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 dermatomyositis and hemorrhagic vasculitis. Tactics
GPs.
Differential diagnosis of nonspecific aorto-arteritis nodosa and periarthritis. Tactics GPs
Tashkent
Compiled by:
Compiled by:
Education technology approved:
At the faculty meeting minutes №
from «___ » ____________ 2012 г
SUBJECT Differential diagnosis of dermatomyositis and hemorrhagic vasculitis. Tactics
GPs.
Differential diagnosis of nonspecific aorto-arteritis nodosa and periarthritis. Tactics GPs
1. Location classes
1. - Department of Internal Medicine for the preparation of a general practitioner with an
endocrinologist, a hospital
2. Chronological content activities
1.
Time
Activities
Content
Materials
Continued
8.30– 9.00
9.00-11.00
11.00-11.55
11.55-12.40
12.40-13.30
13.30-14.15
Morning conference
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.
Hospital records
of patients.
30 min.
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.
2h.
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 min
45 min
50 min.
45 min.
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
Dermatomyositis (polymyositis) - systemic disease with characteristic lesions of striated
muscle and skin. The term "polymyositis" is used in cases where the patient no skin changes.
Etiology and pathogenesis. Assumed a viral etiology of dermatomyositis (DM). Some
importance is attached to genetics, neuroendocrine shifts. In the pathogenesis of the disease
leading role of autoimmune disorders. Almost every fourth patient DM develops in the presence
of malignant tumors (so-called secondary, "tumor", dermatomyositis).
The clinical picture. Most suffer from women aged 40 to 60 years. The disease may begin
acutely or gradually - from the skin, muscle or skin-muscle syndrome. The most common signs
of this period are a pain in the muscles, muscle weakness, swelling of the face, especially
paraorbital areas, low-grade fever, loss of body weight. In other cases, the onset of the disease,
general weakness, myalgia, arthralgia, dermatitis.
Muscle pathology in the clinic takes a leading place in the second, symptomatic, period. Often
there is a generalized loss of the striated muscles of the limbs, trunk and neck. Typically
preferential involvement in the pathological process of proximal muscle groups (muscles of the
shoulder girdle and hips). Aching muscles during movement and palpation, progressive muscle
weakness, a significant limitation of active movements. The patient can not stand on their own,
to sit, to tear his head off the pillow, a foot from the floor, brushing my hair, take off your shirt,
etc. In the sitting head falls to his chest. There may be a masklike face. Limb muscles in the
affected area become dense, swollen. Many patients, especially in acute phase, there is a visceral
and muscular symptoms. Affects the muscles of the pharynx, esophagus and primary larynx.
Wherein the liquid food can be poured out through the nose, the patient poperhivaetsya appears
hoarseness. Often affects the respiratory muscles, including the diaphragm (shortness of breath,
high standing of the diaphragm, reducing the VC). In cases of involvement in the extraocular
muscles are observed diplopia, ptosis.
Gradually developed severe atrophy of the affected muscles, they can deposit calcium salts.
Superficial lesions calcifications can be opened independently from the department "cheesy"
limestone mass. In severe cases there may be tendon-muscle contraction, significantly limiting
the functional ability of the patient.
Skin lesions - one of the most striking and characteristic features of dermatomyositis. Pathology
of the skin is mainly located on the exposed parts of the body. Appears stable, bright erythema
face resembling sunburn skin. Sometimes erythema grabs the neck, shoulders, forearms and
shins. Possible peeling, desquamation, ulceration, and even parts of erythema. The elements of
the rash can be painful, accompanied nesterpimymkozhnym itching. With regression of erythema
becomes brown pigmentation, which may remain for a long time. Rare are papular, bullous and
petechial rash. Unlike SLE skin lesions in dermatomyositis characterized by high resistance, a
bluish tint, scaling and itching. In many patients the kapillyarity palms and finger joints caused
vascular pathology.
Erythema is often accompanied by a dense testovatoy or swelling of the skin and subcutaneous
tissue mainly in the face and extremities. Edema can be both limited and widespread. The most
typical paraorbital edema and erythema with purple coloring of the skin around the eyes (a
symptom of "purple glasses", "half-mask"). When DM often in the pathological process involved
the mucous membranes, which is manifested by conjunctivitis, rhinitis, laryngitis, pharyngitis,
stomatitis, glossitis. Almost all patients are Nutritional: nail changes, increased hair loss,
alopecia, dry skin, loss of body weight. In some patients, skin lesions are absent.
Joint syndrome is not typical of DM, is rare and weak. Often observed polyarthralgia. Emerging
contracture in most cases are not associated with pathology of the joints, and mainly affecting
the tendons and muscles. The internal organs are involved in the disease process is rare. More
likely to suffer heart attacks because of the defeat (myocarditis, cardio). The pathology of other
organs due to vasculitis. In the lungs, sometimes found in-vascular or terstitsialny pneumonitis
symptoms of fibrosing alveolitis. Some patients can be observed hepatomegaly, kidney, eye, and
endocrine glands. 'Almost a third of patients have damage the nervous system, are rare disorders
of the nervous system polinevrity.Klinicheski manifested hyperesthesia, hyperalgesia,
paresthesia, sometimes areflexia.
Tumor dermatomyositis in their clinical manifestations is no different from idiopathic.
Laboratory performance. Specific laboratory tests for the diagnosis of dermatomyositis does not
exist. Some patients revealed leukocytosis, mild anemia, eosinophilia, increased ESR,
disproteinemia. May increase serum creatinine and creatine, creatine phosphokinase,
transaminases, especially the ACT and FGD. A small number of patients show a single LE-cells.
Diagnosis is based on clinical data. The leading role is given characteristic skin, muscle, visceral
and muscular syndromes. Secondary importance are laboratory data, results of
electromyography. In a hospital where every patient with suspected DM to be hospitalized, to
confirm the diagnosis is usually made of skin-muscle biopsy.
DM patient should first be carefully examined to exclude neoplastic nature of the disease. In
most cases, the "tumor" DM clinical features of the tumor are not available. Especially should
alert in terms of oncology cases of DM with persistent changes in laboratory parameters and
refractory to corticosteroid therapy. In identifying cancer patient is placed under the supervision
of oncologists, because no drug therapy does not eliminate the secondary manifestations of DM.
The differential diagnosis is performed with SLE, SSc, RA, periarteritis nodosa, pannikulitom
Weber-Christian, polymyalgia rheumatica, trichinosis, Cohn syndrome, neurological disorders.
Treatment. The drug of choice in the treatment of DM are considered high doses of
corticosteroids (methylprednisolone, 32 to 100 mg / day, depending on the activity and the
nature of the flow, or prednisone, 40 to 120 mg / day). Dose of hormonal methods, appropriate
severity of the disease, apply 2-3 months, and then at a distinct clinical effect is reduced to a
maintenance (methylprednisolone, 8-24 mg / day prednisolone 10-30 mg / day). When DM
should not be given corticosteroid hormones such as triamcinolone and polkortolona because of
the possibility of myopathy, which exacerbates the course of the underlying disease.
Prednisone dose depends on the severity and activity of the pathological process. Generally, the
higher the level of acute phase reactant in the blood, the higher the dose of corticosteroids must
be assigned to the patient. Increasingly use high dosages (32 to 100 mg per day orally
megilprednizolona).
The effectiveness of corticosteroid therapy is monitored by clinical parameters (disappearance
nasal voice, choking when swallowing, reducing swelling of the face and extremities, pain and
muscle weakness) and laboratory parameters (normalization of serum organ-specific enzymes).
Patients have steroid requires reconsidering the possibility of having the body of a malignant
tumor.
With significant clinical and laboratory improvement of the patient is necessary to move to a
gradual reduction in dose of corticosteroids to the minimum maintenance, the intake of which it
is possible to control the pathologic process at the minimum activity or state of clinical
remission. Minimum maintenance dose depends on the characteristics of the patient and the
nature of the pathological process. It can vary from patient to patient from 4.0 to 20 mg of
prednisone per day.
High-dose corticosteroids for dermatomyositis is often accompanied by the development of side
effects. Possible gastrointestinal bleeding, ulceration of the gastric mucosa, bone fractures due to
osteoporosis, hypertension, psychosis, steroid diabetes, and others to prevent the development of
complications of steroid therapy is important selection of optimal doses of drugs, coadministration to the patient of antacids, drugs potassium, calcium, careful monitoring of the
patient and the dynamics of the most important laboratory parameters.
In acute and subacute dermatomyositis along with corticosteroids shows the use of cytotoxic
drugs. The drug of choice is methotrexate weekly dose 7,5-15,0 mg. He is to take 1 tablet (2.5
mg) every 12 hours (all weekly dose) or 1 tablet every day. In some cases, the dose of
methotrexate can be increased up to 22.5 mg / day. Intolerance to the drug or the development of
side effects of methotrexate may instead appointment shigioprina (azathioprine), 2-3 mg / kg per
day. Cytotoxic drugs in the therapeutic dose patients take at least 3-5 MCC or until clinical
improvement, and then gradually move on to receive maintenance doses. Maintenance doses of
cytotoxic drugs if tolerated taken years.
Assigning patient dermatomyositis methotrexate doctor constantly, regardless of the timing of
administration of the drug should be aware of the possibility of side effects. The most
threatening is myelotoxic agranulocytosis, and the most frequent - ulcerative stomatitis,
esophagitis, and liver damage.
As a non-specific anti-inflammatory and antioxidant therapy should be adopted for course
(within 10 days of each month) appointment of ascorbic acid and atokoferola in high doses. Dose
of ascorbic acid in these situations is 0.5-1.0 g / d, and a-tocopherol - up to 0.5 g / day.
After the relief of acute disease process shows prescriptions that improve metabolism in muscle
tissue. Useful riboksin 0.4 g 3 times a day for 3-4 weeks, potassium orotate 0.5 g 3 times a day,
anabolic steroids (retabolil 1 ml intramuscularly 1 every 10-14 days, 3 injections per course ),
creatine, multivitamins, etc.
Along with the reduction of inflammatory activity, reduce symptoms of muscle weakness
extends motor mode and assigned to physical therapy. Only in the inactive phase of the disease is
recommended massage muscles of the trunk and extremities.
Spa treatment for dermatomyositis, as in other diseases of the connective tissue is not
recommended. Can only stay in the local health centers for recreation.
Prevention of exacerbations is taken regularly support dosages of drugs, primarily
corticosteroids. Periodically, the courses strengthening therapy. Strongly recommends regular
physical therapy sessions. Patients should avoid factors that contribute to the exacerbation of the
pathological process (giperinsolyatsiya, hypothermia, cold, abortion, stress, etc.).
Systemic vasculitis (SV)- group of diseases with similar pathogenesis, which are based on
generalized lesion vessels (arteries and veins of different caliber) with inflammation and necrosis
of the vascular wall and secondary involvement in the pathological process of organs and
systems.
There are primary and secondary ST. Primary NE are independent nosological forms of diseases.
When these pathological process is generalized. Secondary vasculitis may occur in infectious
diseases (infectious endocarditis, septicemia, rickettsiosis), certain tumors (volosatoklstochnaya
leukemia, lymphoma, solid tumors), drug (serum) intolerance, systemic connective tissue
diseases (systemic lupus erythematosus, cryoglobulinemia, rheumatoid arthritis), chronic active
hepatitis, occupational diseases (berrilioz, arsenic intoxication). Secondary vasculitis are local in
nature and developed as a reaction to an infection, exposure to chemical agents, tumors, etc.
Leading role in the treatment of secondary vasculitis is successful treatment of the underlying
disease or elimination of externalities factor.
Systemic vasculitis - a disease of various etiologies. Disease process may be caused by drugs
(antibiotics, sulfonamides, vaccines, serums, anti-TB drugs, etc.), radiopaque diagnostic agents,
allergens (food, cold, hay fever), viruses (hepatitis B, herpes, cytomegalovirus). Generalized
vascular damage under the influence of etiology develops in individuals with genetically based
defect immune response and altered vascular reactivity.
When vasculitis is possible as a direct effect of the etiological factor for vascular wall and
damage it as a result of immune response to a foreign antigen or autoantigen with the formation
of circulating immune complexes. The latter can be recorded in the vessel wall and through the
activation of the complement system, polymorphonuclear neutrophils cause the development of
the inflammatory response.
NE nomenclature adopted in the CIS countries, is presented in Table. 3.
Tab. 3. Nomenclature of systemic vasculitis
1. periarteritis nodosa
2. Granulomatous arteritis:
2.1. Wegener's granuloma
2.2. Eosinophilic granulomatous vasculitis
Extension Table. 3.
3. Giant cell arteritis:
3.1. Temporal arteritis (Horton's disease)
3.2. polymyalgia rheumatica
3.3. Nonspecific aortoarteriit (Takayasu's disease)
4. Hyperergic arteritis:
4.1. Hemorrhagic vasculitis (Henoch's disease)
4.2. Mixed cryoglobulinemia (krioglobulinemicheskaya purpura)
4.3. Hypersensitivity allergic vasculitis
5. Thromboangiitis obliterans (Buerger's disease-Vinivartera)
6. Thrombotic thrombocytopenic purpura (syndrome Moszkowicz)
7. Behcet's syndrome
8. Kawasaki syndrome (muco-cutaneous-glandular syndrome)
The clinical picture. Outlines the main clinical manifestations in some forms of systemic
vasculitis.
Periarteritis nodosa in typical characteristic of kidney disease (nephritis), nervous system
(mononeuritis, asymmetric polyneuropathy or polyneuritis), arterial hypertension. There may be
abdominal syndrome (vasculitis of the abdominal cavity), exhibit pain and often a picture
simulating acute abdomen. There are "unfounded" weight loss, skin lesions by type of livedo
reticularis, muscle-joint pain. In the study of blood revealed anemia, susceptibility to
leukocytosis and eosinophilia, increased erythrocyte sedimentation rate. In 60% of patients in the
present krdvi hepatitis B surface antigen (HbsAg). In the analysis of histological material are
granulocytes and mononuclear leukocytes in the arterial wall.
Wegener's granulomatosis is inherent in the emergence of painful or painless ulcers in the mouth
or pus and bleeding from the nose (rhinogenous or localized stage). Then, in the form of light
units, fixed infiltrates or cavities, observed radiographically. Perhaps hemoptysis (pulmonary
stage). Renal pathology manifested picture glomerulonephritis (generalized stage).
When thromboangiitis obliterans mainly affected arteries and veins of the lower extremities.
Increasingly common in men aged 30-40 years. Characterized by symptoms of migrating
thrombophlebitis arterialOpredelenie criterion
The decrease in body weight of 4 kg and no longer as a result of diet and other factors
Spotted reticular lesions of individual sections of limbs or trunk
Pain or tenderness of the testicles is not due to an infection, injury, or other cause
Diffuse myalgias (excluding shoulder and pelvic girdle), or muscle weakness, leg pain or leg
muscles
Mononeyropatii development, multiple mononeyropatii or polyneuropathy
The development of hypertension with diastolic blood pressure above 90 mm Hg
Tab. 6. Diagnostic criteria for giant cell arteritis
Increased urea> 6.66 mmol / l or creatinine> 0.133 mmol / l due to dehydration or obstruction
The presence of serum hepatitis B surface antigen or antibody
Aneurysm or occlusion of visceral arteries on arteriogram not because of arteriosclerosis, fibrosis
muskulyarnoy dysplasia, or other noninflammatory causes
For classification purposes of the patient is considered to have polyarteritis nodosa if at least
three of the 10 criteria.
The presence of any three or more criteria yields 82.2% sensitivity and 86.6% specificity.
Tab. 5. Diagnostic criteria for Wegener's granulomatosis
Certain criteria
Development of painful or painless oral ulcers or purulent or bloody nasal discharge
A chest radiograph with the presence of nodes, fixed infiltrates or cavities
Microhematuria (> 5 red blood cells per field) or red blood cell crystals in the urinary sediment
4. Histological evidence of granulomatous inflammation on biopsy palenie in the wall of an
artery or in the perivascular region (arteries or arterioles) For the purposes of classification, the
patient should have at least 2 of the 4 criteria. The presence of any two criteria are met 88.2%
sensitivity and 92.0% specificity.
The criteria used in the diagnostic process further.
The onset of symptoms or findings at the age of 50 years and older.
A new beginning or a new type of localized headache.
Temporal artery tenderness to palpation or decreased pulsation, unrelated to arteriosclerosis of
cervical arteries.
Erythrocyte sedimentation rate> 50 mm / h, which is determined by the method of Westergren.
Bioptat.soderzhaschy artery with signs you kulita.harakterizuyuschegosya predominance of
mononuclear cell infiltration or granulomatous inflammation, usually with multinuklearnymi
giant cells.
Development of painful areas of the scalp or nodules is the temporal artery or other cranial
arteries.
Certain criteria.
Development of symptoms or findings related to Takayasu arteritis at age <40 years.
The development and worsening of fatigue and discomfort in one or more limbs with a load
especially the upper extremities.
Reduced pulsation of one or both brachial arteries
4. The difference in blood pressure> 10 mmHg
5. The noise of the subclavian artery or the aorta
6. Changes in the arteriogram
1. Palpable purpura
2. Age at onset <20 years
3. Intestinal colic
4. Granulocytes in the vessel wall biopsy
1. . Gastrointestinal bleeding
The difference of more than 10 mmHg in systolic blood pressure at the hands of
Noise, listen to auscultation over one or both subclavian arteries and abdominal aorta
Arteriograficheskoe narrowing or occlusion of the entire aorta, its primary branches, or large
arteries in the proximal upper or lower extremities due to atherosclerosis, fibromuscular
dysplasia or other similar reasons, the changes usually focal or segmental
Slightly raised "Palpable" hemorrhagic rash, non-thrombocytopenic
A patient 20 years or younger at the time of the first symptoms
Diffuse abdominal bol.usilivayuschayasya after meals, or the diagnosis of intestinal ischemia,
usually including bloody diarrhea
Histological determination of granulocytes in the wall of arterioles and venules
Passage melena, hematochezia, or intensely positive for occult blood in the stool (benzidine test).
More criteria
Recurrent aphthous ulcers of the oral cavity
Skin lesions of erythema nodosum-type subcutaneous thrombophlebitis lesions by type of
folliculitis skin hypersensitivity.
Iridocyclitis retinal eye disease uveitis (chorioretinitis), genital ulcers
3. Modulation of the immune mechanism underlying the development of the inflammatory
response.
In each case of systemic vasculitis is extremely important early, comprehensive and timely
initiation of treatment. Significance attached to individual selection of drugs and their dosages,
determination of optimal duration of treatment. In the case of advanced disease to a long multiyear treatment. With the need for potent drugs physician must remain aware of the possibility of
severe complications.
The basis of pharmacotherapy NE are corticosteroid hormones, which have potent antiinflammatory, and in large doses - and immunosuppressive action. Reduce the inflammatory
response in the vascular wall also helps depression migration of neutrophils. Corticosteroids
primarily affect the mobility of monocytes, their chemotaxis. Under the influence of steroids
decreases the level of prostaglandins, inhibited the functional activity of T-and B-lymphocytes,
decreased production of immunoglobulins.
With the purpose of treatment can be used methylprednisolone, prednisolone, triamcinolone,
dexamethasone, betamethasone. Most often, they are appointed inside. Daily dose of
corticosteroids in terms of prednisolone is usually from 20 to 80 mg, depending on the form of
N, degree of activity, characteristics of the disease. Initially shown therapeutic dosage of the
drug or dose reduction, and after a significant clinical and laboratory improvements need to go to
receive maintenance doses. Supporting dose prednisolone in various forms of N can range from
5 to 25 mg / day.
In prognostically unfavorable cases, with a maximum activity of disease or poor efficacy of the
therapy, corticosteroid hormones may be administered intravenously. The most widespread of
methylprednisolone pulse therapy. The patient intravenously for 3 consecutive yes introduced
1000 mg. The use of such high doses of corticosteroids shock quickly enough to suppress the
immunopathological process.
In order to suppress the immune mechanisms of the inflammatory response, the correction of
impaired immune status in NE widely used cytotoxic drugs. Drugs of choice are
cyclophosphamide 2 mg / kg, azathioprine (2 mg / kg), methotrexate (10-15 mg / week). In
critical situations, cytostatics, such as cyclophosphamide (15 mg / kg) administered
intravenously.
Indications for use of cytotoxic drugs in the NE are: 1) generalization and progressive course of
the pathological process, and 2) a clear kidney with persistent hypertension, and 3) central
nervous system, and 4) treatment failure corticosteroids or contraindications to their use.
With systemic vasculitis requires the use of non-steroidal anti-inflammatory drugs (NSAIDs) in
the usual therapeutic doses. They have anti-inflammatory, analgesic and disaggregation activity.
The choice of a particular drug in principle irrelevant. Can use derivatives of salicylic,
indoluksusnoy, phenylpropionic acid, and others.
Important pathogenetic importance in the East has a purpose anikoagulyantov and antiplatelet
agents. The most commonly used heparin. The latter is an anticoagulant of direct action. Heparin
improves microcirculation, reduce blood pressure, increase diuresis. Absolute indication for the
use of heparin is the presence of DIC with a deficit of antithrombin III. Heparin is also indicated
if there is evidence of hypercoagulability, manifested shortening clotting time, increased
tolerance to heparin plasma.
Heparin can be administered intravenously, intramuscularly and subcutaneously. Most often it is
administered under the skin of the abdomen in a daily dose 20-30000 IU (5000 IU 4 times a day,
or 10,000 IU intravenously, and the rest-daily dose subcutaneously in 2-3 range). With
intramuscular injection is rapidly inactivated by the enzyme muscle. Course duration of heparin
therapy should be at least 3-5 weeks. To avoid overdose periodically monitored clotting time and
(or) plasma tolerance to heparin. The most frequent complications of heparin therapy are
gastrointestinal bleeding and hematuria.
To improve the therapeutic effect of heparin is recommended to combine with antiplatelet
agents. For this purpose, appointed by dipyridamole (chimes) at 150-400 mg / day for several
months. Dipyridamole affect platelet aggregation through cyclic nucleotides. Similar action has
and pentoxifylline (Trental, agapurin). When peripheral circulation shown prescriptions
nikotinovoykisloty (nicotinic acid inside of 0.1 grams per day or intravenously in 1 ml of a 1%
solution 1-2 times a day, complamin 2.0 ml intravenously, intramuscularly ksantinola of 2.0 ml
of 15 % solution 1-3 times a day or 0.15 g orally 3 times nikoshpan tabletke3 to 1 times per day,
etc.). Recommended intravenous drip infusion of low molecular weight dextran (reopolyglucin
400 ml of 4.8 injections a day or something like it). Low molecular weight dextran reduce
platelet aggregation, reduce blood viscosity, improve microcirculation.
Recommended the appointment angioprotectors (Parmidin 0.25 g orally 3-4 times a day, and
prodektin anginin in the same dosage). If the patient is not receiving cytostatics, appointed
aminohinolinovogo drugs. When C is not shown in complex therapy with antihistamines,
vitamins and antibiotics.
Essential to prevent recurrence of the disease has a competent management of these patients in a
clinic. Recommended maintenance doses of long-term use of pathogenetic therapy. The need for
periodic checkup of patients in order to control the dynamics of the disease and early recognition
of the complications. The clinic offers courses of physiotherapy, massage therapy to rehabilitate
patients and rehabilitation. It is recommended to avoid taking any medicines that are not shown
in the afternoon. Not allowed chill. Contraindicated in patients with active NE physiotherapy and
spa treatment.
Reduced overall treatment plan NE has the features and some of the nuances in the different
lymphoma forms. In some cases, treatment is based anticoagulants and antiplatelet (illness
Vinivartera - Burgess), in others - corticosteroids and cytotoxic agents (Wegener's
granulomatosis, polyarteritis nodosa), in the third - only corticosteroid hormones (giant cell
arteritis), etc. Examination and treatment of patients with systemic vasculitis is recommended in
specialized rheumatology department.
The theoretical part is carried out by the method of "snowballs."
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. Chronic gastritis - chronic inflammation of the gastric mucosa in violation of physiological
regeneration and progressive atrophy of the specialized glandular epithelium with the
development of intestinal metaplasia, dysplasia, and in the future, and a violation of motor and
secretory functions.
2. EFGDS biopsy, fractional study of gastric juice, revealing H.pylorici (cytological and
histological study, the degree of contamination of the mucous membranes, immune).
3. First-line therapy in 7 days: omeprazole 20 mg 2 times / day clarithromycin 500 mg 2 times /
day. amoxicillin 1000 mg 2 times / day
metronidazole 500 mg 2 times / day, second-line therapy 10 days: omeprazole 20 mg 2 times /
day bismuth subcitrate 120 mg 4 times / day tetracycline 500 mg 4 times / day. metronidazole
500 mg 2 times / day,
13.2. The analytical part of
13.2.1. Case studies:
Objective number one.
40-year-old patient suffering from prolonged fever, is not reduced antibiotic therapy, severe
hypertension, polyneuropathy. A month lost 10 kg. In the analysis of the blood: anemia,
accelerated ESR, a urinalysis: proteinuria, microhematuria
1. Your diagnosis?
2.Plan examination.
3.The treatment plan
№
ANSWERS
Max.
Full score
1.
2.
Periarteritis nodosa (classic form)
Complete blood count, urinalysis,
biochemical blood HbsAga study,
biopsies of skin-muscle flaps
30
40
20-30
30-40
unsatisfactory Not answered
response.
5-19
0-4
5-29
0-4
3.
Corticosteroids, cytotoxic drugs,
anticoagulants, antiplatelet agents,
Angioprotectors
30
20-30
5-19
0-4
Objective number two
Patient 60 years complains of weakness and pain in the muscles of the hands and feet, fever,
arthralgia. On examination, the muscles increased in volume, tenderness palpatsii.Na face and
neck visible erythematous changes paraorbital swelling. The patient can not raise your hands,
comb, can not lift his leg on the step.
In general, the analysis of blood: hemoglobin -70 g / l, erythrocyte sedimentation rate, 55 mm /
h,
in the biochemical analysis of blood - a marked increase in transaminases and Kretinina.
1.Vash preliminary diagnosis?
2.Metod diagnosis, confirming the diagnosis?
3. The treatment plan
№ ANSWERS
Max.
Full score unsatisfactory Not
response.
answered
1.
Primary dermatomyositis, but still
needs to eliminate the tumor nature.
30
20-30
5-19
0-4
2.
3.
muscle biopsy
Prednisolone at a daily dose of at least
60-80 mg
30
20
20-30
10-20
5-19
5-9
0-4
0-4
3. Patient 23 years, pregnancy 6 weeks, examined by a doctor in general practice. Complaints of
shortness of breath, irregular heart area. These complaints emerged during pregnancy. According
to the patient in childhood have been episodes of joint pain.
OBJECTIVE: cyanosis of the lips. Pulse 110 beats per minute, respiratory rate 24 per minute.
Apical impulse is diffuse, diastolic tremor ("cat purring"). Auscultation: on top of presystolic
noise, clapping I tone, click opening of the mitral valve. The lungs in the lower fine moist rales
are heard. Liver + 2 cm margin rounded. On ECG broad, bactrian prong P in lead I, II, aVL and
V5-6. Deviation of the electrical axis of the heart to the right, QRS in V1 M - shaped.
1.List least four diseases for which auscultated diastolic heart sounds and hearing the best place
for these diseases;
2. The preliminary diagnosis;
3.Informativnye survey methods;
4. Identify the specific proposed changes in echocardiography in this patient and the indications
for surgical treatment according to the data;
5.Taktika GPs (prntsipe treatment and prevention);
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.List 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.List 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.List 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.List 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.List 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
5
Identify risk factors
6
Defined the problem patient
7
Conducted an objective
examination
8
Has issued a preliminary
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
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
diagnosis indicating the
category of services
9
10
11
Made a plan for the survey
with the type of services
Hands-on practice skill
Analysis and interpretation
of laboratory and
instrumental studies
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
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, X-ray of. chest 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
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
Secondary b - treatment are drugs of proven efficacy
Tertiary - treatment of complications, rehabilitation, clinical
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. 2. Relief of active inflammation, NSAIDs (diclofenac)
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
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
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)
of clinical examination
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, fibrinogen-420mg%
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
demonstration of skills IPC
2
Determined leaders and
minor complaints
3
Anamnesis morbi
Greeted, seated in front of him, collected ratings, addressed
to the patient by name, using simple words and sentences
understandablto the patient
Leading complaints: pain in the small joints of both hands,
morning stiffness
Minor complaints: fatigue
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
4
Anamnesis vitae
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
Made a plan for the survey
with the type of services
9
10
11
Hands-on practice skill
Analysis and interpretation
of laboratory and
instrumental studies
12
The differential diagnosis
13
Final diagnosis with the
type of services
14
15
Determined the form in
which the patient requires
prevention
Drug-free treatment
16
Medication
rheumatologist and GPs.
As a child, often get cold, has 1 child, the pregnancy was
normal. Sister of the patient suffers from rheumatism.
Unmanaged: gender, age, family history (sister of
rheumatism).
Managed: hypothermia.
Summary: pain in the small joints of both hands, morning
stiffness
Related: fatigue
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.
DOS.: Rheumatoid Arthritis: arthritis, slowly progressive
course, FNS I
Category 2
3.1.: KLA, OAM, ECG.
3.2.: BAC acute-phase samples (RF, CRP, haptoglobin,
fibrinogen, total protein and protein fractions, ASO), R-gene
joints EhoKS (to prevent rheumatic process).
ECG
KLA: Hb-impaired., Al-impaired., ESR-incr.
LHC ob.belok-red., Fibrinogen higher.
OAM: b / o
Acute-phase sample-CRP + +
ECG: b / o
X-ray of joints: periarticular osteoporosis. Joint space
narrowing proximal interphalangeal joints of the fingers of
both hands.
EhoKS: b / o
Reactive arthritis, rheumatic fever, repeated, osteoarthritis of
small joints of the hands
DOS.: Rheumatoid Arthritis: arthritis, seropositive, 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, clinical
examination
Healthy living, hardening, nutrition, compliance work and
rest, rehabilitation centers of infection, a spa treatment.
1. 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
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.
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
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
The list of skills that GPs should possess after completing studies on the subject
1. Conduct a survey of patients with arthritis and arthralgia.
2. Interpret the ECG and chest X-ray in patients with arthritis and arthralgia.
Pain in joints
Dermatomyositis, vasculitis, bleeding, non-specific aorto-arteritis nodosa and periarthritis.
Stage №
Performance / interpretation
examination of the patient
Complete blood count,
Total urine
acute-phase samples
uric acid
A blood test for LE-cells revmofaktor, HLA-B27,
etc.
ECG
echocardiography
X-rays of joints
Arthrocentesis with the study of synovial fluid
infectious disease consultation
biopsy
differential diagnosis
The diagnosis
tactics GPs
TOTAL
not done
completely
executed
0
50
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
Characteristics of the student's work
96-100
fine
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
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
55-60,9
not
satisfactor
y
20 - 54,9
20-10
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.
1. 17. Checklists.
2.
3. 1. Especially arthritis and rheumatism arthralgia.
4. 2. Especially arthritis and arthralgia in rheumatoid arthritis.
5. 3. Differential diagnosis of joint syndrome.
6. 4. Classification of rheumatism and rheumatoid arthritis
7. 5. The course and diagnosis of these diseases
8.
9.
LITERATURE:
10. Main:
11. Воробьев. Справочник практического врача в 2-х томах, 1990 г.
12. Вудли М., А.Узлан. Терапевтический справочник Вашингтонского Университета.
Практикум, 1995 г.
13. Денисов И.Н. Справочник путеводитель практикующего врача от "А" до "Я”.
ГЭОТАР, Москва, Медицина.,1999г.
14. Комаров Ф.И. Диагностика и лечение внутренних болезней. Руководство для врачей в
3-х томах, М, Медицина,1999 г.
15. Матвиенко Г.П. Клиническая диагностика. Справочное пособие для семейного врача.
Минск, Беларусь, 1999 г.
16. Мерта Дж. Справочник врача общей практики. М., Практикум, 1998г.
17. Никитин Ю.П. “Все по уходу за больным в больнице и дома”, ГЭОТАР, Москва,
Медицина, 1998 г.
18. Окороков А.Н. Лечение болезней внутренних органов. Том 3, книга 1 и 2. Москва.
Медицинская литература. 2005 г.
19. Ригельман “Как избежать врачебных ошибок?”. 1994 г. М. Практикум.
20. Сенфорд “Антимикробная терапия”. 1996 г. М. Практикум.
21. Симбирцев С.А. “Общая врачебная практика”. 1996 г. П том. С.-Петербург.
22. Чиркин А.А., Окороков А.Н., Гончарик И.И. “Диагностический справочник терапевта.
Беларусь. 1993 г.
23. Чучалин А.Г., “Терапия”, 1996 г.
Addittional:
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