The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical and pedagogical faculty
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- Bu səhifədəki naviqasiya:
- 8. References. The main
- Internet medicine saytlari
- 9. Chronological content classes
- Practical session number 5
- Technology training. Study time: 6:00
- The purpose of the training session
- Learning outcomes: GPs should be aware of
- Forms of organization of learning activities
- Methods and feedback means
- Number Stages of the practice session Form classes
- 3. Interdisciplinary communication and Intra
- 4. The content of classes 4.1. Theoretical part
- Circulatory failure (NC)
-Classification of COPD-The clinical course of COPD. -Differential diagnosis of COPD. -The etiology and pathogenesis of COPD. -Basic clinical and laboratory tests for the diagnosis of COPD. -What are the radiographic changes are detected COPD? -Features of COPD?
1) Kasalliklar testes, Sharapov UF T: Ibn Sina, 2003 2) Kasalliklar testes, Bobozhanov S. T: Yangi Asr avlod 2008 3) Kasalliklar testes, Kamolov NN, 1991 4) Internal Medicine, Volume 1 Mukhin, NA M. GEOTAR - Media 2009 5) Internal Medicine, Volume 2 Mukhin, NAM. GEOTAR - Media 2009 6) Textbook of Internal Medicine Editor-in-Chief William N. Kelley 1997
1) Umumy amaliet vrachlar Uchun maruzalar tuples, Gad, A., T., 2012 2) General practice, Ed.F. G.Nazirova, A.G.Gadaeva.M. GEOTAR Media, 2009. 3) Directory GP.Dzh.Merta. M.: Practice, 1998. 4) Collection of practical skills for general practitioners.Gadaev A. Akhmedov Kh.S. T., 2010. 5) Umumy amaliet vrachlar Uchun Amal kunikmalar tuplyu Gadaev AG, Akhmedov, HS, 2010. 6) Therapeutic Guide Washington, Ed.M.Vudli M. Practice, 2000. 7) Umumy amaliet shifokori Uchun kullanma F.G.Nazirov, A.G.Gadaev Tahrah.M. GEOTAR-Media, 2007. 8) Diagnosis of diseases of the internal organs.AN hams All tomy.2005. 9) Treatment of diseases of the internal organs.AN hams All tomy.2005. 10) Differential diagnosis of internal diseases. AV Vinogradov Moscow: Medical News Agency, 2009. 11) Internal medicine: a textbook. - A 2-ton (2 volumes)Ed. Martynov, etc. M.: GEOTAR - Media, 2005:
Med.-site.narod.ru
www.cardioline.ru
Practical session number 5 Theme: "Shortness of breath, choking. The differential diagnosis of dyspnea in heart and lung disease. Circulatory failure and pulmonary insufficiency. Tactics GPs. Indications for referral to a specialist or hospitalization 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. "
2. Motivation
Dyspnea is one of the most common symptoms are accompanied by cardiovascular and pulmonary diseases. Circulatory failure is a pathological condition is failure of the circulatory system to deliver organs and tissues is the amount of blood that is necessary for normal functioning. For the selection of the most appropriate treatment and management of patients with heart failure and pulmonary disease, GPs should clearly know the difference between them, and should be properly differentiate between these pathologies.
You must have a basic knowledge of anatomy, physiology, pharmacology, propaedeutics internal medicine faculty and hospital treatment. Given that the shortness of breath and choking are a symptom of many diseases, GPs have to attract many specialists - cardiologists, cardiac surgeons, rheumatologists, neurologists and pulmonologists. When parsing of the subject there is a close relationship with the pulmonologist, rheumatology, cardiac surgery and functional diagnostics. 4. The content of classes 4.1. Theoretical part
On a practical lesson in the theoretical part series is considered a differential diagnosis of diseases associated with suffocation. Bronhospastichesky syndrome - a syndrome caused by bronchial obstruction, the leading place in the genesis of which is bronchospasm. The immediate cause of seizures is unusually high bronchial reactivity to endogenous and exogenous stimuli. Diagnosis of pathogenic mechanisms of atopic asthma by the following scheme: 1. allergic history, taking into account family history of allergic diseases; 2. Clinical manifestations - for atopic asthma is characterized by clearly defined attacks of asthma, which in a few minutes cropped conventional bronchodilators, cough often occurs at the end attack and ends with separation of a small amount of viscous mucus.Outside attack on percussion and auscultation no pathology. 3. allergic skin test (intraoral, skarifikatsionnye, intradermal). 4. provocative tests (inhalation, nasal, conjunctival). 5. laboratory diagnostics: direct and indirect test basophilic Shelley; lymphocyte blast transformation test; indirect test of destruction of fat cells; reaction Praustnitsa-Kyustnera; glycogenolysis lymphocyte vvdenii adrenaline in the presence of the allergen; 6. An elimination diet followed by food allergen provocation; 7. determining the level of IgE in the serum; 8. radio allergen sorbent test. 3-8 Studies conducted in Allergic center. The clinic attack in infection-dependent asthma (hut) is divided into 2 types: 1. Prolonged breathing difficulties - from several hours to several days, accompanied by a nearly constant cough with branch mucopurulent sputum. 2. Similar to the classic asthma, but with a less clear beginning and end, slowly stoped bronchodilators. Outside attack the lungs listened dry and moist rales. Dishormonal pathogenic variant of AD primarily involves the change of glucocorticoid activity of the adrenal glands, hormonal activity of the ovaries in women. Clinical signs directly indicating glucocorticoid insufficiency, no. A possible violation of hormonal ovarian function judged by changes of asthma in different phases of the menstrual cycle, during pregnancy and the postpartum period. Indications of increased frequency of asthma attacks during the premenstrual period, stihanie or exacerbation of the disease during pregnancy and after childbirth allows to suspect involvement of hormonal ovarian function in the pathogenesis of AD. Adrenergic imbalance in the diagnosis of medical history should be considered evidence of the presence of the reasons that could lead to changes adrenoreactivity. An important role in the formation of this mechanism plays a viral infection, hypoxemia, acidosis, endogenous giperkateholaminemii associated with various stress effects, excessive use of sympathomimetic agents. The use of complex diagnostic laboratory and instrumental methods reveals the violation adrenoreactivity in different parts of the regulation - the cellular, organ, organism. In addition, asthma attacks in asthma may be influenced not only specific, but non-specific stimuli - emotions, breathing cold air, changes in barometric pressure, humidity, etc. Failure of the left ventricle, which is the cause of congestion, edema, simulate asthma. In addition to shortness of breath, which carry distinct inspiration in nature, it must be remembered that in cardiac asthma in history there is evidence of heart disease, its dimensions are increased, on auscultation of the lungs - stagnant wheezing in basal parts, auscultation of the heart - a gallop rhythm, with vices - noise ECG changes, increased body weight in a short time.Trial therapy (diuretics, cardiac glycosides or bronchodilators) confirm the correctness of the diagnosis. The presence or absence of eosinophilia is a valuable diagnostic for exclusion of bronchial asthma. Etiological treatment of asthma includes the implementation of measures such as the removal of the cause of significant environmental allergens and irritants in the workplace and at home, with the rational employment, readjustment of foci of infection, the cessation of neuro-psychological trauma using this therapy. The main objective of the pathogenetic treatment - rehabilitation of bronchial obstruction. For this purpose, appointed agents that stops the main elements of bronchial obstruction: bronchospasm, swelling of the bronchial mucosa, dyscrinia, warning their development. General principles of treatment measures: atopic form - the identification and elimination of allergens for specific desensitizing therapy (histamine, gistoglobulin, polio, etc.). in hut - antibiotic therapy - treatment of various inflammatory foci bronchopulmonary system. at Dishormonal pathogenic form - correction of glucocorticoid insufficiency (GCS therapy, inhalation and Becotidum beklometa, the activation function of the adrenal cortex - corticotropin etimizol, etc.) for the correction of production and exchange of the female sex hormones - olenodren. at vagotonic version - Atrovent, berodual, efantin, Belloidum etc. under option to the imbalance of adrenergic therapy is aimed at: a) increase in the activity 2-adrenergic receptors (GCS) b) reducing the activity of phosphodiesterase - methylxanthines, INTAL, c) reducing the activity of alpha-adrenoretseptsii and direct impact on 2 - adrenergic (sympathomimetics after recovery sensitivity adrenoretseptsii 2). Under option BA with primary altered reactivity is assigned bronchodilator therapy (sympathomimetic bronchodilators), means that stabilize the membrane of mast cells (INTAL, Becotidum, beklomet, zaditen) held ARD prevention, exacerbation of chronic inflammatory diseases of the bronchi (rimantadine), treatment of asthmatic triad ( specific desensitization small increasing doses of aspirin antilimfomina scheme), physical rehabilitation is carried out in poor exercise tolerance (exercise stress, breathing exercises). Along with drug rehabilitation therapy, the importance of physical methods is given (functional) Rehabilitation (EPR), whose objectives is to accelerate and achieve the most complete recovery of body functions, increasing its defensive capabilities to perform more intense exercise compared to those who were under the power patient during the development of the disease. The need for the DF is that even persistent cessation of attacks of breathlessness, achieved as a result of drug rehabilitation, not a guarantee of full recovery of function of pulmonary respiration, myocardium, central hemodynamics. For this purpose, for each patient selected set of physiotherapy (physical therapy), taking into account age, physical fitness, severity of disease, disorders of lung ventilation, chest compressions, veloergometry. Lesson LFC improve neuro-psychological status of the patient, patient adapts to increasing physical activity, thereby contributing to the preservation of health. For making the patient a normal reaction to physical activity recommended exercises from 30 seconds to 1 minute, repeated at short intervals. An important factor in the restructuring of breathing is to train delays after normal exhalation of breath, volitional control of breathing. Treatment of patients with asthma include planned treatment in acute phase, emergency treatment aimed at symptom relief and treatment in the remission phase. The indications for hormonal therapy is a severe attack of asthma, bronchodilators is not stopped, threatens to go to the asthma status, as well as frequent and prolonged aggravation, not amenable to conventional treatment with full doses of bronchodilators. From natural glucocorticoids for the treatment of asthma using hydrocortisone hemisuccinate, synthetic - prednisolone, methylprednisolone (urbazon, metipred) triamtsinalon (kenokort, polkortolon, berlikort), dexamethasone. The most rational way of introducing inhaled steroids (Becotidum, beklomet), significantly reducing their negative impact on other systems and organs, in case of need expressed exacerbation of asthma, oral or intravenous use them. Because of the risk of severe complications of steroid therapy, the basic rule is the appointment from the start of large doses (50-100 mg based on prednisolone) to eliminate the symptoms of the disease, and then a rapid decline until the complete withdrawal within 5-7 days. Large doses should be spread into 2-3 doses are relatively small - once in the morning. By means of biological prevention is Intalum. It effectively prevents the bronchoconstriction that occurs in response to exercise. Pharmacological analogue Intalum is ketotifen (zaditen) - antihistamine. When remission of exacerbation and remission that a strategic therapy - outpatient rehabilitation. The main objective of the rehabilitation phase is to prevent relapse of the disease and the achievement of full and sustained remission. In this widely used by a variety of non-pharmacological treatments (specific desensitization therapy, acupuncture, physiotherapy, aeropiezotherapy, spa treatment). Universal purpose of pathogenetic treatment for any pathogenic variants of the disease is to restore the bronchial obstruction by eliminating bronchospasm, edema and hypersecretion. For drugs acting on these mechanisms include bronchodilators (agonists, methylxanthines, anticholinergics), INTAL, corticosteroids. At this stage, the treatment should be used immunomodulatory therapy including immune status, severity of asthma, complications and comorbidities, as well as maintenance and preventive treatment. For asthma patients with mild to moderate course, infection-dependent form to include in a course of anti reaferon therapy at a dose of 15 thousand units. per kg of body weight, on the course of 5 injections in the spring and autumn period, for patients with severe asthma advisable to conduct a year-round immunization - 2 times a month at 1,000,000 units. i / m In the appointment of maintenance therapy with bronchodilators, Intalum, tranquilizers appropriate use of the principles of chronotherapy. Must take into account the deterioration of bronchial obstruction at different times of day: as a rule, the maximum pathological changes of the respiratory function parameters that define the airway patency and result gipersinhronizatsii and increase the amplitude of circadian rhythms occur in the period from 0 to 8 hours Each patient should be advised to optimal intervals of medication, including at night.
Depending on the speed of development are acute NC, which manifests itself in a matter of minutes and hours, and chronic NK, which is formed during the period of several weeks to several years. In addition, the isolated heart failure associated with cardiac and vascular insufficiency, in which the fore in the mechanism of impaired circulation acts predominantly vascular component. Classification of heart failure According to the classification, ND Strazhesko and VH Vasilenko HNK distinguish 3 stages: Stage I-Primary: The Hidden circulatory failure, manifested by shortness of breath, palpitations, fatigue only during exercise.Hemodynamics at rest is not broken. Stage II-a period: Signs Tax alone expressed moderately, exercise tolerance is reduced, there are congestion in large or small circle of blood, the severity of mild, period used: severe symptoms of heart failure at rest, severe hemodynamic abnormalities in a large, and in the pulmonary circulation. stage III-final: dystrophic stage of infringement with severe hemodynamic, metabolic, irreversible changes in the organs and tissues. In 1978, FI Mosquitoes and LI Olbinskaya identified in stage I, two periods - a and b. period-I and preclinical or early predzastoyny characterized by the absence of complaints and hemodynamic compromise, but there are signs of physical activity to reduce the pumping function of the heart: decreased cardiac output by 10-20%, a slight increase in end-diastolic pressure and volume, increases in diastolic pressure in the pulmonary artery , decrease in the rate of circulatory shortening of the myocardial fibers in its reduction. b-I period is characterized by signs of stage I classification ND Strazhesko and VH Vvasilenko, i.e. the advent of transient congestion in the pulmonary circulation under the load.NM Mukharlyamov (1978) suggested III - stage HNK also distinguish two stages. period III, and partly irreversible stage of heart failure, in which there are marked stagnation in small and large circulation, low cardiac output, a significant dilatation of the heart, pronounced increase in end-diastolic pressure and volume, but with adequate modern treatment possible to achieve improvement of the patients (reduction of edema, anasarca, stagnation in the internal organs). period III-b completely irreversible stage corresponds to stage III classification ND Strazhesko and VH Vasilenko. With the additions out above classification corresponds to the classification of heart failure of New York Heart Association (NYHA).
CHF clinically manifested a number of characteristic symptoms: Shortness of breath, orthopnea, cardiac asthma, nocturia, peripheral edema and enlargement of the liver, sometimes ascites, anorexia, wheezing over the lungs, enlargement of the heart, atrial gallop, a third heart sound, jugular venous distention, anasarca, ascites.
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