MINISTRY OF HEALTH REPUBLIC OF UZBEKISTANCENTRE OF DEVELOPMENT OF A MEDICAL EDUCATION

TASHKENT MEDICAL ACADEMY

IDIOPATHIC HYPERTENSIA

(The educational-methodical grant on the integrated training For students of IVcourses of medical institutes)

MINISTRY OF HEALTH REPUBLIC OF UZBEKISTANCENTRE OF DEVELOPMENT OF A MEDICAL EDUCATION

TASHKENT MEDICAL ACADEMY

I "confirm" The chief of the main department

Science and educational institutions Ministry of Health Republic of Uzbekistan S.E.Atakhanov ___________________________ “____” ________________ 2011

№ the report

IDIOPATHIC HYPERTENSIA(The educational-methodical grant)

Tashkent - 2011

Composers:

Matchanov S.H. - Associate Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Djuraeva E.R - Associate Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Kasimova M.B. – Senior Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Ziyaeva F.K. - Assistant Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Sagatova D.R - Assistant Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Sultonova M.X. – Assistant Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Bekenova G.T. – Assistant Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Berdieva D.U. - Assistant Professor and Faculty Hospital Therapy Faculty of Medicine, and Internal disease and pre ventive health care department

Reviewers:

A.V.Yakubov - chair of clinical pharmacology ТМА, professor

M.Z.Zohidova - chair on preparation of the doctor of the general practice of the Tashkent institute of improvement of doctors, professor

The educational-methodical grantis considered and confirmedat session CМCТМА (the report № _____ “_____” _____ 2011).

Chairman CМC, professor M.Sh.Karimov

The educational-methodical grant is confirmed on Academic council ТМА and it is recommended to publication (the report № _____ “_____” _____ 2011г.).

The scientific secretary,professor G.S.Rakhimbaeva

Conditional abbreviationsАIAngiotensin IАIIAngiotensin IIАVatrioventricularАHArterial hypertensionAPArterial pressureАDHantidiuretichormone ACEangiotensinconvert enzyme АТ1

angiotensin1

АТ2

angiotensin2

АТFadenosine triphosphoric acidCARTThe world organisation of public health services IHIdiopathic hypertensia HCMPHypertrophic cardiomyopathyHLVHypertrophy of left ventricleDAPDiastolic arterial pressureDCMPdilatationcardiomyopathyDOCSdesoxycorticosteroneIHDischemic heart diseaseITMyocardium heart attackBMIBody mass indexFDPFinal diastolic pressureLHDLipoproteins high densityLVLeft ventricleLLDLipoproteins low densityMWLV

Muscular weight of left ventricleМVMinute volumeIDHThe international department on a hypertensionBWbodyweights ОНМКSharp infringement of brain blood circulationTPRTotal peripheral resistanceVCBVolume of circulating bloodANUFAtrialnatriuretic factor RAASRenin-angiotensin-aldosteron system SAPSistolic arterial pressureSASSimpato-adrenalovaja system DMDiabetes mellitusСССУWeakness syndrome синусового knot RFRisk factorsХПНChronic nephritic insufficiencyСScholesterinCАМPCyclic adenosine monophosphoric acidCNSThe central nervous systemHRHeart rateEHPFEndothelial the hyperpolarizing factorECGElectrocardiographyЭchoCGEchocardiographyJGAJuxtaglomerular apparatusРGI2

Prostaglandinum I2

NОNitrogen oxide

Theme:IDIOPATHIC HYPERTENSIA

1. A place of carrying out of employment, equipmentDivision of Cardiology, cardiorheumatology and general therapy department laboratory and instrumental diagnostics, training room.Blood analyses, serological tests, clinical and biochemical analyses, coagulogram, radiological researches, an electrocardiogram, EchoCG,learning-supervising tests, thematicpatients, a distributing material.Blood tests, serological tests, clinical and biochemical analysis, coagulogram , X-ray examinations, ECG, EhoKS, -control tests, case-patients, handout.ТV-video, оверхет, multimedia, tables, slides, the information-computer program.

2. Duration of employmentTime for illumination of the given theme-270 of minutes

3. The employment purpose:Training of students of an aetiology, pathogenesis, clinical symptomatology, laboratory-tool diagnostics and rational therapy of idiopathic hypertensia , preventive maintenance of complications, rehabilitation. The training purpose - development and strengthening of theoretical knowledge: The educational purpose -formation in preparation of the doctor of interest corresponding to the world standards for a speciality, feelings of responsibility, education of interest to expansion of the knowledge, level formation deontology education, formation of care in the course of performance of practical work, clearness and responsibility.The develop purpose - formation at students of independent thinking and discussion, development of critical thinking in students. .

Problems1. Definitionof arterial hypertension.Aetiologyof arterial hypertensions, concept about idiopathic hypertensia.Pathogenesis ofidiopathic hypertensia.Classification of idiopathic hypertensia.Clinical picture at idiopathic hypertensia: subjective data, the general survey, data of palpation, percussion and auscultation, the conclusion of laboratory-tool methods of researches.Differential diagnostics of idiopathic hypertensia.Main principles of treatment of idiopathic hypertensia.Current and the forecast of idiopathic hypertensia.The student should know:Aetiologyof idiopathic hypertensia

Pathogenesisand haemodynamic infringements at idiopathic hypertensia Classification of idiopathic hypertensia Methods of diagnostics of idiopathic hypertensia Main principles of treatment of idiopathic hypertensia

The student should be able:To collect the anamnesis, complaints of the patient, to spend the general survey, palpation, percussion and auscultationTo make the plan of inspection of the patient To interpret indicators of laboratory dataTo interpret data of radiological researchesTo prove on steps the clinical diagnosisTo write the recipe on preparations and to explain their mechanism of action and collateralActions

4. MotivationNow studying of idiopathic hypertensia has huge value because it occupies one of the first places among cardiological diseasesand can lead dangerous to a life of the patient to complications.

5. Interdisciplinary and intradisciplinary communicationInterdisciplinarycommunication:Idiopathic hypertensia To integrate with following subjects:On a verticalNormal anatomyNormal physiologyHistologyPathological anatomyPathological physiologyPropaedeutics of internal illnesses AcrossBeamdiagnostics

Normal anatomyCardiovascular systemThe Cardiovascular system transfers oxygen and nutrients between fabrics and bodies. Besides, it helps to delete slags from an organism.Heart, blood vessels and blood form a difficult network on which plasma and uniform elements are transported in an organism.These substances are transferred by blood on blood vessels, and blood actuates the heart working as the pump.Blood vessels of cardiovascular system are formed by two basic subsystems: vessels of a small circle of blood circulation and vessels of the big circle of blood circulation.Vessels of a small circle of blood circulation transfer blood from heart to lungs and back.Vessels of the big circle of blood circulation connect heart to allother parts of a body.

Blood vessels

Blood vessels transfer blood between heart both various fabrics and body bodies.

There are following types of blood vessels:arteries, arterioles, capillaries, venules and veins. Arteriesand arterioles bear blood from heart. Veins and venules deliver blood back in heart.Arteries and arterioles Arteries bear blood from ventricles hearts in other parts of a body. They have the big diameter and the thick elastic walls maintaining very a high pressure of blood.Before incorporating to artery capillaries share on more thin branches named arterioles.CapillariesCapillaries are the smallest blood vessels which connect arterioles with venules. Thanks to very thin wall of capillaries in them there is an exchange of nutritious and other substances (such, as oxygen and carbonic gas) between blood and cages of various fabrics.

Depending on requirement for oxygen and other nutrients different fabrics have different quantity of capillaries.Such fabrics as muscles, consume an oxygen considerable quantity and consequently have a dense network of capillaries. On the other hand, fabrics with a slow metabolism (such as false skin and a cornea) at all have no capillaries. The body of the person has many capillaries: if them it was possible расплести and to extend in one line its length would make from 40000 to 90000 km!Venules and veinsVenules are the tiny vessels connecting capillaries with veins which are larger venules. Veins settle down almost in parallel arteries and bear blood back to heart. Unlike arteries, veins have more thin walls which contain less than a muscular and elastic fabric.Heart of the person is the muscular pump divided into 4 chambers. Two top chambers are called as auricles, and two bottom - ventricles.These two types of chambers of heart carry out different functions: auricles collect the blood arriving in heart and push it in ventricles, and ventricles push out blood from heart in an artery on which it gets to all parts of a body.Two auricles are divided interatrial by a partition, and two ventricles - interventricular a partition. An auricle and ventricle each party of heart incorporate atrioventricular an aperture. This aperture opens

and closes atrioventricular the valve. Left atrioventricular the valve is known also as mitral the valve, and right atrioventricularthe valve-asthe three-folding valve.

Normal physiologyAutomatism function.Automatism function is an ability of heart to develop electric impulses in the absence of external irritations.Conductivity function.Conductivity function is an ability to carrying out of excitation of fibres of spending system of heart and retractile a myocardium.Excitability function.Excitability function is an ability of cages of spending system of heart and retractile a myocardium to be raised under the influence of external electric impulses.Function contractility. Contractilityfunction - is ability of a cardiac muscle to be reduced in reply to excitation. This function possesses basically retractile a myocardium.As a result of consecutive reduction and a relaxation of variousdepartments of heart the basic is carried out -pump function of heart.

HistologyMyocardium structure.To light microscopy branching of the fibres consisting from cardiomyocytes is visible to A.Pri. In the centre of everyone cardiomyocyte there is a kernel. B.Stroeniecardiomyocyte (submitted electronic microscopy). The set parallel myofibril, consisting of segments - sarcomereIs visible. V.Stroeniesarcomere.G.Raspolozhenie of threads on a cross-section cut sarcomere. In the centre of disk A (zone) is only thick threads (myosin), in its peripheral departments - both thick, and thin threads (actin), and each thick thread is surrounded by six thin. In a disk I there are only thin threads.

Pathological anatomy.Myocardium hypertrophy of LV it is caused first of all by postloading increase that promotes growth of pressure of wall LV. In hypertrophy formation activation fabric RACES, the leader to increase in development АII which through receptors АТ2 influences on кардиомиоциты has Great value, as is known, causing their hypertrophy. Other factors (эндотелины, growth factors etc.) matter also. In initial stages of formation IG moderate concentric диффузнаяthe myocardium hypertrophy in most cases develops? LV with identical increase in a thickness of a wall of various segments LV (a back wall, IVS, tops etc.). Approximately in 1/3 cases the hypertrophy has asymmetric character when there is primary hypertrophy IVSor back wall LV.

Concentric () and eccentric () a hypertrophy of a myocardium left ventricle at idiopathic hypertensiaThe size of muscular weight LV (ММLV) gradually increases, in a cardiac muscle develops fibrosis. Infringements diastolic functions For a long time prevail? letter= Д &id_term=35> LV with decrease in its pliability during time diastoles and redistribution diastolic a blood stream aside larger volume

atrialemission. In this connection can moderately raise FDP and pressure of filling LV that is quite often accompanied dilatationLA.In due course decreases contractility myocardium LV and dysfunction develops it sistolic. There are signs dilatationLV and the eccentric hypertrophy of a myocardium <http://medbook.medicina.ru/term.php develops? letter= Г &id_term=34> LV. Insufficiency of blood circulation develops in late stages of illness, mainly on left ventricular or biventricular to type.

Pathological physiologyHyperactivation role simpato- adrenal systems (SAS). In most cases AH, especially at early stages of formation of disease, proceeds with expressed hyperactivationSAS-hipersimpatikotonia which is not so much result “cardiovascular neurosis” vasomotorcentre, how many reflects disadaptation the system of blood circulation to usual physiological loadings (physical and emotional). hipersimpaticotonia initiates the whole cascade регуляторных the infringements anyhow influencing level the HELL: The increase LV contractility and HR, that is accompanied by growth of warm emission (MV); Stimulation норадреналином <http://medbook.medicina.ru/term.php?letter= А &id_term=3> , allocated in presynaptic cracks, α1-adrenoretseptorov smooth-muscular cages arterioles, that conducts to increase of a vascular tone and sizes TPR;

Thus, against hyperactivationSAS activity of variety прессорных the mechanisms regulating the HELL raises: increases MV, TPR

Propaedeutics of internal illnessesThe most typical complaints of patients IG are: headaches of various character and genesis; dizzinesses, memory infringements, noise in a head, irritability, fast fatigue; flashing of "front sights" before eyes and other signs of infringement of sight; pains in the field of heart, small pastose hypodermic fat. The analysis anamnestic data allows to reveal some features of current AH, more characteristic for symptomatic AH: youngish age of patients AH; the sharp beginning of disease with fast stabilisation the HELL on high figures; in most cases - sistolo-diastolichesky character AH, and diastolic the HELL often exceeds 110-120 mm hg (exceptions make some cases hemodynamic caused AH - aortal insufficiency, an atherosclerosis of an aorta, etc. for which increase sistolic the HELL is more characteristic); it is quite often observed refractory to antihypertensiv therapies; fast development of complications (a stroke, to IT, sight infringements, ХПН, etc.).Appearance of patients:position - active, except patients transferred ischemic or hemorrhagic stroke, at late stages - orthopnoe; adiposity - especially adverse in prognostic the relation is so-called abdominal adiposity type; hypostases of the bottom finitenesses; colour of a skin - hyperemia persons with unsharply expressed cyanosis, pallor; neurologic semiology - paresises, paralyses, a smoothness nasolabialfolds, language deviation, pathological reflexes, nystagmus, etc.Palpation and percussionI stage - without changes;II stage - strengthening and displacement to the left a top push, displacement of relative dullness of heart to the left, expansion of a vascular bunch.auscultationI tone loud or "deaf"; accent of II tone over an aorta; in initial stages - on a top pathological IV tone is listened; in late stages - on a top pathological III tone is listened; functional noise on an aorta; at relative insufficiency mitral the valve - sistolic noise in a combination to weakened I tone on a top, spent to the left axillary area.Arterial pulseArterial pulse at IG good filling and pressure, big, firm. The tachycardia and arrhythmia quite often comes to light.

Beam diagnosticsRoentgenography at patients IG degree dilatationLV, and at patients with warm insufficiency - signs of venous stagnation of blood in a small circle of blood circulation and a pulmonary arterial hypertensia allows to estimate hearts.Allocate three degrees of increase LV revealed in the left forward slanting projection:I degree - back contour LV reaches backbone edge; II degree - a back contour accumulates on a backbone shade; III degree - a back contour considerably accumulates on a backbone shade, blocking it.

Intradisciplinarycommunication:The knowledge acquired in the course of employment can be applied at studying of subjects:cardiology, ophthalmology, endocrinology, neurology, nephrology.

6. The employment maintenanceTheoretical part

IDIOPATHICHYPERTENSION

Essential hypertension (also called primary or idiopathic hypertension) is the form of hypertension that by definition, has no identifiable cause. It is the most common type of hypertension, affecting 95% of hypertensive patients, it tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Prevalence of essential hypertension increases with age, and individuals with relatively high blood pressures at younger ages are at increased risk for the subsequent development of hypertension. It can increase risk for cerebral, cardiac, and renal events.

Contents1 Classification2 Risk factors3 Pathophysiology4 References

Classification

The variation in pressure in the left ventricle (blue line) and the aorta (red line) over two cardiac cycles ("heart beats"), showing the definitions of systolic and diastolic pressure.

A recent classification recommends blood pressure criteria for defining normal blood pressure, prehypertension, hypertension (stages I and II), and isolated systolic hypertension, which is a common occurrence among the elderly. These readings are based on the average of seated blood pressure readings that were properly measured during 2 or more office visits. In individuals older than 50 years, hypertension is considered to be present when a person's blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with blood pressures over 130/80 mmHg along with Type 1 or Type 2 diabetes , or kidney disease require further treatment.

ClassificationSystolicpressure Diastolicpressure

mmHg kPa (kN/m2) mmHg kPa (kN/m2)Normal 90–119 12–15.9 60–79 8.0–10.5Prehypertension 120–139 16.1–18.5 81–89 10.8–11.9Stage 1 140–159 18.7–21.2 90–99 12.0–13.2Stage 2 ≥160 ≥21.3 ≥100 ≥13.3Isolatedsystolichypertension ≥140 ≥18.7 <90 <12.0

Resistant hypertension is defined as the failure to reduce blood pressure to the appropriate level after taking a three-drug regimen. Guidelines for treating resistant hypertension have been published in the UK, and US.

Risk factorsHypertension is one of the most common complex disorders. The etiology of hypertension differs widely amongst individuals within a large population. And by definition, essential hypertension has no identifiable cause. However, several risk factors have been identified.

Hypertension may be secondary to other diseases but over 95% of patients have essential hypertension which is of unknown origin. Itisobservedthoughthat:

Having a personal family history of hypertension increases the likelihood that an individual develops HPT.

Essential hypertension is four times more common in black than white people, accelerates more rapidly and is often more severe with higher mortality in black patients.

More than 50 genes have been examined in association studies with hypertension, and the number is constantly growing. One of these genes is the angiotensinogen (AGT) gene, studied extensively by Kim et al. They showed that increasing the number of AGT increases the blood pressure and hence this may cause hypertension. Twins have been included in studies measuring ambulatory blood pressure; from these studies it has been suggested that essential hypertension contains a large genetic influence. Supporting data has emerged from animal studies as well as clinical studies in human populations. The majority of these studies support the concept that the inheritance is probably multifactorial or that a number of different genetic defects each has an elevated blood pressure as one of its phenotypic expressions. However, the genetic influence upon hypertension is not fully understood at the moment. It is believed that linking hypertension-related phenotypes with

specific variations of the genome may yield definitive evidence of heritability. Another view is that hypertension can be caused by mutations in single genes, inherited on a Mendelian basis.

Hypertension can also be age related, and if this is the case, it is likely to be multifactorial. One possible mechanism involves a reduction in vascular compliance due to the stiffening of the arteries. This can build up due to isolated systolic hypertension with a widened pulse pressure. A decrease in glomerular filtration rate is related to aging and this results in decreasing efficiency of sodium excretion. The developing of certain diseases such as renal microvascular disease and capillary rarefaction may relate to this decrease in efficiency of sodium excretion. There is experimental evidence that suggests that renal microvascular disease is an important mechanism for inducing salt-sensitive hypertension.

Obesity can increase the risk of hypertension to fivefold as compared with normal weight, and up to two-thirds of hypertension cases can be attributed to excess weight. More than 85% of cases occur in those with a Body mass index greater than 25.[ A definitive link between obesity and hypertension has been found using animal and clinical studies; from these it has been realized that many mechanisms are potential causes of obesity-induced hypertension. These mechanisms include the activation of the sympathetic nervous system as well as the activation of the renin–angiotensin-aldosterone system.

Another risk factor is salt (sodium) sensitivity which is an environmental factor that has received the greatest attention. Approximately one third of the essential hypertensive population is responsive to sodium intake.When sodium intake exceeds the capacity of the body to excrete it through the kidneys, vascular volume expands secondary to movement of fluids into the intra-vascular compartment. This causes the arterial pressure to rise as the cardiac output increases. Local autoregulatory mechanisms counteract this by increasing vascular resistance to maintain normotension in local vascular beds. As arterial pressure increases in response to high sodium chloride intake, urinary sodium excretion increases and the excretion of salt is maintained at expense of increased vascular pressures. The increased sodium ion concentration stimulates ADH and thirst mechanisms, leading to increased reabsorption of water in the kidneys, concentrated urine, and thirst with higher intake of water. Also, the water movement between cells and the interstitium plays a minor role compared to this. The relationship between sodium intake and blood pressure is controversial. Reducing sodium intake does reduce blood pressure, but the magnitude of the effect is insufficient to recommend a general reduction in salt intake.

Renin elevation is another risk factor. Renin is an enzyme secreted by the juxtaglomerular apparatus of the kidney and linked with aldosterone in a negative feedback loop. In consequence, some hypertensive patients have been defined as having low-renin and others as having essential hypertension. Low-renin hypertension is more common in African Americans than white Americans, and may explain why African Americans tend to respond better to diuretic therapy than drugs that interfere with the Renin-angiotensin system. High renin levels predispose to hypertension by causing sodium retention through the following mechanism: Increased renin → Increased angiotensin II → Increased vasoconstriction, thirst/ADH and aldosterone → Increased sodium reabsorption in the kidneys (DCT and CD) → Increased blood pressure.

Hypertension can also be caused by Insulin resistance and/or hyperinsulinemia, which are components of syndrome X, or the metabolic syndrome. Insulin is a polypeptide hormone secreted by cells in the islets of Langerhans, which are contained throughout the pancreas. Its main purpose is to regulate the levels of glucose in the body antagonistically with glucagon through negative feedback loops. Insulin also exhibits vasodilatory properties. In normotensive individuals, insulin

may stimulate sympathetic activity without elevating mean arterial pressure. However, in more extreme conditions such as that of the metabolic syndrome, the increased sympathetic neural activity may over-ride the vasodilatory effects of insulin.

It has been suggested that vitamin D deficiency is associated with cardiovascular risk factors. It has been observed that individuals with a vitamin D deficiency have higher systolic and diastolic blood pressures than average. Vitamin D inhibits renin secretion and its activity, it therefore acts as a "negative endocrine regulator of the renin-angiotensin system". Hence a deficiency in vitamin D leads to an increase in renin secretion. This is one possible mechanism of explaining the observed link between hypertension and vitamin D levels in the blood plasma.

Also, some authorities claim that potassium might both prevent and treat hypertension.

Recent studies claims that obesity is a risk factor for hypertension because of activation of the renin-angiotensin system (RAS) in adipose tissue, and also linked renin-angiotensin system with insulin resistance, and claims that any one can cause the other.

Cigarette smoking, a known risk factor for other cardiovascular disease, may also be a risk factor for the development of hypertension.

Pathophysiology

A diagram explaining factors affecting arterial pressure

Cardiac output and peripheral resistance are the two determinants of arterial pressure. and so blood pressure is normally dependent on the balance between cardiac output and peripheral resistance. Cardiac output is determined by stroke volume and heart rate; stroke volume is related to myocardial contractility and to the size of the vascular compartment. Peripheral resistance is determined by functional and anatomic changes in small arteries and arterioles. The pathophysiology of essential hypertension is an area of research, and until now remains not well understood, but many theories have been proposed to explain this.

What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal; over time cardiac output drops to normal levels but TPR is increased. Threetheorieshavebeenproposedtoexplainthis:

An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. Theincreaseinbloodvolumeleadstohypertension.

An overactive sympathetic nervous system, leading to increased stress responses.

It is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few candidate genes have been postulated in the etiology of this condition.

The new pedagogical technologies applied on employment:Interactive game «Business game»

At application of "Business game» students are distributed on roles. For example:The student - the patient.The student - the local therapist.The student - the ambulance surgeon.The student - the doctor of a reception.The student - the doctor of an electrocardiogram of an office.The student - реаниматорThe student - the expert.The student - the cardiologistIn the course of game the student should play the role correctly. After game the

student the expert estimates errors and lacks at execution by each student of the role.

6.2. An analytical part.Situational problems

1. At sick 50 years which has addressed to the doctor of the urgent help with complaints to intensive headaches and a nausea, increase the HELL to 200/115 mm hg In the anamnesis an arterial hypertensia in a current of 7 years is found out. Constant therapy does not receive. I. You will appoint What two preparations the patient:

A. Dibazolumin/mB. Furosemidum in/v*C. magnesia sulphatein/mD. papaverinin/mE. nifedipine*

II. As heart borders change:A. are displaced to the left and to the rightB. are displaced upwards and to the rightC. are displaced to the left and downwardsD. are displaced upwards, to the right and to the left

2. The patient of 45 years, shows complaints to strong headaches, face skin and neck reddening, a shiver in hands, palpitation, dizziness, потливость.Objectively: a condition of average weight. In lungs - vesicularbreath. Tones of heart are muffled, a tachycardia, II tone over an aorta is strengthened. The HELL of 160/100 mmс.у.т., pulse of 100 blows 1 minute, rhythmical. An electrocardiogram: a sinus rhythm,ЧСС 95 blows 1 minute. Signs of a hypertrophy left ventricle. Your diagnosis?

A. Sharp heart attack of a myocardiumB. Sharp infringement of brain blood circulation

C. Idiopathic hypertensia , hypertensive crisis*D. Pheochromocytoma

What stage of disease?A. IB. II*C. III

3. In branch of intensive therapy the patient of 45 years with following complaints has arrived: noise in ears, headaches, dizziness, dimness before eyes, palpitation, fatigue, the general weakness. Objectively: a condition of average weight. Integuments damp, pure. Pulse 60 1 minute the rhythmical. The HELL of 170/90 mm hg an electrocardiogram: a rhythm синусовый, ЧСС 58 in 1мин, signs of a hypertrophy left желудочка,AV-blockade of 1 degree. Your diagnosis:

A. Idiopathic hypertensia *B. IHD, a myocardium heart attack C. IHD, a pressure stenocardiaD. Neurocirculatory dystonia oncardial type

What preparation is counter-indicative:A. Atenololum*B. CorinfarumC. kapotenumD. Nitrosorbidum

4. The patient 42 years, is on stationary treatment in cardiological branch with the diagnosis:Idiopathic hypertensia of II degree.Prospective left border of heart:

A. 5 intercostal space 1,5 sminside from left mediaclavicular lines.B. 5 intercostal space 1,0 sminsidefrom left mediaclavicular linesC. 5 intercostal space1,0 smoutside from left mediaclavicularlines

Changes on an electrocardiogram:A. RI> RII> RIII; RAVL> RAVF; RV5> RV4*B. RII> RI> RIII; RAVL> RAVF; RV5> RV4C. RI> RII> RIII; RAVF> RAVL; RV4> RV5

7. A quality monitoring of practical skills and theoretical knowledge.1. Professional inquiry and survey of the patient with idiopathic hypertensia.

The purpose:- Reception of the information necessary for diagnostics;- An estimation of probability of disease;- Definition of other sources of the information (relatives, other doctors, etc.);- An establishment of confidential mutual relations with the patient;- An estimation of the person of the patient and its relation to illness (an internal picture of illness);- To estimate a condition of consciousness and the mental status of the patient, its position, a general view, a condition of external covers and separate sites of a body.Indications: interrogation necessarily for all patients who are in consciousness; survey is spent by all patient.Equipment: well shined chambers, offices of doctors, lamps of day illumination.Performance conditions: absence of extraneous persons, confidential conditions.

Carried out stages (steps):

№ Action Has not executed Completely has correctly executed

1 Inquiry of nameplate data 0 52 Gathering of complaints 0 153 Gathering of the anamnesis of disease 0 204 Gathering of the anamnesis of a life 0 155 The epidemiological, allergic anamnesis 0 56 Objective survey of the patient 0 57 Will make the inspection plan 0 58 Correct statement of the diagnosis 0 59 Differential diagnostics 0 2010 Will make the treatment plan 0 5In total 0 100

2. Drawing up of dietary recommendations and the treatment program.The purpose: Treatment of illnessand preventive maintenance of complications.

№ Action Has not executed Completely has correctly

executedStudying of the characteristic of medical tables on Певзнеру

0 10

2 Correct choice of a dietary table according to the diagnosis

0 10

3 Estimation of full value of a diet

0 20

4 According to the diagnosis, weight of disease and a stage appointment of the basic therapy

0 20

5 According to the diagnosis, weight of disease and a stage appointment of symptomatic therapy

0 20

6 Preventive actions 0 20In total 0 100

Tests

1. Not medicamentoustreatment of an arterial hypertensia does not concern:A. restriction physical activity*B. sufficient physical activityC. decrease in superfluous bodyweight D. restriction of consumption of table salt

2. To блокаторам receptors of angiotensin II do not carry:A. losartanumB. valsartanumC. enalapril*D. irbesartanum

3. As irrational combinations in treatment of an arterial hypertensia consider:A. β-adrenoblockers + nondihydropyridine slow calcium channelblockers*B. β-adrenoblockers + diureticsC. ингибиторыАПФ + slow calcium channelblockers

D. ингибиторыАПФ + diuretics4. The most exact method of revealing of a hypertrophy left ventricle:

A. percussionB. ECGC. EchoCG*D. radiological research

5. At objective research of the patient with idiopathic hypertensiaof II stage it is found outA. sistolic noise on the basis of heart on the rightB. accent of II tone over an aortaC. increase heart bordersD. displacement of borders of heart to the left*

6. On what basis of symptoms III stage of idiopathic hypertensia is defined:A. a hypertrophy of left ventricleB. a hypertrophy of right ventricleC. high proof arterial pressureD. complications from bodies target*

7. The basic electrocardiograms signs of a hypertrophy left ventricle:A. absence of tooth ТB. lengthening of interval Q-TC. increase R II. V1, V2

D. increase in amplitude of tooth R I. V5, V6, AVL*8. The choice of a preparation for treatment of idiopathic hypertensia (IG) is always difficult. Most 2 correct principles of selection are:

A. the account of stage IG and degrees of increase the HELL B. the account of clinical variant IG (the reasons of increase the HELL and its expressivenesses

in each concrete case) *C. the account pathophysiological variant IG (the reasons of increase the HELL and its

expressivenesses in eachconcretecase) *D. step selection of appointment of monotherapy in all cases IGE. sharp medicinal tests

9. Specify 2 basic of a preparation, the most effective in treatment volume-dependent of the form of idiopathic hypertensia:

A. ObsidanumB. clonidine C. Triampurcompositum *D. Corinfarum *E. captopril

10. Under the maintenance renin allocate forms of an arterial hypertensia:A. normorenin*B. hyporenin*C. hyperrenin*D. normokineticE. hyperkineticF. hypokinetic

11. In pathogenesisidiopathic hypertensia all listed factors have leading value, except:A. the hereditary or got infringements of cellular membranes with electrolyticinfringements B. the raised reactance of sympathetic nervous system C. deficiency (or exhaustions) depressory systems D. hyperactivity of system renin - angiotensin-II - AldosteronumE. decrease in the maintenance of calcium in smooth-muscular cages of walls arterioles*

F. the raised reactance of parasympathetic nervous system *12. To group of risk of disease of idiopathic hypertensia carry all listed, except:

A. hereditary predisposition B. superfluous consumption of salt C. a stomach ulcer *D. excess weight E. bronchial asthma*

13. To not selective/Z-adrenoblokatorov carry all preparations, except (3):A. atenolol*B. methoprolol*C. propranololD. bisoprolol*E. Corvitin

14. Bodies-targets at an arterial hypertensia everything, except (2):A. liver*B. kidneysC. heartsD. a brainE. lungs*

15. Increase the HELL can cause long reception of all ЛС, except (2):A. anaprilin*B. NSAIDC. inhibitorsMAOD. peroral contraceptivesE. enalapril*

16. The Alpha-adrenoblokatoramcarry everything, except (2):A. Reserpinum*B. Clonidinum*C. PrazozinumD. doxozinum

17. As contra-indications for appointment inhibitorsACF consider (4):A. pregnancy*B. a hypertensive crisisC. dry tussis*D. the expressed stenosis of a mouth of an aorta and mitral orifice*E. diabetes mellitusF. bilateral stenosis of nephritic arteries*

18. InhibitorsАПФ block (2):A. receptors of angiotensin IIB. transformation of angiotensin I in angiotensin II*C. transformation of angiotensin II in angiotensin ID. action of the enzyme, transforming angiotensin I in анигиотензин II*

19. Features of an arterial hypertensia at elderly (4):A. more expressed reduction brain кровотока*B. decrease secretory functions kidneys*C. reduction warm выброса*D. high total peripheralvascular resistance*E. anything from the listedF. increase in warm emissionG. increase secretory functions of kidneys

20. For treatment of an arterial hypertensia use the following diuretics (3):A. Thiazid*B. loopback*C. kalium savings*D. osmotic

8. Criteria of an estimation of the current control

Level of knowledge of the student Progress in % and pointsEstimation

The student on the basic questions of a theme and concerning independent work of students (IWS): Sums up and makes of the decision Creatively thinks Independently analyzes Puts into practice Shows high activity, the creative approach at carrying out of interactive games Correctly solves situational problems with a full substantiation of the answer Understands a question essence Knows, tells confidently Has exact representations Prepares modern informative visual aids or abstracts of high quality with use of data of last literature from 7-10 sources and the Internet.

96-1005

The student on the basic questions of a theme and concerning IWS: Creatively thinks Independently analyzes Puts into practice Shows high activity, the creative approach at carrying out of interactive games Correctly solves situational problems with a full substantiation of the answer Understands a question essence Knows, tells confidently Has exact representations Prepares modern informative visual aids or abstracts of high quality with use of data of last literature from 4-6 sources and the Internet.

91-955

The student on the basic questions of a theme and concerning IWS: Independently analyzes Puts into practice Shows high activity, the creative approach at carrying out of interactive games Correctly solves situational problems with a full substantiation of the answer Understands a question essence Knows, tells confidently Has exact representations Prepares modern informative visual aids or abstracts of high quality with use of data of last literature from 3-5 sources and the Internet.

86-905

The student on the basic questions of a theme and concerning IWS: 81-85

Puts into practice Shows high activity, the creative approach at carrying out of interactive games Correctly solves situational problems with a full substantiation of the answer Understands a question essence Knows, tells confidently Has exact representations Prepares modern informative visual aids or abstracts of high quality with use of data of last literature from 3-5 sources and the Internet.

4

The student on the basic questions of a theme and concerning IWS: Shows high activity at carrying out of interactive games Correctly solves situational problems, but a substantiation of the answer the incomplete Understands a question essence Knows, tells confidently Has exact representations Prepares modern visual aids or abstracts with use of data of last literature from 1-2 sources.

76-804

The student on the basic questions of a theme and concerning IWS: Correctly solves situational problems, but a substantiation of the answer the incomplete Understands a question essence Knows, tells confidently Has exact representations orThe student on the basic questions of a theme and concerning IWS: Commits errors at the decision of situational problems Knows, tells uncertainly Has exact representations on separate questions of a theme Prepares modern informative visual aids or abstracts of high quality with use of data of last literature from 7-10 sources and the Internet. Prepares modern visual aids or abstracts of high quality with use of data of last literature from 4-6 sources and the Internet.

71-754

The student on the basic questions of a theme and concerning IWS: Understands a question essence Correctly solves situational problems, but cannot prove the answer Knows, tells confidently Has exact representations on separate questions of a theme

66-703

The student on the basic questions of a theme and concerning IWS: Commits errors at the decision of situational problems Knows, tells uncertainly Has exact representations on separate questions of a theme

61-653

The student on the basic questions of a theme and concerning IWS: Knows, tells uncertainly Has partial representations

55-603

The student on the basic questions of a theme and concerning IWS: Has no exact representation Does not know

Less than 552

9. A chronological card of employment.

№ Stages of practical employment Employment forms

Duration270minutes

Opening address of the teacher (theme substantiation).

10

Discussion of a theme of practical employment, check of basic knowledge of students with use of new pedagogical technologies, a demonstration material

(slides,audio - videocassettes, roentgenograms, electrocardiogram, etc.).Interrogation, explanatories.

60

Discussion end. 20

Distribution of tasks to students for performance of a practical part of employment. Instructing and the explanatory under the requirements shown to practical tasks.

Independent exemine patients.

30

Development by means of the teacher of a practical part of employment (курация the thematic patient).

Case records, interactive games, situational problems.

50

Interpretation of laboratory-tool methods of researches of the thematic patient, differential diagnostics, treatment and preventive maintenance scheduling, extract of recipes, etc.

Work with kliniko-laboratory toolkit.

40

Discussion of theoretical and practical knowledge of students, their reinforcement and estimation of activity of group in respect of achievement of an object in view of employment.

Oral interrogation, the test, discussion, check of results of practical work.

40

The conclusion of the teacher on the passed employment, an estimation of activity of each student and the announcement of results. Working out of tasks for preparation for following employment (the collection of questions).

Questions for independent work.

20

10. Questions for the control of knowledge

1. An aetiology and патогенез idiopathic hypertensia.2. Classification of idiopathic hypertensia.3. A clinical picture of idiopathic hypertensia.4. Electrokardiografichesky changes at idiopathic hypertensia.5. Radiological измененения at. Idiopathic hypertensia.6. Complications of idiopathic hypertensia.7. Treatment of idiopathic hypertensia.8. Preventive maintenance of idiopathic hypertensia.

11. The recommended literatureThe basic:

1. Internal illnesses: the textbook in 2t./under the editorship of N.A.Mukhin, V.S.Moiseyev, A.I.Martynova, 2 изд., испр. And доп.- М: GEOTAR-MEDIA, 2009.- Т.2.592с.: silt.

The additional:2. Rojtberg G. E, Strutynskij A.V. «Internal illnesses: Cardiovascular system». 856 p.

Moscow, 2007.3. Okorokov A.N. “Diagnostics of illnesses of internal bodies”.Т.6. Diagnostics of

illnesses of heart and vessels.Moscow,2003 464 p.4. Okorokov A.N. “Treatment of illnesses of internal bodies”.Т.3, кн.1. Treatment of

illnesses of heart and vessels.Moscow,2005 464 p.5. Sites: www. ТМА .uz<http://www. ТМА .uz> .,6. <http://www.meddean.luc.edu>, 7. http://www.embbs.com

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