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

2. Motivation

The majority of patients with functional and inflammatory bowel diseases that are accompanied by abdominal pain in the epi-, meso-, gipogastralnoy areas for the first time to seek medical help from a general practitioner (GP). In this situation, the effort is directed at the GP diagnosis of diseases for medical care under the GWP (SVP), 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

4.1. The theoretical part

When parsing the theme focuses on the following aspects: the most common functional disorders of the digestive tract can be identified irritable stomach, aerophagia, habitual constipation, irritable bowel syndrome, and biliary dyskinesia.

Habitual constipation - prolonged disturbance of bowel movements (stools less often than 1 time in 2 days, the amount of feces is less than 100 g, the lack of a sense of complete evacuation) is not associated with organic diseases. Habitual constipation is 10-12% of all diseases of the intestine.

Fecal normally retained in the left side of the colon (sigma restum). Often disturbed reflex of rectal ampulla, stimulating peristalsis. By the development of intestinal constipation cause a number of factors, primarily psychogenic factors. They are frequently observed in depressive states in patients with neuroses, atherosclerosis of cerebral vessels, cyclothymia.

On palpation of the abdomen can be felt painless, dense sometimes uneven (stool) sigmoid colon. Sigmoidoscopy and radiography in functional constipation nor any organic changes did not reveal. For the diagnosis of constipation is set duration with no tendency to a sharp increase and a good general state of the patient, as well as dietary and occupational history.

Treatment involves removal of a neurotic condition, adjust the mode of work, the appointment of a balanced diet and laxatives stimulate defecation reflex - receiving a glass of cold water on an empty stomach, a hearty breakfast, a comfortable posture for defecation (on the cards - "eagle pose"), self-hypnosis, pectin containing products.

Irritable bowel (colon primary dyskinesia) - punctuated by constant or impaired function of the colon (mainly motor) is not caused by organic disease and is characterized by pain, disruption of normal bowel movements, and sometimes an increased secretion of mucus.

Etiological basis of the disease is a neurosis, and men dominated depression, hypochondria, psihasteniya and women - the hysterical reaction, phobia, paranoid state hyperreactivity. In all patients the vegetative dystonia of the nervous system.

The clinical picture of the front are the "intestinal" complaints, primarily pain and frustration of a chair, often accompanied by increased production of intestinal mucus. The severity of pain varies from a sense of pressure in the lower abdomen to intense, such as colic, pain lasting from several minutes to several days, with periodic amplification. The pain is localized in the lower quadrant of the abdomen, but sometimes spreads to the entire intestine, radiating to the lower back, left side of the chest, often accompanied by a rumbling, a feeling of bloating, distention. Less often mistaken for colic hepatic, renal, or associated with duodenal ulcer disease. Pain usually occur after stress or after a certain foods. Violation of the chair often seen constipation, less constipation alternating with diarrhea.

Sigmoidoscopy and barium enema are difficult because of irritation and spasm of the sigmoid colon.

The final diagnosis can be made only after the exclusion of organic disease, intestinal dysbiosis, allergic enterocolitis.

Treatment is based on the elimination and prevention of neuroses, diet, depending on the nature of changes in her chair with constipation - food rich in fiber, with diarrhea - easily digestible foods with restriction of carbohydrates, fiber.

USING METHOD "brainstorming"

The method of "brainstorming" ("brain attack").

The main provisions of the technique:

• any comments and criticisms that interfere formirovke ideas;

• greeting soaring thought, given that the more unusual the idea, the better it is;

• obtaining the greatest number of proposals;

• The combination of ideas and their development;

• a brief statement, without argument deployed;

• divide the group into those who generates ideas and those of their processes.

Each student is given one point.

1. What are the functional diseases of the stomach and intestines.

2. What are the diseases of the chest, accompanied by abdominal pain.

3.Nazovite diseases not related to the pathology of the digestive diseases for which there are pain in the abdomen.

4. Determination of irritable bowel syndrome

    Answers:

1. Irritable stomach, aerophagia, habitual constipation, irritable bowel syndrome, and biliary dyskinesia.

2. Myocardial infarction, pericarditis, lobar pneumonia, pleurisy.

3. Abdominal epilepsy, rheumatism, malaria, porphyria, recurrent disease, uncontrolled use of anticoagulants, nodular periartereit.

4. Irritable bowel (colon primary dyskinesia) - punctuated by constant or impaired function of the colon (mainly motor) is not caused by organic disease and is characterized by pain, disruption of normal bowel movements, and sometimes an increased secretion of mucus.

№	evaluation	PERFECT	GOOD	SATIS.	UNSATIS.	BAD
	Усвоение в %	100%-86%	85%-71%	70-55%	54%-37%	36% and less
1	The theoretical 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) 32 year old woman presented to the GP complaining of severe attacks of pain in the upper abdomen zoster character. Pain associated with taking fatty foods and are often accompanied by vomiting and uncertain chair. From history revealed that the patient often takes the food from the refrigerator. An objective examination of marked abdominal pain in the area and Chauffard at Desjardins. Patient malnutrition. There is a violation chair alternating diarrhea with constipation.

1. Enter at least 4 diseases that manifest the above symptoms;

2. Your preliminary diagnosis;

3. Necessary studies for the diagnosis and what changes do you expect to see;

4.Taktika GPs and treatment.

Answers:

№	Answers:	point
1	Pancreatitis, peptic ulcer, cholecystitis, gastritis.	20
2	acute pancreatitis	30
3	blood diastase, sugar. AST, ALT, bilirubin, diastase urine, ultrasound of the pancreas. Increase in blood diastase than 32 units in the urine of -64 units	25
4	Emergency hospitalization in a surgical ward.	25

2) The patient is 41 years old, a young man was treated for tuberculosis, complicated by pleurisy and pericarditis. In the past 6 months have trouble dry cough, sweating and fever up to 37,70 C, loss of appetite, weight loss, pain and heaviness in the right hypochondrium, general weakness. In connection with what appealed to GPs. Objectively: the skin is clean, scleral icterus, cyanosis of the cheeks, acrocyanosis, face swollen. The swollen neck veins, a positive gepatoyugulyarny phenomenon. In the lungs, vesicular breathing. Borders of the heart: the right by the right edge of the sternum, left 2 cm medially from the left mid-clavicular line, upper III intercostal space on the left. Sharply muted tones, three-term rhythm due to the additional tone at the beginning of diastole. Paradoxical pulse -100 beats / min., Rhythmic. BP 100/70 mmHg Belly increased by ascites. +5-6 Cm painful liver, spleen 2 cm swelling in the foot there.

1. Your complete a presumptive diagnosis of 30-points.

2. What research is needed to confirm the diagnosis, 20 points.

3. How is the phenomenon gepatoyugulyarny-20 points.

4. List the triad of Beck, which is the main symptom of this condition, 20 points.

5. Clinical management of patients-10 points.

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3) The patient, aged 52, appealed to the GP complaining of nausea and occasionally vomiting, diarrhea 10-15 times a day (liquid feces, poorly washed off the surface of the toilet bowl), epigastric pain of herpes zoster character. From history: for many years suffered from alcoholism, periodically disturbed the pit of pain radiating to the back. Objectively: the patient sharply reduced supply, the skin dry places with peeling at the corners of the mouth binding. Heart: the ones muffled, rhythmic. Pulse 85 beats. per min. AD-120/70 mmHg In the lungs, vesicular breathing. The abdomen was soft, painful epigastric and right upper quadrant. Liver + 1 cm, the spleen is not enlarged. Symptom frenikus is positive on the left.

1. List at least five diseases for which there are the above signs and symptoms, 15 points.

2. The preliminary diagnosis-30 points.

3. Informative methods of examination-15 points.

4. What changes are observed in the feces of this patient, 20 points.

5. Tactics GPs and treatment-20 points.

4) Patient P., 44 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, signs of scratching on the back. Heart sounds, rhythmic, heart rate 88 bpm. per min. Belly increased by ascites, tenderness in the right upper quadrant. Liver Kurlov 12-18-8 see 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 5 possible diseases, which are the above symptoms-20 points.

2. Your initial diagnosis, 30 points.

3. Specify which enzymes are increased in the early stages of cholestasis in this patient, 20 points.

4. The tactics of the GP-10 points.

5. Principles of treatment of 20-points.

5) Man 42 years old approached the GP complaining of severe epigastric pain, nausea, heartburn. The pain occurs in 20-30 minutes after ingestion and is local. From history: last spring, there were also similar pains. The patient was not treated, the pain itself passed in a month. On-no: abdominal palpation there was a huge local tenderness in the epigastrium. Constipation.
1. List at least four diseases which may be the above symptoms;

2. Your preliminary diagnosis;

3. What additional studies be carried out to confirm the diagnosis;

4. What complications can occur with this disease;

Please specify the scheme and principles of conservative treatment of this
6) The patient K. 54 years old, suddenly had severe pain in the epigastric pain, nausea, vomiting, bloating, shortness of breath, weakness. In the history of coronary artery disease and GB for 6 years and Mt. gastritis. Home is not regularly taken nitrosorbid pain in the heart, and Adelphanum with an increase in blood pressure. The deterioration of ties with the emotional stress and the use of pilaf. Objective: In light vesicular breath. NPV -24 p in minutes. Heart sounds, arrhythmic by the EC, heart rate 96 bpm. per min. BP 165/90 mmHg The abdomen was soft painful in the epigastric region and right hypochondrium. The liver and spleen were not palpable. Jabs: 17.4 x 109 leukocytes, erythrocyte sedimentation rate 10 mm / h, 0.6 AST, LDH-2.4 mmol / l, CRP +.

1. List at least 5 diseases that are accompanied by the above symptoms, 15 points;

2. Your complete a preliminary diagnosis, 25 points;

3. Basic laboratory variation for diagnosis (specify time increase) -25 points;

4. The tactics of the GP-10 points;

5. Pain relief for up-hospital-25 points.

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7) Patient 24 years, complaints of pain in the epigastric pain, joint pain, intermittent fever, cough, nausea, vomiting, blurred vision, body itching, hair loss. Sick for the past 2 years.

Objectively: general state of moderate severity. The skin and mucous membranes are pale. On the face and the neck, erythematous rash. When you are in the sunlight blisters appear. In the lungs: Right in the lower dull sound:, auscultation: a weakened vesicular breathing, isolated rales. Heart: dilated left border of 1.5 cm Ps 90 beats. per min. Blood pressure 110/60 mm Hg. Ulcerative stomatitis. The abdomen was soft, epigastric tenderness. Liver 4 cm

An. Blood: HB-60 g / l, er-2, 5 × 1012 / L leyk.-4 x109 / L ESR-38 mm / hour. Blood urea, 10 mmol / l creatinine, 0 8 mmol / l. OAM oud. Weight-1012-2 protein, 65% er-10-12/1, cylinders hyaline, granular unit.

1. List at least five probable diseases, which are the above symptoms-15 points.

2. Your initial diagnosis, 30 points.

3. What characterizes the lesion
8) Patient G. 39 years appealed to a general practitioner, complaining of constant dull epigastric pain, heaviness, a feeling of fullness, belching with the smell of rotten eggs, nausea, vomiting, food eaten the day before, weakness and cramps in the calf muscles. In the history of suffering from peptic ulcer disease for 15 years. Objectively: the patient malnutrition, skin pale and clean. Heart of: the tones are muted, rhythmic. Pulse of 100 beats. 1 min. Blood pressure 110/70 mm Hg In the lungs auscultated vesicular breathing. The tongue is coated with a grayish bloom. Abdomen enlarged in the upper, the same tenderness, splashing sound. The liver and spleen were not zoom. The chair is prone to constipation.

1.Perechislite least four diseases and at least two events which occurs when the above mentioned symptoms;

2. A presumptive diagnosis;

3. Informative research methods;

4. The tactics of the GP;

                                  

 9) 33 year old patient is turned to the GP with sharp pain around the navel, is not related to food intake. From history: The patient took pills warfarin and heparin ointment externally by a doctor. An objective examination of: the patient was pale, there is bleeding gums, and frequent nosebleeds. On palpation of the abdomen there is a slight soreness around in the blood PTI - 50 navel at normal voltage of the abdominal muscles. %.

1. List at least three diseases that manifest the above symptoms;

2. Your preliminary diagnosis;

3. What additional research is needed to confirm the diagnosis, and that are crucial;

4. Tactics GPs and treatment of pre-hospital (specify non-drug and drug treatments including name, dose and route of administration of these drugs).
10) Patient R. 44, appealed to the GP complaining of feeling of heaviness and fullness in the epigastrium after eating, loss of appetite, general weakness, constipation alternating with diarrhea. More than 15 years ago, sought medical help for any disease of the stomach. The deterioration of the notes for the week. Bad habits do not matter. Objectively: general condition is satisfactory, adequate nutrition, clean skin. Peripheral lymph nodes were not enlarged. Cor-high tones sonorities, rhythmic. Pulse 70 beats. 1 min. Blood pressure 120/70 mm Hg Tongue moist, coated with white bloom, taste buds are smoothed. Abdomen apparently not changed and is actively involved in the act of breathing, palpation soft, slightly painful in the epigastric region. Liver at the costal margin. Analysis of gastric fractional method: total acidity - 10 tit.ed., free hydrochloric acid - abs, associated hydrochloric acid - 5 tit.ed.

 

1. List at least four diseases for which there are the above signs and symptoms;

2. The preliminary diagnosis;

3.Informativnye survey methods;

4. The tactics of the GP with a detailed description of administration (medical and non-medical) patients.
11) 73 year old man at the reception of the GP complaining of severe abdominal pain when coughing and reinforcing when lifting weights. In any history of gastrointestinal diseases are not ill, has a good appetite. 10 days ago in his garden was a small abdominal trauma. An objective examination revealed changes relevant to their age, just by tilting the head forward there was a huge pain in the abdomen. On palpation of the abdomen, tenderness in the area of ​​injury at normal voltage of the abdominal muscles.

1. List at least three diseases that manifest the above symptoms;

2. Your preliminary diagnosis;

3. Additional studies to confirm the diagnosis;

4. Tactics GPs and treatment.

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12) Patient 31, appealed to the GP with complaints of pain in the chest, burning sensation, impaired swallowing, heartburn, belching, regurgitation is tilted. History of these complaints for several years, smoking 5-6 cigarettes a day, is a construction worker.

Objectively: the patient thin, peripheral lymph nodes were not enlarged. Tongue coated, white coating, abdomen was soft and painless. The liver and spleen were not enlarged. Heart sounds are muffled, rhythmic. Pulse 72 beats per minute., BP 120/80 mm Hg. Art.

The solution according to 20-step PRINCIPLE

№	Evaluation	Perfect	Good	Satis.	Unsatis.	Bad
	Assimilation in%	100%-86%	85%-71%	70-55%	54%-37%	36% and less
2	Case study	50-43 point	42,5- 35,5 point	35- 27,5 point	27-18,5 point	18 point

4.2.2 Graphic Organizer: Venn Diagram

• used for comparison or matching iliprotivopostavleniya 2 to 3 dimensions and show them both traits.

• Develop systems thinking, the ability to compare, compare, analyze and synthesis.

Acquainted with the rules of construction of a Venn diagram. Individually / in pairs construct a Venn diagram and fill part of the non-overlapping circles (X)

Are paired, compare and complete their charts.

The intersection of circles make a list of those features that, in their opinion, are common to information 2 to 3 laps (xx / xxx)
4.3. The practical part

The list of skills that GPs should possess after completing training on the subject

1. Perform a visual inspection of patients with abdominal pain.

2. Interpret laboratory and instrumental in patients with abdominal pain.
Pain in the epi-, meso-and gipogastralnoy areas

№	evaluation	Perfect	Good	Satis.	Unastis.	Bad
	Assimilation in%	100%-86%	85%-71%	70-55%	54%-37%	36% and less
4	The practical part	15-12,9 point	12,75-10,6 point	10,5-8,25 point	8,1-5,5- point	5,4 point