The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical an Medical Pedagogical Faculty

Practical session number 10

Theme: "hepatomegaly. Differential diagnosis of acute and chronic hepatitis, alcoholic liver disease. Tactics GPs. Indications for referral to a specialist or hospital in the profile department. The principles of treatment, follow-up, control and rehabilitation in a hovercraft or a joint venture. The principles of prevention. The principles of teaching topics. "

learning Technology

Study time: 6.4 hours
The structure of the training session		5. Training themed room. 6. Cabinet GPs. 7. Tutorials, phantoms, models, handouts, a collection of case studies and tests 8. TV, video equipment, multimedia
The goal of lesson: Teach GP diagnosis and differential diagnosis, conducting best option for treatment policy hepatomegaly due to a variety of infectious diseases, and alcoholic liver disease, as well as the principles of management of patients in primary care, provided the requirements of the "Qualification characteristics of the general practitioner."
Pedagogical objectives: 1. Consider diagnosis of hepatomegaly in acute and chronic liver diseases. 2. Consider the issues of diagnosis of infective hepatitis, hepatitis: B, C, chronic hepatitis 3. Demonstrate patients with hepatomegaly in these diseases. 4. Discuss the results of clinical, laboratory and instrumental studies at hepatomegaly 5. Differential diagnosis of diseases - infectious disease, hepatitis B: B, C, chronic hepatitis 6. Discuss questions about tactics in the qualifying characteristics of GPs 7. Discuss the principles of treatment (medication and non-medication). 8. Discuss the principles of management, supervision and monitoring of patients in a hovercraft or a joint venture. 9. Discuss the principles of primary, secondary and tertiary prevention in these diseases	Learning outcomes: GPs should be aware of: 1. The mechanism and causes of hepatomegaly 2. Clinical manifestations of hepatomegaly 3. diagnosis of hepatomegaly 4. Differential diagnosis of hepatomegaly 5. The principles of treatment (medication and non-medication) in these diseases. 6. Principles of follow-up and monitoring of patients in a hovercraft or a joint venture. 7. The principles of primary, secondary and tertiary prevention in these diseases. GPs should be able to: 1. Analyze the data and history of complaints for the diagnosis of hepatomegaly 2. Diagnose, differentiated by clinical and laboratory-instrumental investigations different types of hepatomegaly 3. Choose drugs with proven efficacy 4. Advise on non-drug therapies. 5. To monitor in a hovercraft or a joint venture.
training Methods	Brainstorming, graphic organizer - Vienna chart, demonstration, entertainment experience, discussion, conversation, decision tests and case studies
Forms of organization of learning activities	Individual work, group work, team, classroom, extracurricular.
learning Tools	Hand-learning materials viziualnye materials, videos, models, graphic organizers, kits medical charts, tables, and benches.
Methods and feedback means	Quiz, test, presentation of the results of the learning task, filling medical records implementation of practical skill "professional debriefing"

Flow chart classes

№	Stages of the practice session	Form classes Venue	Duration classes 225
1	Chapeau (justification themes)		10
2	The discussion on the practical lessons with the use of new educational technologies (method of "brainstorming"), as well as demonstration material (sets of medical charts, tables, posters, x-ray), define the initial level.	The survey, discussion Classroom, GP surgeries	40
3	conclusion discussion		10
4	Definition of tasks to perform the practical part - professional questioning. Explanation of the provisions and recommendations for the job by filling in medical charts.	discussion GP doctor's office	20
5	Mastering the practical part of the training under the guidance of a teacher.	Prof. questioning. A conversation with patients and honey filling cards, situational problems. Admission of patients in the clinic, examination at home	20
6	Interpretation of the survey data of patients, complaints, inspection, palpation, percussion, auscultation of patients, as well as research OAM KLA and biochemical analysis and diagnosis	Medical history,   laboratory data situational problems	25
7	Discussion of theoretical and practical knowledge of the students, securing the material to determine the level of assimilation of knowledge assessment.	Oral questioning, tests, discussion, identification of practical skills Classroom in a clinic	75
8	Defining output on practical sessions on a 100-point rating system and ad evaluations. Homework next practice session (a collection of questions).	Information, questions for homework. Classroom in a clinic	25

2. Motivation

The majority of patients with hepatomegaly seek medical help. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of diseases (acute and chronic hepatitis - infectious disease, hepatitis B: B, C, alcoholic liver disease), accompanied by hepatomegaly. In the case of diagnosis of hepatomegaly GPs have to solve the question of the definition of the group of patients to be treated in a hovercraft or a joint venture, or referral to specialized hospitals. These and other conditions are the basis for the inclusion of this subject in the training of GPs.
3. Interdisciplinary communication and Intra

The teaching of this subject is based on the knowledge of the students basics of anatomy, physiology, pathophysiology, pathology, microbiology, biochemistry, therapeutics, propaedeutics childhood diseases, clinical pharmacology. The results obtained in the course of training knowledge will be used during the passage of the GP - internal medicine and other clinical disciplines.
4. The content of classes

When parsing threads need to pay attention to the following aspects.

 Chronic hepatitis - an inflammatory disease of the liver, accompanied by an overgrowth of connective tissue of portal tracts without the formation of false lobules. Among the etiological factors of chronic hepatitis B virus infection is a leader. In our practice we recommend GPs use the classification proposed by the Association of Hepatology in 1994 (Los Angeles).

Clinical manifestations of hepatitis ambiguous due, on the one hand, the extremely high capability compensatory liver, on the other - in the pathological process involving adjacent organs and of the whole organism.

The typical syndromes: asthenovegetative, dyspeptic syndrome, jaundice, cytolytic, mesenchymal-inflammatory, cholestatic, hemorrhagic syndrome, hypersplenism.

Diagnosis of chronic hepatitis B in a clinic, in addition to a thorough analysis of complaints, medical history and physical examination including lab tests the patient.

Laboratory studies in outpatient conditions typically include: determining the level of prothrombin, fibrinogen level determination, albumin and albumin-globulin coefficient, sedimentary samples (thymol and sulemovaya) determining cholesterol immunoassays (IgM, IgG and IgA, IgE).

Instrumental studies usually require referral to specialized facilities and include: radiogepatografiyu, liver scan, endoscopic retrograde cholangiography, liver ultrasound, needle biopsy of the liver.

Thus, the diagnostic algorithm for all types of hepatitis consists of three steps:

1. The first stage - focused katanamnez and identifying clinical signs of liver (hepatomegaly, jaundice, telangiectasias - "spider veins"), laboratory diagnosis: a study of bilirubin, ALT and AST, lactate dehydrogenase, sublimate and thymol, as well as the protein spectrum of blood, identification of specific antigens.

2. The second stage - Instrumental: liver ultrasound, radiogepatografiya, laparoscopy

3. The third (the most important stage) - a morphological study of the liver using light-optical, immunological and electron microscopic analysis.

Cirrhosis (from the French kirros - red) - diffuse process characterized by fibrosis and reorganization of the architectonics of the liver, leading to the formation of structurally abnormal nodes.

At present, the international gastroenterology committee recommended in clinical hepatology following classification of cirrhosis of the liver:

Classification of cirrhosis of the liver (Los Andzhelec, 1994).

According to the etiology: viral, alcoholic, autoimmune, metabolic, альфаантитрипсиндефицитный, holestogenny (primary, secondary), cryptogenic.

Morphology: Portal, Postnecrotic, postgepatitny, laennekovsky, metabolic, biliary, CKD, SKD.

Payment: compensated, subcompensated, decom-sate.

Diagnosis of cirrhosis of the liver, as well as chronic hepatitis is to identify the main clinical and biochemical syndromes and your use of these imaging studies. Please be aware that hepatomegaly is more typical of biliary cirrhosis of the liver and in these cases prevails cholestatic syndrome (hyperbilirubinemia, increased alkaline phosphatase in the blood, jaundice, itching, xanthelasmas, etc.). When portal cirrhosis of the liver hepatomegaly observed in the initial stages of the disease with the consequent reduction of its size and appearance of splenomegaly. Dominated by other signs of portal hypertension (telangiectasias, varicose veins, splenomegaly, ascites, etc.)., Jaundice may be absent.

Differential diagnosis of hepatomegaly with hepatitis and cirrhosis of the liver is carried out with a variety of liver diseases that are accompanied by an increase in its size, but in the general practice they are much rarer.
The theoretical part is conducted on a "tour of the gallery."

Objective: To teach students critically evaluate information and identify the completeness of knowledge on the subject.

     Each small group is invited one problem they solve for 10 minutes in writing and then exchange tasks. Revealing mistakes of the previous group, and additions made to the answers discussed by all members of the adoption of the final version of the responses. Methodology tour gallery requires students to maximum concentration and a good theoretical background for this section.

Example:

1. Determination of hepatitis.

 2. Diagnostic algorithm for all types of hepatitis

 3. Determination cirrhosis

 4. Classification of liver cirrhosis

Answers:

1. Chronic hepatitis - an inflammatory disease of the liver, accompanied by an overgrowth of connective tissue of portal tracts without the formation of false lobules.

2. Diagnostic algorithm for all types of hepatitis consists of three stages: I stage - focused katanamnez and detection of clinical signs of liver (hepatomegaly, jaundice, telangiectasias - "spider veins"), laboratory diagnosis: a study of bilirubin, ALT and AST, lactate dehydrogenase, sublimate and thymol and proteinaceous blood spectrum, identification of specific antigens.

 Stage II - Instrument: liver ultrasound, radiogepatografiya, laparoscopy

 III (the most important stage) - a morphological study of the liver using light-optical, immunological and electron microscopic analysis.

3. Cirrhosis (from the French kirros - red) - diffuse process characterized by fibrosis and reorganization of the architectonics of the liver, leading to the formation of structurally abnormal nodes.

4. According to the etiology: viral, alcoholic, autoimmune, metabolic, альфаантитрипсиндефицитный, holestogenny (primary, secondary), cryptogenic.

Morphology: Portal, Postnecrotic, postgepatitny, laennekovsky, metabolic, biliary, CKD, SKD.

Payment: compensated, subcompensated, decompensated.

№	Evaluation	Perfect	Good	Satisfactorily	Unsatisfactorily	Bad
	assimilation %	100%-86%	85%-71%	70-55%	54%-37%	36% and less
1	The theorical part	20-17,2 point	17-14,2 point	14-11 point	10,8-7,4 point	7,2 point

4.2 The analytical part

Case Studies:

1. Patient P., 45 years old, complains of itching more at night, pain in the right upper quadrant, pain in the joints of the limbs, general weakness, menstrual disorders. History of suffering GSD, often treated with antibiotics at the Mt. pyelonephritis. Periodically drinking alcohol. Objectively: the patient malnutrition, the body temperature 38.40 C. Skin is jaundiced with a greenish tinge, ksantilazmy at the inner corners of the eyes, marks on the back scratching. In the lungs, vesicular breathing, no wheezing. Heart sounds, rhythmic, heart rate 88 bpm. per min. Belly increased by ascites, tenderness in the right upper quadrant. Liver Kurlov 12-18-18 cm spleen 2 cm extend below the costal margin. UAC: Hb 92 g / l erythrocytes 3.0 x 1012 / L Leukocytes 8.7 x 109 / L ESR 35 mm / hr. In blood total protein - 60 g / l, total bilirubin 42.7 pmol / L 26.0 direct, indirect-16, 7 mmol / L, cholesterol 9.4 mg / L, Alkaline Phosphatase by V. Dolgov 205 U / l.

1. List at least four probable disease in which the symptoms are above 20-points.

2. Your initial diagnosis, 30 points.

3. List the major (at least 5) symptoms of cholestasis-25 points

4. Tactics GP - 25 points.

Answers:

№	Answers:	point
1	CL: chronic calculous cholecystitis, chronic hepatitis, alcoholic liver cirrhosis, secondary biliary cirrhosis	20
2	chronic gastritis type B with an increased secretion.	30
3	increase in total bilirubin due to the direct bilirubin, cholesterol and alkaline phosphatase, jaundiced skin with a greenish tinge, ksantilazmy at the inner corners of the eyes.	25
4	Surgical treatment - removal of violations by passage of bile bile duct	25