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

4.1 The analytical part

Case Studies:

1.Bolnaya 19 years appealed to the GP complaining of pain after eating, especially solid, chest pain lasting 10-15 minutes, sometimes up to several hours after taking the pass erinita, difficulty swallowing and passage of the bolus in the projection of the xiphoid process, palpitations , after growing unrest regurgitation (spitting up food eaten), often at night (according to the patient's pillow in the morning get wet), excessive salivation. Objective: The general condition is satisfactory. pale skin, dry. Low power. In the lungs, vesicular breathing. Cardiac clear, rhythmic. Pulse 92 beats per 1 minute. BP 100/70 mmHg Marked elongation of auscultatory time swallowing, auscultation over the xiphoid process is determined by the deaf, a gurgling sound, appearing in 1.5-2 minutes after a sip of water. Tongue moist. The abdomen was soft and painless. Loose stools and urine. Complete blood count, ECG was normal.
1.Perechislite than two diseases in which the above-mentioned symptoms can be observed;

2.Specify your most likely a preliminary diagnosis;

3. More research is needed to confirm your diagnosis;

4. Specify the method of research, which is crucial in making a diagnosis;

5. Tactics GPs and treatment guidelines;

Example answer:

1.Ahalaziya cardia cardiospasm, esophagitis, stenkarditicheskie pain, mediastinal tumors.

2.Kardiospazm (achalasia cardia)

3.Rentgenoskopiya esophagus with barium, EGFDS

4.Rentgenografiya esophageal biopsy

5Konsultatsiya gastroenterologist, if necessary, hospitalization Dep. Gastroenteroogii.Lechenie: antispasmodics-Noshpa, platifillina g-t, uspakaivaetsya therapy.

1. 
   2.Bolnoy 52 years at a reception at the GP complaining of chest pain, epigastric (especially after coughing and physical effort), heartburn (especially torso and in the supine position), burping air and eaten food, occasionally persistent hiccups, quick sense of saturation, sometimes vomiting with blood, on the night regurgitation of food (a symptom of "wet pillows"). Objectively: the patient's general condition is relatively satisfactory. Pale skin. On the part of the lungs, heart and other internal organs was normal.
   
2. 
   Jabs: hypochromic anemia.
   
3. 
   ECG was normal. Enter at least 3 diseases, which are characterized by the above symptoms;
   
4. 
   4. Your preliminary diagnosis;
   
5. 
   5. Additional research is needed to confirm the diagnosis;
   
6. 
   6. The method of investigation, which is crucial in making a diagnosis;
   
7. 
   7. Treatment;
   
8. 
   8. Tactics GPs.
   
9. 
   
   
10. 
    3. A patient 22 years old, student, turned to the GP complaining of a burning sensation behind the breastbone and around the xiphoid process, soreness or burning sensation when passing food through the esophagus, impaired swallowing, regurgitation of food sometimes, sour or bitter liquid, worse torso in a horizontal position .
    
11. 
    With fluoroscopy esophagus detected from the flowing contrast agent stomach into the esophagus.
    
12. 
    Complete blood and urine tests, as well as an electrocardiogram was normal.
    
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14. 
    1. List at least three diseases that manifest the above symptoms;
    
15. 
    2. Your preliminary diagnosis;
    
16. 
    3. Additional studies to confirm the diagnosis;
    
17. 
    4. Specify the method of research, which is crucial in the diagnosis;
    
18. 
    5. Tactics GPs and principles of treatment (non-pharmacological and pharmacological).
    
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20. 
    4. Patient 34 years old at the reception of the GP complaining of a violation of swallowing, burning sensation behind the breastbone, cold hands, especially in the cold, pain in the joints of the hands, shortness of breath, slight cough, difficulty opening the mouth, general weakness. Objective: The general condition of moderate severity. Consciousness is clear. Position is activated. Skin is thick, shiny, on the forearms and hands are not taken into the fold. In the light scattered dry rales. Heart sounds are muffled, rhythmic. Pulse 104 beats per 1 minute. BP 120/80 mm Hg The abdomen was soft, slightly painful in the epigastric region. The liver and spleen were not enlarged. Chair and mochespuskanie free.
    
21. 
    UAC: Hb - 92 g / l, leukocytes - 3.6 x 10 / l, 28-ESR mm / hour.
    
22. 
    
    
23. 
    1. List at least four diseases with the above symptoms;
    
24. 
    2. Your preliminary diagnosis;
    
25. 
    3. Additional studies to confirm the diagnosis;
    
26. 
    4. The method of investigation, which is crucial for diagnosis;
    
27. 
    5. Tactics GPs and treatment guidelines.
    
28. 
    __________________________________________________________________________
    
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30. 
    5. A patient 67 years old, at a reception at the GP complaining of pain and a feeling of pressure in the chest, sometimes in the night, impaired swallowing, belching air, food regurgitation, vomiting, drooling, loss of appetite, hoarseness. Objectively: the patient malnutrition. Consciousness is clear. Skin is ashy gray. Palpable enlarged cervical lymph nodes. In the lungs, vesicular breathing heart sounds are muffled, rhythmic. Rhythmic pulse of 100 beats per minute 1. BP 150/70 mmHg Tongue coated with white bloom. The abdomen was soft and painless. The liver and spleen were not palpable. The chair is prone to constipation. Urination is free.
    
31. 
    Jabs: revealed anemia, ESR-36 mm / hour.
    
32. 
    
    
33. 
    1. List at least 3 diseases with which is necessary to conduct a differential diagnosis;
    
34. 
    2. Your preliminary diagnosis;
    
35. 
    3. Additional studies to confirm the diagnosis;
    
36. 
    4. The method of investigation, which is crucial for diagnosis;
    
37. 
    5. Tactics GPs.
    
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    ________________________________________________________________________
    
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40. 
    6. Patient 25 years old at the reception of the GP complaining of retrosternal pain associated with swallowing, a delay in the esophagus dry and poorly chewed food, belching, regurgitation of food at torso. Dysphagia is intermittent, sometimes occurs on a liquid diet and disappears if swallowed solid food. Objectively: the pathological changes of the internal organs were found. KLA and OAM unremarkable.
    

1. List at least 3 diseases, which is necessary to conduct a differential diagnosis;

2. Your preliminary diagnosis;

3. What additional research is needed to confirm the diagnosis;

4. Specify the method of research, which is crucial for diagnosis;

5. Tactics GPs and treatment guidelines.

_________________________________________________________________________

7. A patient 37 years appealed to the GP complaining of chest pain in the epigastric region, emerging and evolving with food or immediately after, sometimes in the supine position, lasting from several minutes to several hours. Concerned about dysphagia, heartburn, belching, regurgitation of acidic stomach contents, worse torso and in the supine position. At times there is vomiting with blood streaks. On radiographs of the lower third of the esophagus revealed a symptom of "niche". From other internal organs revealed no pathology.
1. List at least four diseases with which is necessary to conduct a differential diagnosis;

2. Your preliminary diagnosis;

3. What additional research is needed to confirm the diagnosis;

4. What complications can be in this disease;

5. Treatment. Tactics GPs.

__________________________________________________________________________

8. Patient 84 years old at the reception of the GP complaining of pain and a feeling of pressure in the chest, sometimes in the night, impaired swallowing, belching air, food regurgitation, vomiting, drooling, loss of appetite, aversion to meat. Objectively: the patient malnutrition. Consciousness is clear. Skin is ashy gray. Palpable enlarged cervical lymph nodes. In the lungs, vesicular breathing heart sounds are muffled, rhythmic. Rhythmic pulse of 100 beats per minute 1. BP 130/70 mmHg Tongue coated with white bloom. The abdomen was soft and painless. The liver is enlarged dense, hilly. The spleen is not palpable. The chair is prone to constipation. Urination is free.

Jabs: revealed anemia, ESR-56 mm / hour.

1. List at least four diseases in which the above symptoms are observed;

2. Your preliminary diagnosis;

3. What is the most frequent and early symptom of the disease;

4. The method of investigation, which is crucial for diagnosis;

5. Treatment. Tactics GPs.

9. Patient R., 36, a longshoreman, he turned to see a GP with complaints of frequent heartburn, about which constantly takes teaspoon soda. In recent days there pain in the xiphoid process, especially after the heavy lifting at work and tilted forward. In the history of gastrointestinal disease denies. Objectively: the patient moderate power, the skin and mucous normal color, clean. Cor-high tones sonorities, rhythmic. Pulse 70 beats. 1 min. Blood pressure 120/70 mm Hg In the lungs auscultated vesicular breathing. The abdomen was soft, with no pain. The liver and spleen were not enlarged. A chair and a regular urine output. Society. An. Blood: Hb-130 g / L, white blood cells, 7.2 × 10 9 monocytes. - 5, lymphocyte. - 27 ESR 10 mm / hr.

1. List at least five 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.

10. A patient 40 years appealed to the GP complaining of chest pain in the epigastric region, emerging and evolving with food or immediately after, sometimes in the supine position, lasting from several minutes to several hours. Concerned about dysphagia, heartburn, belching, regurgitation of stomach contents, worse torso and in the supine position. List at least four diseases with which is necessary to conduct a differential diagnosis;

1. Your preliminary diagnosis;

2. What additional research is needed to confirm the diagnosis;

3. What complications can be in this disease;

4. Treatment. Tactics GPs.Критерии оценки

Maximum point 20-19	18-17 point	16-15 point	14-13 point	12 point
Perfect	Good	satisfactory	unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less

Tests.

1. Primary achalasia (cardiospasm) of the esophagus is more common:

a) in the elderly

b) children

c) in young and middle-aged

r) in newborns

d) teenagers

2. An early symptom of cancer of the esophagus is:

a) dysphagia

b) constant chest pain

c) melena

d) hoarseness

e) weight loss
3. Factors contributing to the development of reflux esophagitis does not apply:

a) hiatal hernia

b) obesity

c) pregnancy

d) alcohol, smoking

d) receiving Cerucalum

4. Drug normalizing gastric motility and used for the treatment of reflux esophagitis is:

a) metacin

b) atropine

a) cimetidine

g) tserukal

d) ranitidine

5. Male 50 years old, height 180 cm, weight 70 kg. complains of a painful burning sensation behind the breastbone, which is increasing at a slope, in a horizontal position, after eating, radiating to the neck, back, subside after taking the soda burp eaten food. It is most likely that the patient:

a) reflux esophagitis

b) stable angina

c) the output of the gastric cancer

g) unstable angina

e) a stomach ulcer

6. Female 46 years old are overweight complain of pain in the heart, epigastric pain arising in the performance of work related to the slopes, alone at night, periodically occurring heartburn.

On examination: ECG at rest and during exercise - no pathology. It is most likely that the patient:

a) angina

b) peptic ulcer

c) osteochondrosis with radicular syndrome

g) hiatal hernia

d) painless form of coronary artery disease
7. A patient 52 years for 5-6 years old notes chest pain after eating, when tilted in the horizontal position, which nitroglycerin not cropped, reduced in the transition to a vertical position. The ECG changes during pain have been identified.
1. The likely diagnosis:

a) angina

b) vegetative-vascular dystonia

c) hiatal hernia

g) Tietze's syndrome

e) intercostal neuralgia

8. The tactics of GPs:

a) surgical consultation

b) consultation of a cardiologist

c) consulting gastroenterologist

g) treatment and supervision in a family health center (rural medical station)

d) in-patient treatment

9. For the drug ranitidine pick him characterization:

a) H2-blocker gistaminoretseptorov

b) the total anticholinergic action

c) topical anticholinergic

d) an antacid

e) miotonik

10. For drug almagel pick him characterization:

a) H2-blocker gistaminoretseptorov

b) the total anticholinergic action

c) topical anticholinergic

d) an antacid

e) miotonik

The evaluation criteria

Maximum point 20-19	18-17 point	16-15 point	14-13 point	12 point
Perfect	Good	Satisfactorily	Unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less

4.2.2.Grafichesky organizer "fishbone".

The purpose of the scheme "fishbone" to describe the whole range of field problems and try to solve it, develops and activates the system, creative, analytical thinking.

Progress chart: students get acquainted with the rules of construction of the scheme. Individually or in pairs to write down the top bone wording of sub-problems and on the bottom - the facts prove that these problems exist.

Together in a mini group, compare and complement your scheme.

Next, conduct a presentation of the results. Presentation of the completed scheme to demonstrate the relationship of sub. Their comprehensive.

worn out similar latent simulation

clinic Symptoms course disease
dyspepsia diagnostics

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Lack of               patient             shortage economic

laboratory in time Lack of equipment

Didn’t come

Doctor doctor doctor doctor

illiterate inattentive negligent does not develop

dyspepsia

diagnostics

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Nurse Nurse Nurse

dereliction of duty illiterate Non-executive

Maximum point 20-19	18-17 point	16-15 б point	14-13 point	12 point
Perfect	Good	Satisfactorily	unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less

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 diseases with dysphagia.

2. Interpretation of the analyzes, the data of laboratory and instrumental studies (clinical and biochemical analyzes of blood, urine, feces, vomit, gastrointestinal radiographic studies of the esophagus in particular, EFGDS)

3. Prescription of drugs depending on the etiology of diseases that are accompanied by dysphagia. dyspepsia

Gastritis, duodenitis, peptic ulcer disease, biliary dyskinesia, cholecystitis, postcholecystectomical syndrome, a disease of the operated stomach

№ stage	indicators \ interpretation	Not fulfilled	Fully met
	examination of the patient
	Complete blood	0	50
	enzymes diastase
	Analysis of gastric juice
	EGDFS
	X-rays of the gastrointestinal tract
	Ultrasound of the liver, gallbladder, pancreas
	infectious disease consultation
	surgical consultation
	differential diagnosis	0	20
	The diagnosis	0	10
	tactics GP	0	10
	preventive measures	0	10
TOTAL		0	100

The evaluation criteria

Maximum point 20-19	18-17 point	16-15 point	14-13 point	12 point
Perfect	Good	Satisfactorily	Unsatisfactorily	bad
100%-86%	85%-73%	70-56%	53%-46%	43% and less