signs of increase, and
Examine the thyroid gland.
depending on the size of the thyroid gland to
distinguish the degree of goiter
The student must be able to evaluate the function
FSK.
The student must be able to identify features:
- Peripheral paresis or paralysis
- Central paresis or paralysis.
The student must be able to evaluate reflexes (with
Conduct a neurological examination.
neurological hammer) and identify features:
- Hyperreflexia
- Hyporeflexia
- Areflexia
The student must be able to assess motor function and
signs of
Student should be able to inspect the throat with the
Examination of the throat
principle of step and identify signs of tonsillitis,
pharyngitis
Student should be able to conduct rectal examination
Conduct a rectal examination
with the incremental principle.
Student should be able to hold ophthalmoscopy with
Hold ophthalmoscopy
the principle of step and look of the eye
The student must be able to identify features:
Calculate the index weight / body
- Underweight
180
Interpret the clinical and biochemical
Interpret the X-ray picture of light
ECG and decrypt it.
Differentiate disease accompanied with
fever
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
fever
Conduct monitoring and surveillance of
patients
- Increased weight.
The student must be able to identify signs of shifts
from the norm
The student must be able to identify features:
- Pneumonia
- Pneumothorax
- Pleurisy
- Lung cancer and tuberculosis
The student must be able to record the ECG with the
incremental principle.
Student should be able to decipher the results of the
ECG and identify signs:
- Myocardial ischemia
- MI
- Hypertrophy of the heart
- Arrhythmia
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
- Economy.
The student must list the principles of management
and surveillance of diseases that occur with fever.
Practical № 3
Topic: "Fever of unknown origin. Nature, types of fevers, survey plan at a fever. Tactics GPs.
Indications for referral to a specialist or hospital in the profile department. Treatment, followup, monitoring and rehabilitation in rural health units or family policlinics. Principles of
prevention. Principles of teaching topics. " Total hours - 6.7
Justification of the theme:The majority of patients with diseases that are accompanied by a feverish
syndrome formed medical attention.In this situation, the force of a general practitioner (GP) is directed
to the diagnosis of diseases,of transmitting the fever syndrome caused by various diseases. In the case
of diagnosis of fever of GPs have to solve the problem of defining a group of patients to be treated in a
conventional RHU or family policlinics, or referral to specialized hospitals.
The aim of teaching:Getting GPs on timely diagnosis and differential diagnosis in febrile syndrome
caused by various diseases, as well as the principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
181
 Teach GP-diagnosis of diseases associated with febrile syndrome, especially clinical flow
depending on the etiology.
 Educate GPs provide differentiated treatment of diseases associated with fever syndrome (choice
of drug, dose, route of administration, duration, combinations, side effects).
 Familiarize GPs with a choice of treatment options for patients with febrile syndrome in FCP (FP)
or hospitals.
 Discuss the principles of management, supervision and monitoring of patients in rural health units
or a family policlinics.
 Discuss the principles of primary, secondary and tertiary prevention.
Anticipated results.
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies fever, caused by different diseases, to establish a preliminary
diagnosis.
GPs should know:
1.
Clinical manifestations of diseases associated with a feverish syndrome, features of the
flow, depending on the etiology.
2. Differential diagnosis of diseases accompanied by feverish syndrome.
3.
Treatment of various types of diseases associated with febrile syndrome.
4.
The principles of treatment (medication and non-medication).
5.
Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
6.
The principles of primary, secondary and tertiary prevention.
GPs should be able to:
 Data analysis and history of complaints for the diagnosis of fever
 Diagnose, to differentiate on clinical and laboratory instrumentation illnesses with fever.
 Choose the right medications for specific diseases involving fever.
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Conduct a survey of patients with diseases that are accompanied by fever syndrome.
 Establish diagnosis and differential diagnosis of diseases involving fever syndrome.
 Interpret the test results, the data of laboratory-instrumental studies in patients with diseases
associated with febrile syndrome.
 Prescribe medication and perform clinical examination of patients with diseases that are
accompanied by a feverish syndrome caused by various etiological factors.
 See the list of diseases associated with febrile syndrome and be further examination and / or
treatment in specialized units.
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with diseases associated with fever
2. Interpretation of analyzes of laboratory and instrumental studies, X-rays of patients with diseases
that are accompanied by fever syndrome.
3. Billing drugs depending on the etiology of fever.
Place of activity:
182
1. Training themed room.
2. GP office
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Fever of unknown
genesis. Diseases that can occur as a fever of unknown origin character, types of fevers,
survey plan for fever. Tactics GPs. Indications for referral to a specialist or hospitalization
in specialized department. The principles of treatment, follow-up, monitoring and
rehabilitation in RHU or family policlinics. Types prevention.Principles of Teaching "
2. Decision analysis and situational problems.
3. Supervision of patients with uric acid diathesis and cystitis
4. Clinical analysis of supervised patients.
5. Role-playing game to assess knowledge on training.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students using the 'Tour
of Gallery. "A decision
on a task on the
subject and roleplaying.
183
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class, a
folder with ECG,
laboratory and
instrumental data
research, case
studies.
At the lesson you need to consider that hyperthermia - a pathological condition in which the
heat production exceeds heat dissipation.
The main causes of fever in outpatients:
- Acute viral infection;
- Acute bacterial infections;
- Exacerbation of chronic bacterial infections;
- Hypersensitivity reactions (drugs, vaccines, foods, etc.);
- Metabolic abnormalities (hyperuricemia);
- Clinical debut (relapse) tumors;
- Clinical onset (acute) systemic vasculitis.
There is a group of disorders that occur with high fever.
1.Bacterial infections: pneumococcal (pneumonia, empyema, pericarditis), meningococcal,
streptococci (erysipelas, otitis, tonsillitis, scarlet fever, endocarditis), staphylococcal (furunculosis,
osteomyelitis), septicemia, diphtheria, typhoid fever, paratyphoid fever, Salmonella enteritis ,
dysentery, miliary tuberculosis.
2. Viral infection: influenza, adenovirus infection, measles, rubella, mumps, infectious mononukleoz,
chicken pox, psittacosis, poliomyelitis.
3. Rickettsiosis: typhus, Q fever, quintan.
4. Epizootic diseases and parasitic diseases: brucellosis, leptospirosis, trichinosis.
5. Protozoal diseases: malaria, toxoplasmosis.
6. Rheumatic diseases: rheumatism, systemic lupus erythematosus, Still's syndrome, gout, Reiter's
disease.
7. Tumors: Hodgkin, hypernephroma, increased myeloid leukemia.
8. Other diseases: periodic disease, drug disease.
Disease occurring with subfebrile temperature.
1.Infectious-toxic fever - focal infection (otitis media, sinusitis, sinusitis, toothache, tonsillitis),
bronchiectasis, digestive diseases (chronic cholecystitis, cholangitis, appendicitis, enteritis), diseases of
the genitourinary system (chronic pyelonephritis, adnexitis, prostatitis , uterine fibroids), purulent foci
(postinfection abscesses, osteomyelitis, paranephritis, abscess, liver abscess, etc.), bacterial
endocarditis, brucellosis, infectious mononucleosis, typhus, paratyphoid disease, syphilis, herpes.
2. Toxic and immunological fever - rheumatism, non-reumatic fever, asthma, chronic urticaria, drug
disease, systemic sclerosis, nodular periarteriitis, nonspecific aortoarteriitis, dermatomyositis,
postinfarction syndrome, parasitosis (giardiasis, amoebiasis, ascariasis).
3. Subfebrile tumor - clear-cell carcinoma, hepatoma, lung, stomach, pancreas, hematological
malignancies.
4. Subfebrile neuroendocrine origin - cardiopsychoneurosis, hypothalamic syndrome, thyrotoxicosis,
pathological menopause, hypercortisolism, premenstrual syndrome.
5.Other conditions that occur with low-grade fever - sarcoidosis, iron deficiency anemia, thrombosis,
thrombo-embolia small branches of the pulmonary artery, the resorptive fever, pneumonia, myocardial
infarction, hypertension in tissue, constitutional low-grade fever.
Types of fevers.
Some diseases have very characteristic temperature curves, so the type of temperature curve is
very important for diagnosis.
Intermittent fever is characterized by daily fluctuations in temperature over 10 C, and of the
minimal daily temperature is below 370C. Intermittent fever is observed in malaria. When four-day
Malaria (pathogen Rlasmodium malariae) temperature increase every 72 hours (every fourth day,
including the day preceding the attack), the three-day malaria (pathogen Plasmodium vivax) fever
occurs every 48 hours (every third day, including the day preceding the attack) .Intermittent fever also
observed in cytomegalovirus infection, infectious mononucleosis, and purulent infection, such as
ascending cholangitis.
184
For remitting fever characterized by daily fluctuations in temperature over 100C, the minimum daily
temperature is above 370C. This type of fever observed in purulent infections, such as pelvic abscess,
empyema of the gall bladder, wound infection and malignancy.
At constant undulating fever or remittent fever for several days alternating with periods of normal
temperature, and the temperature decreases gradually. Undulating fever discussed chronic brucellosis
and chlamydia.
At a constant temperature of fever increased during the day, its fluctuations do not exceed 10°C. This
type of fever is usually seen in viral infections, such as influenza.
Relapsing fever at high temperature comes with periods of normal temperature, several days. Fever
begins suddenly and just as suddenly terminates.This type of typhus fever is typical returnable.
Draining, or hectic, fever resembles aperient (relapsing), but daily fluctuations in temperature
with her is 4 - 50C. This type of fever can occur in tuberculosis, sepsis.
Perverted fever. It is characterized by a higher temperature morning. This type of fever is
common in patients with tuberculosis, sepsis, with processes, etc.
Incorrect fever is characterized by moderate to high fever with different daily fluctuations,
without any regularity.This type of fever may at meningitis, flu and other diseases.
Laboratory tests.
Major studies: complete blood count (hemoglobin, color index, leukocyte count, ESR),
urinalysis (general analysis and culture), biochemical blood analysis, blood cultures, chest radiograph
and paranasal sinuses, stool microscopy and culture - Study sputum (if any), and special studies for the
diagnosis of typhoid fever, infectious mononucleosis, Q fever, brucellosis, psittacosis,
cytomegalovirus, toxoplasmosis, and syphilis blood test for antibodies to HIV, the identification of
immune disorders (rheumatism, systemic lupus erythematosus), tuberculin. Sample; radiocontrast
study gastrointestinal tract ultrasound - find tumors and abscesses, research gall bladder, isotopic
studies, puncture and aspiration of the bulk of education material for cytological examination,
laparoscopy (a suspected pelvic abscess), biopsy, such as lymph nodes, skin, , liver, bone marrow
histology.
Physical examination.
History and examination should be carried out once, because not all symptoms occur
simultaneously. Particular attention should be paid to: inspection of the skin (hives); inspection and
palpation of the superficial temporal artery, inspection and palpation of the projection of the paranasal
sinuses, oral examination of the teeth (periodontitis), auscultation of the heart (heart sounds,
pericardial rub) examination of the respiratory (symptoms of hardening of the lung tissue, pleural
effusion), inspection and palpation of the abdomen (increase and tenderness of the liver, spleen,
kidney), rectal and vaginal examinations, palpation of lymph nodes, especially the supraclavicular and
studies leg veins (thrombosis).
Fever of unknown origin.About a fever of unknown origin say when: fever for more than 3
weeks, the temperature above 380 C, the cause remains unknown whether fever after a thorough
examination at the hospital for a week.With fever of unknown origin in the first to suspect not some
exotic disease, and spread the word, but are often atypical, (tuberculosis, infectious endocarditis, a
disease of the liver and biliary tract, lung cancer, Hodgkin's disease, hypernephroma).For the diagnosis
of important information about medical history, occupational hazards (including with chile work with
animals), travel.The presence of fever, rash and character can be decisive in diagnostics. In adults,
fever of unknown origin can accompany following illness.
Infection (40%):
1. bacterial,
2. viral and chlamydial infection, rickettsiosis, infectious mononucleosis, cytomegalovirus infection,
HIV infection, Q fever, psittacosis;
3. protozoal infections (malaria, toxoplasmosis, amebiasis).
Cancers (30%):
Immune diseases (20%):
Simulation (1 - 3%).
185
Cause of fever is unknown (5 - 9%).
When deciding on the cause of fever general practitioner should first verify that the patient or
infection, or systemic disease relatively tissue or tumor.All febrile patients with an unclear diagnosis to
exclude typhus, paratyphoid diseases and malaria tests were performed blood on blood culture, put
Widal reaction, CFT, malaria (thick film), antibodies to HIV, spend radiographof the chest and do an
electrocardiogram. Be aware of the opportunities for the development of tuberculosis in the prevalence
of the disease.The patients underwent radiography and tomography of the lungs, tuberculin skin tests,
sputum smears from bronchial lavage or gastric contents, crops in Mycobacterium tuberculosis.
Infected vascular grafts or aneurysms can also cause fever. In the diagnosis of fevers
important epidemiological history, consider the clinical course of the disease, using special methods.
To exclude the diffuse connective tissue diseases studied blood for rheumatoid factor, cells, antibodies
to DNA, immunoglobulins. If necessary, the skin and muscle biopsy.
In order to prevent cancer used endoscopic, radiological and ultrasonographic methods for
studying the chest and abdomen.
It should be remembered that any modern diagnostic technique may give false-positive and
false-negative results.So there is diagnostic methods that could replace the full clinical examination of
the patient, physician intuition and rational approach to the diagnosis.
Handout:
Students distributed lists containing the names of topics, definitions fevers, peculiarities of their
course. The following are the test questions and references.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Tables: clinical manifestations in fevers
Independent work and self-education.
Topic: "Fever of unknown origin. Nature, types of fevers, survey design for fever. GPs tactics. "
Number of hours - 1 hour.
1. Independent work with literature in the library, at home, the repetition of earlier mvany.
2. Prepare and deliver a presentation on the topic at the morning sessionof the conference on
clinical department.
3. Mastering the interpretation of laboratory and instrumental studies in kidney disease,
occurringing febrile syndrome.
Teaching practice during the lesson.
Supervision of patients with fever
The number of hours is 1 hour.
Quiz
1. Etiopathogenic causes of the onset of fever
2. Types of fevers
3. Differential diagnosis of fevers
4. Clinical management of patients with febrile syndrome in a rural health units, or family
policlinics.
Practice session № 4
Topic: "The differential diagnosis of fever in infectious diseases (bacterial, virusones). GPs
tactics depending on the disease. Indications for referral to a specialist or hospital in the profile
department. The principles of treatment, follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of prevention. Principles of teaching topics. "Number of hours - 6.7
186
JustificationTopics: The majority of patients with diseases that are accompanied by a feverish
syndrome for medical attention. In this situation, the force of a general practitioner (GP) is directed to
the diagnosis of diseases,of transmitting the fever syndrome caused by various diseases. In the case of
diagnosis of fever of GPs have to solve the problem of defining a group of patients to be treated in a
conventional in RHU or family policlinics, or referral to specialized hospitals.
The aim of teaching: Getting GPs issues and timely diagnosis and differential diagnosis of infectious
diseases (bacterial, viral) and the principles of management of patients in primary care, provided the
requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Teach GPs - diagnosis of diseases associated with febrile syndrome, clinical features,
depending on the etiology.
2. Educate GPs provide differentiated treatment of diseases associated with febrile syndrome
(choice of drug, dose, route of administration, duration, combinations, side effects).
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in a rural health
units or a family policlinics.
6. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
GPs should know:
1. Clinical manifestations of diseases associated with a feverish syndrome, features of the flow,
depending on the etiology.
2. Differential diagnosis of diseases involving feverish syndrome.
3. Treatment of various types of diseases associated with febrile syndrome (choice of drug, dose,
route of administration, duration, combinations, side effects).
4. The principles of treatment (drug and non-drug) under the given conditions (choice of drug,
dose, route of administration, duration, combinations, side effects).
5. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
6. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
1. Diagnose, differentiated by the clinic to laboratory and instrumental studies diseases associated
with febrile syndrome.
2. Choose the right medications in cases involving a feverish syndrome, depending on the
etiology and stage of disease.
3. Choose products with proven efficacy
4. Advise on non-medicated treatments.
5. To monitor the RHU or in family policlinics.
GPs should do:
1. Data analysis and history of complaints for the diagnosis of diseases associated with febrile
syndrome.
2. Conduct a survey of patients with diseases that are accompanied by fever syndrome.
3. Establish diagnosis and differential diagnosis of diseases involving fever syndrome.
4. Interpret test results, laboratory data and instrumental studies in patients with diseases
associated with febrile syndrome.
5. Prescribe medication and perform clinical examination of patients with diseases that are
accompanied by a feverish syndrome caused by various etiological factors, the list of which
is included in the first category of additional services "Qualification characteristics of GPs."
187
6. See the list of diseases associated with febrile syndrome and be further examination and / or
treatment in specialized units.
The list of skills that GPs should possess after completing studies on the subject
 Conduct a survey of patients with diseases associated with fever
 Interpretation of analyzes of laboratory and instrumental studies, X-rays of patients with
diseases that are accompanied by fever syndrome.
 Billing drugs depending on the etiology of fever.
Place of activity:
 Training themed room.
 Cabinet GPs.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Differential diagnosis
famouslyRadka in infectious diseases (bacterial, viral). GPs tactics depending on diseases.
Indications for referral to a specialist or hospital in the profile department. The principles of
treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics. Prevention.
Principles of Teaching"
2. Decision analysis and situational problems.
3. Supervision of patients with uric acid diathesis and cystitis
4. Clinical analysis of supervised patients.
5. Role-playing game to assess knowledge on training.
Contents classes
Time
8.309.30
9.3010.30
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
Lesson
time
Morning
Report on subordinators examined by Hospital records of 1 hour
conference.
patients in the clinic and the patients
challenges at home.
Admission
Each student is receiving patients The
patient, 1 hour
outpatients
with GPs, followed by a discussion phonendoscopes,
under control of patients examined in the audience. tonometer.Clinical
of
the
and
Laboratory
teacher.
data,
hospital
records of patients.
Service calls Examination of patients at home, The
patient, 1 hour
at home.
medical
history,
a
complete phonendoscopes,
inspection of the patient, data tonometer.Clinical
analysis
and
laboratory
and and
Laboratory
instrumental studies, and preliminary data,
hospital
study of a definitive clinical records of patients
diagnosis.Defining the further tactics.
Break.
Events
Content
Study skills.
Student under the supervision of a
teacher must complete a minimum of
two skills.
Theoretical
Checking the initial level of
analysis of preparedness of students using the
188
Materials
Patient
volunteer.
or 20 minutes
Table,
corresponding to a
80 minutes
the topic.
'Tour of Gallery. "A decision on a
task on the subject and role-playing.
subject class, based
on laboratory and
instrumental
studies, case
studies.
Atypical mycobacterial infection- a complex granulomatous lesions caused by mycobacteria that
are different from the classical pathogens - agents of tuberculosis and leprosy.
Most pathogens prevalent in the environment, somerye live in water and coastal zone, causing
disease in fish and other birds.The most common infection occurs by inhalation of bacilli, the use of
contaminated products and penetration agent by microtrauma through the skin and mucous
membranes.
The clinical picture.
Tuberculous-like defeat. In the pathological process involved the lungs, kidneys, skin
and bones and joints. Emphysematous often complicate the process. In 40-50% of patients with
Immunodeficiency state cause generalized lesions.
Lymphadenitis.Often manifested clinically lesions of the cervical lymph nodes (called
skrofuly), the latter are painless, may ulcerate or drained out; systemic manifestations often
weak or absent.
Skin lesions.Consider typical wound infections course, getting on impact with the wall
babasin or any object on the bottom and banks of the pond. Often ulcerating granuloma
formation observed spontaneously restrict, within a few weeks, more rarely formed chronic
infection.
Less likely to have chronic pulmonary lesions in middle-age, registered to date
bathrooms everywhere. Perhaps elbow bursitis joint repeated injuries and skin lesions, target
limphadenitis and carpal tunnel syndrome in patients with immune deficiencies (most often
after therapy hormones).
Methods of the research. Isolation and identification of the pathogen growth rate, the formation of
pigments (in the light or in the dark) and pathogenicity laboratory animals.
Syphilis.
Syphilis - infectious disease caused by Treponema pallidum, transmitted primarily through sexual
contact with a chronic relapsing course and the characteristic frequency of clinical symptoms that can
affect all organs and systems.
Tertiary develops in about 40% of patients, the disease is 3-4 and continues indefinitely. The
distinctive features of the Tertiary period - the emergence of false inflammatory infiltrates inideal
knobs and gum, are prone to collapse and subsequent extensive destructive changes affected organs
and tissues, productive inflammation and infectious granuloma formation, a small amount of
precipitation (in the tens of tubercles, gum - units) ; ubiquity defeats, undulating course.
In clinical manifestations diagnosed active tertiary syphilis, in the absence thereof - Tertiary latent
syphilis.
Relapses tertiary lesions observed infrequently, they are separated from each other by a long latent
period. Tenure of tertiary syphilides calculus with months or years, they are characterized by low
infectiousness of a small number of pale breaking in tissues.The most commonly affected skin, mucosa
and bone system. Skin lesions are syphilides and gummy.
Papulose syphilide - small dense mound, located in the skin, every example of hemispherical shape
with a cherry stone, bluish red. After a few weeks or months mound softened and ulcerated rounded
education rather deep ulcer, with smooth, steep tight margins. Gradually epithelialized ulcer and
becomes a segmented atrophic scar on the periphery, where once no new lesions.
Gummy syphilide (Gunma) - node dense texture size of a walnut, rising above the level skin,
painless on palpation, not soldered to the surrounding tissues.The skin over it at first did not change
itseon, then become bluish red. Subsequently gummy assembly softens in the center and opened with
excretion of glue-like exudate. Promoter and cell defect rapidly increases in size and becomes an ulcer.
189
It is painless, clearly demarcated from the surrounding skin is not tight roller disintegrated gummy
infiltration edge of its steep, bottom is covered with necrotic masses.Gummatous ulcer months there,
and at the secondary and- even years.For healing gumma is characteristic stellate scar. In some cases,
sodarzhimoe gumma is replaced by fibrous tissue with the formationof dense formations
nodes.Gumma of the mucous membranes, frequent. Most often affects of the nasal cavityof the hull,
then the throat.Gummatous destruction of language, hard and soft palate, nose, pharynx, larynx cause
severe, often fatal disorders of speech, swallowing,and of stomach, change the appearance of the
patient (saddle nose, the complete destruction of the nose, perforation of the hard palate). Of gummy
other organs are more frequently observed syphilides periosteum, bones and joints, bone is affected
legs, arms, skull, knees, elbows and ankles.
Treatment - penicillin.
Among the various options for viral diarrhea are the most important clinical diarrhea rotavirus (the
most common form of infectious diarrhea in children), diarrhea, virus and adeno-and astroviruses.The
clinical picture of viral diarrhea noteworthy frequent combination, dyspeptic disorders, and often (with
rotavirus diarrhea) - and with the defeat of the upper respiratory tract.Confirm diagnosis when a virus
in stool by electron microscopy or during special immunological studies (eg, monoclonal antibodies).
Course of viral diarrhea is usually favorable.Disease duration does not exceed, as a ruleandlo, 3-5
days. Treatment is symptomatic and is to remove fluid and electrolyte disturbances.
Infection (40%):
1. Bacterial
2. Viral and chlamydial infection, rickettsiosis, infectious mononucleosis, cytomegalovirus
infection, HIV infection, Q fever, psittacosis,
3. Protozoal infections (malaria, toxoplasmosis, amebiasis).
Cancers (30%).
Immune diseases (20%).
Simulation (1 - 3%).
Cause of fever is unknown (5 - 9%).
When deciding on the cause of fever general practitioner should first verify that the patient or
infection, systemic disease or connectivetissue relatively, or neoplasm. All febrile patients with an
unclear diagnosis to exclude typhus, paratyphoid diseases and lowblood yarii examine blood cultures,
put Widal reaction, CFT, malaria (thick film), antibodies to HIV, spend radiographof the chest and do
an electrocardiogram. Be aware of the opportunities for the development of tuberculosis in the
prevalence of the disease.The patients underwent radiography and tomography of the lungs, to make
tuberculin test, sputum smears from bronchial lavage or gastric contents, crops in Mycobacterium
tuberculosis.
Infected vascular grafts or aneurysms can also cause fever. In the diagnosis of parasitary fevers
important epidemiological history, is taken into account the clinical course of the disease, using special
methods.
To exclude the diffuse connective tissue diseases studied blood for rheumatoid factor, cleftnight
cells, antibodies to DNA, immunoglobulins. If necessary, the skin and muscle biopsy. The presence
of clinical signs characteristic of hemeoblastosis, an indication for sternal puncture or trepanobiopsy
and study myeloprogram.Enlarged lymph nodes - the argument for their biopsy.
In order to prevent cancer used endoscopic, radiological and ultrasonographic methods for
studying the chest and abdomen.
Figure 2 shows the most common causes of fever of unknown origin.
It should be remembered that any modern diagnostic technique can produce false-positive and falsenegative results.
Fever may be accompanied by cardiovascular disease (cardiac aneurysm, thrombophlebitis), chest
infection (pneumonia, lung abscess and gangrene, bronchiectasis with suppuration, empyema).
Pulmonary tuberculosis (disseminated, focal, infiltrative) initially has symptoms similar to
pneumonia.
Disseminated tuberculosis may begin with a high fever, intoxication, and dyspnea.
190
Focal tuberculosis occurs in almost all primary TB patients.It occurs at a relatively satisfactory
state of health of patients with low-grade fever are observed.
Infiltrative tuberculosis is detected in approximately 30% of patients and is characterized by the
occurrence of peripheral inflammation locally around old tuberculous lesions. Appears fever maybe
hemoptysis.
Diagnosis: the importance of x-rays are in the dynamics.Sputum examination for the presence of
Mycobacterium tuberculosis.
Treatment: anti-TB drugs, isoniazid (tubazid) ftivazid, salyuzid, rifampin, ethionamide,
streptomycin, canamycin, viomitsin, Pasco, tibon. Treatment of newly diagnosed patients starts
withthe appointment of three component antibiotics (streptomycin +INH + PAS).
Handout:
Students distributed lists containing the names of topics, definitions fevers, peculiarities of their
course.The following are the test questions and references.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Tables: clinical manifestations in fevers
Independent work and self-education.
Topic:"Fever of unknown origin. Nature, types of fevers, survey design for fever. GPs tactics. "
1. Independent work with literature in the library, at home, the repetition of earlier.
2. Prepare and deliver a presentation on the topic at the morning sessionof the conference on
Clinical department.
3. Mastering the interpretation of laboratory and instrumental studies in kidney disease,
occurringing with febrile syndrome.
Teaching practice during the lesson.
 Supervision of patients with fever
 The number of hours is 1 hour.
Quiz




Peculiarities of fevers bacterial infections
Peculiarities of fevers in viral infections
Differential diagnosis with them
GP treatment and tactics in fevers of bacterial and viral
Practice session № 5
Topic: "The differential diagnosis of fever in rheumatic diseases and malignant neoplasms
transformations. Tactics of GP’s. Indications to direct a narrow specialists and hospitalization to
the profile department. The principles of treatment, control and rehabilitation in RHU or family
policlinics. Principles of prevention.Principles of teaching topics. "Number of hours - 6.7
Justification Thread: most patients with diseases accompanied by fever (in neoplasia, with relatively
diffuse connective tissue diseases and systemic vasculitis), seek medical attention. In this situation, the
force of a general practitioner (GP) directed the diagnosis of diseases associated with fever caused by
differences diseases.In the case of diagnosis of fever of GPs have to solve the problem of defining a
group of patients to be treated in a rural health units or a family policlinics, or direction,and
Speciacialized hospitals. These and other circumstances are the basis for the inclusion of this subject in
program for training GPs.
191
The aim of teaching: Getting GPs issues and timely diagnosis and differential diagnosis of rheumatic
diseases and malignant tumors, as well as the principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. Teach GPs - diagnosis of diseases associated with fever (in neoplasia, in diffuse connective
tissue diseases and systemic vasculitis), clinical features depending on the etiology.
2. Educate GPs provide differentiated treatment of diseases associated with fever (choice of
drug, dose, route of administration, duration, combinations, side effects).
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in rural
health units or a family policlinics.
6. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
GPs should know:
1.
Clinical manifestations of diseases associated with fever, especially the flow, depending
on the etiology.
2. Differential diagnosis of diseases involving fever.
3.
Treatment of various diseases associated with fever (choice of drug, dosage, route of
administration, duration, combinations, side effects).
GPs should be able to:
1. Diagnose, differentiated by the clinic to laboratory and instrumental study researches
illnesses with fever.
2. The principles of treatment (drug and non-drug) for the diseases.
3. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
4. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should do:
1. Data analysis of complaints and medical history for the diagnosis of diseases associated
with fever (in neoplasia, in diffuse connective tissue diseases and systemic vasculitis).
2. Conduct a survey of patients with diseases that are accompanied by fever.
3. Establish diagnosis and differential diagnosis of diseases involving fever.
4. Interpret the test results, the data of laboratory-instrumental studies in patients with diseases
associated with fever.
5. Prescribe medication and perform clinical examination of patients with diseases associated
with fever caused by various etiological factors, the list of which is included in the first
category of additional services "Qualification characteristics of GPs."
6. See the list of diseases associated with fever and be further examination and / or treatment
in specialized units.
The list of skills that GPs should possess after completing studies on the subject
1.
Conduct a survey of patients with diseases accompanied by fever.
2. Interpretation of analyzes of laboratory and instrumental studies, X-rays of patients with
diseases accompanied by fever.
3.
Billing drugs depending on the etiology of fever.
Place of activity:
1. Training themed room.
2. Cabinet GPs.
192
The structure of the lessons:
1. Clarification of diagnosis and differential. diagnosis, accompanied by fever.
2. Supervision of patients with diseases accompanied by fever.
3. Clinical analysis of supervised patients.
4. Role-playing, case studies to assess the level of knowledge on the subject.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students using the 'Tour
of Gallery. "A decision
on a task on the
subject and roleplaying.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and instrumental
studies, case studies.
Fever in neoplasia. Many tumors (especially lymphoma, Hodgkin's disease, nephrocarcinoma,
tumors of the colon, lung, liver, pancreas, etc.) accompanied by fever of various types. It can
outperform symptoms tumors dominate or at some time be the only sign. Fever often associated with
other paraneoplastic masks (with rheumatic, hematologic, npathological, clinical manifestations of
which are reduced or disappear against steroid and non-steroid anti-inflammatory drugs). In many
cases, the cause is joined infection, such as pneumonia, lung cancer. Fever can occur under the
influence of the tumor itself, because they believe that it highlights the pyrogenic substances that act
on the centers termoregulation and cause fever.
193
Fever in malignant tumors is subfebrile, intermittent, wavy orthe right type may be accompanied
by chills.In some patients, the maximum temperature risein the morning. Characterized by fever,
antibiotic resistance, and vice versa, on the background of corticosteroids or NSAIDs fever, like other
paraneoplastic mask may reduce or even temporarily and disappears.In patients with tumors observed
moderate anemia, increased erythrocyte sedimentation rate and of alpha2-globulins.When hepatoma
and hypernephroma possible polycythemia. Pancreatic cancer is often accompanied by recurrent
thrombophlebitis.
On the possibility of a tumor in a patient nature fever should think Where uncertainty exists,
clinical manifestations, especially in the elderly, when observed during treatment with unexplained
deterioration of general condition, growing weakness, loss of weight, measure progresstion laboratory
parameters.These patients are subject to a thorough and comprehensive examination to find out the
causes of febrile syndrome and eliminate the possibility of cancer.In order to avoid malignant tumors
used endoscopic, radiological and ultrasonographic methods of investigatingthe chest and abdomen.It
should be remembered that any tell liesntion diagnostic technique may give false-positive and falsenegative results.So there is no diagnostic tests that can be replaced with clay full clinical examination
of the patient, physician intuition and rational approach to the diagnosis.
Immune disease systemic lupus erythematosus, rheumatoid arthritis, rheumatism vasculitis often
accompanied by fever.
In rheumatic diseases, except febrile reaction is usually revealed by expression of the internal
organs. Observed systematic process. And more frequent the pathological changes found in the joints,
heart, lungs, and kidneys. In rheumatoid arthritis, in contrast to bacterial endocarditis, never shivering,
Otsutstvuet also toxic granularity of neutrophils.
Fever - a common manifestation of systemic lupus erythematosus. The maximum temperature rise
with walks in the daytime. In adults, persistent or intermittent fever (sometimes up to 400C),
accompanied by severe general condition of the patient and weight lossraw body, characteristic of
Still's syndrome. In addition to disease onset moderate articular changes may recede into the
background. If you suspect a syndrome in adult Still's necessary to pay attention to the possibility of
pleurisy and / or pneumonitis, pericarditis and / or myocarditis, hoarseness, hepatolienal syndrome,
lymphadenopathy, anemia, which are also small diagnostic criteria for the disease.
Attacks of two-and three-week fever may accompany Felty's syndrome and Reiter's disease. Body
temperature in patients with autoimmune fevers rapidly decreases after NSAIDs. Especially effective
corticosteroid hormones. Fever is usually docked small doses of corticosteroids, although the visceral
manifestations of the disease can persist. If the intake of 20 mg per day prednizolona body temperature
is not reduced, it should be immune to doubt the origin of the fever.
Vasculitis is a group of allergic diseases, mainly affecting the blood vessels.
Temporal arteritis - (giant cell arteritis) - a systemic disease characterized by granulomatous
inflammation of the tunica vessels, mainly basin sleeparteries (temporal, cranial, and others) elderly.
Disease begins acutely, high fever.
Nodosa periateriitis - systemic vasculitis necroziting, the type of lesion with segmental arteries
aneurysmatic bulging muscle of type and a smaller caliber. Mostly men aged 30 - 40 years. The
disease begins with acute or gradual increase in body temperature, fast growing potyeri body weight,
skin rashes, symptoms of heart disease, kidney disease, gastro - intestinal tract, or peripheral nervous
system.
Thromboangiitis obliterans - a systemic inflammatory vascular disease with the primary arteries of
muscular type, and the veins. Mostly men aged 30-45 years. Disease beginning with the appearance of
thrombophlebitis, a feeling of heaviness in the calf muscles, intermittent claudication, pain in the
finiteness, are slow, and later disappearance of pulsation on the arteries of the lower extremities.
Sometimes disease system acquires the character of the process with the involvement of a coronary,
cerebral is characterized by low-grade fever, increased inflammatory activity.
Takayasu's arteritis (aortoarteritis) - a systemic disease characterizedby inflammation of the aorta
and forming the radiating branches with the development of partial or total obliteration.The main
symptom is the absence of pulse on one or both arms, at least on the carotid, subclavian, the temporal
194
arteries. Common symptoms of the disease,and low-grade fever and fatiguezation. Diagnostics arteriography.
Wegener's granulomatosis - giant cell granulomatous vasculitis-necrosing cue mainly affecting
the respiratory tract, lungs and kidneys. Increasingly common in men. Mucosal biopsies
nazopharengeal area reveals granulomatous character pathology.
Handout:
Students distributed lists containing the names of topics, definitions pyelonephritis, especially
their flow. The following are the test questions and references.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Table: Clinical manifestations of pyelonephritis
Independent work and self-education.
Subject: Definition, etiology, pathogenesis fevers (Field work).
1. Independent work with literature in the library, at home, the repetition of earlier mvany.
2. Prepare and deliver a presentation on the topic at the morning session of the conference on
clinical department.
3. Mastering the interpretation of laboratory and instrumental studies in kidney disease,
occurringing with nephrotic syndrome.
Teaching practice during the lesson.
Supervision of patients with fevers.
The number of hours is 1 hour.
Quiz
 Peculiarities of fever in rheumatic diseases
 Differential diagnosis of fever in rheumatic diseases
 Peculiarities of fevers with malignant diseases
 Differential diagnosis of fever in malignant diseases
 The tactics of the GPs in fever genesis
REFERENCE:
MAIN
1) Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2) Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3) Ички касалликлар, Камолов Н.Н., 1991
4) Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
5) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
ADDITIONAL
Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С., 2010. Т.
Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
8) Диагностика болезней внутренних органов. Окороков А.Н. 2005.
9) Лечение болезней внутренних органов. Окороков А.Н. 2005.
1)
2)
3)
4)
5)
6)
7)
195
10) Дифференциальный диагноз внутренних болезней. Виноградов А.В. М.: Медицинское
информационное агенство, 2009.
11) Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005:
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/cgibin/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
Med.-site.narod.ru
www.medlook.ru
www.medbok.ru
www.medicum.ru
www.medtext.ru
www.medkniga.ru
196
NEPHROLOGY
CONTENT THAT CASE STUDIES
№
Topic name practice session
1
Dysuria. Differential diagnosis of urine acid diathesis and cystitis.Tactics
GPs. Indications for referral to a specialist or hospitalization of the profiled
department.The principles of treatment, observations, control and
rehabilitation in RHU or family policlinics. Principles of
prevention.Principles of topics.
Topics for independent work:
Etiology, pathogenesis, clinical signs, diagnosis, criteria for activity.
Practical skills:
Interpretation of tests, ECG, renal ultrasound, radiography of the kidneys.
2
3
The references
Dysuria. The differential diagnosis of acute and chronic pyelonephritis.
Tactics GPs. Indications for referral to a narrow cecare professional or
hospitalization profile department.Treatment principles, follow-up,
monitoring and rehabilitation in rural health units or family policlinics.
Principles of prevention.Principles of Teaching the topic
Topics for independent work:
Laboratory Methods urine on a daily proteinuria, Nechiporenko sample,
sample Addis-Kakovskogo. Normal analysis meyes.
Practical skills:
Interpretation of urine tests, X-rays, ultrasound of the kidneys, with the
above mentioned diseases.
"Changes in urinary sediment. Differential diagnosis of nephrotic
syndrome. Tactics GPs. Indications for referral to a specialist.The principles
of treatment, outpatient observed, control and rehabilitation in RHU or
family policlinics. Principles of prevention.Principles of Tools "
Topics for independent work:
Laboratory Methods Urine: urinalysis, urine on a daily proteinuria, the
etiology and pathogenesis of nephrotic syndrome
Practical skills:
Interpretation of urine tests, X-rays, ultrasound of the kidneys, with the
above mentioned diseases.
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS WITH DYSURIA
Purpose: 6-7 courses teach students syndromal addressing patients with dysuria, as well as the
principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:



Train students in solving the problems associated with dysuria.
Giving students a timely diagnosis in the presence of symptoms associated with dysuria.
To teach students to differentiate the disease, accompanied with dysuria.
197

Improve the knowledge, skills, and practical skills in solving problems of patients with
dysuria (information gathering, problem identification and physical examination, as well as the
ability to reasonably assign laboratory and instrumental methods of investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHUs and FP;
What the student needs to know to solve the problems of patients with dysuria:
The list of knowledge
The list of diseases that occur with dysuria
A list of the most dangerous diseases that present with
dysuria
The list of states that require management in FCP (1
category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in FCP (3.1-category)
The list of research areas requiring outside RHU (3.2category)
Dysuria
Key points (criteria) diagnosis, occurring with dysuria
Symptoms of internal organs
Signs of nephrotic syndrome
Indicators of laboratory and instrumental methods of
investigation
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with dysuria in a
rural health units or OP (4-category)
198
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
the student should know:
- What does pallokiuriya?
- What does the strangury?
- What does nocturia?
- What is enuresis?
- What does oligouriya?
- What is polyuria?
- What is anuria?
- What does nocturia?
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student should know the
symptoms of defeat
The student must list the major
manifestations
the student should know:
- Performance standards
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with dysuria:
№
List of skills
Basic level

Student should be able to ask questions of
rational concise questions that really helps to set the
probable diagnosis.
 The student must be able to specifically identify
and assess the patient's complaints.

The student must be able to analyze medical
Ask the patient and his relatives
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics
of their development.
 The student must be able to analyze life history:
the identification of risk factors, the health of parents
and family members.
The student must be able to identify unmanaged and
Identify risk factors
uncontrolled risk factors as on questioning patient,
based on an objective approach
Measure blood pressure.
Student should be able to hold tonometry with the
incremental principle.
The student must be able to detect the presence of:
- Pale
An inspection of the skin
- Cyanosis,
-The presence of rash
- Seal
The student must be able to detect:
Explore the pulse of the carotid, radial
- The presence or absence of a pulse
and femoral arteries
The student must be able to evaluate the properties of
the radial artery.
The student must be able to assess:
- A tour of the chest
Conduct palpation, percussion and - Voice trembling
auscultation of breath.
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
Conduct palpation, percussion and - If the heart murmur, be able to identify their
auscultation of heart and vascular system. epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
Student should be able to conduct surface and deep
palpation of the abdomen
An inspection, palpation, percussion, The student must be able to identify features:
belly
- Hepatomegaly,
-Splenomegaly.
The student must be able to assess:
199
- All available structures in the abdomen
the student should be able to:
Conduct percussion and palpation of the
- Test for tapping the lumbar region
kidneys.
- Palpation to evaluate the properties of the kidneys
Conduct auscultation over the renal The student must be able to detect the presence of:
arteries
-Systolic murmur.
The student should see the limbs and body, and to be
able to detect:
- Local or generalized edema. Fingers should be able
to put pressure on the dorsum of the foot and
Inspect the limb
Detectuzhit:
- There is a pit or not.
Should pay attention to the condition of the veins of
the lower limb
The student must be able to identify signs of spinal
Neurological examination
cord lesions.
The student must be able to identify features:
- Abnormal discharge from the urethra
An inspection of the penis and scrotum
- Balanitis
-Epididymitis
Student should be able to conduct rectal examination
with the incremental principle.
The student must be able to identify features:
Conduct a rectal examination
- Prostatitis
- Diffuse prostatic hyperplasia
- Prostate Cancer
The student must be able to identify features:
Calculate the index weight / body
- Underweight
- Increased weight.
Student should be able to hold ophthalmoscopy with
Hold ophthalmoscopy
the principle of step and examine the eye.
the student should be able to:
- To determine the protein in the urine
Uroscopy
- Interpret urinalysis
- Interpret the results of tests on Nechiporenko
- Interpret the results Zimnitsskogo
The student must be able to identify signs of shifts
Interpret the clinical and biochemical
from the norm
The student must be able to identify features:
Interpret the X-ray picture of light
- TB
- Abscess
Student should be able to carry out catheterization
Conduct catheterization.
including bladder
The student must be able to differentiate the disease
Differentiate disease accompanied with on the basis of the distinctive features (history,
dysuria
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
Give non-medical advice
- Advise on diet
- Advise on healthy living
200
Student should be able to help renal colic and acute
urinary retention.
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
Rational use of medicines in the
evaluate:
treatment of diseases that occur with
Effectiveness
dysuria
safety
- Eligibility
- Economy.
Conduct monitoring and surveillance of The student must list the principles of management
patients
and surveillance of diseases that occur with dysuria.
Provide prehospital care
Practical class № 1
Topic: "Dysuria. Differential diagnosis of urine acid diathesis. Tactics GPs. Indications for
referral to a specialist or hospital in the profile department. The principles of treatment,
observations, control and rehabilitation in RHU or family policlinics. Principles of
prevention.Principles of Teaching "- 6, 7 hours.
Justification topic: Inflammatory diseases of the kidneys and urinary bladder are often encountered in
the practice of primary care.In this situation, the force of a general practitioner (GP) is directed to the
diagnostician and these diseases. In the case of diagnosis of these diseases GP will decide the question
of definite of groups of patients to be treated in the FCP (FP), or referral to a specialized hospital.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis of optimal variant treatment strategy for
inflammatory diseases of the kidneys and bladder, due to various reasons and the principles of
management of patients in primary care, provided the requirements of "Qualification characteristics of
a general practitioner"
Learning objectives:
1. Consider diagnosis of cystitis and urine acid diathesis
2. Demonstrate patients with uric acid diathesis and cystitis
3. Discuss the results of clinical, laboratory and instrumental studies at urate diathesis and
cystitis.
4. Make a differential diagnosis of urine acid diathesis and cysts.
5. Discuss questions about tactics in the qualifying characteristics of GPs
6. Discuss the principles of treatment (non-drug and drug).
7. Discuss the principles of management, supervision and monitoring of patients in a rural
health units or a family policlinics.
8. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Expected results
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies of kidney disease and bladder establish a preliminary diagnosis
and determine the future tactics of the patient.
GPs should know:
1. The mechanism of urine acid diathesis and cystitis
2. Clinical manifestations of disease: urate diathesis and cystitis
3. Diagnosis of diseases: urate diathesis and cystitis
201
4. Differential diagnosis of these diseases:
5. The principles of treatment (drug and non-drug) for the diseases.
6. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
7. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Data analysis and history of complaints for the diagnosis of cystitis and urine acid diathesis
 Diagnose, to differentiate on clinical, laboratory and instrumental data of the disease.
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Competently carry out inspection of the patient with uric acid diathesis and cystitis
 To fill out the medical history of the patient
 Assign the required survey plan with non-inflammatory and inflammatory diseases of the
kidneys and bladder.
 Interpret the results of laboratory and instrumental these diseases.
 Prescribe treatment for kidney and bladder due to various reasons.
The list of skills that GPs should possess after completing studies on the subject
Examination of patients with non-inflammatory and inflammatory kidney diseases.
The interpretation of laboratory and instrumental data of diseases: cystitis and urine acid diathesis
Place of activity:
 Training themed room.
 Supervision in the clinic.
The course is taught.
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "Dysuria. Differential
diagnostic and urine acid diathesis and cysts.Tactics GPs. Principles of Treatment, monitoring,
control and rehabilitation in RHU or family policlinics. Principles of prevention.Principles of
Teaching"
 Decision analysis and situational problems.
 Supervision of patients with uric acid diathesis and cystitis
 Clinical analysis of supervised patients.
 Role-playing game to assess knowledge on training.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
202
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
10.3011.30.
11.3012.15.
12.2012.40.
12.4014.00
examined
in
the
audience.
Service calls at Examination of patients
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
Break.
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer. Clinical
and Laboratory data,
hospital records of
patients
Study skills.
Patient or volunteer.
Student
under
the
supervision of a teacher
must
complete
a
minimum of two skills.
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students using the 'Tour
of Gallery. "A decision
on a task on the
subject and roleplaying.
20 minutes
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and instrumental
studies, case studies.
On practical training in the theoretical part series includes:
Urine acid diathesis, disease and occur when exchanging nucleoprotein, characterized by
elevated levels of uric acid and its salts in the blood, followed by deposition of uric acid crystals and
amorphous sodium urate.
The mechanism of formation of stones in the urinary tract is not fully understood, but it is known that
the main role belongs to the body of a man who for some reason can not cope with the "purification",
"removal", "solutionof rhenium."These reasons are not fully defined. However, we know that a lack of
magnesium in the organizationzme promotes the formation of stones in the urinary tract, and colloidal
polysaccharides found in abundance, do not allow to join salts (rocks). Most scholars tend to attribute
the cause to the tubulo-and fermentopathy. When initial treatment should know which of the "stones"
have a place in this patient. This is a complex issue diagnostic, but decides on the analysis of urine and
ultrasound. The most frequent oxalate (56%), then - urate (19%), at least - phosphate (8%), others mixed (17%).
Urine acid diathesis (neuro-arthritic).At the heart - a violation of the protein (purine
metabolism) + drug in solution of carbohydrate + lipid. Inherited by type fermentopathy. Critical age school. Syndrome: neurasthenic, skin (urticaria, angioedema, dry seborrheic dermatitis, atopic
dermatitis). Syndrome exchange (or padagrichesky padagra: arthralgia, pain), spastic syndrome
(constipation, sheep feces, vomiting, paroxysmal abdominal pain, dyskinesia, functional diseases of
the stomach.
Diagnosis: acetone in the urine, blood: elevated hemoglobin, hematocrit, chloropenia, hypoglycemia,
the development of metabolicacidosis or alkolosa, uric acid is> 268 umol / l.
Treatment: During the attacks - elimination diet (no protein, alkaline water and enemas, Luminal,
bromine, cocarboxylase, vitamin C, Riboxin, Essentiale, splenin, enzymes), detoxification therapy,
phytotherapy.
203
Cystitis (cystitis; Greek. Kystis bladder +-itis) - inflammation of the bladder wall, one of the
most common urologic diseases.
As a rule, based on infection. Noncommunicable arise irritation bubble urinable chem. substances,
including drugs in their long-term use at high doses, with burns of the mucous membranes, for
example. In the case of the introduction into the bladder of concentrated chemical. substances caused
bladder lavage solution, the temperature-cerned than 45 °; if damaged mucosal foreign body, urinary
stones, as well as in endoscopy, with radiation therapy for tumors of the female genital, rectum,
bladder. In most cases, however, the initially aseptic inflammatory process and soon joint infection.
Germs can enter the urinary bladder ascending path - inflammatory diseases of urethra, prostate,
seminal vesicles, testes and epididymis, the downward path - often in tuberculous lesions kidney,
hematogenous route - with inf. disease or the presence of purulent focus in the body (tonsillitis,
pulpitis, abrasions, etc.) through the lymphatic - diseases of genital organs (endometritis, oophoritis,
parameters). Bladder infection is possible with his catheterizationp eration or during cystoscopy.
In the development of Ts, besides infection, are important additional predisposing factors:
lower body resistance, caused, for example., hypothermia, fatigue, exhaustion, past illnesses, surgery,
impaired outflow and stagnation of urine in patients with an enlarged prostate, urethral stricture ,
neurogenic bladder dysfunction, impaired blood flow in the bladder wall or in the pelvis.
There are primary, D., arising initially healthy body, and as a complication secondary Ts pre-existing
disease of the bladder or other organs, depending on the distribution process - focal or diffuse Ts;
cervical Ts, with a rum involved in the inflammatory process only the neck of the bladder; trigonitis inflammation of the mucusmembrane of vesico simple triangle. By the nature of the morphological.
changes and wedge. current release acute and chronic C., and the particular form of chronic Ts interstitial cyctitis.
Acute cystitis usually occurs suddenly, after hypothermia or exposure to other gravitating provoking
factor.Its main symptoms are often painful urinating, pain in the lower abdomen, the intensity
urinating increases, pyuria.In connection with fast imperative desires to uranting patients (especially
children and undershoots) are not able to hold urine.Severity of symptoms of acute C. different. In
certain, lighter cases, patients feel heaviness in the lower abdomen, moderately severe pain
accompanied by weak pollakiuria the end of urination. Sometimes these things are observed for 2-3
days and go without treatment.However more acute Ts even early and timely treatment that takes 6-8
days. Longer for evidence of the presence of the diseases puts FIT supporting the inflammatory
process, and requires further investigation.
The diagnosis of acute C. established on the basis of characteristic signs of medical history,
the results of urine.The urine are white blood cells, red blood cells and a small amount of protein (due
to the presence for variables of blood). In hemorrhagic Ts, there has also been gross hematuria (see
Hematuria). Cystscastrate acute C. contraindicated.
Patients need bed rest, and in severe cases to be hospitalized.Assign the abundance drink diet
with the exception of spicy dishes, pickles, sauces, condiments, canned food, prohibit the use of
alcoholic beverages. Recommend vegetables, fruits, dairy products. Useful to apply the decoction
(kidney tea, bearberry, corn silk) has a diuretic effect. To reduce pain appoint those bath heaters. In
stark cuttings dysuria used antispasmodic drugs (papaverine, no-spa, etc.), with a 2% microclysters
warm solution of novocaine, and in severe cases produce presacralis procaine blockade.
Assign furagin 0.1 g 2-3 times a day, blacks at 0.5 g four times a day, 5-NOK 0.1 g four times a day
and other broad-spectrum antibiotics (oletetrin, oxacillin, tetracycline, erythromycin, etc.) inside or
internal intramuscularly. Usually used one of these drugs for 8-10 days, which leads to a rapid
decrease of dysuria and normalization of urine. The prognosis is usually favorable.
In the prevention of acute Ts are important personal hygiene, prompt treatment of
inflammatory diseases, illnesses, urodynamics, prevent hypothermia, aseptically at endovesical studies
and catheterization.
Chronic cystitis. In pathological. the process involves the usual whole wall of the bladder.
Symptoms same as for acute C., but less pronounced. For either, more or less severe complaints and
204
changes in urine (leukocyturia, bacteriuria) or relapsing, with exacerbations occurring similarly acute
C., and remissions, while all signs Ts missing.
In the diagnosis of chronic C. and identifying the reasons supporting inflammation, the importance of
cystoscopy. If necessary, use other methods of general and urological examination (see Examination of
the patient, urology). The differential diagnosis spends Ch. arr. with urethritis. The presence of
pathologies
changes
only
in
the
first
urine
sample
during
urethritis.
Treatment of chronic C. aimed at restoring impaired urodynamics, elimination of hotbeds of infection
Institute, removal of urinary stones, etc. Antibiotic treatments for chronic C. hold until bacteriol. urine
and sensitivity of microflora to antibacterial drug mediaproperties. To improve the blood supply to the
affected bladder wall used UHF therapy inductotermission, mud applications (see therapy).
Iontophoresis is used to nitrofurans (see Electrophoresis, lekarsTwain), antiseptics.
The prognosis of chronic Ts is less favorable than in acute. Improvement canonly step on the
intensive
treatment
in
the
early
stages
of
the
disease.
Trigon. acute trigonitis usually is the result of sharing excite infection inflammation posterior
urethra and the prostate.The main feature – pronounced dysuria, hematuria, sometimes terminal.The
urine in the neck oflyayut significant number of white blood cells.Treatment is the same as for acute
cystitis. Chron. trigonitis observed Ch. arr. in women. It is based on blood disorder of vesico triangle
and bladder neck in the wrong position or with descent of the uterus anterior wall of the vagina, and in
some cases is set cron. inflammatory process in the parameter., little pronounced symptoms, usually
several speeded urination, marked unpleasant oschinabsorption during the act of urination.Changes in
the urine are not available. Treatment is symptomatic. Forecast favorablelogical profile.
Handout:
Students distributed lists containing the names of threads determining bladder syndrome, proteinuria
classification, types of hematuria, leukocyturia, the list of diseases associated with abnormal urinary
sediment samples of urine for various diseasestions, differential diagnostic criteria.The following are
the test questions and references.
Equipment Workshop:
 Patterns of laboratory and instrumental studies.
 Tables.
 Slides
Independent work and self-education.
Topic: etiology, pathogenesis, clinical signs, diagnosis, criteria theory of inflammatory and noninflammatory diseases of the kidneys and bladder.(Extracurricular Using).
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the topic at the morning session of the conference at the
Department of Clinical.
3. Mastering the interpretation of laboratory and instrumental studies.
Teaching practice during the lesson.
Supervision of patients in a half-ke
The number of hours is 1 hour.
Quiz




Etiology and cystitis urine acid diathesis.
Clinic and cystitis urine acid diathesis.
Diagnosis of urine acid diathesis and cystitis
Differential diagnosis of cystitis and urine acid diathesis
205
Practical lesson № 2
Topic: "Dysuria. The differential diagnosis of acute and chronic pyelonephritis. Tactics GPs.
Indication for a referral to a specialist or hospitalization profile department. Principles
treatment, follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles of
prevention. Principles of teaching the topic. "- 6.7 hours.
Justification of the theme: Most patients with urinary sediment seek treatment, the reasons for which
can be different.In this situation it is important to know how to differentiate. The force of a general
practitioner (GP) is directed to the diagnosis of urinary symptoms caused by various diseases. In the
case of the diagnostics disease accompanied by pyelonephritis, GPs have to solve the problem of
defining a group of patients to be treated in a primary care or referral to specialized hospitals. These
and other circumstances are the basis for the inclusion of this subject in the program training GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis and selection of the optimal treatment
strategy options for pyelonephritis, and the principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
Learning objectives:
1. GPs familiarize with the list of diseases associated with pyelonephritis and to be treated in
the FCP (FP) or specialized hospitals.
2. Teach GPs diagnose pilonefritov.
3. Discuss questions about tactics in the qualifying characteristics of GPs
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in rural
health units or family policlinics.
6. Discuss the principles of primary, secondary and tertiary prevention in these diseases.
Anticipated results.
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies pyelonephritis caused by different diseases, to establish a
preliminary diagnosis.
GPs should know:
1. The mechanism of pyelonephritis
2. Differential diagnosis of pyelonephritis
3. The principles of treatment (drug and non-drug) for these diseases.
4. Principles of follow-up and monitoring of patients in a rural health units, or family
policlinics.
5. The principles of primary, secondary and tertiary prevention in these diseases.
GPs should be able to:
 Diagnose, to differentiate on clinical and laboratory-instrumental data pyelonephritis
 Choose products with proven efficacy
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Data analysis and history of complaints to diagnose pyelonephritis
 Interpret the results of laboratory data instumentalnyh pyelonephritis.
 Prescribe medication and perform clinical examination of patients with pyelonephritis
206



The list of skills that GPs should possess after completing studies on the subject
Conduct a survey of patients with pyelonephritis
The interpretation of laboratory and instrumental data of patients with pyelonephritis
Place of activity:
 Training themed room.
 Hospital rooms in the Nephrology Unit.
The course is taught
The structure of the lessons:
1. Checking the initial level of preparedness of students to engage in "Dysuria. The differential
diagnosis of acute and chronic pyelonephritis. Tactics GPs. Indications for referral to a
specialist or hospital in the profile department. The principles of treatment, follow-up,
monitoring and rehabilitation in RHU or family policlinics. Principles of prevention.Principles
of Teaching the topics »
2. Explanation of the diagnosis and differential diagnosis of pyelonephritis pr
3. Decision analysis and situational problems.
4. Supervision of patients with pyelonephritis
5. Clinical analysis of supervised patients.
Contents classes
Time
Events
8.30-9.30 Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
207
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
12.4014.00
Theoretical
Checking the initial
analysis of the level of preparedness of
topic.
students using the 'Tour
of Gallery. "A decision
on a task on the
subject and roleplaying.
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and instrumental
studies, case studies.
On practical training in the theoretical part series includes:
Pyelonephritis - nonspecific infectious kidney disease that affects the renal parenchyma, mainly
interstitial tissue, pelvis and calyx. Pyelonephritis can be one-and two-way and secondary, acute
(serous or purulent), chronic or recurrent.
Etiology and pathogenesis. Most often caused by intestinal Escherichia pyelonephritis,
enteritisofcocci, Proteus, staphylococci, streptococci.U 1 / 3 of patients octring pyelonephritis and 2/3
of patients with chronic pyelonephritis is a mixed flora. During treatment, the microflora and its
sensitivity to antibiotics and change that requires repeated urine culture to determine adequate
uroantiseptics. It must be remembered as recovery and L-form bacteria in the recurrences of
pyelonephritis. If the infection in the kidney supported, the urine culture does not detect them.
Development of pyelonephritis is largely dependent on the total with microorganism, reducing
immuno-reactivity. Infection enters the kidney, pelvis and calyx hematogenous or lymphatic path of
the lower urinary tract on the wall of the ureter, in his ray of lightin the presence of ETU-retrograde.
Important in the development of pyelonephritis have stasis of urine, impaired venous and lymphatic
drainage of the kidney.
Acute pyelonephritis is interstitial, serous or purulent.
Symptoms within. Disease begins acutely, there are high (up to 40 ° C) temperature, chills,
sweat, pain in the lumbar region on the side ofthe expressions on the kidney-tension abdominal wall,
sharp pain in the costovertebral angle, malaise, thirst, dysuria or pollakiuria. Added headache, nausea,
vomiting indicate rapidly increasing intoxication.Marked neutrophilic leukocytosis, aneozinophilia,
piuria with moderate proteinuria and hematuria. Sometimes, when the deterioration of the leukocytosis
followed by leukopenia, which is a bad prognostic sign.Sign of Pasternatskiy usually is positive. With
bilateral acute pyelonephritis often show signs of kidney failure. Acute pyelonephritis can
paranephritis, necrosis of the renal papillae.
Diagnosis. Important role in the diagnosis of a history play instructions on recent acute
purulent process or the presence of chronic disease (subacute bacterial endocarditis, gynecological
diseases et al.). Characterized by a combination of fever with dysuria, pain in the lumbar region,
oliguria, piuria, proteinuria, hematuria, high relative density of urine. Keep in mind that pathologic
elements in the urine may occur with any acute suppurative disease and that can have piuria origin
(prostate, lower urinary tract).
Treatment.In the acute period prescribed table number 7a, the consumption of up to 2 -2.5
liters offluid per day.Then,with the growing diet, increasing its content of protein and fat.With the
development of metabolic acidosis prescribe sodium hydrocarbonate inside 3.5 m or / in 40-60 ml of
5.3% solution.To improve local blood circulation, reduce pain prescribed thermal treatments (hot
compress, hot water bottles, diathermy lumbar region).
Conducted antibiotic therapy nalidixic acid (nevigramon, blacks), the treatment of which should last at
least 7 days (0.5-1 r4 times a day), nitrofuran derivatives (furadonin 0.15 g 3-4 times a day, the course
treatment 5-8 days), nitroxolin (5-NOC), appointed by 0.1-0.2 g 4 times a day for 2-3 weeks.The use
of these drugs should be alternate. You can not simultaneously assign nalidixic acid and nitrofuran
new derivatives, as this weakens the antibacterial effect. During the first 5-6 days, especially when
infections resistant to antibiotics can be used hexamethylen entetramin (methenamine) inside of 0.5-1
g 3-4 times a day, or in / 5.10 ml of a 40% solution every day.
Very effective combined treatment with antibiotics and sulfonamides.Selection of antibiotics
depending on the sensitivity to them microflora.Prescribe drugs penicillin group (benzyllpenitsillin by
208
1000 000-2 000 000 IU / day, orally or oxacillin / m at 2.3 g / day, ampicillin inside to 6-10 g / day, for
ampicillin sodium salt / m or / in at least 2-3 g / day, etc.) or with streptomycin (0.25-0.5g / m 2 twice
daily). Also used tetracyclines (tetracycline interior of 0.2 -0.3 g 4-6 times a day, its derivatives morfotsiklin, methyl tatsiklin etc.), antibiotics, macrolides (oletetrin, tetra-Olean inside of 0.25 g 4-6
times a day), antibiotics, aminoglikozidy (kanamycin / m at 0.5 g 2-3 times a day, Gentamitsin / m at
0.4 mg / kg 2-3 times daily) , antibiotic-cephalo-losporiny (tsefaloridinom, tseporin / m or / in 1.5-2
gramsper day), etc.
Of sulfa drugs prescribed and urosulfan etazol (1 g 6 a day), long-acting sulfonamides (sulfapiridazina
1-2 g in the first day, followed by 1 gfor 2 weeks; sulfamonometoksin, sulfadime-toxin). In most
patients, after a few days disappear changes in the urine, but antibacterial therapy should continue an
(usually a course of treatment lasts for 4 weeks).The ineffectiveness of conservative therapy (often
with apostematoznom nephritis and renal carbuncle) shows an operation.
Chronic pyelonephritis may be due to untreated acute pyelonephritis (often), or primary, but chronic,
ie, can occur without acute symptoms of illness. Most patients with chronic pyelonephritis occurs in
children, especially girls ge.U1 / 3 of the patients in the normal examination fails to identify the
unmistakable signs of pyolonephritis.Often, only the periods of unexplained fever indicate a worsening
of the disease. In recent years more and more frequent cases of the disease combined with chronic
glomerulonephritis and pyolonephritis.
Symptoms within.Unilateral chronic pyelonephritis is characterized by a dull nofconstant
pain in the lumbar region on the side of the affected kidney. Disuria phenomenon, most patients are
not available. In exacerbation only 20% of patients the temperature rises. As determined by the
prevalence of urinary sediment of lymphocytes over other formed elements of urine. However, as the
kidneys of wrinkling pyolonephritic cuttings bladder syndrome decreases.The relative density of urine
remains normal. For the diagnosis of significant importance is the discovery of active leukocytes in
urine. When latent course pyelonephritis holding pyrogenal or prednisolon test (30 mg prednisolona
dissolved in 10 ml of isotonic sodium chloride solution, introduced in / for 5 min at 1, 2, 3 hours a day
and then collected urinerayut for research). Detection in urine cells Stehrngeymera - Malbina only
indicates the presence in the urinary system of the inflammatory process, but does not prove the
existence of pyelonephritis.
Handout:
Students distributed lists containing the names of topics, definitions pyelonephritis, singularities of
their course.The following are the test questions and references.
Equipment Workshop:
1. Patterns of laboratory and instrumental studies.
2. Table: Clinical manifestations of pyelonephritis
Independent work and self-education.
Subject: Definition, etiology, pathogenesis of pyelonephritis (Field work).
1. Independent work with literature in the library, at home, the repetition of earlier mvany.
2. Prepare and deliver a presentation on the topic at the morning session of the conference at the
Department of Clinical.
3. Mastering the interpretation of laboratory and instrumental studies in kidney disease, occurringing
with nephrotic syndrome.
4. Tour of duty in the department of nephrology schedule.
Teaching practice during the lesson.
 Supervision of patients with pyelonephritis.
 The number of hours is 1 hour.
Quiz
209





Definition. Etiology. Pathogenesis of acute and chronic pyelonephritis.
Clinic for acute and chronic.
Diagnosis of acute and chronic pyelonephritis.
Diff. Diagnosis of acute and chronic pyelonephritis
Complications and tactics GPs in acute and chronic pyelonephritis
REQUIREMENTS FOR KNOWLEDGE, SKILLS AND ABILITIES IN TEACHING STUDENTS
TO APPROACH TO THE PROBLEM OF PATIENTS WITH CHANGES IN URINARY
SEDIMENT
Purpose: Teach students syndromal addressing patients with changes in urinary sediment, as well as
the principles of their management in primary health care in the qualifying characteristics of GPs
Key learning objectives:

Train students in solving problems related to changes in the urinary sediment

Giving students a timely diagnosis in the presence of symptoms associated with changes
in urinary sediment.

To teach students to differentiate the disease are accompanied with changes in urinary
sediment.

Improve the knowledge, skills, and practical skills in solving problems of patients with
changes in the urinary sediment (information gathering, problem identification and physical
examination, as well as the ability to reasonably assign laboratory and instrumental methods of
investigation);

Giving students a reasonably choose tactics;

To teach students to exercise reasonable medical and preventive measures and
surveillance in RHU and FP.
What the student needs to know to solve the problems of patients with changes in urinary
sediment:
The list of knowledge
The list of diseases that occur with changes in urinary
sediment
A list of the most dangerous diseases that occur with
changes in urinary sediment
The list of states that require management in a rural
health units or FP (1 category)
The list of states that require a specialist consultation
or hospitalization (category 2)
A list of studies requiring in RHU or FP (3-1 category)
The list of research areas requiring outside RHU or FP
(3.2-category)
Key points (criteria) diagnosis, with changes occurring
urinary sediment
Symptoms of internal organs
210
Basic level
The student should know at least 10
of the most common diseases
The student should know at least five
diseases
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
According to the characteristics of the
GP qualifying
A student must know features and
symptoms of each disease, and the
criteria for their diagnosis.
The student should know the
symptoms of defeat
Signs of nephrotic syndrome
Indicators of laboratory and instrumental methods of
investigation
Treatment policy
The principles of primary, secondary and tertiary
prevention
The principles of clinical examination and
rehabilitation of disorders that occur with changes in
urinary sediment RHU or SP (4-category)
The student must list the major
manifestations
the student should know:
- Performance standards
The student must know the techniques
and principles of treatment (including
non-drug).
The student should know the basic
activities required for primary,
secondary and tertiary prevention
The student must list the main
activities for clinical examination and
rehabilitation
That the student should be able to solve problems of patients with changes in urinary sediment:
№
List of skills
Ask the patient and his relatives
Identify risk factors
Measure blood pressure.
General inspection
Examination of the mouth
An inspection of the skin
Explore the pulse of the carotid, radial
Basic level

Student should be able to ask questions of
rational concise questions that really helps to set the
probable diagnosis.
 The student must be able to specifically identify
and assess the patient's complaints.

The student must be able to analyze medical
history: the beginning of the disease, the first
symptoms, the causal relationship and the dynamics
of their development.
 The student must be able to analyze life history:
the identification of risk factors, the health of parents
and family members.
The student must be able to identify unmanaged and
uncontrolled risk factors as on questioning patient,
based on an objective approach
Student should be able to hold tonometry with the
incremental principle.
The student must be able to identify:
-Fasies nephrotica
-Puffiness
- Liver palms
-Gynecomastia
-Swelling of the neck veins
- Cachexia.
The student should be able to appreciate the language.
The student must be able to detect the presence of:
- Pale
- Cyanosis,
- Icterus,
-The presence of rash
- Seal
- Teleangiectasy.
The student must be able to detect:
211
and femoral arteries
Conduct palpation, percussion
auscultation of breath.
and
Conduct palpation, percussion and
auscultation of heart and vascular system.
An inspection, palpation, percussion,
belly
Conduct percussion and palpation of the
kidneys.
Conduct auscultation over the renal
arteries
Inspect the limb
To inspect the bones and joints
An inspection of the penis
Conduct a rectal examination
Calculate the index weight / body
Hold ophthalmoscopy
Uroscopy
- The presence or absence of a pulse
The student must be able to evaluate the properties of
the radial artery.
The student must be able to assess:
- A tour of the chest
- Voice trembling
- Change of lung sounds and their meaning
- The types of breathing
- The presence of breath sounds and wheezing
The student must be able to identify features:
- Hypertrophy of the heart
The student must be able to assess:
- Heart sounds;
- If the heart murmur, be able to identify their
epicenter, and the relation to the phase of the cardiac
activity (systolic or diastolic murmur);
- To be able to differentiate functional from organic
heart sounds.
- Pericardial friction noise
Student should be able to conduct surface and deep
palpation of the abdomen
The student must be able to identify features:
- Hepatomegaly,
-Splenomegaly.
The student must be able to assess:
- All available structures in the abdomen
the student should be able to:
- Test for tapping the lumbar region
- Palpation to evaluate the properties of the kidneys
The student must be able to detect the presence of:
-Systolic murmur.
The student should see the limbs and body, and to be
able to detect:
- Local or generalized edema. Fingers should be able
to put pressure on the dorsum of the foot and
Should pay attention to the condition of the veins of
the lower limb
The student must be able to detect:
- The presence of the articular syndrome
The student must be able to identify features:
- Abnormal discharge from the urethra
- Balanitis
Student should be able to conduct rectal examination
with the incremental principle.
The student must be able to identify features:
- Underweight
- Increased weight.
Student should be able to hold ophthalmoscopy with
the principle of step and examine the eye.
the student should be able to:
- To determine the protein in the urine
212
Interpret the clinical and biochemical
Interpret the X-ray picture of light
ECG and decrypt it.
Differentiated disease, accompanied with
the changes of the urinary sediment
Give non-medical advice
Rational use of medicines in the
treatment of diseases that occur with
changes in urinary sediment
Conduct monitoring and surveillance of
patients
- Interpret urinalysis
- Interpret the results of tests on Nichiporenko
- Interpret the results Zimnitsskogo
The student must be able to identify signs of shifts
from the norm
The student must be able to identify features:
- TB
- Abscess
The student must be able to record the ECG with the
incremental principle.
Student should be able to decipher the results of the
ECG and identify signs:
- Hypertrophy of the heart
The student must be able to differentiate the disease
on the basis of the distinctive features (history,
physical examination and laboratory and instrumental
investigations)
the student should be able to:
- Educate patients on self-management
- Advise on diet
- Advise on healthy living
The student should be able to choose products with
proven effectiveness.
When choosing drug student should be able to
evaluate:
Effectiveness
safety
- Eligibility
Efficiency.
The student must list the principles of management
and surveillance of diseases that occur with changes
in urinary sediment.
Practical lesson № 3
Topic: "The changes of the urinary sediment. Differential diagnosis of nephrotic
syndrome.Tactics GPs. Indications for referral to a specialist or hospitalization profile
department. The principles of treatment, follow-up, monitoring and rehabilitation in RHU or
family policlinics. Principles of Teaching"- 6.7 hours.
Justification of the theme: The majority of patients with abnormal urinary sediment seek treatment,
the causes of which may be different. In this situation it is important to know how
todifferentiateont.The force of a general practitioner (GP) is directed to the diagnosis of urinary
symptoms caused by various diseases. In sequchae disease diagnosis, accompanied by nephrotic
syndrome, GPs have to solve the problem of defining a group of patients being treated in primary care
or direction in specialized hospitals.These and other facts are the basis for this subject in the training
of GPs.
The purpose of teaching:
Teach GPs on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy
options in the nephrotic syndrome, as well as the principles of management of patients in primary care,
provided the requirements of "Qualification characteristics of a general practitioner"
213
Learning objectives:
1. GPs familiarize with the list of diseases associated with nephrotic syndrome and to be treated in the
FCP (FP) or specialized hospitals.
2. Teach GPs diagnosis of nephrotic syndrome.
3. Discuss questions about tactics in the qualifying characteristics of GPs.
4. Discuss the principles of treatment (non-drug and drug).
5. Discuss the principles of management, supervision and monitoring of patients in rural health units
or family policlinics.
2. Discuss the principles of primary, secondary and tertiary.
Anticipated results.
Conducting this training allows the learner time and correctly diagnose and differentiate the clinic to
the laboratory and instrumental studies nephrotic syndrome caused by various diseases, to establish a
preliminary diagnosis.
GPs should know:
1. The mechanism of nephrotic syndrome
2. Differential diagnosis of nephrotic syndrome
3. of drugs used in the treatment of nephrotic syndrome, their pharmacodynamics and dosage.
4. The principles of treatment (drug and non-drug) in the nephrotic syndrome
5. Principles of follow-up and monitoring of patients in a rural health units, or family policlinics.
6. The principles of primary, secondary and tertiary prevention in the nephrotic syndrome.
GPs should be able to:
 Diagnose, to differentiate on clinical and laboratory-instrumental data nephrotic
syndrome.
 Choose products with proven effectiveness.
 Advise on non-medicated treatments.
 To monitor the RHU or in family policlinics.
GPs should do:
 Data analysis and history of complaints for the diagnosis of nephrotic syndrome
 Interpret the results of laboratory and instrumental data in the nephrotic syndrome
 Prescribe medication and perform clinical examination of patients with nephrotic syndrome
 The list of skills that GPs should possess after completing studies on the subject
 Conduct a survey of patients with nephrotic syndrome
 The interpretation of laboratory and instrumental data of patients with nephrotic syndrome
Place of activity:
 Training themed room.
 Cabinet GPs.
The course is taught
The structure of the lessons:
 Checking the initial level of preparedness of students to engage in "Changes in urinary
sediment. Differential diagnosis of nephrotic syndrome.Tactics GPs. Indications for referral to
a narrow and special sheet or hospitalization profile department.The principles of treatment,
follow-up, monitoring and rehabilitation in RHU or family policlinics. Principles of prevention.
Principles of Teaching"
 Explanation of the diagnosis and differential diagnosis of nephrotic syndrome.
214


Decision analysis and situational problems.
Supervision of patients with nephrotic syndrome.
Contents classes
Time
8.30-9.30
Events
Morning
conference.
Content
Report on subordinators
examined by patients in
the clinic and the
challenges at home.
9.30-10.30 Admission
Each
student
is
outpatients
receiving patients with
under control of GPs, followed by a
the teacher.
discussion of patients
examined
in
the
audience.
10.30Service calls at Examination of patients
11.30.
home.
at
home,
medical
history, a complete
inspection
of
the
patient, data analysis
and laboratory and
instrumental
studies,
and preliminary study
of a definitive clinical
diagnosis.Defining the
further tactics.
11.30Break.
12.15.
12.20Study skills.
Student
under
the
12.40.
supervision of a teacher
must
complete
a
minimum of two skills.
12.40Theoretical
Checking the initial
14.00
analysis of the level of preparedness of
topic.
students using the 'Tour
of Gallery. "A decision
on a task on the subject
and role-playing.
Materials
Lesson time
Hospital records of 1 hour
patients
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients.
The
patient, 1 hour
phonendoscopes,
tonometer.Clinical
and Laboratory data,
hospital records of
patients
Patient or volunteer.
20 minutes
Table, corresponding 80 minutes
to a subject class,
based on laboratory
and instrumental
studies, case studies.
On a practical lesson includes:
Nephrotic syndrome (NS) - one of the "big" nephrologic syndromes, the development of which
always indicate the severity of kidney damage. Persistence of symptoms NA (massive proteinuria)
points in risk of progression of renal failure. NA and its complications continue to occupy one of the
prevalent place among the causes of death in patients with chronic progressive nephropathy.
NA diagnosed with a combination of the "big" proteinuria (> 3 g / day in adults,> 50 mg / kg / day
in children), hypoalbuminemia (<30 g / dL), including a decrease in total blood protein and edema
varying up to analysis sarcomas. In addition, when the National Assembly is almost always observed
hypercholesterolemia and other options metabolic lipoproteins, activation of coagulation factors
(including fibrinosis) as well as the growing disorders of calcium-phosphorus metabolism
(hypocalcemia, osteoporosis) and immunosuppression (eg, decreased concentration IgG).
215
Hypertension, in patients with hematuria NA possible, but about trush to his characters.The reasons are
varied NA. NA can be observed in all cases of chronic glomerulonephritis, renal amyloidosis, Diabetic
nephropathy.We must also bear in mind the possibility of the National Assembly in thrombosis of
renal veins, severe chronic heart NE sufficiency, it may also be due to different drugs.In elderly and
senile inzrasta NA often has paraneoplastic genesis.
Pathogenesis and clinical variants. E.M.Tareev pointed out that for nephritic syndrome
"characterized by degenerative changes not only in epithelial tubules and glomeruli but" thus
formulating
on
morphogenesis
of
this
state,
the
standard
now.
Damage to the kidney glomeruli, accompanied by a significant increase in urinary protein excretion,
which can reach 20-50 g / d, leads to other symptoms of the National Assembly, especially
hypoalbumin emission.The latter is a very severe and causes nounerespectively reduced oncotic
pressure, with a portion of the plasma moves into tissue interstitium, and blood volume decreases.In
response to the decline ofema intravascular fluid stimulates compensatory mechanisms to maintain
normovolemia primarily activated renin synthesis with the formation of angiotensin II, followed by
increased production of adrenal hormones - aldosterone, you are said to be an increase in sodium
reabsorption by the kidneys.The districthe findings formed hypovolemic version NA, dangerous
because of the high risk of complications - thrombotic and thromboembolic, but especially nephrotic
crisis.
Hypovolemia is optional feature of nephrotic syndrome, there is aversion of hypervolemic. Currently
accepted view is that the basis of sodium and water in the National Assembly is not only and not so
much hypovolemia with subsequent activation of the renin-angiotensin-aldosterone system, but in any
hemodynamic version - direct (so-called primary kidney) mechanisms: significant reduction in
glomerular filtration of sodium and / or breach of its transport in the tubules, leading to an increase its
reabsorption. In the genesis of sodium retention in the nephrotic syndrome is also important decrease
in the production of renal prostaglandin synthesis disorders natriuretic hormone - atrial and B-type (socalled brain of the first - "brain") - and / or reducing the intensity of renal response to these factors. At
the same time, the selection hypovolemic NA option is critical in terms of determining the indications
and contraindications for the value of diuretics.When hypovolemic version NA these drugs may
aggravate and hypovolemy and cause nephrotic crisis.Tentative identification of the status of
circulating blood volume (CBV) in patients with HC is possible on the basis of the analysis of clinical
data (Table 2).
Hypoalbuminemia causes a decrease in transport of many substances, including medicines
preparations, such as furosemide. Resists this diuretic in patients with NS due to decreased delivery to
the target cells in the tubules of the kidneys due to hypoalbuminemia and loss of urine albumin-bound
furosemide.
The search continues for saluretics, transport is not dependent on their binding to plasma
proteins, with the result that the effectiveness of these drugs in the state hypoproteinemic, including
the National Assembly, is preserved. So, at the NA perspective is of virtually no binding to albumin
analog furosemide - torasemida.
Edema in patients with NS often reach much anasarca - except for the peripheral, and is
characteristic of abdominal swelling (hydrothorax, ascites, hydropericardium). Nephrotic edema loose,
with about pit on pressure, can be easily moved. Massive common edema can stretch the skin, forming
stretch marks. With the development of abdominal swelling worsens the condition of patients, the
appearance of ascites preceded bloating, nausea and diarrhea. Hydrotherapy and accumulation of fluid
in the pericardial cavity accompany dyspnea, tachycardia, arrhythmias and signs of myocardial
restrictive disturbances revealed by echocardiography. In modern conditions, etc. first name of
powerful diuretics or extracorporeal removal of excess fluid methods (hemodialysis mode
ultrafiltration)
can
ease
the
condition
of
patients.
In addition to hypoalbuminemia and hypoproteinemia, in NA reveals significant disproteinemia almost always have a pronounced hyper- 2-globulinemia often hypogammaglobulinemia (systemic
lupus erythematosus, with its pronounced immunological changes - hypergammaglobulinemia).
An important feature of the National Assembly, dyslipoproteinemia characterized by
216
hypertriglyceridemia, elevated levels of total cholesterol bylow-density. Severity of hyperlipidemia
inversely correlated with the degree of hypoalbuminemia, which explains the compensatory increase in
the synthesis of lipoproteins printed at the National Assembly. It has also reduced the value of
lipoprotein catabolism due to reduced activity of lipoprotein lipaz. Lipid metabolism are often
particularly pronounced in the National Assembly of persistent currents receiving steroids.
Due to a long-term dyslipoproteinemia in patients with UA may accelerate the progression of
atherosclerosis the formation of cardiovascular complications. In addition, lipid metabolism directly
contribute to the progression of kidney: filtered through the glomerular filter lipoproteins low densities
stimulate mesangial cell proliferation and production of components of mesangial matrix and
glomerular basement membrane material, contributing to glomerulosclerosis. In addition, lipoproteids
related to albumin, can activate cells of tubular epithelium, triggering damage renal tubulointerstitium,
leading to his fibrosis.
In parallel with impaired protein and lipid metabolism in the NA-syndrome often develop
changes in blood coagulation, usually activated by a variety of mechanisms of hemostasis - increased
production of primary antiplasmin - 2-macroglobulin in the blood decreases the level of antithrombin
III and other natural anticoagulants due loss in the urine.Hypercoagulable promotes strengthening of
platelet adhesion and activation and comrade in their locally-renal activation. In this regard, the
National Assembly referred to the so-called states must prothrombogen with the possibility of local or
disseminated intravascular coagulation.When the National Assembly is developing shortage of active
metabolites of vitamin D,and the consequenceof that is eating hypocalcemia. In the development of
hypocalcemia has also reduced the value of the intensity of.binding of this ion to albumin.In
connection with hypocalcaemia in children with NS often reveal tetany in adults can osteomalatia.
NA considered in a number of acquired immunodeficiency.Violations recorded mainly in
the system of humoral immunity: significantly reduces the production of antibodies, often observe a
significant reduction in the content in the serum.Infectious complications in pre-antibacterial era were
one of the main causes of death in patients with UA. Atrium are often cracked skin and lang you in the
localization of edema.To infectious complications in patients with UA predisposes also appointed
immunosuppressants.
Complications of the National Assembly. Prognosis of patients with UA, along with frequent
infections is determined by the risk of other complications - thrombosis and embolism, cerebral edema,
acute renal failure, nephrotic crisis.
General principles of treatment. Treatment strategy determined from the NA version of renal
disease, lyingsecond at its base and the activity of immune mechanisms of progression of renal
disease.Apply corticosteroides, cyclophosphamide, including ultra-high doses (so-called pulse
therapy), and the more modern immunosuppressive drugs - cyclosporine A, tacrolimus and
mycophenolate mofetil.
There is no doubt advisability of drugs that block the RAAS, - ACE inhibitors and angiotensin
receptor blockers II, have an antiproteinuric effect, particularly when high doses of the FIR.The use of
RAAS blockers always requires mofmonitoring serum creatinine and potassium.All the patients with
UA shows cortical inhibition of HMG-CoA reductase inhibitors - statins.
One of the most effective measures to reduce the swelling is salt-free diet. Necessarily limiting
consumption of salt - less than 3 g (2/3 teaspoon) a day and it should be possible to exclude foods rich
in salt, until replaced by the usual how drinking distilled water. In general, the volume of fluid per day,
not to exceed the amount ofurinevydeuniverse of more than 200 ml.The use of diuretics in the National
Assembly requires special, because even with massive edema can be reduced, and the crossing of
diuresis in this situation leads to a dangerous aggravation of hypovolemia.Thiazide diuretics are
ineffective; kaliygathering diuretics should not be appointed because of the risk of hyperkalemia.
Preference is loop diuretics (in large doses parenterally) in combination with salt-free albumin or
reopoliglucin to fill the inside of the vascular volume. If there are signs of intravascular coagulation
recommend intravenous administration of fresh frozen plasma. Increase in urine output can be
achieved with the help of "nonspecificnical" measures, such as the patient's room in a warm bath.
In cases where the cause of the National Assembly can not install, can be successful etiologicmatic
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approach to the treatment of this condition.However, the majority of patients it can arrest the NA
pathogenetic and symptomatic treatment, which is important for the inhibition of progression of renal
insufficiency.
Handout:
Students distributed lists containing the names of topics, definitions of nephrotic syndromema, the
characteristics of their flow.The following are the test questions and a list of literatureurs.
Equipment Workshop:
 Patterns of laboratory and instrumental studies.
 Tables: clinical manifestations in the nephrotic syndrome
Independent work and self-education.
Subject: Definition, etiology, pathogenesis of nephrotic syndrome.
1. Independent work with literature in the library, at home.
2. Prepare and deliver a presentation on the topic at the morning session of the conference at the
Department of Clinical.
3. Mastering the interpretation of laboratory and instrumental studies in kidney disease, occurring with
nephrotic syndrome.
4. Tour of duty in the department of nephrology schedule.
Teaching practice during the lesson.
 Supervision of patients with nephrotic syndrome
 The number of hours is 1 hour.
Quiz




Definition. Etiology. Pathogenesis of nephrotic syndrome
Clinical manifestations of nephrotic syndrome.
Diagnosis of nephrotic syndrome
Diff. diagnosis of nephrotic syndrome
Reference:
Main:
1) Ички касалликлар, Шарапов У.Ф. Т: Ибн Сино, 2003
2) Ички касалликлар, Бобожанов С. Т: Янги аср авлод, 2008
3) Ички касалликлар, Камолов Н.Н., 1991
4) Внутренние болезни, том 2 Мухин Н.А. М.:ГЭОТАР - Медиа, 2009
5) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
Additional:
Умумий амалиёт врачлар учун маърузалар туплами , Гадаев А.Г., Т., 2012
Общая врачебная практика, Под ред.Ф.Г.Назирова, А.Г.Гадаева. М.: ГЭОТАР-Медиа, 2009.
Справочник врача общей практики. Дж.Мёрта. М.: Практика, 1998.
Сборник практических навыков для врачей общей практики. Гадаев А., Ахмедов Х.С. Т., 2010.
Умумий амалиёт врачлар учун амалий куникмалар туплами Гадаев А.Г., Ахмедов Х.С., 2010. Т.
Терапевтический справочник Вашингтонского Под ред. М.Вудли М.: Практика, 2000.
Умумий амалиёт шифокори учун кулланма Ф.Г.Назиров, А.Г.Гадаев тахр. М.: ГЭОТАР-Медиа,
2007.
8) Диагностика болезней внутренних органов. Окороков А.Н. 2005.
9) Лечение болезней внутренних органов. Окороков А.Н. 2005.
1)
2)
3)
4)
5)
6)
7)
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10) Дифференциальный диагноз внутренних болезней. Виноградов А.В. М.: Медицинское
информационное агенство, 2009.
11) Внутренние болезни: учебник.- в 2-х т. (2 т.) Под ред. Мартынова и др. М.: ГЭОТАР Медиа, 2005
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