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 № 6-7

Theme: "Diarrhea. Differential diagnosis of diarrhea of infectious and noninfectious etiologies. Hypovitaminosis. 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 about "

learning Technology

Study time: 6.4 hours
The structure of the training session	1. Training themed room. 2. cabinet GP 3. Tutorials, phantoms, models, handouts, a collection of case studies and tests 4. TV, video equipment, multimedia
The purpose of the training session: Getting GPs choosing the optimal treatment strategy options for diarrheal diseases, as well as the principles of management of patients in primary care, provided the requirements of the "Qualification characteristics of the GP
Pedagogical objectives: 1. Consider the issues of diagnosis and hypersecretory diarrhea hyperosmolar 2. Consider diagnosis of hyper-and hypokinetic diarrhea 3. Demonstrate patients with diarrhea 4.Obsudit clinical and laboratory data and instrumental research for diarrhea. 5. Differential diagnosis of diarrheal disease. 1. Discuss questions about tactics in the qualifying characteristics of GPs 2. Discuss the principles of treatment (medication and non-medication). 3. Discuss the principles of management, supervision and monitoring of patients in a hovercraft or a joint venture. 4. Discuss the principles of primary, secondary and tertiary prevention in these diseases.	Learning outcomes: The student must: GPs should be aware of: 1. The mechanism and causes of diarrhea. 2. Clinical manifestations of diarrhea. 3. Diagnosis of diarrhea. 4. Differential diagnosis of diarrhea. 5. The principles of treatment (medication and non-medication) in these diseases, diarrheal. 1. Principles of follow-up and monitoring of patients in a hovercraft or a joint venture. 2. The principles of primary, secondary and tertiary prevention in these diseases. GPs should be able to: 1. Analyze the data and history of complaints in the diagnosis of diarrhea. 2. Diagnose, differentiated by clinical and laboratory research tool diarrhea. 3. Choose drugs with proven efficacy 4. Advise on non-drug therapies. 5. To monitor in a hovercraft or a joint venture.
training Methods	the method of "rotation", a pyramid. 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, history, tables, 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

Theme: "Diarrhea. Differential diagnosis of diarrhea of infectious and noninfectious etiologies. Hypovitaminosis. 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 about "

№	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 "rotation"), 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

Often, in the practice of primary care patients with the syndrome are diarrhea. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of diarrhea caused by various diseases, to provide medical care in a GWP (SVP), or direction, or in specialized hospitals. These circumstances are the basis for the inclusion of this subject in the training of GPs.

3. Interdisciplinary communication and Intra

Anatomy, histology and cytology with embryology, biology, normal physiology, biochemistry,. Pathological Anatomy, Pathological Physiology, Topographic anatomy and operative surgery, internal medicine Propedeutics, Tuberculosis. Oncology, Radiology and Nuclear Medicine, Physiotherapy, Endocrinology, Faculty Therapy, Hospital Therapy, Orthopedics.

4. The content of classes

4.1. The theoretical part

When parsing the theme focuses on the following points.

Violation of the passage of intestinal contents and intestinal motor function in chronic enteritis most commonly manifested by diarrhea. In the development of diarrhea involves four mechanisms: intestinal hypersecretion, increased osmotic pressure in the intestinal lumen, intestinal giperekssudatsiya, impaired transit of intestinal contents. Intestinal motility disorders are of great importance in the development of diarrhea. In a large proportion of patients with diarrhea accelerated transit of intestinal contents is not due to increased peristaltic activity of the intestine, and the weakening of the motor, especially the distal small intestine. Rectosigmoid department plays the role of a functional sphincter, he relaxes with diarrhea, it is his failure, termination or weakening of segmenting contractions leads to what cal passively moves through the colon, meeting no resistance, which in normal circumstances, have a bowel movement it is segmented, mixing the contents and forming a "fecal pole." However, some patients may be due to diarrhea and a significant increase in motor function of the intestine.

Intermittent diarrhea is one of the most constant symptoms of chronic bowel disease. This term refers to the increase in stool frequency (more than 3 times a day) with the release of large amounts of liquid and more fecal consistency compared with a conventional part of the individual's bowel.

Intestinal hypersecretion caused by disturbance of electrolyte transport in the intestine. The most typical example of secretory diarrhea is cholera. Secretory diarrhea is characterized by a water chair, polifekaliey, steatorrhea due to fatty acids with long-chain, high losses of sodium, potassium, chlorine and feces, metabolic acidosis, high pH of faeces.

The increase in osmotic pressure in the intestine occurs in the following cases: 1) violation of the digestion and absorption of carbohydrates, 2) malabsorption syndrome, and 3) an increased flow in the intestines of osmotically active substances (saline laxatives, sorbitol). Osmotic diarrhea characterized by loose stools, polifekaliey, increasing faecal concentration of short chain fatty acids and lactic acid, minor fecal loss of electrolytes, low pH feces.

Acceleration of transit of intestinal contents occurs when: hormonal and pharmacological stimulation of transit (serotonin, prostaglandins, secretin, pancreozymin, gastrin) neurogenic stimulation transit acceleration evacuation activity of the intestine, increasing pressure intraintestinal. Increasing the speed of intestinal transit more often observed in functional diarrhea and is characterized Frequent, small stool, sometimes with mucus, especially in the morning or after a meal, are often observed cramping abdominal pain

Treatment of diarrhea: a health food - a diet 4b (with a high content of protein and fat physiological norm), a gluten-free diet, recovery eubioz bowel enzyme preparations, adsorbents, astringents, enveloping, linking excess organic acids preparations, means that slow peristalsis, anti-secretory drugs.

How is the method of "rotation"

Objective: The involvement in the educational process of all students while controlling their knowledge of the topic under discussion.

The main provisions of methods. In the audience numbered posted several tasks. Each small group (2-3 people). Provides po10 minutes to discuss and record their answer choices, followed by exchange of jobs. Then collectively discussed the quality of the responses of each group, of which the best is selected.

Differential diagnosis of diarrhea:

1Kakie mechanisms are involved in the occurrence of diarrhea

2. Laboratory and instrumental methods of diagnosis for diarrhea.

3. Characteristics of osmotic diarrhea.

answers:

1. four mechanisms: intestinal hypersecretion, increased osmotic pressure in the intestinal lumen, intestinal giperekssudatsiya, impaired transit of intestinal contents.

2. KLA general analysis of feces, feces bak.posev and susceptibility to antibiotics, fecal bacteria overgrowth, diastata blood and urine tests, serological tests, x-ray gastrointestinal tract.

3. Osmotic diarrhea characterized by loose stools, polifekaliey, increasing faecal concentration of short chain fatty acids and lactic acid, minor fecal loss of electrolytes, low pH feces.

№	Evaluation	Perfect	Good	Satis.	Unsatis.	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). 38 year old woman complains of severe cramping pain in the left half of the abdomen, occasionally diarrhea with mucus and blood streaks, tenesmus, abdominal distention, fever up to 38,50 C, weight loss, general weakness. Sick for the past 6 years. Exacerbation of the disease occurs in spring and autumn. The deterioration in 3 weeks. An objective examination of the patient malnutrition, pale and listless. In the lungs, vesicular breathing, no wheezing. Heart sounds, heart rate and pulse 86 beats per minute. BP 90/60 mm Hg On palpation of the abdomen marked pain in the left iliac region. The liver and spleen were not enlarged.

1. List at least 4 probable diseases for which there are symptoms listed above, 15 points.

2. Your initial diagnosis, 25 points.

3. What changes are characteristic of this disease in the general analysis of feces (please specify) -15 points.

4.Harakternye endoscopic data for this pathology-25 points.

4. Tactics GPs and treatment guidelines, 20 points.

Answers:

№	Answers:	point
1	Chronic colitis, ulcerative colitis, Crohn's disease, dysentery.	15
2	NUC	25
3	liquid stool with mucus and pus, scatology: leukocytes, erythrocytes	15
4.	redness, swelling, bleeding, erosion and ulcers, thinning and pale mucous membranes.	25
4	A referral to a gastroenterologist at stats.lechenie, treatment of 5 - ASA (sulfasalazine), corticosteroids administered orally.	20