Lecture 1
Theme: ““SSuuddddeenn ddeeaatthh””. 2 hours.
The purpose: to explain students with a problem “Sudden heart death” and tactics
DGP (the doctor of the general practice).
Problems: to discuss the reasons leading to sudden death. To teach students basic
methods of prevention and treatment of the diseases leading to sudden death.
Expected results: Students DGP should understand the urgency of the problem of
sudden death.
Content of the Lecture. : In research ESVEM (Electrophysiology Study Versus
Electrocardiographic Monitoring) individual prospects of antiarrhythmic
researches of malignant rhythm disturbance of heart were studied. It has been
shown that 6 preparations of I class (imipramin, meksiletin, pirmenol,
novokainamid, propafenon, hinidin ) essentially conceded to sotalol at their long
application in prevention of relapses ventricle tachycardia and fibrillations of
ventricles. Sotalol was more effective also in prevention of arrhythmic death,
cardial death and death from all reasons.
In researches of the first half of 80th years it has been proved that using betablokators can reduce the risk of sudden death at post infarction patients.
In 1997 results of the met-analysis 13 random(рандомизированных) researches
on application of amiodaron at post infarction patients and patients with chronic
heart insufficiency have been published. Met-analysis for the first time has shown
that long application of amiodaron at patients with potentially malignant ventricle
arrhythmia reduces not only sudden arrhythmic death, but also indicators of
general lethality.
In summary it would be desirable to give words of B.N.Singh and R.Lazzara “…
searching of more effective and safe preparations, capable to warn sudden
arrhythmic death, will proceed. These preparations should have a lot of effects.
While these preparations will be created, the most effective drugs still remain betablokators, sotalol, amiodaron …”.
Lecture 2
Theme: «Diagnostics and differential prevention various clinical variants of
current IDH, a heart attack of a myocardium and its complications. The
immediately help and tactics of DGP».
The purpose: the lecture purpose to introduce the students with the reasons,
pathogenesis , diagnostics and differential prevention chest pains and tactics DGP
at a syndrome of pains in a thorax. To expand and fix knowledge of students on
clinic, diagnostics, modern therapy, rendering of the urgent help and prevention of
a heart attack of a myocardium. To teach the students a sense of responsibility at
survey and appointment of urgent medical actions as the patient with a sharp heart
attack of a myocardium (SHAM).
Problems: The lecturer should consider, show, discuss, analyse, compare together
with students the theme .There are some questions of this theme:
1.
The reasons of pains in a thorax: chest pains the hearts connected with
diseases; chest pains connected with diseases of lungs; chest pains connected
with gullet diseases; chest pains connected with a pathology of large vessels.
2. Algorithms differential Diagnostics of pains in a thorax
3. Tactics DGP.
4. To research factors of the risk , epydemiology, classification of IDH and
SHAM.
5. To analyse clinical forms SHAM.
6. To discuss laboratory-tool methods of diagnostics SHAM.
7. To discuss rendering of the immediately help, treatment, rehabilitation and
prevention of SHAM.
8. To show cases from practice.
Content of the Lecture. :
Pain in the heart region – one of most often meeting symptoms in daily medical
practice. On nozologic or to an organic sign of a pain in a thorax it is possible to
divide in following groups:
The pains caused by disease of heart (so-called cordial pains). The pains caused by
a pathology of large vessels (an aorta, a pulmonary artery and its branchings).
The pains caused by a pathology of the bronho-pulmonary device and a pleura.
Pains connected with a pathology vertebralis, a forward chest and muscles of a
humeral shoulder belt.
The pains caused by a pathology of bodies mesenteries.
The pains connected with diseases of bodies of a belly cavity and a pathology of a
diaphragm.
Pains are subdivided also on sharp and is long existing, with the obvious reason
and for no apparent reason, "harmless" and the pains that can break your health.
The pains caused by diseases of heart. There are 2 kinds:
Anginosus -the pains connected with an ischemia of a myocardium of resulting
insufficiency coronarycirculation.
Not anginosus pains or cardialgia that based in other mechanisms, than that causes
a myocardium ischemia.
For differential diagnostics of chest pains the great value is taken away to
following parameters allowing to characterize a pain:
-Character;
-Localisation and "depth" (superficial or deep);
-Spreading;
-Intensity;
-Duration (short, long, intermittent);
-Occurrence condition;
-Accompanying symptoms;
-Prescription of a pain (sharply arising or exist long time).
-Diagnostics.
Electrocardiogram, daily an electrocardiogram – monitoring, loading tests: an
electrocardiogram test (tredmil, veloergometria), stress – EhoKG (tredmil,
veloergometria), scintigrafia a myocardium with Тl 201 (tredmil, veloergometria)
isotope ventriculagrafia; pharmacological tests.
The reasons and pathogenesis of cardialgia (not anginosus pains caused by those or
other diseases of heart) are various.
1. Primary or secondary cardiovascular functional frustration .
2. Pericardium diseases.
3. Inflammatory diseases of a myocardium.
4. Prolans mitral valve.
5. ГКМП.
6. Arterial hypertensia.
7. The got heart diseases.
8. Myocardiodystrophy (the anemias, a progressing muscular dystrophy, an
avitaminosis).
The chest pains caused by the extracardial reasons:
Diseases of lungs: a pneumonia, abscess lungs, a tumour of lungs, a pleurisy.
Gullet diseases: esophagitis , a reflux-ezophagit, ахалазия a gullet, a hernia gullets
diaphragm apertures.
The urgent conditions demanding emergency diagnostics and adequate treatment
concern:
1. SHAM.
2. Massive TEPA.
3. Stratifying aneurysm of chest department of aorta.
4. Spontaneous pneumothoracs.
5. Gullet rupture.
Treatment of stenocardia.
Major principles of treatment patients of a stable stenocardia – the prevention or
restriction of ischemia myocardium and reduce its clinical displays.
Principles of treatment of a stable stenocardia:
Antianginalis preparations: nitrates, beta-blokators, antagonists of calcium,
antiagregations, hypolipidis preparations.
Treatment of astable stenocardia:
The treatment purpose – plaque stabilisation, function improvement endotelian:
antiagregations , anticoagulants, nitrates, beta-blokators.
SHAM– sharp necrosis the cardiac muscle site, arising owing to absolute or
relative insufficiency of coronary blood circulation.
Aetiology : in 95 % cases it is found out stenosis an atherosclerosis of coronary
arteries.
Pathogenesis : disintegration and decomposition a fibrous capsule, rupture and exit
ateromatosis plaque in a hole of vessels, increase of activity of aggregation
trombocytes and trombocytis occlusion of coronary arteries .
Risk factors: smoking , adiposity, a diabetes, a heredity. Men at the age of 45-50
years in 5 times are ill SHAM, than women of this age is more often. In the USA
for a year SHAM meets at 1,5 million people. In our republic occurrence SHAM of
0,3-0,5 %. Pre-hospital lethality – 60 %, hospital lethality 17-18 %, after an extract
from a hospital of 10-15 %.
Complications SHAM.
During the sharp period there are the complications which majority can cause a
lethal outcome: rhythm and conductivity infringements, cardio genesis shock, a
cardiac asthma, a hypostasis of lungs, sharp a heart aneurysm, heart ruptures,
тромбоэмболия.
The immediately help at SHAM:
1. Knocking over of a painful syndrome – narcotic analgetics, закись nitrogen
with oxygen.
2. Restoration of a coronary blood-groove – trombolytics (in the presence of
pathological tooth Q), anticoagulants (without pathological tooth Q),
antiagregations.
3.
4.
5.
6.
Preparations that limit size of necrosis (selective betta-adrenoblokators,
nitrates).
Prevention of infringement of a rhythm and conductivity (magnesium
sulphate, lidocaine, potassium preparations,cordaron).
In case of bradycardia – добутамин, дофамин.
In the presence of cardial insufficiency –diuretics.
The basic medical products for secondary prevention after transferred SHAM:
betta-adrenoblokators , nitropreparations, antiagregations, statins, antagonists
calcium, antiarrhythmic preparations, indirect anticoagulants.
Lecture № 3
Theme: the Differential diagnosis of cough, sputum and spitting. Tactics of
DGP».
The purpose: the lecture purpose is to explain students with the reasons,
pathogenesis, diagnostics and differencial diagnostics .cough, sputum and blood
spitting and tactics of DGP. To expand knowledge of students on clinic,
diagnostics, modern therapy, rendering of the urgent help and preventive
maintenance.
Problems: to consider, discuss and analyse the reasons of the cough, proceeding
with sputum and spitting. To consider factors of risk. algorithms of diagnostics, to
discuss laboratory both tool methods of diagnostics and tactics of DGP.
Expected results: Students should be able to carry out differential diagnostics of
cough, sputum and spitting and if necessary to render immediately medical aid and
to render services of 1 category.
Content of the Lecture. :
Cough is mechanical protection tracheobronchialis ways. Thus speed
movement of air considerably increases – about 24 km at an o'clock to 1000 km at
an o'clock, volume speed of an air reaches 12l/second. Inside chest pressure
accrues to 140 mm.Frequency and intensity of cough depends on many factors.
There are dry (useless) and damp cough.
Diagnostic value has characteristic of sputum (poor, mucous, purulent, mixed,).
The main value has an establishment of duration of cough. It is in detail stated to
feature of cough at sharp and chronic. Diseases of the top respiratory ways, and
also bronchial tubes, lungs, at pleura diseases, tumoral diseases
broncho_lungs systems,
antroponosus (a whooping cough, a scarlet
fever), dyskinesia of tacheobronchialis, a pneumosclerosis, a hypostasis of lungs,
etc.
Treatment is directed on liquidation of basic cause of cough (an infection, a foreign
matter, allergen, toxic substance and т.д).
At dry cough appoint opium preparations, tecodin, terpingidrat терпингидрат,
sodium benzoat.
At damp cough: termopsis, altey, mukalitin, licviriton, bromgeksin.
Treatment with antitussive and expectorant should be short. At long cough it is
necessary to presence of more serious primary disease. If necessary to appoint
mucolytics –acetylcistein , tripsin, hymotripsin, bromgeksin. Mukolitics promote
accumulation and slime deducing. They are effective in the form of aerosols,
however they should not be applied at plentiful sputum.
Hemoptysis and a pulmonary bleeding are serious giagnostic characteristic,
appearing at diseases of lungs and top respiratory ways. Most often the bleeding is
observed at a heart attack of a lung, a cancer, a tuberculosis, bronchoectasis,
stenosis of mitral valve, disturbance of interventricular wall. Spitting is possible
at pneumonia, a flu, pulmonary suppurations, fungoid diseases, systemvasculite,
blood diseases, avitaminosisC, uraemias etc.
Immediately diagnostic made with a view of establishment the reason of a
bleeding. To stop the bleeding appoint oxygen inhalations, aminocapron acid,
ПАМБА and others.
Lecture 4
Theme: the Differential diagnosis of intestinal dysfunctions. A dysbacteriosis.
Tactics of DGP».
The purpose: to discuss with students the reasons and pathogenesis of intestinal
dysfunctions. To the differential diagnosis. And tactics of DGP.
Problems: the Lecturer should consider, discuss, analyse, compare together with
students a theme on following questions: ekzokrine insufficiency of a pancreas. A
syndrome malabsorption.
Expected results. Graduates should be able to diagnose intestinal dysfunctions and
a dysbacteriosis, to do right treatment and to know tactics of DGP.
Content of the Lecture. :
Pancreatic secretion plays a dominant role in intestinal cavitary digestion because
of the high activity of a secret - to presence in it of the enzymes splitting almost all
groups of nutrients. Their subsequent splitting depends on efficiency of hydrolysis
nutritions in a small intestine cavity, absorbing and digestion -telnotransportation
the conveyor. The basic clinical manifestations broken cavity digestion is
malabsorption, caused close hormonal and neurohormonal interrelation between a
pancreas and an intestines.
The syndrome malabsorption caused by digestion infringement (maldigestision)
and actually absorbing (malabsorption) in a small intestine of one or several
nutrients, shown by a chronic diarrhea and leading to disturbance of a food and
heavy metabolic shifts. Allocate a primary and secondary syndrome malabsorption.
To the primary carry congenital or hereditary caused enzymopathology. The
reasons secondary malabsorption numerous also are various. Gastro genesis:
gastritis’s with secretor insufficiency, a stomach resection, a dumping-syndrome.
Hepatobiliaris: chronic hepatitis’s, hole stasis a syndrome, billi-stone illness.
Pancreatogenesis. Enterogenesis: enzymopathology, celiakia, nonspecific ulcer,
illness the Crone, an intestinal dysbacteriosis. Vascular. System diseases with
visceral displays. endocrine : diabetic enteropathology. Medicinal, radiating, toxic
(alcohol, an uraemia).
The clinical picture of a syndrome malabsorption is different also depends on the
basic disease. Such factors as degree of indemnification of the broken functions of
different bodies, weight of a dysbacteriosis, timeliness and adequacy of treatment
Besides, matter. Clinical manifestations can vary from absence of visible
symptoms before heavy disturbance of a food.
The basic clinical displays of a syndrome malabsorption concern:
1. The diarrhea.
2. Stheathorea.
3. Disturbance of albuminous exchange. 4. Infringement of an exchange of
vitamins
. 5. An anaemia.
Diagnostics. A fast and inexpensive way of revealing early ekzokrine insufficiency
of a pancreas - definition in the analysis excrement elastazy-1, specific proteolytic
gland enzyme. If as a result of the done test indicators exceed 200 mkg/g кала it
is possible to consider function normal. If an indicator less than this value it is
possible to speak about infringement and if it less than 100 mkg/g кала - about
serious insufficiency ekzokrine functions. Distinctive signs of the test are high
specificity and sensitivity.
Lecture 5
Theme: the Differential diagnosis of a fever with not clear genesis. Tactics of
DGP».
The purpose: to teach students to carrying out to differential diagnostics and
tactics of DGP.
Problems: to Consider the reasons leading to a fever, the plan of laboratory and
tool methods of research, individual selection of therapy.
Expected results: students should know the characteristic of a fever with not
clear genesis. To carry out differential diagnostics and tactics of DGP .
Content of the Lecture. :
the Term the Fever with not clear genesis(FNCG) quite often meeting in clinical
practice at which the fever is the basic or a single sign of the various diseases
which diagnosis remains not clear after carrying out usual and additional
inspection.
Criteria of a fever are.
When the patient have temperature 38 and above
Duration of a fever of 3 weeks and more or periodic liftings of temperature during
of this term.
Ambiguity of the diagnosis after carrying out examination with the standard
(routine) methods.
Body temperature occurrence is caused by influence internal pirogen (IP) on the
centre of thermoregulation settling down in forward hypothalamus.
IP concerns to interleukins and it is produced by macrophages, monocytes,
neytrophils as a result of the immune answer to various microbes and not microbus
antigens, immune complexes, sensible T-lymphocytes, endotocsics a various
origin, products of cellular disintegration.
The reasons:
Local infectious-inflammatory processes-30-50 of % of all cases FNCG
Tumoral diseases-20-30 of %
System defeats of a connective tissue (systemvaskulits)-10-20 %
Other diseases, various on an aetiology, pathogenesis, to methods of diagnostics,
treatment– 10-20 %
Fever not clear genesis:
Approximately at 10 % of patients it is not possible to find reason FNCG
The temperature can be :
Ephemeral - from several o'clock about 2 days
Sharp – till 15 days
subacute- From 16 till 45 days
Chronic - over 45 days
On expressiveness of rise in temperature of a body:
subfebrilis - 37-37,9 C
Moderate - 38-38,9 C
High - 39-40 C
hyperpyrexia– 41 C and above
Lecture № 6
Lecture theme: “Gerontology and the general geriatrics”, 2 hours.
The purpose: Should teach features of diagnostics and treatments of diseases of an
internal at elderly and senile age.
Problems: Studying of pathological processes of ageing promoting acceleration
and the basic diseases at elderly and people of senile age.
Expected results: students should know the pathological processes occurring at
people senile and elderly age and tactics of DGP.
Content of the Lecture. :
Studying of diseases at senile age is engaged gerontology, and the subject is called
geriatrics.
Aging is process disturbance of self-control which has universal, progressing
characteristics and is observed in all bodies and organism systems. In an organism
gradually develop atrophies changes which lead to fall of its functional and jet
possibilities. At the same time there is the pathological old age connected with
numerous infringements in an organism as a result there comes an early old age.
To the factors supporting a normal physiological condition and working capacity
at elderly age an important role, belongs to hygiene of a food, factory hygiene.. At
senile age there is a change in SCV that is connected with hyperlipidemia,
dislipidemia, hypertension. With the years there are changes and in respiratory
system: the capacity of a capillary network is reduced, interalveolar partitions are
reduced, the residual volume increases, the emphysema of lungs develops. There
are changes in GIT: it is slowed down peristaltic, secretion of all glands, activity
of enzymes decreases, is broken absorb, secretory function is weakened.
Frequency of chronic diseases of digestive organs increases: chronic atrophies a
gastritis, stomach ulcer, a stomach tumour, a chronic pancreatitis, a hypodynamic
constipation. Changes from outside urinary excretion are observed: an urine
incontience, nicturia , an adenomaof prostate , infections of parts uremic system ,
tumors. At elderly age the most frequent defeat of a skeleton is the osteoporosis,
as a result of a degeneration of an articulate cartilage and infringement absorbing
calcium in small intestines. At elderly and senile age there are particularities in
medicamentous treatment.
Lecture № 7.
Theme: “the Differential diagnosis at arrhythmia. The differential diagnosis at
blockade. Clinical both an electrocardiogram-diagnostics. Treatment and the
immediately help”. 2 hours.
The purpose: to know the basic pathogenetic mechanisms of occurrence
arrhythmia , the mechanism re-entry, to consider classification of arrhythmia , to
acquaint students with the basic antiarrhythmic medical products .
Expected results: Students of DGP should know definition of arrhythmia,
classification of arrhythmia, to know modern medicines from arrhythmia.
Lectures content . The concept "Aritmija" includes any anomalies of frequency, a
regularity, and a place of occurrence of excitation, and also carrying out of
impulses and changing of normal sequence of activation of atrium and ventricles .
All arrhythmia divide in to three basic classes:
1. Owing to infringement of formation of an impulse.
2. Arrhythmia owing to infringement of getting through of an impulse
3. Arrhythmia owing to infringement formation and getting through of an impulse .
Electrophysiological mechanisms of infringements of a rhythm of heart. Heart cells
divide on two types: these cells differ from 2 type with ability to an automatic
discharge, that is shows automatism. 2nd type: they differ from cells of the first
type absence of ability to spontaneous discharge.
There are 3 main characteristics of heart cells:
Rest (polarisation), activation
(repolarisation), returning in a rest condition (repolarisation).
Lecture №8
Theme: “Differential diagnostics at DDCT. Tactics of DGP.”. 2 hours.
The purpose: to explain students with diffusion illnesses of a connecting tissue.
Diagnostics. Therapy principles.
Problems:
To find the reasons of aetiology DDCT.
To study pathogenesis of DDCT.
Expected results: Learn to find DDCT, to understand bases of immune
inflammation, to do differential diagnosis.
Students can analyze symptoms, the syndromes entering into given group. The
Lectures content. DDCT is a disease, characterizing immune-inflammatory defeat
of a connecting tissue. The SRV is chronic system autoimmune disease that defeat
internal organs: develops mainly at young men. Environment factors of revealing
SRV are: superfluous insolation, cooling, stress, physical overloads. Aetiology –
the viruses containing RNK, and family genetic predisposition. Pathogenesisowing to virus action arises disregulation the immune answer in the form of
decrease in control of t-cages that leads to hyper reactance humoral immunity.
Diagnostic charecteristics of SRV:
1. Defeat of the musculoskeletal system, a muscular atrophy, myosits.
2. Integuments – eritromatosus rash on a nose, cheeks, the butterfly.
3. Defeat of serosus covers - a pleurisy,pericardits.
4. Cardiovascular systems -myocardits, pericardits.
5. Defeat of lungs - a pneumonia,
6. Defeat of kidneys.
7. Defeat of vessels - a syndrome of Rejno.
8. A syndrome of Verlgofa.
9. Defeat reticuloendothelial system -polyadnopathology, liver and spleen increase.
10. Change in the blood.
Treatment:
1. Basic therapy - glucocorticoids and cytostatics.
2. Pulse therapy -corticosteroids.
3. Plazmoforez
4. Haemosorbtion.
Lecture № 9.
Theme: the Differential diagnosis of nephrotic a syndrome. Tactics of DGP.
The purpose: to explain students illnesses that include in nephrotic syndrome.
Glomerulonephritic. ChIK(ХПН).
Problems:
1. To consider the reasons of nephrotic syndrome.
2. To show patients with Glomerulonephrit.
3. To discuss modern methods of treatment and prevention of ChIK (ХПН).
4. To analyse tactics of DGP.
Expected results: student should know the reasons of nephrotic syndrome their
kinds, learn to do correct diagnosis, understand importance of a clinical course and
complication, to know modern methods of treatment, to analyze preventive
maintenance.
Lectures content . The length of uric tubular nephron fluctuates from 18 to 50
mm. The total length uric tubular nephron reaches 100 kilometres. In a glomerule
goblet capsules nephrone is to 50 capillary loops. From 1700-1800 metres of blood
which for days passes through itself both kidneys, 150-180 primary urine and 1-1.5
litres of the secondary are formed. The filtering surface of both kidneys is equal
approximately 5-6 square metres. The destruction even 50 % from total (2млн)
nephrons can not be accompanied by clinical manifestation. There are 3 nephrotic
syndrome:
Fast progressive - is characterised focal and segmentary necrosis with
proliferation cells epithelial nephritic balls, in a clinical picture -proteinuria,
haematouria and erythrocytic cylinders, development of nephritic insufficiency
within several weeks or months.
Clinic: In the anamnesis reveal sharp flu kin disease 4 weeks prior to occurrence of
symptoms of nephritic insufficiency. Symptoms ChIK develop for some weeks or
months: weakness, fatigue, a nausea, vomiting, an anorexia, pains in joints and a
stomach.Olygouria. proteinuria.haematouria. A malignant arterial hypertensia.
Treatment: Glucocorticoids. A diet № 7а. Cytostatics. Antiagregants.
2. Sharp - it is characterised by sudden occurrence haematouria and proteinuria,
signs azotemia (decrease of glomerule filtrations), a delay in organism salt and
waters, a arterial hypertensia.
Clinic: Disease (1-6 weeks)develops after a streptococcal infection. Classical signs
of a sharp nephrite.Haematuria . Hypostases. An arterial hypertensia. Olygounuria .
A nausea, vomiting, a headache, a hypertensia, increase weight of a body.
Treatment: the Diet 7а, disturbance of fibers, antibiotics, diuretics, antagonists of
calcium.
Current: Sometimes disease slowly progresses to ChIK.
3. Chronic - a syndrome accompanying a number of diseases of a different
aetiology, characterising, diffusion a sclerosis of the glomerules , leading to ChIK,
clinical manifestation: proteinuria, cylindrouria, haematouria and arterial
proteinuria.
Clinic: Disease develops gradually. The patient can have uraemia signs - a nausea,
vomiting, a short wind, an itch, fatigue. orthostatic hypostases and an arterial
hypertensia.
The diagnosis confirms biopsy of kidneys.
Treatment: the Diet with salt restriction. Antigipertenzive preparations.
Treatmentthe ChIK.