MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
THE TASHKENT MEDICAL ACADEMY
CHAIR OF INTERNAL ILLNESSES ON PREPARATION OF DGS
WITH CLINICAL ALLERGOLOGY
Subject – INTERNAL ILLNESSES
Theme: “Syndrome of an arterial hypertensia”
Tashkent – 2011
THEME: Differential diagnostics of an idiopathic hypertensia with endocrine arterial
hypertensias.
1 Venues of employment, equipment.
Chair of internal illnesses with clinical allergology on preparation of the DGS, thematic, an
educational room, chambers in units of the general therapy, cardiology and nephrology. Rooms
of an electrocardiogram, EchoCS, US, a X-ray.
- Evident materials: Case histories, slides, tables, a distributing material: an electrocardiogram,
analyses, situational problems, tests
- Subjects of new information technology - electron presentations., banners
2. Duration of studying of a theme. - 6 hours.
3. The employment purpose: to teach the student to carry out according to algorithm early
diagnostics, differential diagnostics endocrine АG with IH, early diagnostics and a choice of
tactics of conducting patients and optimum treatment.
The student should know:
Etiopathogenesis of diseases of the endocrine system accompanied by an arterial hypertensia.
Risk factors at endocrine diseases.
Criteria of the diagnosis of diseases of endocrine system with AG.
Standards of treatment endocrine АG.
Indications to a direction on consultation and hospitalization.
Rehabilitational actions at endocrine АG.
The student should be able:
To carry out professional inquiry and survey on organs and systems.
To make the preliminary diagnosis.
To prescribe the inspection plan.
To interpret the data of laboratory and tool researches (USD of adrenals, a thyroid gland, a
pancreas, skull roentgenography, scanning of endocrine glands, CТ.)
To carry out differential diagnostics endocrine АG.
To prove and make the clinical diagnosis.
To render the first medical assistance at urgent conditions.
To prescribe corresponding therapy.
To make references to the patient (on a diet and a maintenance therapy).
4. Motivation
Prevalence of АG, a variety of the diseases accompanied by АG (including endocrine),
frequency of overdue diagnostics, appreciable percent of its complications, difference of therapy
depending on an etiology and pathogenesis of AG dictate necessity of studying of the given
theme.
5. Intersubject and intrasubject communications.
For studying of this theme it is necessary to know bases of anatomy, physiology, a
pathophysiology, pathoanatomy, pharmacology, propaedeutics, faculty and hospital therapy,
endocrinology.
Differential diagnostics spend together with cardiologists, oculists, neuropathologists, vascular
surgeons, gynecologists, roentgenologists, endocrinologists and oncologists.
6. The employment maintenance:
6.1. A theoretical part.
When the reason of an arterial hypertensia it is possible to find out it name symptomatic. When it
isn't possible to find out reason of АG - an idiopathic hypertensia
The pathogenesis of symptomatic АG differs, so at endocrine diseases at the heart of
development АG the raised formation of some hormones lies. A kind of a hyperproduced
hormone: Aldosteronum or other mineralocorticoid, catecholamines, STH, ACTH and
glucocorticoids - depends on character of a pathology.
THE TABLE OF DIFFERENTIAL DIAGNOSTICS
Criteria
Etiology
Pathogenetic
features of AG
Passport part
Comlaints
Objectivly
Feohromocytoma
Sindrome of
Conne
Tumors of a cerebral
Tumors of a
layer of adrenals
cortex of adrenals
and/or a hyperplasia
of an
extraepinephral
chromaffin tissue
Hyperproduction of
Superfluous
catecholamines,
production of
augmentation of
Aldosteronum,
heart emission and
enlarged
PSS. Mainly
reabsorption Na
paroxysmal a
and waters, an excurrent, rising of
traction of K, a
syst. and diast. BP
hypopotassemia,
augmentation
CBV and a BP to
220 260/120-140,
BP constant,
almost without
crises
20 – 40 years
Often women of
20-50 years
Headaches,
Headaches, sharp
sweating, dyspnea,
muscular
palpitation,
delicacy, pains in
abdominal pains and muscles, cramps,
in a breast, a nausea, thirst, a polyuria,
vomiting, delicacy
a polydipsia,
and fatigability
paresthesias, a
dyspnea,
palpitation, faults
Wet skin,
tachycardia, the
arrhythmia, the
strengthened apical
jerk, expansion of
pupils, mottled
coloring of a skin,
depression of BVI
Augmentation of
borders of heart,
deafing of tones,
sysy. hum, a
tachycardia,
flaccid paralyses,
a paresis
Tirertoxicosis
Diffusive toxic
struma
Sindrome and illnesses of
Icenco-Kushing
Tumors of a pituitary body
and adrenals
Hyperproduction
Excess of ACTH,
of thyroid
hyperproduction of GCS, a
hormones, genetic hypernatremia, BP Rising
predisposition,
(150-240/110-160). АG is
disbalance in
constant
system Tlymphocytes.
Hyperdynamic
type of a
circulation,
increased systolic.
and diast. a BP
Often women of
Often women of 20-50
20-50 years
years
The stimulus,
Adiposity, muscular
tearfulness,
delicacy, hair fall,
palpitation, faults, dysmenorrhea, osalgiya, a
sweating, tremor,
sleeplessness
weight loss, fever,
dyspnea, can be a
diarrhea, an
impotency, a
dysmenorrhea,
photophobia,
lachrymation
Emotional
"Climacteric hump", the
lability, thyroid
lunar face, mottled skins,
gland
face is crimson - red, wide
augmentation,
strias, lilac on a stomach,
skin hot, red wet, the hips, the raised pilosis
BVI is lowered, at women, an osteoporosis,
an exophthalmos,
Urolithiasis
a tachycardia,
Laboratory and
tool datas
GAB - a
leukocytosis, an
eosinophilia, a
hyperglobulia,
increased ESR,
GAU – a
proteinuria,
sometimes, a
glucosuria,
BAB - rising of
catecholamines in a
blood and urine. An
electrocardiogram –
truncated Р-Q,
HLV, extrasystoles,
CA
tachypnoae,
augmentation of
the sizes of heart,
a liver, an
osteoporosis
GAB –
GAB – a
giperizostenu-rija,
lymphocytosis,
a proteinuria, the
нормохромная
BAB a
an anemia, the
hypernatremia
BAB - decrease
hypokaliaemia,
of cholesterol, an
an
albumin, bilirubin
electrocardiogram
rising, ALT,
elongation Q-T,
glucoses. AI –
negative. Т, S-T
Depression an
below an isoline,
immunoglobulin
high level of
y.
Aldosteronum,
USD – diffusive
and renin
augmentation of a
depression. USD thyroid gland, and
and CT - an
Irregular change
adenoma of
of echogenes, an
adrenals
electrocardiogram
– augmentation of
voltage Р and Т,
rising of
indicators of
thyroid hormones
GAB – rising Нb,
erythrocytes, leucocytes, a
lymphopenia, ESR
acceleration, GAU alkaline medium, a
glucosuria, a proteinuria, a
leukocyturia. The BAB
depression K, increasing
Na, Ca, activity of an
alkaline phosphatase,
ALT, triglycerides, PTI,
proteins, an
electrocardiogram hypertrophy of LV, USD
augmentation of adrenals,
chr. pyelonephritis, a Xray of a skull - an
osteoporosis of a Turkish
saddle.
The new pedagogical technologies used on employment:
Competition «Round on gallery»
Accessories to work:
- Tasks for students
- Blank sheets of a paper, a pen
One problem on all is offered to small groups. Each group within 10 minutes writes down the
judgement and exchanges sheets of answers with other group. The following group should
estimate the answer of the previous group and if the answer incomplete, to offer the variant.
Upon termination of work the task is discussed by all participants and choose most the right
answers which deserve the higher point.
Tasks: the Scheme of pathogenesis of АG at the Cones syndrome.
Features of current АG at a pheochromocytoma.
Criteria of the diagnosis of a syndrome of Iceng-Kushing.
6.2. An analytical part.
Situational problem №1
The patient M, 48 years, disturb intensive headaches, delicacy, periodically edemas on face in
the mornings, BP rising. Last 6 years stably high a BP 200 260 / 90-120, serious hypertensive
crises against extremely high pressure twice developed, the patient fainted, periodically notes a
numbness in extremities. Treatment by various hypotensive preparations didn't give essential
effect. In biochemical researches – the expressed hypopotassemia (2.3 – 2.5 mmol/l). HLV on an
electrocardiogram and on a X-ray. Urine analyses – a hypoisosthenuria. The presumable
diagnosis? Recommended researches? A treatment planning, tactics of the DGS.
The answer: the Primary hyperaldosteronism (a syndrome of Conne)
USD, scanning, CT of adrenals.
Verosprironum
Situational problem №2
The patient, 35 years, is hospitalized concerning malignant current of AG. Headaches, a nausea,
vomiting, sharp disturb sight deterioration, a sweating, thirst, a weight loss, the palpitation
pricking pains in the field of heart. Within last 10 years is registered proof АG with the least BP
170/120. Last 3 years – crises with rising of a BP to 220/120, strong headaches, palpitation, for
last year has grown thin for 10 kg, sight has sharply worsened. A moderately severe condition,
slackness, an adynamia, the appetite depression, a proof tachycardia, a BP 250/120.
Augmentation of borders of heart to the left. On electrocardiogram HLV, sinusal tachycardia.
Consultation of the oculist – serious аngioretinopathy. The presumable diagnosis?
Recommended researches? A treatment planning, tactics of the DGS.
The answer: Pheohromocitoma.
USd, scanning, CТ of adrenals
α-adrenoblokatory, surgical treatment, chemotherapy.
Situational problem №3
The patient K, 28 years, complaints to thirst, rising of mass of a body, a sweating, disturbance of
a menstrual cycle.
Objectively:
The patient of the raised food, face is lunar, a BP 190/100, on a stomach lilac strias. Heart
borders are enlarged to the left, tones sonorous, systolic. hum on an apex. The presumable
diagnosis? Recommended researches? A treatment planning, tactics of the DGS.
The answer: Illness of Icenco-Kushing. Roentgenography of "a Turkish saddle». Urine research
on 17-KS and 17 OKS
Operative treatment, radial therapy.
6.3. A practical part.
The student should own skills:
1. Propagation of a healthy way of life.
2. Dialogue with patients.
3. Poll, survey and an estimation of the received data.
4. Substantiations of the clinical diagnosis, inspection and treatment.
5. Fillings of the medical documentation.
6. Consultations
7. Audit of the done work
8. Work with the literature.
Monitoring the patient
The general analysis of a blood
The general analysis of an irine
Cholesterol in a blood
Saccharum in a blood and urine
ELECTROCARDIOGRAM
EchoCS
Angoigraphy
Consultation of an oculist
Differential diagnostics
Diagnosis substantiation
Treatment planning appointment
References
7. Forms of control of knowledge, skills, abilities:
Indicator
Monitoring the patient
The general analysis of a blood
The general analysis of an irine
Cholesterol in a blood
Saccharum in a blood and urine
ELECTROCARDIOGRAM
Not Executed
0
EchoCS
Angoigraphy
Consultation of an oculist
Differential diagnostics
Diagnosis substantiation
Treatment planning appointment
References
Total
Completely executed
50%
6%
6%
7%
7%
7%
6%
5%
6%
0
0
0
0
0
50
20
10
10
10
100
TESTS:
1. The reasons of a secondary arterial hypertensia:
Glomerulonephritis
Pheochromocytomas
insulinoma
Myocardites
Aorta coarctations
Syndrome of Konna
2. To group of risk of a case rate an idiopathic hypertensia carry, except
Hereditary predisposition
Superfluous salt consumption
Peptic ulcer
Excess weight
Myocardial dystrophy
Chronic bronchitis
3. In an idiopathic hypertensia pathogenesis factors matter, except
The hereditary or got disturbance of cellular membranes with electrolytic disorders
Hyperreactivity of sympathetic nervous system
Deficiency (or attritions) pressor systems
Hyperactivity of system a renin - angiotensin-II - Aldosteronum
Depressions of the maintenance of calcium in smooth musculed cells of walls of arterioles
Intensifying of development of Gastrinum
4. For a syndrome of Conna it is not characteristic:
Hypopotassemias
hyperreninaemiya
Hypernatremia
Hyperglycemia
The high maintenance of Aldosteronum in a blood
hyperinsulinaemiya
5. At patients with a pheochromocytoma symptoms can be taped, except:
Hypopotassemia
Hyperglycemias
Hypoglycemias
Hypertensive crises
Bradycardia
Rising of catecholamines in urine
6. The clinical picture of a syndrome of Conna develops of symptoms, except:
Muscular delicacy
strias
Fervescence
BP risings
Cramps, paresthesias
Paresthesias
7. What sign doesn't correspond to the diagnosis: the Idiopathic hypertensia
1 degrees at the patient of 35 years?
Angiosclerosis of vessels of a retina
Glomerular filtration of 40 ml/mines
Tooth R on V5-V6 = 35 mm
Fast normalization of a BP
BP to 160/90
Efficiency of non-drug treatment
8. Criteria of an estimation of the current control:
The characteristic of actions of students
The student is ready to employment on the basic questions and
questions of IWS, activly participates in theme discussion, has
deeply mastered a theme, creatively thinks, completely owns
practical skills, accurately knows criteria of statement of the
diagnosis of endocrine AG and IH, applying clinical, logic thinking
at bed of the patient (on the basis of the data of inquiry, survey,
interpreting of analyses and an electrocardiogram) carries out
differential diagnostics. Defines tactics of THE DGS and
differentative selects medicamental therapy, makes preventive
references to the patient. During the duty independently supervises
patients, accurately reports.
Comprehensibility Estimation
96-100
«5»
The student is ready to employment on the basic questions and 91-95
questions of IWS, activly participates in theme discussion, has
deeply mastered a theme, completely owns practical skills
accurately knows criteria of statement of the diagnosis of endocrine
«5»
AG and IH, applying clinical, logic thinking at bed of the patient
(on the basis of the data of inquiry, survey, interpreting of analyses
and an electrocardiogram) carries out differential diagnostics.
Defines tactics of the DGS and differentially selects medicamental
therapy, makes preventive references to the patient. During the
duty independently supervises patients, accurately reports.
The student is ready to employment on the basic questions and
questions of IWS,
Participates in theme discussion, has mastered a theme, owns
practical skills, knows criteria of statement of the diagnosis of
endocrine AG and IH, at bed of the patient (on the basis of the data
of inquiry, survey, interpreting of analyses and the
electrocardiogram) carries out differential diagnostics, but
supposes some discrepancies. Defines tactics of the DGS and
selects medicamental therapy, makes preventive references to the
patient. During the dutysupervises patients, reports indistinctly.
The student is ready to employment on the basic questions and
questions of IWS,
Participates in theme discussion, has mastered a theme, owns
practical skills, knows criteria of statement of the diagnosis of
endocrine AG and IH, at bed of the patient (on the basis of the data
of inquiry, survey, interpreting of analyses and the
electrocardiogram) carries out differential diagnostics, but
supposes some discrepancies. Defines tactics of the DGS and
selects medicamental therapy, makes preventive references to the
patient. During the dutysupervises patients, reports indistinctly.
The student is ready to employment on the basic questions and
questions of IWS,
Participates in theme discussion, but inactively, has mastered a
theme, owns practical skills, can diagnose the endocrine AG and
IH, at bed of the patient (on the basis of the data of inquiry, survey,
interpreting of analyses and the electrocardiogram) carries out
differential diagnostics but supposes some discrepancies. Defines
tactics of the DGS and medicamental therapy, makes preventive
references to the patient. During watch supervises patients by
means of the doctor on duty, reports not accurately.
The student is ready to employment, has mastered a theme, owns
practical skills, can make the preliminary diagnosis of endocrine
AG and IH, at bed of the patient (on the basis of the data of
inquiry, survey, interpreting of analyses and the electrocardiogram)
hardly, carries out differential diagnostics but supposes some
discrepancies. Defines tactics of the DGS and medicamental
therapy, makes preventive references to the patient. During watch
supervises patients by means of the doctor on duty, reports not
accurately.
The student is ready to employment, has insufficiently mastered a
theme, indistinctly owns practical skills, can't independently make
the preliminary diagnosis of endocrine AG and IH at bed of the
patient (on the basis of the data of inquiry, survey, interpreting of
analyses and an electrocardiogram. Hardly defines tacticsof the
DGS and medicamental therapy, makes preventive references to
the patient not completely. During the duty supervises patients by
means of the doctor on duty, reports not accurately.
The student isn't completely ready to employment, has
insufficiently mastered a theme, indistinctly owns practical skills,
can't independently make the preliminary diagnosis of endocrine
AG and IH, at bed of the patient (on the basis of the data of
86-90
«5»
81-85
«4»
76-80
«4»
71-75
«4»
66-70
«3»
61-65
«3»
inquiry, survey, interpreting of analyses and an electrocardiogram.
Hardly defines tactics of the DGS and medicamental therapy,
makes preventive references to the patient not completely. During
watch supervises patients only by means of the doctor on duty,
reports not accurately.
The student isn't completely ready to employment, has 55-60
insufficiently mastered a theme, indistinctly owns practical skills,
can't independently make the preliminary diagnosis of endocrine
AG and IH, at bed of the patient (on the basis of the data of
inquiry, survey, interpreting of analyses and an electrocardiogram.
Hardly defines tactics of the DGS and medicamental therapy,
makes preventive references to the patient not accurately and not
completely. During watch supervises patients by means of the
doctor on duty, isn't able to report.
The answer incorrect on all questions.
55 and down
«3»
«2»
9. A chronological card of employment.
№
1
2
3
4
5
6
7
8
Stages of employment
Morning conference
Discussion of a theme with use of interactive
game
Mastering by practical skills
Independent monitoring of patients in the attached
chambers, thematic patients, participation in
detours of professors and senior lecturers
Break
Analysis in unit of the examined thematic patients
Discussion of tests, cards - problems
Comprehensibility check, the announcement of
estimations, the task for the house
Time
8.30-9.15
9.20-10.00
Duration of employment
45 min
40 min
10.00-10.30
10.30-11.55
30 min
90 min
11.55-12.40
12.40-13.15
13.20-13.50
13.50-14.00
45 min
35 min
30 min
10 min
10. Control questions:
1. Pathogenesis of AG at the Cone syndrome?
2. Pathogenesis of AG at a pheochromocytoma?
3. Pathogenesis of AG at a thyrotoxicosis?
4. Pathogenesis of AG at illness and an Icenco-Cushing syndrome?
5. Clinical implications of a hypopotassemia at the Cone syndrome?
6. Hypopotassemia signs on an electrocardiogram?
7. Criteria of the diagnosis of a primary hyperaldosteronism?
8. Criteria of the diagnosis of a thyrotoxicosis?
9. Recommended researches at a pheochromocytoma?
10. Clinical implications at illness of an Icenco-Cushing syndrome?
11. Recommended researches at suspicion on illness or an Icenco-Cushing syndrome?
11. The literature:
Textbooks, monographies,
lectures
1. V.I.Metelitsa. A directory of
the cardiologist on clinical
pharmacology. М, 2002
2. Chirkin. L.A. Diagnostic
Basic literature
Additional literature
1. J. Merta. A directory of the general
practitioner. Moscow 1998.
2. Internal deseases, S.N.Bobodzhanov,
2004
1. Usmanov R. I, E.B.Zueva,
V.M.Kozhinsky Modern recommended
Rules of treatment of therapeutic patients. A
method. References, Т, 1999
directory
3. Flanks. Н.П., Nasonov. V.A.
Directory of the doctor of the
general practice. – in 2 volumes2000.
4. Stenford. Antiarrhytmic
therapy, 1998
5. Murashko V.V., Strutinsky.
А.В. An electrocardiogram.
1987
6. A clinical echocardiography
1990
7. Komarov F.I.., Kukes. V.
Internal illnesses. 1990
3. Algorithms of diagnostics and treatment
of the basic syndromes for preparation of
DGS, 2003
4. Algorithms of diagnostics and treatment
of diseases of a therapeutic profile, 2003
5. Treatment of illnesses of an internal in 4
volumes, Gammons, А.Н., 2003
6. Diagnostics of illnesses of an internal in 4
volumes, Gammons, А.Н., 2003
7. Differential diagnostics of an internal,
Heglin, Р, 1997
8. Gadaev. A.G.Management of DGS, 2006
9. A therapeutic directory of the
Washington university under M.Vudli,
transfer from eng., М, 1995.
10. Michigan. Cardiology in tables and
schemes 1997
2. Demonstrative medicine. Clinical
references to practising doctors, 2001
3. Kurbanov R. D, Yeliseyev M.R.
Ingibitory enzyme angiotensin-transforming
in cardiologic practice. Methodical
references. Т, 2000.
4. Kurbanov. R.D. Modern methods of
diagnostics and treatment of chronic
insufficiency, 2004
5. Usmanov R. I, E.B.Zueva Cardiology
problem in schemes and tables. 2005
6. Zueva. E.B., Saidova. SH.A. Modern
principles and clinical pharmacology of
antiarrhytmic medical products, 2003
7. Magazines - Therapeutic archive
Cardiology
Medical sites on the Internet: www.medmir.ru, www.doctor.ru,
www.medbox.ru, www.medicum.ru, www.medline.ru