Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
«Approved»
Vice Rector for Academic Affairs
Prof. ___________ Тешаев О.Р.
«____» ___________ 2012 г
Department: INTERNAL MEDICINE MEDICAL FACULTY
Item: GPs with an endocrinologist
TECHNOLOGY EDUCATION
on practical training on the topic:
«JOINT SNDROME»
SUBJECT: «Differential diagnosis of seronegative spondylarthritis (reactive arthritis,
ankylosing spondylitis, psoriatic arthritis).
Tactic of GP.
Tashkent
Compiled by:
Education technology approved:
At the faculty meeting minutes №
from «___ » ____________ 2012 y
Тема: « JOINT SNDROME »
1. Location classes
1. - Department of Internal Medicine for the preparation of a general practitioner with an
endocrinologist, a hospital
2. Chronological content activities
Time
8.30– 9.00
9.00-11.00
11.00-11.55
11.55-12.40
12.40-13.30
13.30-14.15
Activities
Morning conference
Content
Report subordination
tori calling at the
house. Conducting
clinical audit.
Admission outpatients or
Each student is in
patients Supervision in day
charge of certain
care. Talk supervised patients. patients Chamber
day hospital receives
patients under the
supervision of a GP.
Theoretical analysis of topics Checking the initial
level of preparedness
of students survey of
college students on
the topic classes. The
decision of
situational problems
on the topic.
break
Service calls at home.
Examination of
patients at home,
medical history, a
complete inspection
of the patient, data
analysis and
laboratory and
instrumental studies,
study the preliminary
and final clinical
diagnoses. Further
defined tactics.
Preparing for the problemAnalysis of patients,
based training
clinical cases of
students with a
teacher for 20
rounds.
Materials
Continued
Hospital records
of patients.
30 мин.
Sick, stethoscope,
blood pressure
monitor, patient
card with the data
of clinical and
laboratory studies.
Table,
corresponding to a
subject class, a
folder with ECG,
laboratory and
instrumental data
research, case
studies.
2 ч.
Sick, stethoscope,
blood pressure
monitor, patient
card (with data of
clinical and
laboratory
research).
Volunteer,
stethoscope, blood
pressure cuff, the
clinical situation
(with the data of
clinical and
laboratory
research).
55 мин.
45 мин
50мин.
45 мин.
3. Duration of study subjects
Hours - 6:00
4. purpose of the lesson
- Teach GPs on timely diagnosis and differential diagnosis of seronegative spondylarthritis.
5. Pedagogical objectives:
1. Teach GPs on timely diagnosis, differential diagnosis, selection of the optimal treatment
strategy in reactive arthritis, ankylosing spondylitis, psoriatic arthritis
2. Mastery of theoretical knowledge and to strengthen them
3. Mastery of practical skills
4. Used in the practice of learning and skills
6. Learning outcomes
The student should know:
1. Differential diagnosis with reactive arthritis, ankylosing spondylitis, psoriatic arthritis
2. Risk factors and criteria for diagnosis of reactive arthritis, ankylosing spondylitis, psoriatic
arthritis
3. Clinic and early diagnosis of these diseases.
4. Tactics GPs (direction for examination, consultation, hospitalization).
be able to:
1. Implement professional questioning and examination of organs systems
2. Inspection, palpation, determination of motion of the joints
3. Interpret data: clinical and biochemical, bacteriological research methods
4. Interpret X-ray images
5. Put the preliminary and the final diagnosis
6. Making the necessary documentation (medical history, direction)
7. Run n \ to. In \ m in \ IV injection
8. Promotion of a healthy lifestyle: good nutrition, personal hygiene, fighting addictions,
nutrition, prevention of focal infection, exercise
9. Screening programs for the early detection of diseases
7. Methods and techniques of teaching
Brainstorming, graphic organizer - a conceptual table
8. Learning Tools
Manuals, training materials, ECG and X-rays of patients, slides, video, audio, medical history
9. Forms of learning
Individual work, group work, team
10. Conditions of Learning
Audience, the Chamber
11. Monitoring and evaluation
Oral control: control issues, the implementation of learning tasks in groups, performing skills,
CDS
12.Motivation
Joint pain - almost universal symptom of rheumatic diseases, although the direct mechanisms of
its occurrence in different processes are not fully clarified, in principle it should be noted that the
joint pain in rheumatic diseases can be linked directly with the pathological process in the joint
and periarticular tissues are either emotional, accompanied by a certain color of pain. For the
diagnosis of rheumatic diseases is important not only to establish the presence of pain in the
joints, but also to determine their nature, duration, intensity, time of onset during the day. Joint
damage even moderate inflammatory or noninflammatory type may be the first sign of various
diseases, such as reactive arthritis, ankylosing spondylitis, psoriatic arthritis, pulmonary
hypertrophic osteoarthropathy due to bronchogenic cancer or hemochromatosis. Such problems
have to solve doctor GPs.
13. Intra and interdisciplinary communication
Because articular syndrome is observed in renal disease, endocrine glands, heart and blood
vessels, nervous system, GPs face working with cardiologists, neurologists, endocrinologists,
nephrologists, rheumatologists. Acquired during the course knowledge will be used during the
passage of the GP - internal medicine and other clinical disciplines.
14. Contents classes
14.1. The theoretical part
Reactive arthritis - inflammatory joint diseases, developing as a result of immunopathological
reactions to a previous infection and in most cases occur after 1-4 weeks after the last one.
In reactive arthritis infectious agent is a trigger factor. Directly into the joint cavity, do not find
the pathogens or infectious antigens relevant. Important role in the occurrence and development
of arthritis in these patients play a genetically determined features of the immune response,
although the final arrangements of reactive arthritis is not clear.
To the group of reactive arthritis include postenterokoliticheskie (shigellosis, yersiniosis,
salmonellosis), urogenital, arthritis after nasopharyngeal and other infections, vaccination,
arthritis, rheumatism.
Yersinia arthritis caused by Yersinia enterocolitica. Joint syndrome, usually preceded by
intestinal manifestations. They can occur on the type of abdominal pain in different locations,
enterocolitis, cholecystitis, appendicular colic, etc.
Usually within 1-3 weeks from the start of intestinal manifestations occur asymmetric acute
poly-or oligoarthritis (less monoarthritis), mainly affecting the large joints of the feet. The
process often involved the acromioclavicular and sterno-clavicular joint. May experience pain in
other joints, damage to the spine, sacroiliac joint. Perhaps the development of tenosynovitis and
tendoperiostitov of ankle, wrist and shoulder joints. Unlike rheumatoid arthritis often affects the
distal joints of the first fingers and toes. In protracted course of the disease are detected unilateral
sacroiliitis. Arthritis may be associated with fever, damage to the heart. Characteristic expression
of the intensity of pain in the joints.
In the blood - neutrophilic leukocytosis, increased erythrocyte sedimentation rate, sometimes to
considerable numbers.
Ankylosing spondylitis (ankylosing spondylitis) - a chronic inflammation of the joints, mainly
affecting the joints of the spine, limiting his mobility by ankilozirovaniya, education
sindesmofitov and calcification of spinal ligaments. Sick young man antigen carriers in 27 of
HLA (90% of patients the disease is detected the antigen spondylitis if its in the general
population in only 7-10%). There are several clinical forms of the disease: the central form of the
defeat of the spine or only some of its departments; rizomelicheskuyu with the spine and
indigenous (am. .. rhiso - root) of the joints (shoulder and hip), peripheral shape with the spine
and peripheral joints, Scandinavian - damage to the spine and small joints of the hands and feet.
The main difficulties in the differential diagnosis of joint syndrome occur in the peripheral form,
especially since the loss of peripheral joints may occur before symptoms spondylitis and
sacroiliitis. Articular syndrome is subacute asymmetrical mono-or oligoarthritis with joint
disease of the lower extremities. Arthritis is usually unstable, but can recur and rarely takes a
chronic course. In rare cases, the destruction of small joints of the hands and feet (Scandinavian
version) difficulties of differential diagnosis of RA. Mandatory feature of the disease is the
presence of bilateral sacroiliitis. Extra-articular manifestations of ankylosing spondylitis include
eye disease (iritis, iridocyclitis), aortitis, renal amyloidosis.
4. Psoriatic arthritis (PA) - an independent nosological form of inflammatory joint disease in
patients with psoriasis (found in 5-7% of patients with psoriasis). In most patients, joint damage
occurs simultaneously with psoriasis, but in some cases precedes the development of skin
manifestations. Joint syndrome can manifest asymmetrical mono - or oligoarthritis
predominantly large joints (knee, ankle), lesions of the distal interphalangeal joints of the hands.
Characteristic of "axial" defeat of the distal, proximal, and metacarpophalangeal joint of the
same finger until the development of ankylosis (see Fig. Miniatlasa 5). Sakroilet often unilateral,
detected radiographically. Spondylitis in PsA resembles that in ankylosing spondylitis. In their
blood uric acid, which in some cases requires a differential diagnosis with gout. Along with skin
lesions may occur in the PA of the eyes (conjunctivitis), and ulceration of the mucous
membranes in the mouth and genitals (difficulty in differential diagnosis of Reiter's disease).
Chronic mono-and oligoarthritis and character poliartritichesky joint syndrome without
involvement of the distal interphalangeal joints reminiscent of RA.
5. Reiter's disease (BD) - an inflammatory joint disease associated with urogenital (chlamydia,
ureaplasma) or intestinal (Salmonella, Shigella, Yersinia) infection, which manifests itself in the
classic version of the triad - arthritis, conjunctivitis, urethritis (women - cystitis, vaginitis,
cervicitis) . Sick more often young men. Articular syndrome is characterized by an asymmetric
acute (subacute), polyarthritis (less oligoarthritis), mainly affecting the joints of the lower
extremities (knee, ankle, interphalangeal joints of the foot). The defeat of the sacroiliac joints
(sacroiliitis) is usually unilateral and predicts a chest X-ray. Along with urethritis and
conjunctivitis in BR possible skin lesions (palmar and plantar keratoderma, psoriasiform rash),
mucous membranes (balanitis, proctitis, stomatitis), infarction (conduction disturbances). The
characteristic clinical feature is tendinitis, bursitis of the lower limbs (ahilobursity,
podpyatochnye bursitis, etc.), which allows to suspect BR young men, even if no other extraarticular features. The greatest diagnostic difficulties due to transient or mild expressed urethritis
and conjunctivitis. Joint syndrome usually resolves completely within a few months, but the
possibility of recurrence of the disease and, in rare cases it is chronic. BR is associated with the
presence of antigen in 27 of HLA. Important diagnostic value in the recognition of BR has a
verification of infection by microbiological testing of various biological secrets (urine, prostatic
juice, cervical mucus, synovial fluid, etc.), including with the use of polymerase chain reaction.
It is generally included in a group of spondyloarthropathies following diseases: ankylosing
spondylitis (ankylosing spondylitis), Reiter's disease, psoriatic arthritis, arthritis associated with
intestinal diseases.
The theoretical part is carried out by the method of "snowballs."
Objective: The involvement in the learning process of all students while controlling their
knowledge on the subject under discussion.
The main provisions of techniques.
The group is divided into 2-3 small subgroups that discuss the same problem or situation in order
to set the maximum number of correct answers. Each correct answer is written on the score of
the group in the form of snowballs. Group receiving the highest number of points put higher
scores.
1.Opredelenie seronegative spondylarthritis (reactive arthritis, ankylosing spondylitis, psoriatic
arthritis).
2. Diagnosis of seronegative spondylarthritis (reactive arthritis, ankylosing spondylitis, psoriatic
arthritis).
3. Treatment seronegative spondylarthritis (reactive arthritis, ankylosing spondylitis, psoriatic
arthritis).
Answers:
1.Spondylitis - a chronic inflammation of the joints, mainly affecting the joints of the spine,
limiting his mobility by ankilozirovaniya, education sindesmofitov and calcification of spinal
ligaments
2. Radiography ileo-sacral joint, antigen detection in 27 of HLA, CRP, ESR increase, the
limitation of joint mobility (positive samples Otto, Schober, Kushelevsky)
3. Basic therapy: sulfasalazine 500mg x 1t 4r/sut., Indomethacin 1t x 3r/sut., Physiotherapy,
massage.
14.2. The analytical part of
13.2.1. Case studies:
Objective number one
33 year-old man complained of pain and stiffness in the cervical, thoracic and lumbar spine, pain
in the buttocks, worse at night. Ill for 5 years. Constantly taking indomethacin.
OBJECTIVE: kyphosis of the cervical spine, "pose petitioner" paravertebral muscles tense.
Peripheral joints are not changed. In the analysis of blood - ESR -38 mm / h
1. What research will clarify the diagnosis?
2. What changes do you expect to find in this study?
3. Formulate the clinical diagnosis
4. Assign treatment
№ ANSWERS
Max.
Full score unsatisfactory Not
response.
answered
1.
X-ray of the pelvis
20
10-20
5-9
0-4
2.
bilateral sacroiliitis
30
20-30
5-19
0-4
3.
Ankylosing spondylitis, a form of
20
10-20
5-9
0-4
central
4.
Indomethacin is long. Physical
therapy, massage, swimming in the
30
20-30
5-19
0-4
pool.
Task number two
Patient Sh 49 years, complained of pain and limitation of motion in the cervical, lumbar-sacral
spine, red eyes, general weakness.
Objectively: the general state of moderate severity. Pale skin, no rash. Pose "the petitioner".
Lumbar spine in the form of an ironing board. Simtomy Forestier Thomayer Kushelevsky 1,2,3
and positive. In the lungs, vesicular breathing. Heart: muted tones. Blood pressure 110/75 mm
Hg Pulse 70 beats in 1 minute. The abdomen is soft and painless.
Laboratory tests: Complete blood count: Hb - 90 g / L, white blood cells - 7 x • 109 EST 25mm/chas.
General urine analysis: specific gravity 1015, protein - abs, leukocytes - 3-4/1, epithelium - 12/1,
+ CRP, RF negative.
I. What form of ankylosing spondylitis expect:
2. What additional research needs to be carried out for the diagnosis:
3.Treatment
№
ANSWERS
Max.
Full score
1.
Central
40
30-40
unsatisfacto Not answered
ry response.
5-29
0-4
2.
3.
X-ray of the pelvis and joints ileosakralnyh
Indomethacin, physical therapy, muscle
relaxants
30
30
20-30
20-30
5-19
5-19
0-4
0-4
Task number three
Patient L., 39, mechanic arrived complaining of constant pain in the lumbosacral spine and the
hip and knee joints, worse by motion, sneezing, exercise, morning stiffness for 40 minutes in the
spine, limitation of movement in the affected joints.
Anamnesis revealed that suffers from this disease for 10 years. Acute onset, with the defeat of
the lumbar spine, knee and hip joints. Knee joints swell, inflammatory changes in the joints were
recurrent in nature. During the last 2 years exacerbation accompanied by a feeling of morning
stiffness in the affected joints. Repeatedly was treated by a neurologist about back pain and
dramatically accelerated sedimentation rate of 50 mm / h
OBJECTIVE: The patient had difficulty walking due to pain in the knee and hip joints.
According to the constitution astenikov, food satisfactory. Integuments clean enough
vlazhnosti.Otmechaetsya smoothness of the lumbar lordosis, muscle atrophy, positive symptom
"string." Severe swelling of the knee and defiguratsiya by exudative changes. Determined by
pain on palpation in the lumbosacral spine in the sacroiliac joints and knees. Positive symptoms
Kushelevsky, Ott, Schober and Thomayer.
Internal organs without significant changes.
1.What you expect to find in the laboratory and instrumental examination of the patient?
2.Vash clinical diagnosis. The differential diagnosis
3.Tactic of treatment
№
ANSWERS
1.
KLA: Hb-125 g / l, L - 8,2 x 10 / l, ESR - 50 40
mm / h
Obsch.belok - 85.2 g / L, CRP - + +, HLA B27 (+). RF (-)
The study of synovial fluid of the knee leukocytes 4000-6000 cells / mm.
An. urine unchanged.
Radiographs of the pelvis: signs of bilateral
sacroiliitis - narrowing of the sacroiliac joint
gaps with single erosion of the articular
surfaces of the sacroiliac
sochleneniy.Na radiograph of the knee joint space narrowing, single bone erosion.
Radiographs of the lumbosacral spine in 2
projections: nalichiesimptoma "square the"
vertebrae sindesmofitoz Front of vertebral
ossification
2.
Ankylosing spondylitis, a form of 30
peripheral, Step 2, the degree of activity of 2
FTS 2 degrees.
The differential diagnosis of rheumatoid
arthritis, Forestier's disease, psoriatic
arthropathy with, Reiter's disease with
paraneoplastic process.
Max.
Full
score
Not
answered
30-40
unsatisf
actory
respons
e.
5-29
20-30
5-19
0-4
0-4
3.
Social rehabilitation, NSAIDs, intraarticular administration of corticosteroids,
muscle relaxants, physical therapy, massage
30
20-30
5-19
0-4
4. A woman aged 42, appealed to a general practitioner with complaints of edema in the legs,
shortness of breath on exertion and fatigue. Deterioration felt recovering from tonsillitis. Is
registered rheumatologist about rheumatism, regularly receives bitsillinoterapiyu. OBJECTIVE:
pale skin, cyanosis of the lips, acrocyanosis. Blood pressure 100/70 mm Hg, pulse 92 beats /
min. The boundaries of the heart enlarged to the left and up. Auscultation: I tone clap, systolic
and presystolic noise on top, atrial fibrillation. In the lungs - in the lower congestion wheezing.
Abdomen soft, liver 1.5 cm, medium density, moderate swelling of the legs. ECG hypertrophy of
the left and right ventricles and the left atrium. KLA: HB 110, erythrocytes. 2.9 mil., Lei. 7.2.,
ESR 28 mm / hour.
1.Perechislite acquired at least three and one congenital heart defects, which are heard in both
systolic and diastolic heart sounds and listening to the best place;
2. The preliminary diagnosis;
3. Informative survey methods;
4. Tactics GPs;
5. Patient 45 years examined by a doctor in general practice. Notes morning stiffness up to 12
hours of the day, the pain in the small joints of the hands, body temperature 38.2 C, and
weakness. OBJECTIVE: malnutrition, pale skin, deformity wrist, interphalangeal joints of the
fingers, lymphadenopathy, hepatosplenomegaly. Blood pressure 100/60 mm Hg heart - muted
tones and rhythm. In the lungs - vesicular breathing. In the blood: Hb-90 g / l, Lake 3, 5 × 10 9 /
L, the calculation formula of leukocytes marked leukopenia, ESR 40 mm / h ECG revealed sinus
rhythm, and tachycardia.
1.Perechislite least five diseases for which there are the above complaints and symptoms;
2. Specify for each characteristic radiographic changes in the joints;
3. The preliminary diagnosis;
4. Informative survey methods;
5. Tactics GPs;
6. Patient K. 44, appealed to a general practitioner with complaints of pain and swelling in the
wrist, interphalangeal joints of the hands, feet, ankles, stiffness in the morning to continue until
lunchtime. Ill for a year. Objectively: the general state of moderate severity. Low-grade
temperature. Wrist, interphalangeal, ankle twisted by exudative phenomena. Of the heart and
other organs are no changes. Erythrocyte sedimentation rate of 50 mm / hour. DPA - .260.
1.Perechislite least five diseases for which there are the above complaints and symptoms;
2. The preliminary diagnosis;
3. Informative survey methods;
4. Are the seven diagnostic criteria for the disease according to the American Association of
Rheumatology;
5. Tactics GPs;
7. Patient S. 32, appealed to a general practitioner with complaints of persistent pain in the joints
of the hands, feet at rest and in motion. He considers himself a patient for 5 years. Connects the
disease with frequent angina. She was treated with stationary and periodic health improvement.
On examination, clearly defined muscle atrophy forearms, shins and thighs. Severe defiguratsiya
and deformation joints of the hands, wrist, elbow, knee and ankle joints by proliferative changes.
KLA: Hb-80 g / l, leucocytes 5.5 h109 / l, erythrocyte sedimentation rate 30 mm / hour.
Rheumatoid factor positive.
1.Perechislite least five diseases for which there are the above complaints and symptoms;
2. The preliminary diagnosis;
3. Informative survey methods;
4. Please provide details radiographic stage of the disease;
8. Patient 48 years, appealed to a general practitioner with complaints of intense pain and
swelling in the wrist, pyastnofalangovyh joints, worse at night and in the morning, morning
stiffness for 12 hours, raising the temperature to 38 C, a heavy feeling in the right side of the
chest during breathing. Objective: defeat marked symmetrical joints of the hands, ulnar deviation
of the hands in the side, the elbow detected nodules, firm to the touch, the size of 0.5-0.8 cm in
radiography joints of the hands - narrowing of the joint gaps, single Uzury articular surfaces.
Chest X-ray - is determined by the liquid in the right pleural cavity to the level of 6 ribs. OAM
oud. weight. 1018, protein 5.8, erythrocytes. 2/3 in p / s, lei. 4/5. individual cylinders.
1.Perechislite least four diseases for which there are the above complaints and symptoms;
2. The preliminary diagnosis;
3. Informative survey methods;
4. List at least 6 other organs are affected in this disease, and one multi-organ complications and
reliable method for its diagnosis;
5. Tactics GPs;
9. Patient 42 years old complained of headache, dizziness, pain, and swelling in the ankles,
palpitations and shortness of breath on exertion.
Anamnesis: in childhood often ill with angina, has 4 children, the last resolved Caesarean section
births. Housewife diet. The mother has diabetes.
Objectively: the state of moderate, pale skin, acrocyanosis, swelling in the legs. On palpation of
II m / d to the right while exhaling marked systolic tremor. The boundaries of the heart enlarged
to the left. Auscultation weakening at the top I tone of the aorta II tone. To the right of II m / d at
the point on the top of Botkin and auscultated systolic murmur, which is held in the
supraclavicular and carotid artery. Pulse 66 ud.v min. Blood pressure 110/70 mm Hg The liver is
enlarged, spleen not palpable
Lab. instrumental studies:
KLA: HB-110, al-4.0-9.2 leyk., ESR-18mm / h
TANK: urea-7.3, creatinine, 0.08, ob.belok-74g / l sugar-5.4 mmol / L
OAM: transparent, otn.plot. - 1018, protein abs., Epit.-0-1/1, leyk.-1-2/1,
al-0-1/1
Acute-phase sample-CRP +, ASO titre 1:300.
ECG showed sinus rhythm, heart rate of 90 beats. EOS away to the left. Intraventricular
conduction. Metabolic changes in the myocardium.
EhoKS:
1
Patient received a
demonstration of skills IPC
2
Determined leaders and
minor complaints
3
4
Anamnesis morbi
Anamnesis vitae
Greeted, seated in front of him, collected ratings, addressed to the
patient by name, using simple words and sentences understandablto
the patient
Leading complaints: headache, dizziness, pain, and swelling in
the ankles, palpitations and shortness of breath on exertion
Minor complaint:
Ill for several years
As a child, often ill with angina, has 4 children, the last generations
5
Identify risk factors
6
Defined the problem patient
7
Conducted an objective
examination
8
Has issued a preliminary
diagnosis indicating the
category of services
9
Made a plan for the survey
with the type of services
Hands-on practice skill
Analysis and interpretation
of laboratory and
instrumental studies
10
11
12
13
The differential diagnosis
Final diagnosis with the
type of services
14
15
Determined the form in
which the patient requires
prevention
Drug-free treatment
16
Medication
to resolve "Cesarean section". Housewife, diet, habits not. The
mother has diabetes.
Unmanaged: gender, age, family history (mother has diabetes).
Managed: frequent sore throats and childbirth.
Summary: headache, dizziness, pain, and swelling in the ankles,
palpitations and shortness of breath on exertion
Related:
State of moderate severity, pale skin, acrocyanosis, swelling in the
legs. On palpation of II m / d to the right while exhaling marked
systolic tremor. The boundaries of the heart enlarged to the left.
Auscultation: weakening at the top I tone of the aorta II tone. To
the right of II m / d at the point on the top of Botkin and
auscultated systolic murmur, which is held in the supraclavicular
and carotid artery. Pulse 66 ud.v min. Blood pressure 110/70 mm
Hg The liver is enlarged, spleen not palpable
DOS.: Re rheumatic fever. Polyarthritis. Aortic defect. Stenosis of
the aortic orifice. The relative failure of the mitral valve.
Osl.: NC II B.FK III (according to NYHA).
Category 2
3.1.: KLA, OAM, blood sugar, ECG
3.2.: BAC, R-gene gr.kletki and joints, acute-phase sample EhoKS.
ECG
KLA: leukocytosis, increased erythrocyte sedimentation rate.
OAM: b / o
LHC b / o
Ostrofaz.proby: DRR +, higher. ASO titre
ECG showed sinus rhythm, heart rate of 90 beats. EOS away to
the left. Intraventricular conduction. Metabolic changes in the
myocardium.
Reactive arthritis, RA, UPU
Basic.: Re rheumatic fever. Polyarthritis. Aortic defect. Stenosis of
the aortic orifice. The relative failure of the mitral valve.
Osl.: NC II B.FK III (according to NYHA).
Category 2
Secondary b - treatment are drugs of proven efficacy
Tertiary - treatment of complications, rehabilitation, prophylactic
medical examination
Healthy living, hardening, nutrition, compliance work and rest,
rehabilitation centers of infection, a spa treatment.
1.
1. Etiological treatment-bicillin 5 1.5mln.Ed every 3 weeks.
During 1.5-2 months.
2.
17
Spent feedback
18
We define the group 'D'
observations
2. Relief of active inflammation, NSAIDs (diclofenac)
3.
3. Symptomatic treatment of treatment-NC (diuretics, ACE
inhibitors)
Asked the patient if all clear to-treat, made sure whether there was
other issues, problems, everything is clear for non-drug and drug
therapy. Set a date for a return visit.
D3 - patients with chronic diseases who require treatment
a. - Compensate (rare disease exacerbation, without reducing
19
Theoretical knowledge and
practical steps of all
prevention
20
Theoretical knowledge and
practical steps on the stages
of clinical examination
efficiency)
b. - Subcompensated (frequent exacerbations, decreased
performance)
a. - Decompensated (inoperative)
1 Speedlight care prof-ka: hardening of the body, improving the
standard of living, better housing, combating congestion in det.sad,
schools, early treatment of angina, proper nutrition, respect for
work and rest.
2 Speedlight care prof-ka: early detection ZAB-I in the early stages
(baseline medical examination, screening). Non-pharmacological
and pharmacological treatment with proven efficacy.
3 Speedlight care prof-ka: timely observation of patients,
prevention of acute and chronic complications, monitoring lab.instrumental. Research, quality rehabilitation of existing
complications.
1st - proved and established nosological form of the disease and
identified a group of "D" up (D3)
2nd - To determine the frequency of observations in the course of
the year (check rheumatologist 4 times a year, ENT and dental 1 p /
year, optometrist 1 time in 2 years, according to testimony heart
surgeon, neurologist)
Third - based inspection specialists if needed
4th - to define and justify the name and frequency lab.instrument.
Research during the year (OAK 4 p / year, OAM, R-gene gr.kletki,
ECG, PCG, EhoKS, BAK 2 p / year)
5 th - was a coherent plan of therapeutic activities for the year (of
anti-treatment is 2.3 p / a)
6th - established performance criteria and knew Dr. observations
upon nosology with subsequent transfer to a different group of Dobservation.
10. Patient 32 years old complained of pain in the small joints of both hands, morning stiffness,
fatigue.
Of history: According to the patient the above complaints concerned in the last two weeks,
which connects with hypothermia (works at the market). He considers himself a patient in the
course of 1.5 years, when the swelling of the small joints of hands. Consists on the 'D' registered
rheumatologist and GPs. As a child, often get cold, has 1 child, the pregnancy was normal. Sister
of the patient suffers from rheumatism.
OBJECTIVE: relatively satisfactory condition, skin and visible mucous membranes pale.
Auscultation of the lungs vesicular breathing. Cardiac clear, rhythmic. Blood pressure 120/70
mm Hg Small joints (metacarpophalangeal and proximal interphalangeal joints) when viewed
swollen. The movement in the joints painful.
Lab. instrumental studies:
KLA: HB-100, al-3.0-6.2 leyk., ESR-25 mm / h
TANK: urea-7.3, creatinine, 0.08, ob.belok-56 g / l, sugar-5.4 mmol / L, fibrinogen420mg%
OAM: transparent, otn.plot. - 1020, protein-0.033., Epit.-0-1/1, leyk.-3-2/1,
al-0-1/1
Acute-phase sample-CRP + +, ASO titre of 1:150.
ECG showed sinus rhythm, heart rate 82 bpm. EOS is not rejected. Metabolic changes in
the myocardium.
X-ray joints: periarticular osteoporosis. Joint space narrowing proximal interphalangeal
joints of the fingers of both hands, single Uzury.
EhoKS: left ventricular cavity is not enlarged. CRA-4, 6, SW-2, 7, EF-69%, PL-2, 8. Mitral
valve V-shaped, not compacted. LV wall normokinetichny. IVST-0, 9; TZSLZH-0, 85.
Tricuspid valve and pulmonary artery were normal. Doppler: no abnormal flow.
Myocardial contractility was normal.
1
Patient received a
Greeted, seated in front of him, collected ratings, addressed
demonstration of skills IPC to the patient by name, using simple words and sentences
understandable to the patient
2
Determined leaders and
Leading complaints: pain in the small joints of both hands,
minor complaints
morning stiffness
Minor complaints: fatigue
3
Anamnesis morbi
According to the patient concerned about the above
complaints in the last two weeks, which connects with
hypothermia (working at the market.) He considers himself a
patient in the course of 1.5 years, when the swelling of the
small joints of hands. Consists on the 'D' registered
rheumatologist and GPs.
4
Anamnesis vitae
As a child, often get cold, has 1 child, the pregnancy was
normal. Sister of the patient suffers from rheumatism.
5
Identify risk factors
Unmanaged: gender, age, family history (sister of
rheumatism).
Managed: hypothermia.
6
Defined the problem patient Summary: pain in the small joints of both hands, morning
stiffness
Related: fatigue
7
Conducted an objective
Relatively satisfactory condition, skin and visible mucous
examination
membranes pale. Auscultation of the lungs vesicular
breathing. Cardiac clear, rhythmic. Blood pressure 120/70
mm Hg Small joints (metacarpophalangeal and proximal
interphalangeal joints) when viewed swollen. The movement
in the joints painful.
8
Has issued a preliminary
Basic.: Rheumatoid Arthritis: arthritis, slowly
diagnosis indicating the
progressive course, FNS I
category of services
Category 2
9
Made a plan for the survey
3.1.: KLA, OAM, ECG.
with the type of services
3.2.: BAC acute-phase samples (RF, CRP, haptoglobin,
fibrinogen, total protein and protein fractions, ASO), Rgene joints EhoKS (to prevent rheumatic process).
10 Hands-on practice skill
ECG
11 Analysis and interpretation
KLA: Hb-impaired., Al-impaired., ESR-incr.
of laboratory and
LHC ob.belok-red., Fibrinogen higher.
instrumental studies
OAM: b / o
Acute-phase sample-CRP + +
ECG: b / o
R-gene joints: periarticular osteoporosis. Joint space
narrowing proximal interphalangeal joints of the fingers
of both hands, single Uzury.
EhoKS: b / o
12 The differential diagnosis
Reactive arthritis, rheumatic fever, repeated, osteoarthritis of
small joints of the hands
13 Final diagnosis with the
Basic.: Rheumatoid Arthritis: arthritis, antibody-positive,
type of services
14
15
Determined the form in
which the patient requires
prevention
Drug-free treatment
16
Medication
slowly progressive course, the activity of II degree,
radiological stage II, FNS I.
Category 2
Secondary b - treatment are drugs of proven efficacy
Tertiary - treatment of complications, rehabilitation,
prophylactic medical examination
Healthy living, hardening, nutrition, compliance work and
rest, rehabilitation centers of infection, a spa treatment.
4.
4. Basic treatment - methotrexate 2.5 mg 3 p / week,
or krizanol or sulfasalazine at a daily dose of 1-2 g
5. Anti-inflammatory drugs - NSAIDs (diclofenac, the mean
daily dose of 75-150 mg)
17
Spent feedback
18
We define the group 'D'
observations
19
Theoretical knowledge and
practical steps of all
prevention
20
Theoretical knowledge and
practical steps on the stages
of clinical examination
Asked the patient if all clear to-treat, made sure whether
there was other issues, problems, everything is clear for nondrug and drug therapy. Set a date for a return visit.
D3 - patients with chronic diseases who require treatment
a. - Compensate (rare disease exacerbation, without
reducing efficiency)
b. - Subcompensated (frequent exacerbations, decreased
performance)
a. - Decompensated (inoperative)
1 Speedlight care prof-ka: hardening of the body, improving
the standard of living, better housing, combating congestion
in det.sad, schools, early treatment of angina, proper
nutrition, respect for work and rest.
2 Speedlight care prof-ka: early detection ZAB-I in the early
stages (baseline medical examination, screening). Nonpharmacological and pharmacological treatment with proven
efficacy.
3 Speedlight care prof-ka: timely observation of patients,
prevention of acute and chronic complications, monitoring
lab.-instrumental. Research, quality rehabilitation of existing
complications.
1st - proved and established nosological form of the disease
and identified a group of "D" up (D3)
2nd - To determine the frequency of observations in the
course of the year (check rheumatologist 4 times a year,
ENT and dental 1 p / year, optometrist 1 time in 2 years,
according to testimony heart surgeon, neurologist)
Third - based inspection specialists if needed
4th - to define and justify the name and frequency
lab.instrument. Research during the year (OAK 4 p / year,
OAM, R-gene gr.kletki, ECG, PCG, EhoKS, BAK 2 p /
year)
5 th - was a coherent plan of therapeutic activities for the
year (of anti-treatment is 2.3 p / a)
6th - established performance criteria and knew Dr.
observations upon nosology with subsequent transfer to a
different group of D-observation.
14.2.2 Graphic Organizer: chart "Venn"
14.3. The practical part
1. The list of skills that GPs should possess after completing studies on the subject
2. Conduct a survey of patients with arthritis and arthralgia.
3. Interpret the ECG and chest X-ray in patients with arthritis and arthralgia
Joint Pain
Reactive arthritis, ankylosing spondylitis, psoriatic arthritis
Stage № Performance / interpretation
not done
completely
executed
examination of the patient
Complete blood count,
Total urine
acute-phase samples
uric acid
A blood test for LE-cells revmofaktor, HLA-B27,
etc.
0
50
ECG
Echocardiography
X-rays of joints
Arthrocentesis with the study of synovial fluid
infectious disease consultation
Biopsy
differential diagnosis
The diagnosis
tactics GPs
TOTAL
0
0
0
0
0
20
10
10
10
100
15. The number and types of control measures to assess knowledge STUDENT
• Verbally
• In writing
• The decision of situational problems
• Demonstration of skills mastered
16. The evaluation criteria of the current control
levels of
ratings
rating
scores
96-100
fine
Characteristics of the student's work
The answer is original and of the highest quality, exceeding the
requirements of the program. High quality of practical work, processing
medical records and the availability of lecture notes, subordinators book
and workbook, presentation and active participation with the reports in
the morning conferences, use the responses to these activities on the
Internet, and active participation in clinical and case parsing duty and
supervision patients in the hospital and service calls in the clinic.
86-100%
91-95
The high quality of the answer that exceeds the requirements of the
program, good works and their design, the availability of lecture notes,
subordinators book and workbook, make presentations at the morning
conference, active participation in clinical and case parsing duty and
supervision of hospital and service calls in clinic.
Correct, appearances on the secondary literature, the correct number of
case studies, the availability of lecture notes, subordinators book and
workbook, proper management of medical records, and active
participation in morning conferences, clinical and case parsing duty and
supervision of hospital and service calls in the clinic .
86-90
81-85,9
good
71-85,9%
76-80
71-75,9
66-70,9
Satisfies
the works
55-70,9%
61-65,9
55-60,9
not
satisfactor
y
20 - 54,9
20-10
Response to good quality, relevant programs, active implementation of
practical work, the availability of lecture notes, subordinators book and
workbook, timely and correct completion of the medical records and
hospital records, patients and quality Supervision duty in the hospital and
service calls in the clinic.
The answer is above average, mainly corresponding to the program
requirements. Participation in the implementation of practical work, the
availability of the text of lectures, book and workbook subordinators,
timely and correct completion of the medical records and hospital
records, patients and quality Supervision duty in the hospital and service
calls in the clinic.
Reply average quality, there may be some errors in the performance of
work or negligence in the design of protocols and lecture notes, books
subordinators and workbook, as well as record keeping in the hospital
and clinic.
Average response rates, which has inaccuracies, errors in the individual
performance of work, seeing his patients and service calls in the clinic,
duty, supervision of patients in the hospital, the availability of lecture
notebooks, subordinators book and workbook, but insufficient to
maintain, inaccurate registration records in inpatient and outpatient
settings.
The answer has serious errors involved in the implementation of practical
work, no accurate record keeping in the hospital and in the clinic, and
lecture notebooks, untimely performance of tasks, status, supervision of
patients в стационаре и обслуживания вызовов в поликлинике poor
quality.
Average response to the major drawbacks. Passive participation in the
execution of works, the reception of patients and service calls in the
clinic, duty, supervision of patients in the hospital, the presence of
subordinators book and workbook, no texts of lectures.
Answer below average, with substantial errors and gaps in learning
programs (not certification). Do not perform work on the reception of
patients and on duty, supervision of patients in the hospital, in the recordkeeping in the hospital and in the clinic, filling gaps in subordinators
book and workbook, no texts of lectures.
Point of presence on the practical lesson. Failure to follow any of the
requirements imposed on the exercise, lack of documentation and
delayed filling, bad duty, supervision of hospital and service calls in the
clinic.
17. Checklists.
1. Especially arthritis and rheumatism arthralgia.
2. Especially arthritis and arthralgia in rheumatoid arthritis.
3. Differential diagnosis of joint syndrome.
4. Classification of rheumatism and rheumatoid arthritis
5. The course and diagnosis of these diseases
LITERATURE:
Main:
1. Воробьев. Справочник практического врача в 2-х томах, 1990 г.
2. Вудли М., А.Узлан. Терапевтический справочник Вашингтонского Университета.
Практикум, 1995 г.
3. Денисов И.Н. Справочник путеводитель практикующего врача от "А" до "Я”.
ГЭОТАР, Москва, Медицина.,1999г.
4. Комаров Ф.И. Диагностика и лечение внутренних болезней. Руководство для врачей в
3-х томах, М, Медицина,1999 г.
5. Матвиенко Г.П. Клиническая диагностика. Справочное пособие для семейного врача.
Минск, Беларусь, 1999 г.
6. Мерта Дж. Справочник врача общей практики. М., Практикум, 1998г.
7. Никитин Ю.П. “Все по уходу за больным в больнице и дома”, ГЭОТАР, Москва,
Медицина, 1998 г.
8. Окороков А.Н. Лечение болезней внутренних органов. Том 3, книга 1 и 2. Москва.
Медицинская литература. 2005 г.
9. Ригельман “Как избежать врачебных ошибок?”. 1994 г. М. Практикум.
10. Сенфорд “Антимикробная терапия”. 1996 г. М. Практикум.
11. Симбирцев С.А. “Общая врачебная практика”. 1996 г. П том. С.-Петербург.
12. Чиркин А.А., Окороков А.Н., Гончарик И.И. “Диагностический справочник терапевта.
Беларусь. 1993 г.
13. Чучалин А.Г., “Терапия”, 1996 г.
Additional:
1. Хеглин Р. “Дифференциальная диагностика внутренних болезней”. Медицина 1997 г.,
8-том.
2. Денисов И.Д. Энциклопедия клинического обследования больного, ГЭОТАР, Москва,
Медицина.,1998
3. Затурофф “Симптомы внутренних болезней”. М., 1997 г. Практикум.
4. Мерк, Шарп, Доум “Руководство по медицине” - 2 тома, “Мир”, 1997 г.
5. Беркоц Р. “Руководство по медицине”., 1-П том, М. 1997
6. Федеральное руководство для врачей по использованию лекарственных средств.
Выпуск 1,М., 2002