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 № 8-9

Theme: "Constipation. Differential diagnosis of irritable bowel syndrome, senile constipation and colon tumors. 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	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 on timely diagnosis and differential diagnosis, selection of the optimal treatment strategy options for constipation caused by various diseases, 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: • Consider issues of diagnosis of constipation. • Consider issues of diagnosis of irritable bowel syndrome, colitis, colon cancer, diverticulosis, dolichocolon. • Demonstrate patients with constipation. • Discuss the findings of clinical and laboratory research tool for constipation. • Conduct a differential diagnosis of constipation. • Discuss questions about tactics in the qualifying characteristics of GPs • Discuss the principles of treatment (medication and non-medication). • Discuss the principles of management, supervision and monitoring of patients in a hovercraft or a joint venture. • Discuss the principles of primary, secondary and tertiary prevention in these diseases.	Learning outcomes: GPs should be aware of: • The mechanism and causes of constipation. • Clinical manifestations of constipation. • Diagnosis of constipation. • The differential diagnosis for constipation. • Principles of treatment (medication and non-medication) in these diseases. • Principles of follow-up and monitoring of patients in a hovercraft or a joint venture. • The principles of primary, secondary and tertiary prevention in these diseases. GPs should be able to: • Analyze data and history of complaints in the diagnosis of constipation. • Diagnose, differentiated by clinical and laboratory and instrumental investigations constipation. • Choosing the right medication for the treatment of constipation. • Advise on non-drug therapies. • 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: "Constipation. Differential diagnosis of irritable bowel syndrome, senile constipation and colon tumors. 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 »

№	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

Patients with complaints of constipation often first seek medical attention to a general practitioner. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of constipation caused by various diseases, to provide medical care in the FCP (SP), or referral to 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

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

Constipation - this difficulty spotting the dense feces. Rare chair, feeling of incomplete evacuation after bowel movements are less accurate because the soft stool every 2-3 days - this version of the norm, and the tight chair several times a day should be considered as constipation.

Functional constipation. There are three types of functional constipation; simple constipation constipation during hypokinesia bowel constipation without hypokinesia bowel (irritable bowel syndrome). The most common simple constipation, which is caused by poor diet, lack of exercise, the suppression of the urge to defecate, poor working conditions, unusual food during long trips. The constant urge to defecate suppression leads to dyskinesia - a condition when the threshold is increased to stretch the ampoule rectum. Hypokinesia bowel is usually observed in young people. Constipation usually begins in childhood or adolescence increases after birth, a strict diet in order to lose weight or operations. After the examination, and exclusion of organic causes of constipation give recommendations to change diet and a healthy lifestyle

The main causes of acquired megacolon: the abolition of laxatives after prolonged use, hypothyroidism, systemic scleroderma. Clinic: characterized by a pronounced abdominal distention, with a rectal examination - extension of vials of the rectum and lower sphincter of the anus; ergography reveals expansion of the colon, which is filled with feces. Practical advice: should exclude organic causes of constipation, give advice on nutrition and healthy lifestyle and should not be long-term use laxatives, with constipation, with the release of dark blood should be suspected colon cancer, hemorrhoids is typical for the selection of red blood; cause constipation can be hypokalemia in patients taking diuretics.

Colon cancer. Sick usually men older than 50 years, mortality rates as high as 60% due to late diagnosis, and in 70% of cases the tumor is localized in the rectum. Risk factors: ulcerative colitis, congenital familial polyposis of the colon, villous adenoma of the colon. Clinic: admixture of blood and mucus in stool, constipation, sometimes diarrhea, feeling of incomplete emptying of the bowel, abdominal discomfort or cramping pain, discomfort in the rectum, anemia.

With the years the frequency of bowel diverticulosis (in people older than 40 years). It is characterized by the formation of multiple diverticula in the descending colon. The cause of the disease is a rare fiber intake. Clinic: bowel diverticulosis often asymptomatic, sometimes there are constipation or alternating it with diarrhea, pain in the hypogastrium, mostly on the left. Patients complain of pain on palpation of the left iliac region, bleeding, sometimes massive, can join the symptoms of "acute abdomen." Complications: abscess, perforation of a diverticulum, peritonitis, intestinal obstruction, fistula formation. In the blood, there is a leukocytosis, increased erythrocyte sedimentation rate. For a diagnosis is holding sigmoidoscopy, colonoscopy, barium enema. Chronic colitis - a chronic inflammation of the colon. Clinic: Alternating constipation and diarrhea, typical symptom of lack of bowel movements, false urge to defecate, abdominal pain, flatulence, anorexia, a feeling of bitterness in the mouth, polyhypovitaminosis, anemia.

Treatment: mechanical light diet, smaller meals, broad-spectrum antibiotics, sulfa drugs, drugs of freeze-dried cultures of bifida bacteria and E. coli in patients with severe flatulence appoint activated carbon.
How is the method

The method of "snowballs."

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

 The main provisions of methods.

Group 2-3 is divided into smaller sub-groups which discuss the same problem or situation to set the highest number of correct answers. Each correct answer is recorded on the score of this group in the form of snowballs. Group receiving the highest number of points, give higher ratings.

Advantages: competitive principle activates the thought process: enlivens and employment.

Example. Quest on "Constipation" list of laboratory and instrumental data in cases involving constipation.

This method teaches the student the rapidity of thought, pozvolyakt teacher to objectively assess the depth of knowledge of the studied material.

The method of "snowballs."

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

 The main provisions of methods.

Group 2-3 is divided into smaller sub-groups which discuss the same problem or situation to set the highest number of correct answers. Each correct answer is recorded on the score of this group in the form of snowballs. Group receiving the highest number of points, give higher ratings.

1. Types of functional constipation

2. Clinic diverticulosis.

3. Treatment of chronic colitis.

        Answers:

1. Three types of functional constipation; simple constipation constipation during hypokinesia bowel constipation without hypokinesia bowel (irritable bowel syndrome).

2. Clinic bowel diverticulosis often asymptomatic, sometimes there are constipation or alternating it with diarrhea, pain in the hypogastrium, mostly on the left. Patients complain of pain on palpation of the left iliac region, bleeding, sometimes massive, can join the symptoms of "acute abdomen."

3. Treatment: mechanical light diet, smaller meals, broad-spectrum antibiotics, sulfa drugs, drugs of freeze-dried cultures of bifida bacteria and E. coli in patients with severe flatulence appoint activated carbon.

№	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. 32-year-old driver went to the doctor complaining of pain in the epigastric region, resulting in an hour after eating, and constipation. Ill for two years, exacerbations observed in the spring - autumn. The patient regarded his condition as "poisoning", was treated with home remedies, doctors did not address. Last deterioration 3 days ago, accompanied by a darkening of the stool, weakness, dizziness.

Smoke, abuse alcohol, eats regularly. On examination, the condition is relatively satisfactory, normostenik. Tongue coated with white bloom. The abdomen was soft, with deep palpation tenderness in pyloro-duodenal area. From other organs showed no pathological changes. Pulse 98 beats per minute, blood pressure 115/65 mm Hg. Art.

1. List at least five possible conditions under which the above symptoms occur, 20 points.

2. Your initial diagnosis, 30 points.

3. Specify the early symptoms indicating the presence of complications in the patient-25 points.

4. The tactics of the GP-10 points.

Answers:

№	Answers:	point
1	peptic ulcer, peptic ulcer disease 12 sc, cholecystitis, gastritis, pancreatitis.	20
2	ulcer 12 sc, complicated by bleeding.	30
3	darkening of the stool, weakness, dizziness.	25
4	Emergency hospitalization in a surgical ward.	25