Principles of Family Medicine Textbook

MINISTRY OF PUBLIC HEALTH OF UKRAINE
ZAPOROZHE STATE MEDICAL UNIVERSITY

DEPARTMENT OF GENERAL PRACTICE – FAMILY MEDICINE
PRINCIPLES
OF FAMILY MEDICINE
THE TEXTBOOK FOR THE PRACTICAL CLASSES AND INDIVIDUAL WORK

TH
FOR 6 -YEARS STUDENTS OF INTERNATIONAL FACULTY
(SPECIALITY «GENERAL MEDICINE»)
DISCIPLINE: «GENERAL PRACTICE – FAMILY MEDICINE»
Content module 1,2
Zaporozhye, 2015
Approved by:
MоH of Ukrainе protocol № 2, the 16.06.2015 y.
Readers:
Chuhrienko N.D. – Doctor of Medical Sciences, Professor of Family Medicine
department, Dnepropetrovsk State Medical Academy MoH of Ukraine;
Koval O.A. - Doctor of Medical Sciences, Professor of Hospital therapy № 2
department, Dnepropetrovsk State Medical Academy MoH of Ukraine.
Writers:
Mykhailovska N.S. - Doctor of Medical Sciences, Professor, head of General
practice – family medicine department, Zaporozhye State Medical University;
Grytsay A.V. - PhD, associate professor of General practice – family medicine
department, Zaporozhye State Medical University.
Methodical recommendations compiled in accordance with the program of

"General practice - family medicine". Guidelines are intended to help students prepare
for practical classes and learn the material. Can be used for training of 6th-years students
of international faculty, discipline "General practice - family medicine".
Zaporozhye state
medical university
Publishing office of ZSMU
2
CONTENT
The thematic plan of practical classes……………………............................... 5

TOPIC 1. The place of the family medicine in the structure of a healthcare
system and the principles of the family service. The organization of the FD’s
work. The basis recording documentation of FD in medical institution. The
role of information system in FD practice. The basis of information
processing of out-patient clinic……………………………………………… 7
TOPIC 2. Medico-social aspects of the population’s health. The medical
examination of the population, and rehabilitation in the family doctor’s
practice. Medical insurance structure and family doctor activity. The models
of medical insurance in the world…………………………………………… 24
TOPIC 3. The assessment of the risk factors of the main chronic non-
epidemic diseases and the preventive measures in case of the cardiovascular,
bronchopulmonary, gastrointestinal diseases and some other common
syndromes. A role of family doctor in popularization of healthy life style and
prophylaxis. The dietotherapy. The prophylaxis of AIDS…………………. 48
TOPIC 4.The organization of out-of-hospital therapeutic help in case of the
most wide-spread diseases. The organization of the day hospital and home
care. The basis of expertise of disability……………………………………. 85
Recommended literature……………………………………………………… 137
3
PREFACE
The primary medical care develops according international standard of Public
health. The purpose of primary medical care is to decrease the morbidity, disability and
mortality by means of effective, available general practice – family medicine. The
mastering of principles of family medicine is very important.
This textbook is composed according the requirements of typical working
program (2009) and working program (2013) of academic discipline «General practice
– family medicine», specialization 7.12010001 «General medicine», 7.12010002
«Pediatrics». The necessity of this textbook is conditioned by absence of such
workbooks, which satisfy requirements of basic parts of academic discipline «General
practice – family medicine».
This textbook includes the educational material for practical classesand individual
work of students, Module 1 (content modules 1, 2), the tests for initiasl and final
control, situational tasks for academic discipline «General practice – family medicine»,
updated qualification characteristics of family doctor, basic recording documentation of
primary medical care, questions for final module control for academic discipline
«General practice – family medicine», the protocol of patient’s examinatoion (epproved
by department «General practice – family medicine»), recommended literature.
The purpose of this textbook is acquiring of knowledge and practical skills of
6th-years students during preparation for classes and final module control.
4
THE THEMATIC PLAN OF PRACTICAL CLASSES
Module 1: «The organizational aspects of the system of the primary health care in
Ukraine, its role in the development and reforming of the Public health».
Number
№ Topic
of hours
Content module 1. Modern approaches to the medico-social and organizational basis
of a primary health care
1 The place of the family medicine in the structure of a healthcare system 7
and the principles of the family service. The organization of the FD’s
work. The basis recording documentation of FD in medical institution.
The role of information system in FD practice. The basis of information
processing of out-patient clinic.
Content module 2. Medico-social aspects of population‘s health - the basis of the
preventive and curing medicine
2 Medico-social aspects of the population’s health. The medical 6
examination of the population, and rehabilitation in the family doctor’s
practice. Medical insurance structure and family doctor activity. The
models of medical insurance in the world.
3 3.1.The assessment of the risk factors of the main chronic non- 4
epidemic diseases and the preventive measures in case of the
cardiovascular, bronchopulmonary, gastrointestinal diseases and some
other common syndromes. A role of family doctor in popularization of
healthy life style and prophylaxis. The dietotherapy. “The health
school”.
3.2.The prophylaxis of AIDS. 2
4 4.1.The organization of out-of-hospital therapeutic help in case of the 2
most wide-spread diseases. The principles of medico-social expertise.
The organization of the day hospital and home care.
4.2.The consultation in the context of HIV-infectious, voluntary 2
testing.
4.3.The consultation in the context of incurable disease and imminent 2
death. The organization of medical care for non-curable patients. The
principle of multidisciplinary approach to medical care of non-curable
patients and their relatives. Nursing, the methods of palliative care of
symptoms and syndromes.
5
Number
№ Topic
of hours
Content module 3. The emergency in the family doctor’s practice.
5 The emergency in the practice of family doctor. The emergency in the 6

pre-hospital stage in the case of cardiac arrest, acute coronary
syndrome, respiratory standstill, arrhythmias, hypertensic crisis,
bronchoobstructive syndrome.
6 6.1.The emergency in the practice of family doctor in the case of pain 4
syndrome.
6.2.The clinical classification of pain. The mechanism of pain in 2
incurable patient. The principles of treatment of chronic pain syndrome.
The emergency in context of incurable diseases and imminent death.
7 The emergency in the practice of family doctor in the case of seizure, 6

syncope, coma in case of diabetes, acute hepatic failure, alcohol
intoxication, renal insufficiency, narcotic abuse.
8 The emergency in the practice of family doctor in the case of bite, sting, 5
electrical injury, drowning, frostbite and thermal injury.
Final module control. 2
TOTAL 50
THE THEMATIC PLAN OF INDEPENDENT WORK OF STUDENT

Number
№ Тopic Control type
of hours
1 Preparation to the practical classes, the academic level 20
and training of practical skills
2 The implementation and defense of the practical tasks 4
3 Filling of the family doctor’s documentation 3
4 The preparation and writing of the program of 4 Current control
treatment in out-patient in the case of most widespread during practical
diseases classes
5 Drew up the algorithms of the pre-admission 4
emergency in the family doctor’s practice
6 The report at a clinical conference of hospitals. 1
7 Preparation for the final module control 4 Final module
control
Total 40
6
TOPIC 1
The place of the family medicine in the structure of a healthcare system and
the principles of the family service. The organization of the FD’s work. The basis
recording documentation of FD in medical institution. The role of information
system in FD practice. The basis of information processing of out-patient clinic.
I. Theme actuality. According WHO, the family medicine is the system of
Public health which has to provide personal, comprehensive and continuing care for the
individual in the context of the family and the community. This is economically feasible
system. The family doctor has particular skills in treating people with multiple health
issues.
The primary medical care is reforming according to world standards of Public
health. The aim of State program of development of primary medical care is decreasing
of morbidity, disability and mortality by effective work of family doctors.
The family medicine is a provision for continuing care of patients of any age and
sex. A set of skills of family doctor may define a basic diagnosis and treatment of
common illnesses and medical conditions, referral to specialists, formulates a plan
including (if appropriate) components of further testing, specialist referral, medication,
therapy, diet or life-style changes, patient education, and follow up results of treatment,
also counsel and educate patients on safe health behaviors, self-care skills and treatment
options, provide screening tests and immunizations. So, the family medicine is a
medical specialty and the principles of primary medical care.
The family doctor is specialized in family medicine after the medical degree. He
provides continuing and comprehensive health care for the individual and family across
all ages, genders, diseases, and parts of the body, delivers a range of acute, chronic and
preventive medical care services, on the basis on knowledge of the patient in the context
of the family and the community, emphasizing disease prevention and health promotion,
manage chronic illness, often coordinating care provided by other subspecialists.
II. Study purposes: take up questions of place of family medicine in the general
structure of Public health, the principles of family maintenance of population, have a
notion about organization of work of family doctor.
III. Concrete purposes of the module:

• to find out the place of family medicine in the general structure of Public health;
• to explain the basic models of primary medical help;
• to ground principles of family maintenance of population - continuity of medical
care;
• to characterize the basic functions of family doctor: abilities to socialize with a
7
patient and his family and decision of them social-and-medical problems;
• to analyze the indexes of necessary registration medical documentation of
establishments of family medicine.
IV. A student must be able to use basis of legislation of Ukraine about a Public
health and normative documents which regulate activity of bodies and establishments of
Public health, to estimate the basic indexes of health of population, to organize work of
out-patient and hospital establishments, to organize work of emergency.
V. Task for initial independent training

1. The Health protection is:
А. A system of measures, sent to provision, maintenance and development of
physiology and psychological functions, social activity and optimal capacity
of individual.
B. A system of establishments which provide a health protection of population.
C. A control system by the guard of health of population.
D. A system of the medical provision.
E. A system of primary medical help.
2. A medical help is a complex of measures which directed on:

А. help to the persons with acute diseases, opening of new establishments of
Public health, rehabilitation of patients and invalids.
B. help to the persons with chronic diseases and increase of sanitary culture
C. provision of sanatorium-and-spa treatment, increase of sanitary culture
D. prevention of morbidity and disability, increase of sanitary culture,
rehabilitation patients and invalids, help to the persons with chronic diseases,
opening of new establishments of Public health
E. opening of new establishments of Public health, help to the persons with
chronic diseases, rehabilitation patients and invalids.
3. Establishments of Public health are:

А. establishments which provide the management of health a guard
B. enterprise, establishments and organizations which provide the various
requirements of population in industry of Public health and medical provision
C. establishments of medical care for population
D. social establishments for be single and elderly people.
4. The body of Public health is:

А. establishments which provide the management of health a guard
8
B. enterprise, establishments and organizations which provide the various
requirements of population in industry of Public health and medical provision.
C. establishments of medical care for population
D. social establishments for be single and elderly people.
5. What normative document in Ukraine is predefining the professional duties of

medical and pharmaceutical workers?
А. the law of Ukraine "About provision of sanitary and epidemic prosperity of
population"
B. the law of Ukraine "Basis of legislation about Public health"
C. the Ukraine constitution
D. the law of Ukraine "About medications"
E. conception of reformation of system of Public health of Ukraine.
6. Which normative document in Ukraine includes these definitions of concepts

"health", "Public health", "body of Public health"?
А. Law of Ukraine "About provision of sanitary and epidemic prosperity of
population"
B. law of Ukraine of "Basic of legislation about Public health"
C. the Ukraine constitution
D. law of Ukraine "About medications"
E. conception of reformation of system of Public health of Ukraine.
7. Principles of Public health are all, except:

А. freedom of charge for all types of medical care;
B. freedom of charge for medical care which is conducted within the framework
of the government program;
C. priority of prophylactic measures;
D. accessibility of medical help;
E. social security of citizens in case of loss of health.
8. How many forms of compounding function today in practical activity of family

doctor:
А. 2
B. 4
C. 3
D. 1
E. the compounding forms of the ratified forms do not have.
9
9. Who has right to give consent to medical intervention?
А. attending doctor;
B. head doctor;
C. patient;
D. administration of enterprise, where a patient works;
E. paramedical worker.
10. The disclosure of information which makes a medical secret is shut out:
А. on-request the bodies of social security and public welfare;
B. the threat of distribution of infectious diseases;
C. at presence of signs, which allow thinking that it is sorry to the health caused
during realization of socially dangerous actions;
D. on-request descendants;
E. on-request the office of public prosecutor.
Answers :
1 2 3 4 5 6 7 8 9 10
A C B A B B E C C A
VI. Basic questions after a theme

1. Principles of organization of system of primary medical help.
2. Basic principles, advantages of new model of the primary medical help.
3. Transition from the district-territorial principles of medical care to family
medicine in Ukraine.
4. Principles of family maintenance of population are continuity of medical care.
5. Basic normative documentation of family doctor.
6. Basic functions and maintenance of work of family doctor.
7. Features of work of family doctor and district doctor.
8. The interrelation of family doctor with a patient and his family.
9. Psychogenic, deontology aspects of activity of family doctor.
10. Decision of medico-social problems of family.
VII. Practical skills

Practical class is conducted in out-patient's clinic; students together with family
doctors conduct the reception of patients; analyze interrelation of doctor with a patient
and his family, study basic functions and maintenance of work of family doctor, meet
with basic registration documentation of family doctor
1. To design the passport of district in out-patient's clinic.
2. To fill the medical passport of family.
10
3. To design the informed consent of patient, specify the basic columns of
document.
4. Offer the arguments for satisfied the family necessity of urgent operative
intervention.
Independent work: preparation to practical studies - 4 hours.
VIII. The plan and organizational structure of practical training

Educational materials Place of
Hours,
№ Stage Facilities of realization of
min Equipment
studies studies
Control of initial 15 min Tests Classroom
1
level
2 Analysis of theme 90 min Oral test Classroom
Practical work 115 min Out-patients Family out-patient's
3
case record clinic
Current control of 15 min Situational Classroom
4
knowledge tasks
Summation of 5 min Classroom
5
studies
Independent work 4 hours The individual Classroom
preparation to
6
practical
studies
11
IX. The logical structure of theme
Test control of initial level of knowledge: the basis of health legislation of

Ukraine, normative documents which regulate activity of bodies and
establishments of Public health
Analysis of thematic questions
Reception of patients together with family doctors, the analysis of

interrelation of doctor with a patient and his family, study the basic
functions of family doctor, a basic normative
documentation of family doctor
A decision of practical tasks on the basis of the got knowledge
Current control of knowledge after a theme
Resuming by reading with forming of complex

estimation for every student
12
X. The content of theme
In the conditions of adaptation of Public health in Ukraine to the new economic
relations to the primary medical help a leading role is taken in the medical provision of
population. Management disbalance among bodies and establishments of the medical
provision and crisis of health of population is all not only unsatisfactorily affected the
state of health of Ukrainian population but also on activity of the system of health
protection. Therefore a change will allow in Ukraine of the existent system of health
protection, first of all, pointing effort at the improvement of primary medico-sanitary
help, as to foundation of the system of the medical provision. It will allow carrying out
modification orientation of activity on a primary level and will distinguish for him
maximally possible to the shot. Material and financial resources, taking into account
those which are freed from secondary and tertiary levels.
Primary care is the term for the health services by providers who act as the
principal point of consultation for patients within a health care system. The WHO
attributes the provision of essential primary care as an integral component of an
inclusive primary health care strategy.
Primary care involves the widest scope of health care, including all ages of
patients, patients of all socioeconomic and geographic origins, patients seeking to
maintain optimal health, and patients with all acute and chronic physical, mental and
social health issues (including chronic diseases) [3].
Depending on the nature of the health condition, patients may then be referred for
secondary or tertiary care.
A primary care practitioner must possess a wide breadth of knowledge in many
areas.
Continuity is a key characteristic of primary care, as patients usually prefer to
consult the same practitioner for routine check-ups and preventive care, health
education, and every time they require an initial consultation about a new health
problem.
Collaboration among providers is a desirable characteristic of primary care.
The International Classification of Primary Care is a standardized tool for
understanding and analyzing information on interventions in primary care by the reason
for the patient visit.
Common chronic illnesses usually treated in primary care may include, for
example: hypertension, angina, diabetes, asthma, depression and anxiety, back pain,
arthritis or thyroid dysfunction.
Primary care also includes many basic maternal and child health care services,
such as family planning services and vaccinations [1].
In context of global population ageing, with increasing numbers of older adults at
greater risk of chronic non-communicable diseases, rapidly increasing demand for
13
primary care services is expected around the world, in both developed and developing
countries.
In accordance with the concept of reformation of the public health system in the
whole world, the main part in the system of the primary health care will be assigned to
the general practitioners - family doctors (GP – FD).
The primary health care (by WHO) covers the basic medical care, simple
diagnostics and treatment, referral to the higher level in difficult cases, preventive
measures and the principal community health activities [5].
The primary medical care is the first level of contact between the single persons,
families and communities and the national health care system; it approaches the medical
and social care to the place of residence and place of employment as much as possible
and represents the first stage in the community health protection.
“The efficiency, effectiveness and justice of the health care system depends on
the discrete policy of the primary health care development which is the basis of the
public health care because only within the scope of the primary health care the
realization of such an important for the people principle of generally accessibility of the
medical care is realized” (WHO).
Family medicine (FM) is a medical specialty devoted to comprehensive health
care for people of all ages.
It is a division of primary care that provides continuing and comprehensive health
care for the individual and family across all ages, sexes, diseases, and parts of the body.
It is based on knowledge of the patient in the context of the family and the
community, emphasizing disease prevention and health promotion.
According to the World Organization of Family Doctors (Wonca), the aim of
family medicine is: to provide personal, comprehensive and continuing care for the
individual in the context of the family and the community [2].
The issues of values which underlying this practice are usually known as primary
care ethics.
In Europe the discipline is often referred to as general practice, emphasizing its
holistic nature rather as well as its roots in the family.
The term "family medicine" is used in many European and Asian countries,
instead of "general medicine" or "general practice“.
Family physicians deliver a range of acute, chronic and preventive medical care
services.
In addition to diagnosing and treating illness, they also provide preventive care,
including:
a. routine checkups,
b. health-risk assessments,
c. immunization and screening tests, and
14
d. personalized counseling on maintaining a healthy lifestyle.
Family physicians deliver a range of acute, chronic and preventive medical care
services.
A set of skills and scope of practice may define a primary care physician,
generally including basic diagnosis and treatment of common illnesses and medical
conditions.
Diagnostic techniques include interviewing the patient to collect information on
the present symptoms, prior medical history and other health details, followed by a
physical examination.
Many FDs are trained in basic medical testing, such as interpreting results of
blood or other patient samples, electrocardiograms, or x-rays [4].
More complex and time-intensive diagnostic procedures are usually obtained by
referral to specialists, due to either special training with a technology, or increased
experience and patient volume that renders a risky procedure safer for the patient.
FD is usually the first medical practitioner contacted by a patient, due to factors
such as
- ease of communication,
- accessible location,
- familiarity,
- increasingly issues of cost and managed care requirements.
Ideally, the FD acts on behalf of the patient to collaborate with referral
specialists, coordinate the care given by varied organizations such as hospitals or
rehabilitation clinics, act as a comprehensive repository for the patient's records, provide
long-term management of chronic conditions.
Continuous care is particularly important for patients with medical conditions that
encompass multiple organ systems and require prolonged treatment and monitoring,
such as diabetes and hypertension [1].
Therefore actually, in the conditions of reformation of the system of the medical
provision and health protection in Ukraine in direction of priority development of
primary medical help on principles of family medicine, studies of students of
organization of activity of family doctor acquires a large value.
15
Algorithms and tables according theme
Kind and volume of medical care, which is given by a general practitioner/

family doctor
PRIMARY MEDICAL HELP
TYPES OF MEDICAL HELP
Paramedical help Emergency Qualifying medical help
 Measures of  Treatment of  Some infectious and

paramedical help illnesses, traumas, invasion diseases
 Treatment of poisonings, emergency  Neoplasm
illnesses, traumas,  Conducting of  Illnesses of blood, blood
poisonings, emergency. sanitation and anti- forming organs, lymphatic,
Conducting of sanitation epidemic measures spleen
and anti-epidemic  Preventive  Endocrine, metabolic and
measures measures nutritional disorders
 Preventive  Psychological disorders
 Mother and child
measures  Neurological disorders
health protection  Illnesses of eye
 Mother and child  Measures on  Illnesses of ear
health protection hygienic education  Circulatory illnesses
 Measures on  Other emergent  Respiratory illnesses
hygienic education measures and qualifying  Digestive illnesses
 Other measures of therapeutic help  Illnesses of skin
paramedical help  Musculoskeletal illnesses
 Urology illnesses
 Pregnancy, childbirth,
family planning
 Traumas, poisonings and
effect of exogenous factors
Specialists which give

paramedical help: medical
assistant, midwife, nurses GENERAL PRACTITIONER /
FAMILY DOCTOR
16
Typical organization of primary medial
help for rural population
District center
Management functions: Center of

statistics, management, planning, payment primary medical
of services, control, supply, work, record,
help
accounting and others
Out-patient's
clinic
Medical level:
grant of primary medical care, including
realization of express researches, Out-patient's
determination of route of patient clinic
medical
attendant and
obstetric point
Paramedical level:
medical
grant of paramedical help
attendant and
obstetric point
17
Chart of work with a patient at primary level of medical care in rural area
Appoint to district level for

diagnostic researches
An out-
patient's clinic Appoint to permanent
per 2000-5000 establishment
of population
A grant of
Detour of help is on
fastened MAOP MAOP
medical Make an appointment

with family doctor in the
attendant
certain days of reception
and obstetric
patient point
(MAOP) Emergency call
Organization of urban primary medical help (PMSH)
Out-patient's A doctor with

clinic private practice
A model of organization
Center of
of PMH in city:
primary
1 CPMH for 100 000
medical help
people
Out-patient's
clinic
Out-patient's
clinic
Counted on 2-4 doctors (the loading is 1500 -

Out-patient's 2000 persons per 1 doctor)
clinic Lead through of express diagnostics
18
Registration forms and documents of family doctor
Number of
The registration form
registration form
History of development of child F. 112/o
Individual card of pregnant F. 111/o

Check-card of clinical supervision F. 030/o
Check-card of clinical supervision after the risk group persons for F. 030-3/o
development of occupational disease
A card of appeal for antirabies help F. 045/o
Card of vaccination F. 063/o
Case history in day hospital and hospital at home F. 003-2/o
The sheet № 1 to F. 025/oh (preventive examination) -
The sheet № 2 to F 025/oh (annual epicrisis) -
Communication registration forms

Number of
The registration form
registration forms
The appointment card to blood and urine examination F. 200-207/o
The appointment card to doctor-specialist and other examinations
(in diagnostic rooms, laboratories)
The card for sanatorium-and-spa treatment F. 072/o
The children card for sanatorium-and-spa treatment F. 076/o
A child's sanatorium voucher F. 077/o
A medical certificate for student in health camp F. 079/o
Appointment card for medico-social commission of expert F. 088/o
Appointment card for obligatory preventive examination of worker F. 093/o
Case record F. 027/o
List of registration forms which are get to the patient

Number of
Name of registration form
registration forms
A certificate is for the receipt of tour F. 070/o
Doctor advisory opinion F. 086/o
A medical certificate about temporary disability (sick leaf) F. 095/o
Certificate about the term of temporary disability for insurance F. 094-1/o
company
The prescription
19
The record books of general practitioner/family doctor in out-patient's clinic
Number of
Name of registration form
registration forms
Family book of district F. 025-8-1/o
Book of record of maternity help at home F. 032/o
Book of record of medical certificate F. 036/o
Book of record of hygienic education among population F. 038/o
Book of record of visits in out-patient's clinics, dispensary, at home F. 039/o
Book of record of outpatient surgery F. 069/o
Book of record of the death F. 151/o
Book of record of new-born F. 152/o
Book of record of emergency case F. 155-1/o
Book of record of infectious diseases F. 060/o
Book of record of vaccinations F. 064/o
List of statistical accounting forms

The list of record of morbidity and death reasons in F. 071/o quarterly report
medical establishment (among children up to 14 years
old inclusive)
The list of record of morbidity and death reasons in F. 071-1/o quarterly report
medical establishment (among an adult population up
to18 years old)
The list of record of the new cases of traumas and F. 071-2/o quarterly report
poisonings in medical establishment
A report about morbidity among district population 12 annual report
XI. Tasks for final control

1. Which normative document contains basic principles of Public health in
Ukraine?
А. Law of Ukraine "About provision of sanitary and epidemic prosperity of
population"
B. law of Ukraine "Basis of legislation of Ukraine about Public health"
C. The constitution of Ukraine
D. Law of Ukraine "About medications"
E. The conception of reformation of Public health in Ukraine.
2. What normative document in Ukraine determines a right of citizen for health

protection, medical care and medical insurance ?
20
А. Law of Ukraine «About provision of sanitary and epidemic prosperity of
population»
B. Law of Ukraine «Basis of legislation of Ukraine about Public health»
D. Law of Ukraine «About medications»
3. What normative document is marked in Ukraine as «alteration of primary

medical help foresees introduction of principles of family medicine»?
А. Law of Ukraine «About provision of sanitary and epidemic prosperity of
population»
B. Law of Ukraine «Basis of legislation of Ukraine about Public health»
D. Law of Ukraine "About medications"
4. Which drugs are prescribed by prescription form №2?

А. Prescribed to the patient by special price
B. Anabolic hormones
C. Drugs which act in the limited amount
D. Psychotropic drugs
E. Narcotic drug.
5. What drugs are prescribed by prescription form №3?

А. Drugs and wares of the medical setting in accordance with law of МPH of
Ukraine № 233 (25.07.1997 y.)
B. Drugs of non-quantitative account
C. Narcotic drugs and psychoactive drug
D. Prescribed to the patient by special price
E. With alcohol
6. What index includes the ration of first registered cases of major non-epidemic
diseases during year for average annual population size:
А. Index of prevalence of major non-epidemic diseases
B. Major non-epidemic morbidity;
C. Structure of major non-epidemic morbidity;
D. Pathological affected;
E. There is not a right answer.
21
7. Social meaningfulness of major non-epidemic diseases is conditioned by:
А. High prevalence;
B. Considerable disability;
C. High disability;
D. High death rate.
E. All of mentioned above
8. What is included in section "Development of primary medical help" of national

project of Public health?
А. Wage rise to family doctors, district doctors, district pediatricians, nurses;
B. Retraining of family doctors, district internists, district pediatricians;
C. Rigging the out-patient’s establishments diagnostic facilities;
D. Rigging the emergency cars;
9. Tasks of national project in Public health are:

А. Development of primary medical help;
B. Prophylactic measures;
C. Population provision by hi-tech medical care;
D. Guard of maternity and childhood.
10. When have to be used the measures cases of obligatory and forced character
during realization of medico-diagnostic process?
А. During treatment of child;
B. In the case of hospitalization;
C. During quarantine measures realization and diseases in the case special danger
infection.
D. During laboratory examination
E. During x-ray examination
Answers:
1 2 3 4 5 6 7 8 9 10
B C E A C A E E E C
XII. Practical tasks

1. Expect the dynamics of visit of family doctor, if the annual number of visits
in this year is 5750, and previous year was 5945.
22
2. Expect the family doctor loading, if district doctor loading is 1700 persons
(percentage of adults is 75%), district pediatrician loading is 800 patients (percentage of
children is 25%).
3. Expect the family doctor loading, if district population include 28 children till
3 years old, 14 invalids of the I and II groups; 24 persons older than 70 years, 76
children of preschool age.
4. Calculate frequency of exposure of disease, if 1342 persons were examined,
and 5 cases were diagnosed.
5. Design of situation: appoint the patient to necessary instrumental examination
in the range his cost and according to territorial remoteness.
23
TOPIC 2
Medico-social aspects of the population’s health. The medical examination of
the population, and rehabilitation in the family doctor’s practice. Medical
insurance structure and family doctor activity. The models of medical insurance in
the world.
I. Theme actuality. Perspectives on prevention. The primary goals of prevention
in medicine are to prolong life, to decrease morbidity, and to improve quality of life - all
with the available resources. Working in partnership with patients, physicians play
critical roles as educators, managers of access to screening and intervention services,
and interpreters of divergent recommendations for promoting health. Despite evidence
of the effectiveness of many preventive services in prolonging healthy life and
decreasing medical costs, physicians frequently do not integrate appropriate preventive
practices into their care. Obstacles to providing optimal preventive care include lack of
appropriate training, doubt about the effectiveness of preventive interventions,
skepticism about patients' commitment to change, limited reimbursement and time, and
conflicting professional recommendations. Success achieved for populations may not be
visible to individuals, and physicians may not appreciate the cumulative benefit of their
efforts. Despite considerable success in some areas, such as the reduction of smoking by
U.S. adults from 40 percent to 25 percent in the last 30 years, effective behavior change
in other domains is often elusive, challenging and frustrating physicians and patients
alike.
They distinguish primary and secondary prevention. Primary prevention,
including various forms of deciding what types of primary and secondary preventive
care clinicians should health promotion and vaccination, is care intended to minimize
risk factors and the subsequent incidence of disease. Secondary prevention is screening
for detection of early disease, for example the use of mammography to detect preclinical
breast cancer. While the term secondary prevention is also sometimes used for the
prevention of recurrent episodes of an existing illness, most would consider this activity
to be tertiary prevention care intended to ameliorate the course of established disease.
Offer to their patients is not a trivial matter. The U.S. Preventive Services Task Force
(USPSTF), The Canadian Task Force on the Periodic Health Examination and the
American College of Physicians, among other organizations, has critically reviewed the
strength of available evidence for preventive practices and has made recommendations.
Adopting an evidence-based approach to the development of preventive practices policy
is an essential step to assuaging provider concerns about the validity of particular
recommendations, to identifying the specific basis of controversies in prevention, and to
reassuring patients that certain interventions will do more good than harm.
24
II. Study purposes: to outline the basic socio-medical aspects of population
health and find out the role of family doctor in promotion of healthy life style,
preventive work.

- to acquire a basic principles of medical and preventive help to the population of
Ukraine;
- to be able estimate the state of health;
- to analyze meaningful risk factors, to know their classification;
- to expose the early signs of basic clinical syndromes during preventive
examination and realization of the health centre system.
IV. A student must be able to collect prior medical history, examine the patient,
determine risk of development of the most widespread diseases, carry out the primary
prophylaxis of diseases by exposure of risk factors, to appoint and use the medicinal and
non-medicinal methods of treatment for the primary prophylaxis of diseases, to estimate
clinical efficiency of medicinal and non-medicinal methods of prophylaxis of diseases,
carry out the clinical supervision under patients and fill medical documentation,
hygienic education of population.

1. The primary prophylaxis of diseases includes:
А. Prevent further development of illness and its complications.
B. Prevent development of diseases and influence of risk factors.
C. Optimization of life style.
D. Improvement of socio-economic conditions.
E. Medical help to the patients in the case of acute illnesses.
2. The concept "individual health" is:

А. The state of organism, which permits to execute the biological and social
functions
B. The state of organism, when all his functions are balanced with an
environment
C. The state of full physical, spiritual and social well-being and not merely
absence of diseases and physical defects.
D. Conditional statistical concept, which is characterized by the complex of
demographic indices, morbidity, physical development, disability and
frequency to the nosological states
25
E. Interval within the limits of what oscillation of biological processes is retained
organism at the level of functional optimum
3. Leading groups of factors, which negatively impact on population health, are:

А. Medico-biological factors, life style and ethnic;
B. Volume and quality of medical care, education, environment and medico-
biological factors;
C. Life style, medico-biological factors, environment, volume and quality of
medical care;
D. Volume and quality of medical care, medico-biological factors, environment;
E. Environment, education, ethnic, life style.
4. A population health depends on the life style (in %) :

А. 49-53%
B. 18-22%
C. 17-20%
D. 8-10%
E. 55-64%
5. A volume, quality of medical care and inefficiency of prophylactic measures,

negatively impact on population health (in %):
А. 49-53%
B. 18-22%
C. 17-20%
D. 8-10%
E. 55-64%
6. What is a risk factor of morbidity or death?

А. Direct reason of illness or death;
B. Endo- or exogenous additional unfavorable impact on organism, which
promotes probability of disease onset or death;
C. Level of specific antibodies in the serum of blood and essential hypertension;
D. Life style, environment;
E. Environment, psycho-emotional instability.
7. Types of prophylactic reviews which are carried out in medical and preventive
establishments:
А. Periodic, having a special purpose;
B. Medical, quarterly;
26
C. Annual, ambulatory;
D. Previous, periodic, having a special purpose;
E. Previous, medical, quarterly.
8. According WHO classification, the individuals of 60-74 years old are:

А. Long-livers;
B. Elderly age;
C. Senile age;
D. Eenior age;
E. Middle age.
9. A healthy life style is a behavior of people with certain working conditions and
mode of rest, which provides:
A. Maintenance of health;
B. The high functional capacity of organism;
C. Active longevity;
D. All of mentioned above;
E. Good nutrition.
10. The indexes for estimation of primary prophylaxis are:

A. Dynamics of primary morbidity;
B. Decline of acute diseases frequency;
C. Dynamics of primary morbidity, increase of share of healthy persons among
population;
D. Decrease of mortality;
E. Decrease of chronic diseases.
Answers:
1 2 3 4 5 6 7 8 9 10
B C C A D B D B D C
VI. Basic questions after a theme

A notion about a health, transient state, illness. Functional clinical syndromes in
practice of family doctor. Ability to determine the state of health, fill the medical
passport of health.
General principles of health promotion.
Risk of diseases onset, risk factors, elimination of risk factors, primary and
secondary prophylaxis.
27
The principles of prophylaxis, the estimation of the health state, determination of
risk factors.
Health insurance, reimbursement of hospitals and physicians.
VII. Practical skills

Practical class is conducted in out-patient's clinic; students together with family
doctors conduct the primary reception of patients, estimate the state of their health,
determine risk factors, and propose the plans of individual prophylaxis.
1. To fill the medical passport of family.
2. To lay down the genealogical tree of family.
3. Calculate a body mass index of woman 35 years old, which works as a doctor;
her height is 165 cm, body mass 55 kg; define her day's calorie content of food, the
share of albumens, fats and carbohydrates in her ration.
4. Man of 45 years old. He smokes 1 pack of cigarettes a day; his height is 175
cm, body mass is 95 kg, abdominal circumference 105 cm; during 3 years the history of
arterial hypertension (BP 160/100 mm Hg), takes medicine periodically, total
cholesterol level 5,8 mmole/l, a dietary intake with fat, potato, vegetables; his father had
essential hypertension since young years.
 Stratify of risk after a scale SCORE
 Stratify the additional risk for arterial hypertension
 Define a body mass index
 Appoint recommendations for life style modification.
 Medicinal treatment.
 Define purpose level of cholesterol.
5. Woman of 45 years old; smoking; BP 140/80 mm Hg; her father died because
of stroke in the age of 48 years; blood glucose - 4,5 mmole/l, weight - 75 kg, total
cholesterol level - 5,5 mmole/l, a height - 165 cm.
 Define a body mass index.
 Stratify risk after a scale SCORE
 Stratify the additional risk for arterial hypertension.
 Appoint recommendations for life style modification.
 Medicinal treatment.
 Define purpose level of cholesterol.
 Conduct hygienic education of patient about harmful impact of smoking.
Independent work: to fill the medical passport of health of family.
28
VIII. The logical structure of theme
Test control of initial level of knowledge
Analysis of thematic questions
Primary reception of patients with family doctors, estimation of

their state of health, determination of risk factors concrete patients,
propose the plans of individual prophylaxis, to acquaint with principles
of organization of the health centre system
A decision of concrete practical tasks on the basis of the got knowledge
Current control of knowledge after a theme
Resuming by reading with forming of complex estimation

for every student
29
IX. The content of theme
Primary prevention. Risk modification. Of the more than 2 million deaths that
occur in the U.S. each year, as many as half may be due to preventable causes (Table 1).
Life-style and behavior play a central role in the primary causes of morbidity and
mortality for adults - coronary heart disease, cancer, and injuries.
Tobacco. Perhaps the largest potentially modifiable risk to health is the abuse of
tobacco products. Responsible for more than 400 000 deaths each year and an estimated
annual cost to society as high as $50 billion, tobacco abuse accounts for a substantial
fraction of cardiovascular, cancer, and pulmonary morbidity and mortality. Recent
evidence also suggests that passive exposure to tobacco smoke results in chronic
pulmonary disease as well as lung cancer for some adults. Because of the addictive
properties of nicotine, preventing the initiation of tobacco abuse is the tobacco control
intervention of choice. Most adult smokers acquire their habit as teenagers, and primary
efforts to discourage initial tobacco use must engage younger audiences [1].
Counseling regarding the health risks of tobacco and methods for quitting is
advised by all prevention advisory panels. Particular attention should be paid to groups
at highest risk for tobacco abuse, such as men, blacks, and those with only a high
school education or less. Because 70 percent of smokers come into contact with health
professionals each year, the medical encounter provides an opportunity to address the
health implications of tobacco abuse. Ninety percent of successful quitters will stop
smoking without the aid of programmatic interventions. A review of smoking habits,
recommendation to stop, and support from a health care provider may generate the
impetus for an individual to make an effort to stop smoking. Respect for patients' self-
efficacy, reflected in questions such as «What do you understand about the health
consequences of smoking?», «Are you ready to quit?», and «What would it take for
you to stop smoking?» has been suggested as a means to engage patients in the process.
Setting a date to quit, arranging follow-up visits or phone calls during the initial
quitting period, providing literature, and considering the use of nicotine replacement
systems for those who will completely desist from the use of other tobacco products are
all interventions that may improve the quitting success rate [7].
30
Table 1
Actual Causes of Preventable Deaths in the United States in 1990
Deaths
Estimated Percentage of
Cause
No* Total Deaths
Tobacco 400 000 19
Diet/activity patterns 300 000 14
Alcohol 100 000 5
Microbial agents 90 000 4
Toxic agents 60 000 3
Firearms 35 000 2
Sexual behavior 30 000 1
Motor vehicles 25 000 1
Illicit use of drugs 20 000 <1
TOTAL 1 060 000 50
* Composite approximation drawn from studies that use different approaches to derive estimates,
ranging from actual counts (e.g., firearms) to population attributable risk calculations (e.g., tobacco). Numbers
over 100 000 are rounded to the nearest 100 000; those over 50 000 are rounded to the nearest 10 000; those
below 50 000 are rounded to the nearest 5000.
Alcohol and Drugs. The use of alcohol and drugs accounts for more than 100
000 deaths annually. While the ability of health care providers to prevent the initiation
of such behaviors has not been proven, screening for exposure and addiction could
potentially direct medical effort to the prevention of alcohol and drug-associated
problems such as injury, violence, and medical complications of drug abuse. Although
instruments such as the CAGE questionnaire have proven to be valuable for detection
of alcohol abuse, no comparable brief screening strategy is available for the routine
identification of illicit drug abuse. Health care providers screen inadequately for both
disorders, despite evidence for effective early treatment of addictions and their
complications. Recent data suggesting that moderate alcohol intake may prevent heart
disease for some individuals and the lack of a biologic "gold standard" criterion for
alcoholism contribute to difficulties in diagnosing alcohol abuse. Legal implications of
identifying illicit drug use may hinder detection of this problem. When screening for
these disorders is feasible, interventions that have proven effective include brief
counseling, referral to ambulatory and in-patient treatment programs, use of 12-step and
other community organizations, and appropriate use of medications such as methadone
for heroin abuse [2].
Diet. Mounting evidence suggests that modification of caloric intake, both
quantity and quality, can result in decreased morbidity and mortality from
cardiovascular disease, cancer, and diabetes. Excess weight is an independent risk
factor for coronary disease, in addition to its contribution to the incidence of diabetes,
31
hyperlipidemia, and hypertension. Between 20-30% of Americans are overweight,
defined as 20% above the acceptable body-mass index (kg/m2), and more than 40% of
certain subpopulations, such as black, Native American, and Mexican-American
women, are overweight.
Americans derive excess calories from fats, particularly saturated fats, rather than
from more beneficial sources such as complex carbohydrates and fiber. Since intake of
saturated fat correlates with cholesterol level, and coronary heart disease is reduced by
2 to 3 percent for every 1 percent reduction in plasma cholesterol level, dietary
modification will play a central role in decreasing the primary cause of mortality in
America. Excess dietary fat intake has also been associated with breast, colon, prostate,
and lung cancer in epidemiologic studies. Reducing calories from all fats to 30% and
from saturated fat to 10% are widely accepted goals. Increasing the intake of dietary
fiber, such as from plant, legume, and grain sources, may contribute specifically to a
decrease in colon cancer incidence [3].
Dietary sodium restriction may benefit those who have salt-sensitive
hypertension, although the need for such restriction in the general population is unclear.
Calcium and vitamin D are protective against osteoporosis, particularly in young
women prior to reaching menopause, and evidence suggests that females at all ages
have an inadequate intake. Menstruating women are at risk for iron-deficiency anemia.
To achieve the recommended daily intake of vitamins and minerals, a varied diet
including fish, lean meats, dairy products, whole grains, and five to six servings of
fruits and vegetables daily is recommended, rather than the use of vitamin supplements.
While evidence supporting the use of antioxidants such as vitamins E and C is still
incomplete, the recommended quantities of these micronutrients can be obtained from a
balanced diet.
Physicians play a critical role in effecting dietary change in their patients. The
value of providing counseling and literature, referring patients to appropriate
community groups and nutrition professionals, and helping patients set goals and limits
for diet modification cannot be overemphasized. Despite concern about the risk of
weight cycling, the health hazards of obesity appear to outweigh the potential harm of
repeated weight loss and gain [1,7].
Physical Activity. A key counterpart to decreased caloric intake is increased
energy expenditure. Not only can increased physical activity decrease obesity, but
avoiding a sedentary life-style can also decrease the incidence of cardiac disease,
hypertension, diabetes, and osteoporosis. It is estimated that only 22% of U.S. adults
engage in at least light to moderate physical activity, such as walking for 30 min three
to five times per week. A full quarter of the population pursues no vigorous physical
activity at all. The magnitude of benefit derived from physical activity may be as great
32
as a 35% reduction in coronary heart disease, and even light exercise is preferable to no
exercise. While the ultimate goal for optimal cardioprotective physical activity is 20 to
30 min of vigorous activity most days of the week, patients should be encouraged to
approach this level gradually. A sudden onset of vigorous activity in the unfit may
increase the risk for myocardial infarction and sudden death. Patients should be
informed that, despite previous physical inactivity, the incremental adoption of a
regular fitness program can decrease their risk of cardiovascular and other diseases to
the level of those who have remained fit throughout their lives. Successful exercise
programs are integrated into daily routines, self-directed, and injury-free [6].
Sexual Behavior. Because of the substantial risks of infectious diseases and
unwanted pregnancy from unprotected sexual activity, patients should be strongly
advised to use barrier methods for all high-risk practices such as oral, anal, and vaginal
intercourse as well as additional contraceptive methods when pregnancy would not be
welcome.
Environment. Physicians should adopt a broad construction of environmental
risks to health, considering the physical, social, and occupational environments of their
patients. Taking a complete exposure history, focusing on home, work, neighborhood,
hobbies, and dietary habits can help direct interventions and recommendations. While
local circumstances will dictate specific risks to which patients should be alerted, such
as regional infectious diseases or particular toxic exposures produced by local industry,
certain general recommendations should be adopted universally for health promotion.
Since skin cancers, the vast majority of them secondary to sun exposure,
constitute the most common form of malignancy, all patients should be counseled to
avoid sun overexposure and to use sunscreens. Patients should be encouraged to
consider potential toxin exposures, such as those due to air pollution, household
smoking, or carbon monoxide and radon gases, and be informed of the medical
symptoms and consequences of such exposures. Proper food preparation and storage
decrease the incidence of food-borne infectious disease [1,2].
Unintended injury constitutes a significant preventable burden of morbidity and
mortality and is the leading cause of death for the general population under 40.
Automobile accidents are the leading cause of unintentional injuries. The risk of being
involved in a disabling traffic accident may be as high as 30% in the course of an
individual's lifetime, and 50% of deaths from automobile accidents could be prevented
with regular seatbelt use. Physicians should recommend seatbelt use, as well as helmet
use for motorcycle and bicycle riders, since evidence supports a higher likelihood of
use among patients who receive such advice. Clinicians should also recommend against
operating a motor vehicle after drinking, since alcohol (and illicit drugs) is a clear-cut
risk cofactor.
33
Smoke detectors are underused, being found in only 80% of homes. Since most
deaths due to fire occur in the residential setting, patients should be encouraged to
install at least one on each floor of their home.
Attention to health hazards in the workplace can identify those at risk and prevent
long-term consequences of exposure. Evaluation of the work environment should
include questions about exposure to metals, dusts, fibers, chemicals, fumes, radiation,
loud noises, extreme temperatures, and biologic agents [7].
Community and family violence, particularly through the misuse of firearms, is
the second leading cause of death from unintentional injury. Firearms, especially
handguns, are far more likely to injure a family member than an intruder and are
associated with increased rates of suicide and harm to children. Patients should be
encouraged to remove their weapons from the home and should be informed of the risks
associated with improper security and storage of firearms. While community and family
violence are epidemic in the U.S., interventions to curtail violent behavior are not well
established. Screening for exposure to relationship violence, developing plans for safe
havens, and referrals to appropriate community and government agencies can prevent
continued abuse [1].
Immunization. As many as 70 000 deaths due to influenza, pneumococcal
infections, and hepatitis B occur in the U.S. annually. Despite good availability and
evidence for the cost-effectiveness of recommended vaccinations for adults, only 40%
or fewer members of target populations are immunized. Factors explaining poor
adherence to adult immunization guidelines include lack of confidence in vaccine
efficacy among providers and patients, underestimation of the severity of the target
diseases, incomplete reimbursement, lack of systems to identify and vaccinate high-risk
populations, and the absence of an adult requirement for vaccination equivalent to our
vaccination policies for school-age children. Table 2 lists recommended adult
immunizations.
Chemoprophylaxis. There is significant supportive evidence for the use of
certain medications in primary prevention. Therapy of this nature in the otherwise
healthy person, however, is not risk-free. The use of aspirin for the prevention of
cardiovascular disease or colorectal cancer, for example, is supported by evidence from
cohort and, in the case of cardiovascular disease, randomized controlled trials. The
potential for cerebral bleeds and gastrointestinal intolerance, however, must be balanced
against a patient's individual risk for the target diseases. Although no randomized trials
have measured the impact on mortality, postmenopausal hormone replacement therapy
is another therapy given to healthy women for the prevention of future disease
(coronary heart disease and osteoporosis), as well as to control menopausal symptoms.
These benefits must be weighed against the risks of possible breast and endometrial
carcinoma. Patient involvement in the decision-making process, perhaps even informed
34
consent, is recommended to ensure compliance, proper use of medication, and sustained
monitoring for side effects [7].
Table 2
Recommendations for Preventive Medical Care
Screening:
Blood pressure Height and weight Pap smear
FOBT and/or sigmoidoscopy*
Mammography ± breast exam +
Assess for problem drinking
Total blood cholesterol (men aged 35 to 64, women aged 45 to 64>
Vision screening ++
Assess for hearing impairment ++
Counseling:
Tobacco cessation
Avoidance of alcohol and drugs when driving, swimming, boating
Limitation of fat, cholesterol
Maintenance of caloric balance
Emphasis on grains, fruits, vegetables in diet
Adequate calcium
Physical activity
Lap/shoulder belts
Motorcycle and bicycle helmets
Smoke detectors
Storage or removal of firearms
STD prevention
Dental visits, fluoride, flossing
Contraception Fall prevention
CPR training for household++
Hot water heater at <120° ++
Immunization:
Tetanus-diphtheria (Td)
Pneumococcal vaccine++
Influenza vaccine++
Chemoprophylaxis:
Discussion of hormone replacement therapy with perimenopausal women
* After age of 49
+ After age of 49, before age 70
++ Age 65 +
35
Secondary prevention. Widespread screening for the presence of existing
diseases should meet the following criteria:
1. The targeted disease must be sufficiently burdensome to the population that a
screening program is warranted. Minor changes in relative risk should have a
substantial impact on the absolute risk within the population.
2. The target disease must have a well-understood natural history with a long
preclinical latent period.
3. The screening method must have acceptable technical performance
parameters, detecting the disease at an earlier stage than would be possible without
screening and minimizing false-positive and false-negative results.
4. Efficacious treatment for the target illness must be available.
5. Early detection must improve disease outcome.
6. Cost, feasibility, and acceptability of screening and early treatment should be
established [6].
While physicians underprovided certain screening services that have met these
criteria (for example, regular mammograms for women over age 50 years), it is also the
case that some prevalent screening practices today are not solidly rooted in evidence.
Screening tests such as measurement of prostate-specific antigen and mammography in
women under 50 have been adopted for use by many clinicians despite lack of complete
current evidence that these services will decrease the risk of morbidity or mortality or
improve the quality of life. See Table 2 recommendations of the USPSTF for screening
of adults who are at average risk for target conditions. Recommendations for special-
risk and vulnerable populations are available in the USPSTF Guide.
Community health advocacy. In addition to the direct clinical provision of
preventive and health-promoting services, physicians can bring their knowledge,
expertise, clinical experience, and influence to bear at the community level to promote
health. Whether arguing for the denormalization of tobacco use or providing data about
the health risks of local incinerators, physicians are the important sources of information
and support for improving health beyond the clinical office. Such activities are
consistent with the overall objective of caring for patients and may have a substantial
impact on decreasing the prevalence of the root causes of disease [1].
Cost awareness in medicine. Costs of health care in the U.S. Through the
1980s and early 1990s, health care expenditures in the U.S. rose at a rate of more than
10 percent per year, which exceeded the rates of inflation and of growth in the gross
national product (GNP). As a consequence, the percentage of the GNP that is spent on
health care increased from about 7 percent in 1970 to 9 percent in 1980 and to more
than 12 percent by the early 1990s. This escalation exceeded the increases in other
western countries, such as the U.K. and Canada. Much of the difference between the
U.S. and Canada is explained by higher physician fees rather than by a higher per capita
36
use of services. The U.S. also spends substantially more on the administrative costs of
health care than Canada or Great Britain [2].
The reasons for the increase in health care costs are multifactorial. The aging of
the population and the availability of new diagnostic and therapeutic advances have
increased the demand for health care. Furthermore, the supply of specialists has
increased dramatically, providing Americans with easier access to advanced medical
services but also suggesting than an oversupply of physicians contributed to an
excessive escalation in costs. The costs of care are especially influenced by decisions
regarding hospital admission and surgery and by decisions affecting the use of intensive
care units, life-sustaining treatments, and long-term care facilities. Efforts at cost-
containment have attempted to identify unnecessary services, such as routine
preoperative electrocardiograms in healthy young patients, or situations in which
extraordinary expenses occur, such as in the last 6 months of life. Attempts to reduce
"fat" in the health care system may be counterbalanced, at least in part, by growth in the
number and age of the population and by continued advances in technology.
Despite these rising costs an estimated 15% of the population do not have health
care insurance of any kind, even though nearly half are in households in which someone
is employed. This lack of insurance coverage and access to health care is often blamed
for the fact that the U.S., despite its high expenditures on health care, ranks about
twentieth in the world in infant mortality and is not in the top ten in life expectancy [5].
Health insurance. Traditional fee-for-service insurance reimburses the hospital
and the physician for services rendered but frequently does not cover preventive care.
Even when insurance provides coverage for a service, the patient may be responsible
for an initial "deductible" and a copayment, which is usually a fixed percentage of the
entire amount charged.
Patients who must pay such out-of-pocket charges for some of their medical care
seek less care than those whose care is fully covered by insurance. In the working poor
this may result in reduced utilization of services and in an increase in the prevalence of
serious disease. When adults of all socioeconomic classes lose health insurance
coverage, they may use fewer medical services; as a result, their health status tends to
decline.
Most alternatives to traditional fee-for-service medical care require enrolled
persons to prepay a fixed premium, which, except when a relatively small copayment is
required, usually covers acute, chronic, and preventive medical services and sometimes
covers medications and other health care needs. Prepaid plans have varying
organizational and financial structures. Early on in their development, staff-model
health maintenance organizations (HMOs) were among the most popular formats. In
this model, groups of salaried physicians practiced physically together in one or a few
central facilities to provide prepaid care. In recent years, independent practice
37
associations (IPAs) have shown the most rapid growth. IPAs provide prepaid care to the
patient by contracting with office-based practitioners who agree to see patients on a
prenegotiated fee schedule or for a fixed monthly per-patient capitated payment. To
balance the normal fee-for-service incentives and control utilization, IPAs employ
various forms of administrative controls and review. The number of days of
hospitalization has been markedly reduced among enrollees in HMOs, and HMOs have
been among the leaders in attempts to reduce hospital costs and lengths of stay [1].
Reimbursement of hospitals and physicians. In 1983, Medicare introduced a
system of prospective reimbursement using diagnosis-related groups (DRGs), whereby
hospitals were paid a predetermined sum based on the patient's principal diagnosis,
procedures, complications, and comorbidities regardless of the costs or charges that
were actually generated by the hospital stay. This reimbursement system was designed
to reward hospitals for being more efficient, and hospitals could actually be paid more
than their costs. While the prospective reimbursement system has undoubtedly
stimulated efficiency, it also has raised concerns about the practice of discharging
patients prematurely or transferring them to other institutions if the projected cost of
caring for them exceeds the expected reimbursement.
Since the introduction of federal prospective reimbursement, the number of
inpatient hospital days has decreased. This reduction has been accompanied by a
marked increase in ambulatory services, including a shift to the outpatient arena of
services that previously were delivered only on an inpatient basis. This shift should
lower the cost of delivering an individual unit of service, such as the cost of a breast
biopsy, but the overall cost of medical care will rise if, for example, the breast biopsy is
performed on an ambulatory basis and the inpatient resources that the breast biopsy
patient would have used are now consumed by new services such as the treatment of a
breast cancer patient with bone marrow transplantation.
Methods of physician payment also have been revised. Physician reimbursement
in the U.S., whether by Medicare or by private insurers, traditionally was a direct
payment based on the doctor's "usual and customary" fee. Medicare changed this
approach when it adopted the relative value scale, which is based on the concept that
payment rates for medical services should, as with other economic "goods," reflect the
costs of producing those services. This change suggests that procedural tasks were
being reimbursed at rates exceeding those of nonprocedural tasks that require
comparable time, skill, and experience. Medicare's relative rates are similar to
preexisting fee schedules in Canada [2,7].
Control of health care costs. Two different approaches have been suggested to
control health care costs: regulation and competition. Regulations, such as per diem rate
setting, attempt to control costs by setting and enforcing practice or reimbursement
standards. Other regulatory means of attempting to reduce costs include mandatory
38
second opinions prior to elective hospitalization or surgery, but such programs usually
do not save more than the costs of administration of the programs themselves.
The competitive approach encourages hospitals and providers to bid in a free-
market atmosphere, in which consumers will presumably make rational choices based
on the perceived cost and quality of the available alternatives. Insurance plans that
utilize deductibles and copayments reflect this approach. It also has been proposed that
physicians who practice inexpensively should be rewarded financially, but if physicians
are paid to perform fewer services, the quality of care may suffer. In the absence of
legislative reform, the U.S. health care system has been changing rapidly in response to
competitive forces. In some parts of the country, employers have joined together to
demand lower insurance premiums or to contract directly with hospitals and physicians.
In other areas, hospitals, doctors, or doctors with their hospitals have contracted with
insurance carriers to establish comprehensive systems that can deliver the full range of
health services to a large population of individuals. For-profit insurers and hospitals
often compete actively with more traditional not-for-profit entities [3,6].
ALGORITHMS AND TABLES ACCORDING THEME
Recommendations for life style modification of patients

with cardiovascular diseases
A nutrition education (the Mediterranean diet):

 enough share of green vegetables, fruit, corn products;
 saltwater fish, cod-liver oil;
 limitation of fat and cholesterol-contain products
Elimination of harmful habits:

Facilities  smoking;
 alcohol abuse
Physical activity:
 the individual programs of the physical trainings
39
An algorithm of prophylactic medicine for family doctor
a special purpose for activity
Estimation of Preventive Exposure risk Development of

health examination prophylactic measures
Medical control
Decreasing of Establishments, Contingents are

High-risk group
morbidity enterprises decreed
The basic activity
Motivation Reference part
Executive part
Sanological criteria of
efficiency
Health of individual Community health
40
Functional model of prophylactic activity of general practitioner / family doctor
(GP / FD)
Supplier of prophylactic technologies (GP/FM)
Forming of partnership between GP Introduction of the new

/ FD and patient on the basis of technologies for support of health
principles of the adequate of population
information about health
Individual recommendations for

Hygienic education of population support of health which take into
account the state of health,
psychological features and family
life style
Application of screening methods
for exposure of diseases
Lead through the dynamic supervision
under certain groups of patients with
timely correction of measures
A lead through of measures for

prevention of onset of diseases,
their complications, relapses Vaccination
User of prophylactic technologies (patient)
Study the efficiency of prophylactic

technologies
On the incorporated performance By subjective estimation of

of doctor patient’s satisfaction
41
An algorithm of family doctor work in out-patient clinic for relation to patient’s smoking cessation
Intensity of smoking (cigarettes / An estimation of degree of 4. Advice about Information about harmfulness of smoking
days) dependence on nicotine stopping and connection of smoking with illnesses of
patient
3. Objective information Fagerstrem test, blood

index of 5. An estimation of
Laboratory tests on nicotine
smoking patient’s nicotine
dependence
2. Anamnesis of smoking urin
 Duration (experience of smoking) saliva
expired air analysis desire to stop
 Age of start of smoking
 Period from episodic to the daily
smoking Episodic smoker No desire to stop
6. A help for
stopping
Daily smoker Former smoker
Instrumental in decision-
making to stop smoking
The plan for refuse
Not smoker of smoking
1. Determination of attitude toward
Medical records of all consultation
smoking
Setting of NZP and

symptomatic
7. Organization of support and setting therapy is after
Questioning of patient testimonies
of next consultation
Questioning of relatives
Grant of self-help: sights,
brochures, audio-, video data,
8. Estimation by the doctor of Direction to the specialist and others with information
efficiency of the conducted for questions of smoking from Internet resources,
Reception of patient consultation and repeated reception cessation numbers of phone-consultation
42
Prophylaxis of cardiovascular diseases (CVD)
If a patient asks about it
When to estimate the
general risk of CVD? If during consultation:
 a patient of middle ages with smoke habit;
 it’s one or more risk factors, in particular, increase of
cholesterol level in blood;
 family history: early onset of CVD, presence of basic risk
factors, such as a hyperlipidemia;
 there are symptoms which specify on possibility of CVD
Anamnesis: prior disease; family history of early onset of CVD,

smoking, physical activity, food
Examination: BP, heart rate, auscultation heart and lungs,

pulsation on lower extremities arteries, growth, body mass
index, waistline
How to estimate a
risk?* Laboratory finding: glucose and protein level in urine,
cholesterol, glucose and creatinine level in blood
EСG in rest and after loading:

In case of stenocardia suspicion - echocardiography for the
persons of young age and patients with high BP;
determination of C-reactive protein, lypoprotein (а), gomocistein,
fibrinogen.
Consultation of specialist in suspicion on CVD in young age
patient
* * In default of CVD, diabetes mellitus, expressive factors of risk to use the scale of SCORE
DM 2
or DM 1 - Presence A risk A risk
Established Ризик за
microalbuminury considerable according according
CVD SCORE
expressive one SCORE SCORE
≥ 5%
RF ≥ 5% < 5%
43
The recommendation for healthy life style:
 no smoking
 to lose weight, if BMI ≥ 25 kg/m2, and especially at BMI ≥
30 kg/m2
 control of body mass, if waist measurement is 80-88 cm for
women and 94-102 cm for men
 decline of body mass, if waist measurement is ≥ 88 cm for
women and ≥ 102 cm for men
 the 30-minute physical exercise of moderate intensity,
Advices are in physical trainings and declines of body mass, can predict the
relation to the development of DM
healthy way of life Healthy food:
for the maintenances  various food
of low risk  control of calories quantity for the correction of body mass
Systematic  recommended: fruit, vegetables, groats and bread, saltwater
leadthrough of fish (especially fat grade), lean meat, skim milk
estimation of general  replacement of the saturated fats on mono- and polysaturated
risk in the future (vegetables and sea food)
- limitation of the use of salt
Medicinal therapy:
expedient, if a risk after a scale SCORE arrives at 5%,
especially, if it is up to 10%, or at the defeat of targets organs.
In old age people medicinal therapy is recommended, as a rule,
in the case of risk more than 10%
 BP ≥ 140/90 mm Hg of mercury to consider an item question
about antihypertensive drugs presciption
 if total cholesterol level ≥ 5 mmol/l, it’s necessary to
prescribe statins
 for CVD patients - aspirin, for majority - statins
 for patients with DM: to consider a question about setting of
preparations what reduce sugar level
44
X. Tasks for final control
1. Secondary prophylaxis of diseases includes:
А. Warning to further development of illness and her complications.
B. Prevent the onset of diseases and risk factors impact.
C. Optimization of life style.
D. Improvement of socio-economic condition.
E. Medical help to the patients with the used for prevention of acute illnesses
2. The concept "individual health" is:

А. The state of organism, which permits to execute the biological and social
functions
B. The state of organism, when all his functions are balanced with an
environment
C. The state of full physical, spiritual and social well-being and not merely
absence of diseases and physical defects.
D. Conditional statistical concept, which is characterized by the complex of
demographic indices, morbidity, physical development, disability and
frequency to the nosological states
E. Interval within the limits of what oscillation of biological processes is retained
organism at the level of functional optimum
3. The state of environment impact on population health (in %):

A. 49-53%
B. 18-22%
C. 17-20%
D. 8-10%
E. 55-64%
4. Medicobiological factors impact on population health (in %):

А. 49-53%
B. 18-22%
C. 17-20%
D. 8-10%
E. 55-64%
5. To the endogenous risk factors of diseases it is belonged:

А. Level of specific antibodies in the blood serum and arterial hypertension
B. life style, environment
C. eyelids
D. sex
45
E. heredity.
6. To the exogenous risk factors of diseases it is belonged:

А. Psychological instability
B. climate, life style
C. life style, environment
D. unspecific antibodies level
E. environment, level of unspecific antibodies.
7. In the structure of morbidity of population in Ukraine the first place is occupied by:
А. Illness of breathing organs
B. neoplasm
C. illness of the nervous system
D. endocrine diseases
E. illness of the system of blood circulation.
8. The basic criteria of healthy life style are:

A. the rational food
B. elimination of harmful habits
C. correct sexual behavior
D. the harmonious interrelations between people
E. the regular physical activity
9. The risk factors of development and progress of atherosclerosis are:

A. Passive life style
B. smoking
C. excessive body mass
D. hypergomocysteinemia
E. options A, B.
10. The patients with isolated systolic АH is attributed to the group:

A. Low risk of cardiovascular complications
B. the middle risk of cardiovascular complications
C. the high risk of cardiovascular complications
D. no risk of cardiovascular complications
E. neoplasm risk
Answers:
1 2 3 4 5 6 7 8 9 10
A A C B A C A D C B
46
TOPIC 3
The assessment of the risk factors of the main chronic non-epidemic diseases
and the preventive measures in case of the cardiovascular, bronchopulmonary,
gastrointestinal diseases and some other common syndromes. A role of family
doctor in popularization of healthy life style and prophylaxis. The dietotherapy.
The prophylaxis of AIDS.
I. Theme actuality. Computer system of informative support of work of family

doctor, out-patient's clinic of family medicine, establishments of primary medical
sanitary help it is the active helper of family doctor in all directions of his medical
activity, that allows more effectively to organize the work, sparing basic time to the
patients, translating greater part of paper work on the helpers and computer. A computer
helps in registration of medical document due to the conduct of electronic medical
document of patient, that enables automatically to form a currently-registration
document, and allows keeping up with both dynamics of flow of illness and «motion»
of patient. The use of the newest technique provides registration of information about a
patient and his family, facilitates planning of work of medical personnel with patients,
provides the control of work of establishment on all spectrum of prophylactic,
epidemiology, diagnostic, medical, organizational and financial functions. The personal
computer provides the conduct of reception of patients, filling of registration medical
document with possibility of forming of basic data for the control system by statistical
information, and also conduct of the state accounting and operative analytic geometry
for support of administrative account in medical establishments. Technical means give
analytical possibilities after the generation of initial forms which are needed for the
analysis of work by the most family doctor, and also for an administrative account by
administration by estimation of quality of the done medical services, efficiency of
medically-diagnostic work, and also economic analysis of activity of establishment. The
controlled from distance intercourse enables to the family doctor to get information
about the facts of medical service of patients of his area at other medical prophylactic
establishment district, city and regional levels. The use of medical Internet-resources
gives to the doctor information about medications, incorporated in Ukraine, and also
about substandard and falsify series of the medications exposed on territory of Ukraine.
In addition allows meeting with modern directions of development of medicine that is
instrumental in the in-plant training of medical workers.
Medical insurance is a form of social security in the sphere of health protection
which purpose for the population is to ensure receipt of payment on account of
accumulated funds and to raise finance for prophylaxis in case of insured accident.
Medical insurance is realized in two ways: mandatory and voluntary. Mandatory
47
insurance is a constituent part of state social insurance and it secures equal opportunities
for all citizens in medical aid which is given by means of mandatory medical assurance
funds.
Voluntary medical insurance is realized on the basis of correspondent state
programs and secures medical and some other services for the citizens. These services
are determined by programmes of mandatory medical insurance. Voluntary insurance
can be group and individual.
II. Study purposes: to master the methods of medical information retrieval,

using basic informative sources and resources.
To extend students’ knowledge in the most up-to-date approaches in organization
and first aid on the ground of insurance medicine; to learn basic insurance terms and
definitions, kinds of insurance.

- to interpret general description of directions of practical application of medical
informatics;
- to analyse information of the automated centre system health;
- to analyse information of telemetric supervision on the functional indexes of
patients at the cardiovascular diseases (violation of rhythm, ischemic heart trouble,
arterial hypertension and others like that);
- to ground the findings are the methods of screening (measuring of АP) with the
purpose of study of influencing of separate factors of risk on development and motion
of arterial hypertension;
- to link findings of telemetric supervision of the state of health of population
with the purpose of improvement of indexes of slings of activity of family doctor.
IV. A student must be able:

- to interpret the definition „medical insurance", „insurance medicine" – purposes and
goal;
- to define constituent parts of medical insurance and to know rights and duties of
insurance parties;
- to master family doctor activity in conditions of insurance medicine in Ukraine.
V. Aims of initial level

A student must be able to find necessary medical information in Internet-
resources, use basic informative sources and resources.
48
VI. Final objectives
Students must know general definitions and terms relevant to insurance, legal
base of medical insurance and know what voluntary medical insurance is provided, be
able to define insurance parties, know the content of the treaty and basic requirements
concerning medical aid in accordance with patient’s insurance policy.
VII. Task for initial independent training

1. What states can a process during implementation be in?
A. new, executable, ready, reading, completed;
B. new, executable, ready, expectations, completed;
C. new, loaded, ready, reading, completed;
D. new, executable, ready, installation / destroying, completed.
2. External factors can influence on the change of priority:,

A. importance of process;
B. amount of active files;
C. there is a necessity in allocation of memory;
D. time of implementation;
3. What sets priority of process?

A. by a number which marks importance of process;
B. by a number which marks common time of implementation of process;
C. by a number which marks the size of time slice for implementation of
process;
D. by a number which marks the amount of turns which a process can be in.
4. What operative storage fragmentation?

A. loss of part of memory of selected to the process, but not used by him;
B. division of address space on fragments;
C. impossibility of the use of part of memory at the use of algorithms of
division of memory with the fixed sections;
D. impossibility of the use of part of memory at the use of algorithms of
division of memory with variable sections.
5. How is the vehicle device which is imitated by programmatic facilities named?

A. virtual;
B. imaginary;
C. imitated;
D. fictitious.
49
6. How is intermediate data storage named in «rapid» memory for the repeated
working?
A. spooling;
B. paging;
C. swapping;
D. cashing.
7. How are algorithms and data structures named for providing of saving of information
in bulk storage?
A. hard disk;
B. file system;
C. virtual disk;
D. files and folders.
8. How is the logical integral data set which is kept in bulk storage named?
A. file;
B. document;
C. program;
D. cluster.
9. What does the hierarchical structure of saving of information foresee organization of

saving of files in?
A. sectors;
B. clusters;
C. catalogues;
D. to the file system.
10. In medicosocial researches at estimation of health levels are selected:

A. individual health;
B. group health;
C. regional health;
D. public health;
E. all of mentioned above
Answers:
1 2 3 4 5 6 7 8 9 10
B B A C A D B A C E
50
Insurance
1. Legal entity or individual that pays financial (insurance) subscription and legally
have a right to obtain sum of money in case of insured accident:
А. Insured
B. Insurer
C. Insured person
D. Insurance agent
E. Insurance broker
2. Organization (legal entity) that realizes insurance, assumes a liability to indemnify

and questions concearning creating and spending of insurance fund:
А. Insured
B. Insurer
C. Insured person
D. Insurance agent
E. Insurance broker
3. Individual whose life, health and efficiency is the object of insurance security:
А. Insured
B. Insurer
C. Insured person
D. Insurance agent
E. Insurance broker
4. Individual that makes an insurance treaty in the name of insurer for the commission
compensation and who is a part-time servant.
А. Insured
B. Insurer
C. Insured person
D. Insurance agent
E. Insurance broker
5. Insurer’s fee for the insurance contract:

А. Insurance premium
B. Sum insured (insurance money)
C. Underwriting rate
D. Deductible
E. All the above listed
Answers:
1 2 3 4 5
A B C D A
51
VIII. Basic questions after theme
Automated PMSH control systems.
Automated systems of the centre system and rehabilitation of patients health.
Automated systems of analysis of results of functional researches.
Introduction of TVmedical in practice of family doctor.
Expedience of introduction in practice of family medicine of scryning method.
Introduction of new technologies at the grant of medical services on bases of
evidential medicine.
Medical insurance procedure. Insurance policy structure.
Economic essence of insurance medicine. Sources of insurance medicine financing.
Patient rights concerning chose of a doctor in conditions of medical insurance.
Organization of doctor’s activity in sate and non-state health care institutions.
Problems of insurance medicine implementation in Ukraine.
Organization of quality control in different kinds of insurance.
IX. Practical skills: employment is conducted in family out-patient's clinic or

policlinic, students meet with the automated informative systems, teach to use them in
work of family doctor.
1. To put complete register of patients of the area.
2. Design a current card.
3. Find information about the methods of treatment of the set patient.
4. Make an electronic ambulatory card.
5. Design the statistical accounting in an electronic kind.
X. The plan and organizational structure of practical training

Educational materials
Hours, Place of realization
Stage Facilities of
min Equipment of studies
studies
level
Analysis of theme 90 min Oral test Classroom
Practical work 115 min Out-patients case Family out-patient's
record clinic
Current control of 15 min Situational tasks Classroom
knowledge
Summation of studies 5 min Classroom
preparation to
practical studies
52
XI. The logical structure of theme
COMPUTER NETWORKS
Local networks Global networks
Unirank
Server
Internet- resources
Access is to the information

E-mail resources
Gopher- system
Usenet- system
Telnet- system
FTP- system
WWW
Browser
Netscape Navigator MS Internet Explorer
53
Communications
Informatics
Medical
telematics
TVeducation
Medical
informatics
TVmedical
A subject is in the A telematics is in Medicine

management of medical science
health protection
Medical insurance parties
Insured are capable Insured person Insurers are Medical

individuals, is individual, for insurance institutions which
enterprises which benefit of which companies grant an aid
represent the contract of which have concerning medical
individuals’ interests insurance is licenses of insurance and also
and interests of made. realizing this have license of
charitable kind of treatment-and-
organizations and insurance. prophylactic work.
funds.
54
familiarize an insured with the insurance conditions
immediately take measures concerning preparation of all necessary

documents in order to pay insurance money timely in case of notification
about an insured accident
pay insurance money in a date which is specified in a contract in case of

an insured accident. Insurer incurs a liability for breakage in case of late
Insurer is obliged to
payment of insurance money and is obliged to pay forfeit, penalty interest

which sum is defined by insurance conditions or under the agreement by
the parties
pay the damages to the insured in case of insured accident as regards

prevention or decreasing the volume of damages if it is determined in the
contract
renew an insurance contract with the insured according to the application

of the insured in case of performing insurance measures which reduced
insurance risk or in case of property cost increase
keep information concerning the insured secret inspite the cases which are
specifed in Ukrainian legislation.
pay insurance payment promptly
give necessary information concerning all known circumstances to the insurer

while making a contract, which are significant for the evaluation of insurance
risk, and to inform the insurer concerning further changes of insurance risk
Insured is obliged to
inform the insurer about other acting insurance contracts concerning this object
of insurance
to assume the measures to avoid and reduce damages which arose as a result of
insurance accident
inform the insurer about the insurance accident in time determined by insurance
conditions. In case of death of the insured who made the contract of the
insurance property his rights and duties pass to the person who inherit this
property.
55
Social Commercial
Comparative features
insurance insurance
Legal base Mandatory Voluntary
Scope Mass Group with relatively narrow
coverage of population and
individual
Indemnification Secured mechanism and Various "suits" of
conditions unique set of social compensations and services
payments and benefits which forms at opinion of
each insurer
Status of administrator Public or quasipublic Private insurance companies
of insurance facilities organization
Principles of Current financing collective Accumulated finacing of
indemnification goods for others special benefits for the
organization insured performed by legal
entity or individual
Efficiency criteria Funds rearrangement has Rearrangement is limited by
characteristics of social group limits and is subjected
transfers, i.e. depend on goal to cost-based efficiency of
efficiency (including the insurer and insured.
generality of scope).
XII. The content of theme

Risk Factors for chronic bronchitis, emphysema, and airways obstruction
Smoking. Cigarette smoking is the most commonly identified correlate with both
chronic bronchitis during life and extent of emphysema at postmortem. Experimental
studies have shown that prolonged cigarette smoking impairs ciliary movement, inhibits
function of alveolar macrophages, and leads to hypertrophy and hyperplasia of mucus-
secreting glands; massive exposure in dogs can produce emphysematous changes. It is
probable that smoke also inhibits antiproteases and causes polymorphonuclear
leukocytes to release proteolytic enzymes acutely. Inhaled cigarette smoke can produce
an acute increase in airways resistance due to vagally mediated smooth-muscle
constriction, presumably by way of stimulating submucosal irritant receptors. Increased
airways responsiveness is associated with more rapid progression in patients with
chronic airways obstruction. Obstruction of small airways is the earliest demonstrable
mechanical defect in young cigarette smokers, and the obstruction may disappear
completely after cessation of smoking. Although smoking cessation does not result in
complete reversal of more pronounced obstruction, there is a significant slowing of the
decline in lung function in all smokers who give up cigarettes [8].
56
Passive exposure to tobacco smoke correlates with respiratory symptoms such as
cough, wheeze, and sputum production. Not only is cigarette smoking the most
common single factor leading to chronic airways obstruction, it also adds to the effects
of every other contributory factor to be discussed below.
Air pollution. The incidence and mortality rates of both chronic bronchitis and
emphysema may be higher in heavily industrialized urban areas. Exacerbations of
bronchitis are clearly related to periods of heavy pollution with sulfur dioxide (SO2) and
particulate matter. While nitrogen dioxide (NO2) can produce small-airways obstruction
(bronchiolitis) in experimental animals exposed to high concentrations, there are no
data convincingly implicating NO2, at even the highest pollutant levels, in the
pathogenesis or worsening of airways obstruction in humans [8].
Occupation. Chronic bronchitis is more prevalent in workers who engage in
occupations exposing them to either inorganic or organic dusts or to noxious gases.
Epidemiologic surveys have succeeded in demonstrating an accelerated decline in lung
function in many such workers - e.g., workers in plastics plants exposed to toluene
diisocyanate, and carding room workers in cotton mills - suggesting that their
occupational exposure contributes to their future disability.
Infection. Morbidity, mortality, and frequency of acute respiratory illnesses are
higher in patients with chronic bronchitis. Many attempts have been made to relate
these illnesses to infection with viruses, mycoplasmas, and bacteria. However, only the
rhinovirus is found more often during exacerbations; that is to say, pathogenic bacteria,
mycoplasmas, and viruses other than rhinovirus are found just as often between as
during exacerbations. Epidemiologic studies, however, implicate acute respiratory
illness as one of the major factors associated with the etiology as well as the
progression of chronic airways obstruction. Cigarette smokers may either transitorily
develop or worsen small-airways obstruction in association with even mild viral
respiratory infections. There is also some evidence that severe viral pneumonia early in
life may lead to chronic obstruction, predominantly in small airways [10].
Familial and genetic factors. Familial aggregation of chronic bronchitis has
been well demonstrated. Children of smoking parents may experience more frequent
and severe respiratory illnesses and have a higher prevalence of chronic respiratory
symptoms. In addition, nonsmokers who remain in the presence of cigarette smokers
(passive smokers) have increased blood levels of carbon monoxide, which indicate that
they are significantly exposed to smoke. Another well-documented form of indoor air
pollution relates to the use of natural gas for cooking. The role of such pollution,
however, remains controversial. Thus a part of the familial aggregation may be related
to home air pollution. However, some studies of monozygotic twins have suggested
some genetic predisposition to the development of chronic bronchitis independent of
personal or familial smoking habits and other indoor air pollution. The exact genetic
mode of transmission, if it exists at all, is uncertain [15].
57
Alpha1-Antitrypsin Deficiency. The protease inhibitor α1-antitrypsin (αlAT) is
an acute-phase reactant, and normally the serum levels rise in association with many
inflammatory reactions and with estrogen administration. Either deficient or absent
serum levels of αlAT are found in some patients with the early onset of emphysema. By
use of the techniques of acid starch gel and immunoelectrophoresis, genetic typing of
the protease inhibitor types has been possible. Most members of the normal population
have two M genes, designated as protease inhibitor type MM, and have serum αlAT
levels in excess of 2,5 g/L. Several genes are associated with alterations in levels of
serum alAT, but the most common ones associated with emphysema are the Z and S
genes. Individuals who are homozygous ZZ or SS have serum levels often near 0 but
always less than 0,5 g/L and develop severe panacinar emphysema in the third and
fourth decades of life. The panacinar process predominates at the lung bases.
Progressive dyspnea with minimal cough characterizes the clinical presentation,
although chronic bronchitis is prominent in smokers. Given that protease inhibitors can
be chemically synthesized or biologically produced in significant quantities and can be
shown with intravenous infusion to restore the protease-antiprotease balance in liquid
lavaged from the lungs of ZZ patients, it has been suggested that replacement therapy
with α1AT should be of value in preventing the development of emphysema in these
patients. Since replacement therapy was available before efficacy had been assessed, a
prospective, randomized trial has not been possible. Through a national registry, a
natural history study is underway from which it might be possible to evaluate the
effects of therapy if the treated and untreated groups turn out to be sufficiently
comparable at entry [9].
The MZ and MS heterozygotes have intermediate levels of serum αlAT (i.e.,
between 0.5 and 2.5 g/L); hence the genetic expression is that of an autosomal
codominant allele. It is a matter of some controversy whether the heterozygous state is
associated with lung function abnormalities. The matter is of some importance, since
the heterozygous state is common, with incidence estimates varying between 5 and 14
percent of the general population.
The precise way in which antitrypsin deficiency produces emphysema is unclear.
In addition to inhibition of trypsin, αlAT is an effective inhibitor of elastase and several
other proteolytic enzymes. There is experimental evidence that the structural integrity
of lung elastin depends on this antienzyme, which protects the lung from proteases
released from leukocytes. It is tempting to speculate that recurrent inflammatory
reactions related to infection and pollutants play some role in pathogenesis by calling
forth leukocytes whose released proteases are uninhibited and are free to cause the
damage [11].
The role of proteolytic enzymes in the induction of emphysema is not restricted
to patients with αlAT deficiency. Evidence is accumulating that proteolytic enzymes
derived from neutrophilic leukocytes and alveolar macrophages can produce
emphysema even in subjects with normal circulating levels of antiproteases. It is
58
possible that local concentrations of proteolytic enzymes may exceed the inhibitory
capacity of antiproteases, that some proteases present are not susceptible to the
available antiproteases, or that some of the proteolytic enzymes may be physically
inaccessible to the antiprotease activity. The ultimate clinical utility of exogenously
produced protease inhibitors currently under development will undoubtedly depend on
which of the protease-antiprotease interactions predominates in the producion of
emphysema. Reduction of endogenous elastase release from leukocytes in the lung has
been achieved by colchicine (0,6 mg/d orally) in ex-smokers with chronic airways
obstruction. Current smokers showed no such reductions. An assessment of the clinical
efficacy of this inexpensive and nontoxic form of therapy in ex-smokers must await a
large, prospective clinical trial [10].
New ACC/AHA/NHLBI Guidance on Lifestyle for CVD Prevention
(guidelines on cholesterol, blood pressure, and obesity management in adults).
Risk Factors for Atherosclerosis
Evidence for
Factor Modifiable Comment
Causality
Hypercholesterolemia Strong Yes Varies inversely with
Low HDL level Strong plasma triglyceride level
Hypertension Strong Yes
Male gender Strong No
Diabetes mellitus Strong Possibly Effectiveness of stringent
glycemic control uncertain
Family history of Strong No Premature onset before age
premature coronary artery 55 in first-degree relative
disease
High lipoprotein (a) level Strong Modestly Skewed distribution(see
text)
Cigarette smoking Good Yes
Post-menopausal state Good Possibly Estrogen replacement
therapy being evaluated
Hyperfibrinogenemia Good Possibly Fibric acid derivatives may
reduce
Hyperhomocysteinemia Good Yes Some patients respond to
folate supplementation
Physical inactivity Good Yes
Obesity Good Yes
Angiotensin converting Controversial No Homozygous deletion
enzyme polymorphism mutant associated with
myocardial infractions
59
The aim of the lifestyle guidelines was to "reevaluate and update the concept of a
healthy lifestyle," with the specific aim of preventing progression to cardiovascular
disease in at-risk patients.
The lifestyle guidelines were intended for use by primary-care doctors as well as
subspecialists. There are three major findings:
 Eat a dietary pattern that is rich in fruit, vegetables, whole grains, fish, low-fat
dairy, lean poultry, nuts, legumes, and non-tropical vegetable oils consistent with a
Mediterranean or DASH-type diet.
 Restrict consumption of saturated fats, trans-fats, sweets, sugar-sweetened
beverages, and sodium.
 Engage in aerobic physical activity of moderate to vigorous intensity lasting 40
minutes per session three to four times per week
"Did not have the time or resources" to investigate other aspects of lifestyle and
diet - namely calcium, magnesium, and alcohol intake; cardiorespiratory fitness; single
behavioral intervention or multicomponent lifestyle interventions; the addition of
lifestyle intervention to pharmacotherapy; and smoking. These may have "potential
benefits”.
The recommendations are broken out according to whether an adult in question
has higher-than-desirable lipid profiles or higher-than-desirable blood-pressure levels,
although the recommendations for both groups are very similar [13].
Low-Fat Diets Give Way to Mediterranean

The guidelines emphasize Mediterranean-style dietary patterns over a "low-fat
dietary pattern," which is scarcely mentioned in the document, although "low-fat dairy
products" are part of the dietary pattern advice. There are no specific recommendations
to reduce overall fat consumption, only to reduce the percent of calories consumed from
saturated and trans-fats.
Also notable are the recommendations on sodium. The general recommendation
to "reduce sodium intake" is given a level of evidence A (strong), in the NHLBI grading
system or a class IA by the ACC/AHA grading system. By contrast, advice to further
restrict sodium intake to 1500 mg/day as "desirable" is given level of evidence B
(moderate)/class IIa-b.
The mean daily sodium intake in the US is about 3.5 g. "We're all consuming too
much sodium and it's absolutely critical to reduce it." However, "accurately assessing
sodium intake is extremely difficult and probably clouds the whole issue, as does the
[use of a] specific target [Dr. Alice Lichtenstein, Tufts University, Boston, MA].
"What we really need to emphasize is that most of the sodium consumed is
consumed as processed foods, so just focusing on a salt shaker on the table is not going
to result in the reductions we want to see. Therefore, we really need a concerted effort
and a partnership with public-advocacy organizations like the ACC and [the AHA] and
the food industry to reduce sodium content in general across the board". "There is
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evidence that people who cut back a gram a day do have lower blood pressures"[Dr.
Alice Lichtenstein, Tufts University, Boston, MA].
These lifestyle recommendations are intended for people already identified as
having a problem, and in the case of sodium recommendations, that means people with
“prehypertension" or hypertension. "If the question is, does the [sodium intake] level
make a difference? Yes, absolutely. Sodium reduction is an important element of
successful blood-pressure lowering. What level should be achieved? I think as low as
possible is beneficial, but targeted levels are supported moderately by the evidence that
exists and should not be the initial message that we give to our patients at risk" [Dr.
Alice Lichtenstein, Tufts University, Boston, MA].
Risk Assessment and Primary Prevention

Risk Factors and Risk Scores. Primary prevention reduces MI and heart failure,
decreases the need for coronary revascularization procedures, and extends and
improves the quality of life. The American College of Cardiology
Foundation/American Heart Association (AHA) Task Force on Practice Guidelines, in
a 2010 report on cardiovascular risk assessment in asymptomatic adults, recommends
obtaining global risk scores (eg, Framingham Risk Score) and a family history of
cardiovascular disease for cardiovascular risk assessment [9].
The Framingham Heart Study first introduced the term risk factor into modern
medical literature; the term is generally applied to a parameter that is predictive of a
future cardiovascular event. Broadly, risk factors are arbitrarily divided into 3 major
categories:
Table 1
Basic Categories of Risk Factors for Future Cardiovascular Event
Category Risk Factors
Nonmodifiable risk factors Age, sex, family history, genetic
Modifiable risk factors Smoking, atherogenic diet, alcohol intake, physical
activity, dyslipidemias, hypertension, obesity, diabetes,
metabolic syndrome
Emerging risk factors C-reactive protein (CRP), fibrinogen, coronary artery
calcification (CAC), homocysteine, lipoprotein(a), and
small, dense LDL
Several risk scores have been developed to help predict an individual's risk of
future cardiovascular events. For example, the Framingham Heart Study developed a
coronary risk estimate using some of the following major traditional risk factors:
 Age
 Gender
 Family history of premature CHD (first-degree male relative < 55y, female
< 65y)
61
 Elevated total or LDL cholesterol level
 Reduced HDL cholesterol level
 Smoking
 Hypertension
 Diabetes mellitus
 Obesity
 Sedentary lifestyle
Using these risk factors, a Framingham score can be computed that helps assess
the 10-year risk of CHD for individuals with risk factors. The AHA suggests childhood
obesity is likely to lower the age of onset and increase the incidence of cardiovascular
disease worldwide.
The differences in risk-factor burden result in marked differences in the lifetime
risk for cardiovascular disease. They also conclude that these differences are
consistently noted across both race and birth cohorts [14].
In the following tables diabetes is excluded because it constitutes coronary artery

disease risk equivalent.
Table 2
Framingham Point Scores by Age Group in Men
Age Points
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13
62
Table 3
Framingham Point Scores by Age Group and Total Cholesterol in Men
Total Cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0
160-199 4 3 2 1 0
200-239 7 5 3 1 0
240-279 9 6 4 2 1
280+ 11 8 5 3 1
Table 4
Framingham Point Scores by Age and Smoking Status in Men
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1
Table 5
Framingham Point Scores by HDL level in Men
HDL Points
60+ -1
50-59 0
40-49 1
< 40 2
Table 6
Framingham Point Scores by
Systolic Blood Pressure and Treatment Status in Men
Systolic BP If Untreated If Treated
< 120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
160+ 2 3
63
Table 7
10-Year Risk by Total Framingham Point Scores in Men
Point Total 10-Year Risk
<0 < 1%
0 1%
1 1%
2 1%
3 1%
4 1%
5 2%
6 2%
7 3%
8 4%
9 5%
10 6%
11 8%
12 10%
13 12%
14 16%
15 20%
16 25%
17 or more ≥30%
Table 8
Framingham Point Scores by Age Group in Women
Age Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
64
Table 9
Framingham Point Scores by Age Group and Total Cholesterol in Women
Total Cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0
160-199 4 3 2 1 1
200-239 8 6 4 2 1
240-279 11 8 5 3 2
280+ 13 10 7 4 2
Table 10
Framingham Point Scores by Age and Smoking Status in Women
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1
Table 11
Framingham Point Scores by HDL level in Women
HDL Points
60+ -1
50-59 0
40-49 1
<40 2
Table 12
Framingham Point Scores by Systolic Blood Pressure and Treatment Status
in Women
Systolic BP If Untreated If Treated
<120 0 0
120-129 1 3
130-139 2 4
140-159 3 5
160+ 4 6
65
Table 13
10-Year Risk by Total Framingham Point Scores in Women
Point Total 10-Year Risk
<9 < 1%
9 1%
10 1%
11 1%
12 1%
13 2%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
20 11%
21 14%
22 17%
23 22%
24 27%
25 or more ≥30%
Prevalence of coronary risk factors in the U.S. are as follows:

 LDL cholesterol >130 mg/dL – 46%;
 HDL cholesterol 40 mg/dL – 26%;
 Prehypertension – 22%;
 Hypertension – 25%;
 Tobacco use – 25%;
 Diabetes mellitus – 8%;
 Overweight or obese – 65%;
 Physically inactive – 38%;
 Metabolic syndrome – 24%.
Considerable clinical benefit can be derived from the management of 3 major
modifiable coronary risk factors: hypercholesterolemia, hypertension, and cigarette
smoking.
66
The addition of CAC scanning to conventional risk factor modification has been
associated with superior coronary artery disease risk factor control without increasing
downstream medical testing.
Every 1 mmol/L (38,7 mg/dL) decline in LDL cholesterol results in a 21%
decrease in cardiovascular events. A decrease in systolic blood pressure by 10 mm Hg
can decrease cardiovascular mortality by 20-40%. Similarly, the risk of acute MI
increases by 5,6% for every additional cigarette smoked per day [16,17].
Screening guidelines
New guidelines from the American Heart Association/American College of
Cardiology (AHA/ACC) recommend use of a revised calculator for the risk of
developing a first atherosclerotic cardiovascular disease (ASCVD) event, which is
defined as one of the following, over a 10-year period, in a person who was initially free
from ASCVD:
 Nonfatal myocardial infarction;
 Death from coronary heart disease;
 Stroke (fatal or nonfatal).
For patients 20-79 years of age who do not have existing clinical ASCVD, the
guidelines recommend assessing clinical risk factors every 4-6 years. For patients with
low 10-year risk (< 7,5%), the guidelines recommend assessing 30-year or lifetime risk
in patients 20-59 years old.
Regardless of the patient’s age, clinicians should communicate risk data to the
patient and refer to the AHA/ACC lifestyle guidelines, which cover diet and physical
activity. For patients with elevated 10-year risk, clinicians should communicate risk
data and refer to the AHA/ACC guidelines on blood cholesterol and obesity [8].
Hypercholesterolemia/dyslipidemia
Screening should include a full fasting lipid profile including total cholesterol,
HDL, and triglycerides measurements. The ratio of total or LDL cholesterol to HDL
appears to be a powerful risk predictor. The guidelines include initiation of lifestyle and
drug management with the following goals.
A primary goal of reducing LDL cholesterol level is as follows:
 < 100 mg/dL in individuals with CHD, diabetes, or >20% 10-year Framingham
risk;
 < 130 mg/dL in individuals with 10-20% 10-year Framingham risk;
 < 160 mg/dL in individuals with < 10% 10-year Framingham risk.
Secondary goals are as follows:
67
 If LDL goals are achieved and triglyceride levels are >200 mg/dL, the goal for
non-HDL cholesterol level should be set at 30 mg/dL higher than the LDL cholesterol
level.
 There is recommended lowering of the LDL target goals to < 70 mg/dL with at
least 30-40% reduction for very high-risk individuals, such as those with ACS or
diabetes and to < 100 mg/dL for those at moderately high risk. The recent trials have
failed to demonstrate an LDL cholesterol level below which coronary risk does not
decrease.
 Measurement of HDL cholesterol should be used as part of the initial
cardiovascular risk assessment but should not be used as a predictive tool of residual
vascular risk in patients who are treated with potent high-dose statin therapy to lower
LDL cholesterol.
 Prolonged LDL-lowering statin treatment produces larger absolute reductions
in vascular events. The benefits of long-term continuation of statin treatment persisted
for at least 5 years without any evidence of developing risks.
 When LDL cholesterol levels do not require pharmacologic treatment, 20 mg
of rosuvastatin significantly reduces major cardiovascular events in primary prevention
patients with elevated high-sensitivity C-reactive protein who have high global
cardiovascular risk (10-year Framingham risk score >20%).
The 2013 AHA/ACC guidelines on the management of elevated blood cholesterol
no longer specify LDL- and non-HDL-cholesterol targets for the primary and secondary
prevention of atherosclerotic cardiovascular disease. The new guidelines identify four
groups of primary- and secondary-prevention patients in whom efforts should be
focused to reduce cardiovascular disease events and recommend appropriate levels of
statin therapy for these groups [10].
Treatment recommendations include the following:
 In patients with atherosclerotic cardiovascular disease, or those with LDL
cholesterol levels 190 mg/dL or higher (eg, due to familial hypercholesterolemia), and
no contraindications, high-intensity statin therapy should be prescribed to achieve at
least a 50% reduction in LDL cholesterol
 In patients aged 40 to 75 years of age with diabetes, a moderate-intensity statin
that lowers LDL cholesterol by 30% to 49% should be used; in those patients who also
have a 10-year risk of atherosclerotic cardiovascular disease exceeding 7.5%, a high-
intensity statin is a reasonable choice
 In individuals aged 40 to 75 years without cardiovascular disease or diabetes
but with a 10-year risk of clinical events >7.5% and an LDL-cholesterol level of 70-189
mg/dL, a moderate- or high-intensity statin should be used
Before therapy is initiated, the following potential secondary causes of
dyslipidemia should be considered based on the associated dyslipidemia:
68
 High LDL: Hypothyroidism, nephrotic syndrome, primary biliary cirrhosis,
and anorexia nervosa
 Hypertriglyceridemia: Diabetes mellitus, chronic kidney disease, alcoholism,
pregnancy, hypothyroidism
 Low HDL: Diabetes mellitus, cigarette smoking, obesity
Table 14
LDL-Cholesterol Goals and Cut Points for Therapeutic Lifestyle Changes and
Drug Therapy in Different Risk Categories
Risk Category LDL Goal LDL level at which to LDL level at
Initiate Therapeutic which to Consider
Lifestyle Changes Drug
Therapy
║
High risk - CHD or < 100 mg/dL; ≥100 mg/dL ≥100 mg/dL,¶ <
CHD risk equivalent optional goal < 70 100 mg/dL
*
(10-y risk >20%) mg/dL in very consider drug
**
high risk options
††
Moderate-high risk - < 130 mg/dL ≥130 mg/dL ≥130 mg/dL; 100-
2 or more risk factors 129mg/dL consider
†
(10-y risk 10-20%) drug options#
Moderate risk - 2 or < 130 mg/dL ≥130 mg/dL ≥160 mg/dL
more risk factors (10-
year risk < 10%)
Lower risk - 0-1 risk < 160 mg/dL ≥160 mg/dL ≥190 mg/dL; 160-
‡
factor 189 mg/dL
consider drug
options
*
Heart disease risk equivalents include noncoronary forms of atherosclerotic
disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery
disease) and diabetes. Ten-year risk defined by modified Framingham risk score.
†
Risk factors that modify LDL goals include cigarette smoking; hypertension (BP
≥140/90 mm Hg or on antihypertensive medications); low HDL cholesterol (< 40
mg/dL); family history of premature CHD (CHD in male first-degree relative < 55 y or
in female first-degree relative < 65 y); and age (men ≥45 y, women ≥55 y). HDL
cholesterol ≥60 mg/dL counts as a negative risk factor; its presence removes 1 risk
factor from the total count.
‡
Almost all people with 0-1 risk factor have a 10-year risk of less than 10%; thus,
10-year risk assessment in people with 0-1 risk factor is not necessary.
§
When LDL-lowering drug therapy is given, the intensity of therapy should be
sufficient to achieve at least a 30-40% reduction in LDL levels.
║
Any individual at high or moderately high risk who has lifestyle-related risk
factors (eg, obesity, physical inactivity, hypertriglyceridemia, low HDL cholesterol [<
40 mg/dL], or metabolic syndrome) is a candidate for therapeutic lifestyle changes to
69
modify these risk factors independent of LDL level.
¶
If baseline LDL is < 100 mg/dL, institution of an LDL-lowering drug is an
option. This can be combined with a fibrate or nicotinic acid if a high-risk person has a
hypertriglyceridemia or low HDL (< 40 mg/dL).
#
For moderately high-risk persons with LDL of 100-129 mg/dL at baseline or
after lifestyle changes, initiation of an LDL-lowering drug to achieve an LDL of less
than 100 mg/dL is an option.
**
Very high risk favors the optional LDL goal of < 70 mg/dL and, in patients
with high triglycerides, non-HDL cholesterol goal of < 100 mg/dL.
††
Optional LDL goal of < 100 mg/dL.
Triglycerides
Data on the impact of triglycerides on CHD events is not as clearly evident.
However, the elevated triglyceride levels are an independent risk factor for CHD, and
data on the benefits of reducing triglyceride levels were demonstrated by using the drug
gemfibrozil (fibric acid derivative) in a population with low HDL level (< 40 mg/dL).
Non-HDL cholesterol
In patients with mixed dyslipidemia (elevated LDL cholesterol and triglyceride
levels), non-HDL cholesterol is a useful measurement. Non-HDL cholesterol represents
very LDL cholesterol plus LDL cholesterol, both of which are apo-B-100-containing
atherogenic lipoprotein fractions. In hypertriglyceridemic individuals, non-HDL
cholesterol goals are 30 mg/dL higher than the corresponding LDL goals, representing
a triglyceride goal of 150 mg/dL. Non-HDL cholesterol can be measured in a
nonfasting state. Non-HDL cholesterol was found to be more predictive of future CV
events than LDL in several trials, probably because it measures both of the atherogenic
apo-B-containing fractions. LDL and total cholesterol/HDL cholesterol ratios are also
strongly predictive of CVD risk [12].
Secondary prevention
When drug therapy is indicated for reducing LDL cholesterol, statins are
generally initiated as first-line therapy. Exceptions include pregnancy, hepatic disease,
or history of myositis while on these agents. Resins, nicotinic acid, or ezetimibe can be
added if LDL cholesterol level is not reduced to goal. Pharmacologic therapy for
triglyceridemia includes fibrates, nicotinic acid, and omega-3 fatty acids. Fibrates and
nicotinic acid are also effective in raising low HDL, particularly when high triglycerides
are present.
In mixed dyslipidemias, a statin may be combined with nicotinic acid or a fibrate.
As described earlier, non-HDL cholesterol is a useful parameter to monitor therapy
results in mixed dyslipidemia. When using combined therapy, particularly statins plus
fibrates, the risk of myositis increases and, therefore, patients should be educated about
muscle symptoms. To minimize the risk of statin myopathy, the statin dose should be
70
kept as low as possible to achieve the LDL goal, and it may be helpful to separate the
dosing of statins and fibrates to evening and morning, respectively.
Varespladib methyl 500 mg once daily may be an effective antiatherosclerotic
agent.
Compared with placebo or statin monotherapy, evacetrapib as monotherapy or in
combination with statins increased HDL-C levels and decreased LDL-C levels.
However, further investigation is warranted [17].
Blood Pressure Control
Hypertension is a well-established risk factor for adverse cardiovascular
outcomes, including CHD. Systolic blood pressure is at least as powerful a coronary
risk factor as the diastolic blood pressure. Isolated systolic hypertension is now
established as a major hazard for CHD. Compelling data from meta-analyses indicate
that a reduction of diastolic blood pressure by 5-6 mm Hg results in a reduction of
stroke risk by 42% and CHD events by 15%.
The self-management of hypertension, which includes self-monitoring of blood
pressure and self-titration of antihypertensive drugs, along with telemonitoring of home
blood pressure measurements, is an important new addition to the control of
hypertension in primary care. Patients who self-manage hypertension have experienced
a decrease in systolic blood pressure compared to those who sought usual care. Wireless
remote monitoring with automatic clinician alerts significantly reduced the time to a
clinical decision in response to clinical events as well as reduced the length of hospital
stay.
In patients with mild hypertension (systolic 140-159 mm Hg or diastolic 90-99
mm Hg), the following is noted:
 Despite side effects and cost of antihypertensive medications, the beneficial
effects of treatment may outweigh the risks, even in low-risk patients.
 Treatment is initiated with a low-dose of a once-a-day antihypertensive drug in
an attempt to minimize future cardiovascular risk after a prolonged trial of
nonpharmacologic therapy.
 One such antihypertensive medication that is used worldwide is
hydrochlorothiazide (HCTZ). A daily dose of 12.5-25 mg was measured using
ambulatory blood pressure measurement and was shown to be consistently inferior to all
other drug classes. Because data is lacking for dosing, HCTZ is an inappropriate first-
line drug for the treatment of hypertension.
In individuals with high-normal blood pressure (systolic 130-139 mm Hg and/or
diastolic 85-89 mm Hg), the following is noted:
 These persons have an increased risk of cardiovascular events over time
compared with those who have optimal blood pressure.
71
 Antihypertensive drug therapy should be considered among such patients if
diabetes or end-organ damage is present.
 Treatment, particularly with an angiotensin-converting enzyme (ACE) inhibitor
or an angiotensin-II receptor blocker, is also warranted in patients with renal
insufficiency, diabetes mellitus, or heart failure to slow the progression of the
underlying disease [17].
Diet. Two types of dietary guidelines exist.
The first type recommends specific quantities of macronutrients, such as < 200
mg of cholesterol per day and < 7% of calories as saturated fat, as in the AHA Step 2
diet.
A second type recommends the consumption and exclusion of specific foods,
often in combination. An example is the recommendation to eat the following foods to
lower cholesterol: stanol/sterol ester margarines, soy products, soluble fiber, and
almonds or walnuts. This specific food portfolio recommendation has been found to
lower LDL cholesterol more than an AHA Step 2 approach (29% vs 8%, respectively).
The Third type includes a more intense and effective eating plan than previously
advocated. Specific recommendations are as follows: 1) Saturated fat, < 7% of total
calories, 2) polyunsaturated fat, about 10% of total calories, 3) monounsaturated fat,
about 20% of total calories, 4) total fat, about 25-35% of total calories, 5)
carbohydrates, about 50-60%, 6) fiber, about 20-30 g/d, 7) protein, about 15% of total
calories, and 8) cholesterol < 200 mg/d.
 In general, diets containing unsaturated fats, whole grains, fruits, vegetables,
fish, and moderate alcohol are optimal for preventing heart disease. The revised AHA
guidelines place emphasis on foods and an overall eating pattern, rather than on
percentages of food components such as fat [15].
The Mediterranean diet is characterized by high consumption of monounsaturated
fatty acids, primarily from olives and olive oil, and encourages daily consumption of
fruits, vegetables, whole grain cereals, and low-fat dairy products; weekly consumption
of fish, poultry, tree nuts, and legumes; a relatively low consumption of red meat,
approximately twice a month; as well as a moderate daily consumption of alcohol,
normally with meals. Adherence to the diet was associated with reduced risk of
metabolic syndrome and reduced HDL-cholesterol levels and triglycerides levels. The
results are of considerable public health importance because this dietary pattern can be
easily adopted by all population groups and various cultures and is cost-effective.
The Mediterranean diet had more favorable changes in weighted mean
differences of body weight, body mass index, systolic blood pressure, diastolic blood
pressure, fasting plasma glucose, total cholesterol, and high-sensitivity C-reactive
protein than low-fat diets [8].
72
Dietary supplementation with marine ω-3 fatty acids (eicosapentaenoic acid,
docosahexaenoic acid and the plant-derived alpha-linolenic acid) did not significantly
reduce the rate of cardiovascular events among patients with a prior myocardial
infarction.
Alcohol
Moderate alcohol consumption (1-2 drinks per day) is associated with a reduced
overall and CHD-related mortality compared with both abstinence and heavy drinking.
However, alcohol raises HDL (by stimulating the hepatic production of apo-A-I
and A-II), stimulates fibrinolysis, reduces fibrinogen levels, reduces inflammation, and
inhibits platelet activation. Moreover, the personal and social risks of alcohol intake (eg,
violence, trauma, car accidents, binge drinking) appear to be higher in younger
individuals.
In the U.S., additional antioxidant effects have been attributed to red wine, but the
consumption of other alcoholic beverages is associated with a somewhat lower or
similar reduction in CHD risk, and the pattern and amount of alcohol intake appears to
be more important than the type [11].
Antioxidants
In some trials found reduced CVD in those taking large amounts of antioxidant
vitamins, other found no benefit for 400 and 300 IU/d of vitamin E, respectively.
A current meta-analysis of available data suggests no benefit for antioxidant
vitamins.
Herbals
An estimated 40% of Americans use herbal remedies (alternative forms of health
care). Inquiry about the use of herbals is a component of good medical care, especially
in cardiovascular medicine [11].
Alternative medicine approaches to cholesterol lowering include garlic,
policosanol, gugulipid, and red rice yeast extracts, the latter of which contains HMG-
CoA reductase inhibitors. Garlic modestly lowers cholesterol (approximately 3%) and
may lower BP and inhibit platelet aggregation. Fermented red rice yeast extracts contain
statins and lower cholesterol 13-26%. Ephedra-containing herbals, often used as
anorexics, are associated with hypertension and stroke and have been banned in the U.S.
Summary of General Nutritional Recommendations
Achieve and maintain ideal body weight by limiting foods high in calories and
low in nutrition, including those high in sugar, such as soft drinks and candy.
Eat a variety of fruits; vegetables; legumes; nuts; soy products; low-fat dairy
products; and whole grain breads, cereals, and pastas.
Eat baked or broiled fish at least twice per week.
73
Choose oils and margarines low in saturated fat and high in omega-3 fat, such as
canola, soybean, walnut, and flaxseed oils, including those fortified with stanols and
sterols.
Avoid foods high in saturated and trans-fats, such as red meat, whole milk
products, and pastries.
Limit alcohol consumption to no more than 2 drinks per day for a man or 1 drink
per day for a woman.
Eat less than 6 g of salt or < 2400 mg/d of sodium [15].
Physical Activity
Reduced physical activity is a major risk factor for CVD. In elderly individuals,
the risk of MI is reduced by as much as 50% by walking 30 min daily. The vigorous-
and moderate-intensity activity among middle-aged men were associated with lower
risk of disease. On the other hand, low fitness in mid-life was associated with higher
lifetime risk for CVD death [9].
The following general principles need to be considered in recommending
increased physical activity:
 Increased physical activity begins with increasing lifestyle activities, such as
walking.
 A complete exercise program includes aerobic exercise, resistive training, and
stretching.
 More frequent exercise, optimally daily, provides more benefit.
 More strenuous exercise, such as jogging, provides more benefit. A good goal
is 75% of age-predicted maximal heart rate (220 - age of individual).
 Excellent benefit can be derived from 30 minutes of daily exercise.
 Even 15 minutes a day or 90 minutes a week of moderate-intensity exercise
may be beneficial.
 The most recent scientific statement from the AHA provides recommendations
on implementing the most efficacious and effective physical activity and dietary
strategies in adults.
Elevated waist circumference and physical inactivity are associated with an
increased risk of coronary heart disease [10].
Smoking
Of all the lifestyle modifications recommended to prevent CVD, smoking
cessation is the most cost-effective preventive measure, estimated at $220 per year of
life saved. Individuals aged 30 years gain 3-5 years of life by stopping smoking and the
mortality benefit was equally impressive in elderly populations. The most effective
smoking cessation programs involve programmatic and/or group support and the use of
nicotine substitutes and antidepressants, such as bupropion. Varenicline is a recent
74
addition to the armamentarium and has been found to be superior to bupropion in this
respect.
Smoking is a risk factor for CVD in women and men; however, a systemic review
and suggests that in some countries, smoking by women is on the rise; proper
counseling and nicotine addiction programs should focus on young women.
Smoking cessation counseling with supportive contact after a patient with acute
myocardial infarction is discharged is potentially cost-effective and may reduce the
incidence of smoking and further adverse health events [8].
Secondary prevention (after development of CHD)
The overall mortality risk of smokers who quit decreases by 50% in the first
couple of years and tends to approach that of nonsmokers in approximately 5-15 years
of cessation of smoking.
Primary prevention should start with lifestyle modification, including weight
management, diet, physical activity, and smoking cessation. Hormone therapy increases
cardiovascular events in postmenopausal women. Estrogen alone increases stroke, but it
does not alter CHD events.
Aspirin
Aspirin use (75-162 mg/d) decreases the occurrence of primary MI by 25-33%
and has also been shown to decrease death due to vascular causes; these benefits are not
gender specific. However, all benefits have to be balanced against the risk of GI
bleeding. Low-dose aspirin therapy (75 mg/d) is therefore recommended for primary
prevention in individuals with a 10-year Framingham coronary risk estimate greater
than 10%, outweighing risks of gastrointestinal hemorrhage and hemorrhagic stroke.
Aspirin has been shown to be similarly efficacious in secondary prevention of MI,
stroke, and death secondary to vascular causes. However, others suggest aspirin has
only modest benefit in patients without clinical cardiovascular disease and this benefit is
offset by its risk [16].
Classification of Recommendations
Recommendations made herein are based largely on major practice guidelines
from ACC/AHA. The information presented is adapted from recent statements by the
AHA/ACC, which involved the process of partial adaptation of other guideline
statements and reports and supplemental literature searches.
Classification of recommendations and level of evidence is as follows:
 Class I - Conditions for which there is evidence and/or general agreement that
a given procedure or treatment is beneficial, useful, and effective.
 Class II - Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment.
o Class IIa - Weight or evidence/opinion is in favor or usefulness/efficacy.
75
o Class IIb - Usefulness/efficacy is less well established by evidence/opinion.
 Class III - Conditions for which there is evidence and/or general agreement
that a procedure/treatment is not useful/effective and in some cases may be
harmful.
Level of evidence is as follows:
 Level of evidence A - Data derived from multiple randomized clinical trials or
meta-analyses.
 Level of evidence B - Data derived from single randomized trial or
nonrandomized studies.
 Level of evidence C - Only consensus opinion or experts, case studies, or
standard-of-care [12].
Secondary Prevention Goals and Management
Patients covered by these guidelines include those with established coronary and
other atherosclerotic vascular disease, including peripheral arterial disease,
atherosclerotic aortic disease, and carotid artery disease. Treatment for patients whose
only manifestation of cardiovascular risk is diabetes will be the topic of a separate AHA
scientific statement.
Smoking cessation. The goal is complete cessation and no exposure to
environmental tobacco smoke.
 Ask the patient about tobacco use status at every visit. I (B)
 Advise every patient who uses tobacco to quit. I (B)
 Assess the patient’s willingness to quit using tobacco. I (B)
 Assist the patient by counseling and developing a plan for quitting. I (B)
 Arrange follow-up, referral to special programs, or pharmacotherapy (including
nicotine replacement and bupropion). I (B)
 Urge the patient to avoid exposure to environmental tobacco smoke at work
and home. I (B)
Blood pressure control. The goal is BP < 140/90 mm Hg or < 130/80 mm Hg if
the patient has diabetes or chronic kidney disease [16].
For all patients, initiate or maintain lifestyle modification, weight control,
increased physical activity, alcohol moderation, sodium reduction, and increased
consumption of fresh fruits, vegetables, and low-fat dairy products. I (B)
For patients with BP ≥140/90 mm Hg (or 130/80 mm Hg for individuals with
chronic kidney disease or diabetes), as tolerated, add BP medication, treating initially
with beta-blockers and/or ACE inhibitors, with addition of other drugs, such as
thiazides, as needed to achieve goal blood pressure. I (A)
Diet that include nonhydrogenated unsaturated fats as the predominant form of
dietary fat, whole grains as the primary form of carbohydrate, fruits and vegetables,
76
omega-3 fatty acids (from fish, fish oil supplements, or plant sources) offer significant
protection against coronary heart disease.
Light-to-moderate alcohol consumption (5-25 g/d) has been significantly
associated with a lower incidence of cardiovascular and all-cause mortality in patients
with cardiovascular disease. A significant maximal protection against cardiovascular
mortality is consumption of approximately 26 g/d and maximal protection against
mortality from any cause in the range of 5-10 g/d [13].
Lipid management
The goal is LDL cholesterol < 100 mg/dL; if triglyceride levels are ≥200 mg/dL,
non-HDL cholesterol should be < 130 mg/dL. (Non-HDL cholesterol is total cholesterol
minus HDL cholesterol.). The following measures should be taken for all patients:
 Start dietary therapy. Reduce the intake of saturated fats (to < 7% of total
calories), trans-fatty acids, and cholesterol (to < 200 mg/d). I (B)
 Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further
lower LDL cholesterol level.
 Promote daily physical activity and weight management. I (B)
 Encourage increased consumption of omega-3 fatty acids in the form of fish or
in capsule form (1 g/d) for risk reduction. (Pregnant and lactating women should limit
their intake of fish to minimize exposure to methylmercury.)
 For treatment of elevated triglyceride levels, higher doses are usually necessary
for risk reduction. IIb (B)
In addition, to encourage treatment compliance, particularly with cardiovascular
medications in secondary prevention, physician should provide not only clear
discussions about the risk of disease recurrence and medication-specific information at
the start of pharmacotherapy, but they should ease the transition between primary and
secondary care [14].
Assess fasting lipid profile in all patients and within 24 hours of hospitalization
for those with an acute cardiovascular or coronary event. For hospitalized patients,
initiate lipid-lowering medication as recommended below before discharge according to
the following schedule:
 LDL cholesterol level should be < 100 mg/dL. I (A)
 Further reduction of LDL cholesterol level to < 70 mg/dL is reasonable. IIa
(A)
 If baseline LDL cholesterol level is 100 mg/dL, initiate LDL-lowering drug
therapy. I (A)
 If the patient is on treatment and LDL cholesterol is 100 mg/dL, intensify
LDL-lowering drug therapy (may require LDL-lowering drug combination [standard
dose of statin with ezetimibe, bile acid sequestrant, or niacin]). I (A)
77
 If baseline LDL cholesterol level is 70-100 mg/dL, treating to LDL cholesterol
level of < 70 mg/dL is reasonable. IIa (B)
 If triglyceride levels are 200-499 mg/dL, non-HDL cholesterol level should be
< 130 mg/dL. I (B)
 Further reduction of non-HDL cholesterol level to < 100 mg/dL is reasonable.
IIa (B)
Therapeutic options to reduce non-HDL cholesterol level are as follows:
 More intense LDL cholesterol-lowering therapy, I (B)
 Niacin (after LDL cholesterol–lowering therapy), IIa (B)
 Fibrate therapy (after LDL cholesterol–lowering therapy), IIa (B)
If triglyceride levels are 500 mg/dL, therapeutic options to prevent pancreatitis
are fibrate or niacin before LDL-lowering therapy, and treat LDL cholesterol level to
goal after triglyceride-lowering therapy. Achieve non-HDL cholesterol level
of < 130 mg/dL if possible. I (C) (Patients with very high triglycerides should not
consume alcohol. The use of bile acid sequestrant is relatively contraindicated when
triglycerides are >200 mg/dL.) (The combination of high-dose statin plus fibrate can
increase risk for severe myopathy. Statin doses should be kept relatively low with this
combination. Dietary supplement niacin must not be used as a substitute for prescription
niacin.) [11].
The intensive statin dosing reduces the risk of nonfatal events (coronary heart
disease and nonfatal myocardial infarction) and may have a role in reducing mortality.
However, the benefits of high-dose statins must be weighed against the risk of
myopathy, including rhabdomyolysis, at high doses.
When LDL-lowering medications are used, obtain at least a 30-40% reduction in
LDL cholesterol levels. If LDL cholesterol < 70 mg/dL is the chosen target, consider
drug titration to achieve this level to minimize side effects and cost. When LDL
cholesterol < 70 mg/dL is not achievable because of high baseline LDL cholesterol
levels, it generally is possible to achieve reductions of >50% in LDL cholesterol levels
by either satins or LDL cholesterol-lowering drug combinations.
Lowering LDL cholesterol with statin regimens may have an effect in people with
moderate-to-severe kidney disease. Simvastatin (20 mg) plus ezetimibe (10 mg) daily
safely reduces the incidence of major atherosclerotic events in a wide range of patients
with advanced chronic kidney disease.
Statin drugs reduced all-cause mortality, cardiovascular mortality, coronary
events, coronary revascularization, stroke, and intermittent claudication. Statin therapy
significantly decreases cardiovascular events and all-cause mortality in both women and
men [17].
Lipid-lowering therapy is associated with delayed cardiovascular events and
prolonged survival in patients with homozygous familial hypercholesterolemia.
78
Physical activity
The goal of low, moderate, and high physical activity is 30 minutes, 7 days per
week (minimum 5 d/w).
 For all patients, assess risk with a physical activity history and/or an exercise
test to guide prescription. I (B)
 For all patients, encourage 30-60 minutes of moderate-intensity aerobic activity
(eg, brisk walking) on most, preferably all, days of the week, supplemented by an
increase in daily lifestyle activities (eg, walking breaks at work, gardening, household
work). I (B)
 Encourage resistance training 2 days per week. IIb (C)
Advise medically supervised programs for high-risk patients (eg, recent acute
coronary syndrome or revascularization, heart failure). I (B) [17].
Weight management
The goal of weight management is body mass index of 18.5-24.9 kg/m2 and waist
circumference of < 40 inches in men and < 35 inches in women. The AHA released a
Scientific Statement regarding weight management strategies for busy ambulatory
surgery settings.
 Assess body mass index and/or waist circumference on each visit and
consistently encourage weight maintenance or reduction through an appropriate balance
of physical activity, caloric intake, and formal behavioral programs when indicated to
maintain or achieve a body mass index between 18.5 and 24.9 kg/m2. I (B)
 If waist circumference (measured horizontally at the iliac crest) is 35 inches in
women and 40 inches in men, initiate lifestyle changes and consider treatment strategies
for metabolic syndrome as indicated. I (B)
 The initial goal of weight loss therapy should be to reduce body weight by
approximately 10% from baseline. With success, further weight loss can be attempted if
indicated through further assessment. I (B)
Maintaining or improving fitness is associated with a lower risk of all-cause and
CVD mortality in men. Health care providers should encourage men to exercise
regularly, regardless of age, as it is important for longevity regardless of BMI change.
Diabetes management
The goal of diabetes management is to maintain glycosylated hemoglobin
(HbA1c) concentration of < 7%.
 Initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c level. I (B)
 Begin vigorous modification of other risk factors (eg, physical activity, weight
management, BP control, and cholesterol management) as recommended above. I (B)
 Coordinate diabetic care with the patient's primary care physician or
endocrinologist. I (C)
79
Antiplatelet agents and anticoagulants
 Start aspirin 75-162 mg/d, and continue indefinitely in all patients unless
contraindicated. I (A). For patients undergoing coronary artery bypass grafting, aspirin
should be started within 48 hours after surgery to reduce saphenous vein graft closure.
Dosing regimens ranging from 100-325 mg/d appear to be efficacious. Doses higher
than 162 mg/d can be continued for up to 1 year. I (B)
 Start and continue clopidogrel 75 mg/d in combination with aspirin for up to 12
months in patients after acute coronary syndrome or percutaneous coronary intervention
with stent placement (at least 1 month, but ideally 12 months, for bare metal stent; at
least 12 months for drug-eluting stents). I (B). Patients who have undergone
percutaneous coronary intervention with stent placement should initially receive higher-
dose aspirin at 162-325 mg/d for 1 month for bare metal stent, 3 months after sirolimus-
eluting stent, 6 months after paclitaxel-eluting stent, after which daily long-term aspirin
use should be continued indefinitely at a dose of 75-162 mg. I (B)
 Manage warfarin to international normalized ratio of 2.0-3.0 for paroxysmal or
chronic atrial fibrillation or flutter, and in post-MI patients when clinically indicated
(eg, atrial fibrillation, left ventricular thrombus). I (A)
 Use of warfarin in conjunction with aspirin and/or clopidogrel is associated
with increased risk of bleeding and should be monitored closely. I (B)
A nationwide cohort study suggests NSAID treatment duration in patients with
prior myocardial infarction, whether short term or long term, is associated with
increased risk of death and recurrent myocardial infarction in patients with prior
myocardial infarction and is not recommended for this population. NSAID use should
be limited from a cardiovascular safety point of view [14,15].
Renin, angiotensin, and aldosterone system blockers. Consider the following
with ACE inhibitors:
 Start and continue indefinitely in all patients with left ventricular ejection
fraction ≥40% and in those with hypertension, diabetes, or chronic kidney disease,
unless contraindicated. I (A)
 Consider for all other patients. I (B)
 Among lower-risk patients with normal left ventricular ejection fraction in
whom cardiovascular risk factors are well controlled and revascularization has been
performed, use of ACE inhibitors may be considered optional. IIa (B)
Consider the following with angiotensin receptor blockers:
 Use in patients who are intolerant of ACE inhibitors and have heart failure or
have had an MI with left ventricular ejection fraction ≤40%. I (A)
 Consider in other patients who are intolerant of ACE inhibitors. I (B)
 Consider use in combination with ACE inhibitors in systolic dysfunction heart
failure. IIb (B)
80
Aldosterone blockade are used in post-MI patients without significant renal
dysfunction (creatinine should be >2.5 mg/dL in men and > 2.0 mg/dL in women) or
hyperkalemia (potassium should be < 5 mEq/L), who are already receiving therapeutic
doses of an ACE inhibitor and beta-blocker, have left ventricular ejection fraction
≤40%, and have either diabetes or heart failure. One study suggests that higher dietary
potassium intake is associated with lower rates of stroke and may reduce the risk of
coronary heart disease. I (A)
Beta-blockers
 Start and continue indefinitely in all patients who have had MI, ACS, or LV
dysfunction with or without heart failure symptoms, unless contraindicated. l (A)
Consider chronic therapy for all other patients with coronary or other vascular
disease or diabetes, unless contraindicated. lla (C) [8,9].
Influenza vaccination.
Patients with cardiovascular disease should have an influenza vaccination. I (B)
Women and Coronary Artery Disease
Compared with men, LDL cholesterol is lower and HDL cholesterol is higher in
women before menopause. Although women have lower rates of hypertension and
cigarette smoking than men, rates for obesity and diabetes mellitus are higher. Diabetes
mellitus is a particularly serious risk factor in women, tripling the risk of cardiovascular
death and causing diabetic women to have the same frequency of CVD as diabetic men.
HDL cholesterol and triglyceride levels are more predictive of CVD in women than in
men. Women have been noted to have similar or slightly higher prevalence of stable
angina as compared to men.
It is now known that women tend to present more commonly with unstable
angina as compared to men, the reverse of which is true for MI. However, when women
do present with MI, they are more likely to have Q wave rather than non-Q wave.
Mortality rates of MI and CABG are about 50% higher in women, mostly related to
older age of onset. Lipid lowering has shown similar efficacy in women and men in the
angiographic progression and event trials. Cardioprotective agents, including aspirin,
beta-blockers, and ACE inhibitors, appear to have similar efficacy in men and women.
Hormone therapy is no longer recommended to prevent coronary events in
postmenopausal women with or without established CHD. Although hormone therapy
improves LDL and HDL cholesterol levels, it also increases coagulation and
inflammation (as measured by C-reactive protein) and decreases LDL particle size.
Treatment rates for risk factors in women tend to be even lower than in men, as are rates
for coronary angiography and coronary artery revascularization following presentation
with chest pain [15].
Women who may have had radiotherapy through the mid-1980s to treat breast
cancer are also at an increased risk of mortality from cardiovascular disease. The
81
concern is even greater if the woman was treated for a left-sided breast cancer with
contemporary tangential breast or chest wall radiotherapy.
XIII. Tasks for final control

1. What index authenticity of middle arithmetic is determined by:
A. fashions;
B. criterion of authenticity;
C. errors of representative;
D. standard deviation;
E. interval.
2. By what index it is possible to define a difference between two middle indexes:

A. fashions;
B. criterion of the Student authenticity;
C. errors of representative;
D. standard deviation;
E. interval.
3. Which degree of authenticity of middle index, if his oscillation is evened ±2m:

A. 10%;
B. 68%;
C. 95%;
D. 99%;
E. 100%.
4. That from transferred is not the element of variation row:

A. fashion;
B. median;
C. error of representative;
D. amplitude;
E. variant.
5. Which must be degree of authenticity of middle indexes at medical biological

researches:
A. 10%;
B. 68%;
C. 95%;
D. 99%;
E. 100%.
6. How graphicly to represent the dynamics of birth-rate for 5 years:

82
A. by a linear diagram;
B. by a radial diagram;
C. by cartogram;
D. by a sector diagram;
7. In which from the transferred cases the coefficient of correlation can be considered
reliable:
A. t=0.4;
B. t=1,8;
C. t=2,6;
D. t=3,7.
8. How to describe communication between the phenomena, if the coefficient of

correlation is evened –0,62:
A. communication reverse middle crowd conditions;
B. communication reverse weak;
C. communication reverse high;
D. communication direct of middle crowd conditions;
E. communication is direct weak.
9. What stage of statistical research registration and account of signs of the explored
phenomenon is carried out on:
A. on the first;
B. on the second;
C. on the third;
D. on fourth.
10. What characterizes a «group» statistical table:

A. it is characterized by a few interdependent signs;
B. it is characterized by one sign;
C. it is characterized by a few signs unconnected between itself.
Answers:
1 2 3 4 5 6 7 8 9 10
C B B C C A D A B C
83
TOPIC 4
The organization of out-of-hospital therapeutic help in case of the most wide-
spread diseases. The organization of the day hospital and home care. The basis of
expertise of disability.
I. Theme actuality. The reformation of primary medical help on principles of

family medicine allowed approaching a medical help to the rural population by opening
of out-patient's clinics, reducing of radius of service, increasing of doctor's visit number.
The increasing of patient’s number, the organization of day hospital and home care lead
to decreasing of admission to the hospitals. These measures have considerable
economic effect.
The input of model of family medicine in the system of medical service of
population in Ukraine allows changing interrelations between medical establishments.
The family out-patient's clinics are of primary importance in reducing patient’s visit
number and responsibility of physician for patient.
For therapeutic diseases the patient’s out-patient care allows to reduce the
duration of treatment, realize effective preventive and rehabilitation measures. And
reduction of temporary disability has economic efficiency.
II. Study purposes: to know the basic principles of organization of out-patient
care in the case of most widespread therapeutic diseases, the curing algorithms of out-
patient care, the expertise of disability.
III. Concrete purposes of the module: to draw the plan of ambulatory patient
examination and treatment in the case of cardiovascular, bronchopulmonary, gastro-
intestinal, urogenital, musculoskeletal system, and blood diseases, the principles of
expertise of disability.
IV. A student must be able to conduct the complains, medical history, life
history, objective examination of patient, determine risk factors of most widespread
diseases, distinguish symptoms and syndromes of diseases, to make differential
diagnosis, to prescribe treatment, to expertise disability.
1. A primary medical help provides for:
А. treatment in the specialized departments;
B. treatment of the most widespread diseases;
C. patient referral to treatment to specialized and high specialized medical
establishments;
D. making diagnosis, hygienic education of population;
E. consultation of general practitioner, making diagnosis, patient referral to
treatment to specialized and high specialized medical establishments.
84
2. The basic tasks of medical rehabilitation are:
А. help to choice the new profession;
B. acquirement to using a transport and auxiliary measures;
C. adaptation to the everyday life;
D. maximal renewal of capacity of man;
E. medical-labour expertise
3. What kind of morbidity is typical for group of high and long being ill:
А. general morbidity;
B. acute infectious diseases;
C. important non-epidemic morbidity;
D. morbidity with the temporary disability;
E. hospitalized morbidity.
4. The secondary medic is:

А. The appointment of patient for the specialized and high-specialized medical
establishments;
B. making simple diagnosis, hygienic education of population;
C. consultation of general practitioner, simple diagnosis, appointment of patient
for the specialized and high-specialized medical establishments;
D. subspecialty consultation, diagnosis and treatment by specialists;
E. treatment of most widespread diseases.
5. Which indexes characterize morbidity with the temporary disability?

А. absolute number of cases of temporary disability;
B. absolute number of days of temporary disability;
C. average duration of one case of temporary disability;
D. primary morbidity;
E. prevalence of diseases.
6. The tasks of tertiary medical help are:

А. Making difficult diagnosis and treatment of rare diseases;
B. realization of preventive measures;
C. realization of the health centre system;
D. making simple diagnosis, hygienic education of population;
E. treatment of most widespread diseases.
7. The patient is prepared to the discharge from the hospital. She received treatment for
hypertensic crisis. The patient works as weaver of weaving factory. How you’ll expert
her disability?
85
А. after out-patient treatment you’ll recommend the change of job;
B. you’ll close the medical certificate and send her to work;
C. you’ll close the medical certificate and recommend the change of work;
D. you’ll continue the medical certificate for one month;
E. after out-patient treatment you’ll recommend to re-start work.
8. The patient with disability was under long-term follow-up by family doctor. Who will
appoint patient to medico-social commission of expert?
А. head of out-patient department;
B. the medical advisory commission;
C. doctor specialist;
D. family doctor;
E. head of hospital department.
9. In rural out-patient's clinic works only one doctor. The mechanization expert was
treated in this out-patient's clinic. For what period the doctor can give out the medical
certificate?
А. Maximum for 30 days with following appointment to medical advisory
commission;
B. for all period of temporary disability;
C. Maximum for 6 days with following appointment to medical advisory
commission;
D. Maximum for 10 days with following appointment to medical advisory
commission;
E. Maximum for 14 days with following appointment to medical advisory
commission.
10. The worker of private firm had acute respiratory viral infection. He saw a family
doctor, which was established the fact of temporary disability. However, the FD refused
to give out the medical certificate, because a patient worked in private firm. If doctor
had to give out medical certificate to the workers?
А. yes, to give out regardless of ownership;
B. no, to give out only to the workers of public institutions;
C. no, to give out only in the case of temporary disability;
D. yes, to give out if there are guarantee for payment of firm owner;
E. any document was given out.
Answers:
1 2 3 4 5 6 7 8 9 10
E D D D C A A B D A
86
VI. Basic questions after a theme:
Co-operation of family doctor with the secondary and tertiary levels of medical
care.
The indication and contraindication for out-patient treatment at primary level, day
hospital and at home care.
Influence of family on the recovery and reduction of risk of development of
pathologic condition.
Realization of after-hospital care and rehabilitation in the outpatient setting.
Realization of medico-social expertise of disability in the outpatient setting.
Design the patient’s management program, taking into account risk factors,
psychological state and family influence, realize a preventive work, early diagnosis,
treatment and rehabilitation of medical patients.
VII. Practical skills: employment is conducted in a family out-patient's clinic,

students together with family doctors conduct the primary inspection of patients,
compose the individual examination plans and management program, the principles of
after-hospital care and rehabilitation in the outpatient setting, medico-social expertise of
disability.
1. To appoint the patient with arteriosclerosis obliterans of lower limbs to
consultation of angiosurgeon.
2. To fill a medical certificate in different situation.
3. To prepare document for sanatorium-resort treatment of patient.
4. To fill appointment card for hospitalization in the case of out-of-hospital
pneumonia.
5. To make the program of out-patient treatment for 45-years-old man with
arterial hypertension, ІІ stage, 2 degrees, moderate risk.
6. To make the program of out-patient treatment for 65-years-old women with
ischemic heart disease, postinfarction cardiosclerosis, permanent atrial fibrillation, heart
failure I stage, ІІ functional class.
7. To make the program of out-patient treatment for 55-years-old man with a
diabetes mellitus, 2 type, moderately severe, subcompensation stage.
chronic superficial gastritis associated from H. рylori.
chronic obstructive pulmonary disease, ІІ stage.
10. To make the program of out-patient treatment for 25-years-old women with a
chronic secondary pyelonephritis, latent clinical course, pre-hypertension stage.
87
VIII. The plan and organizational structure of practical training
Educational materials Place of
Hours,
№ Stage Facilities of realization of
min Equipment
studies studies
1
level
2 Analysis of theme 90 min Oral test Classroom
Practical work 115 min Out-patients Family out-patient's
3
case record clinic
Current control of 15 min Situational Classroom
4
knowledge tasks
Summation of 5 min Classroom
5
studies
preparation to
6
practical
studies
IX. The content of theme

Approach to the patient with heart disease
The symptoms caused by heart disease result most commonly from myocardial
ischemia, from disturbance of the contraction and/or relaxation of the myocardium,
from obstruction to blood flow, or from an abnormal cardiac rhythm or rate. Ischemia is
manifest most frequently as chest discomfort, while reduction of the pumping ability of
the heart commonly leads to weakness and fatigability or, when severe, produces
cyanosis, hypotension, syncope, and elevated intravascular pressure behind a failing
ventricle; the latter results in abnormal fluid accumulation, which in turn leads to
dyspnea, orthopnea, and systemic or pulmonary edema. Obstruction to blood flow, as in
valvular stenosis, can cause symptoms resembling those resulting from congestive heart
failure. Cardiac arrhythmias often develop suddenly, and the resulting signs and
symptoms - palpitation, dyspnea, angina, hypotension, and syncope - generally occur
abruptly and may disappear as rapidly as they develop [7].
A cardinal principle useful in the evaluation of the patient with suspected heart
disease is that myocardial or coronary function that may be adequate at rest may be
inadequate during exertion. Thus a history of chest discomfort and/or dyspnea that
appears only during activity is characteristic of heart disease, while the opposite pattern,
i.e., the appearance of these symptoms at rest and their remission during exertion, is
rarely observed in patients with organic heart disease.
Patients with cardiocirculatory disease also may be asymptomatic, both at rest
and during exertion, but may present an abnormal physical finding, such as a heart
88
murmur, elevated arterial pressure, or an abnormality of the ECG or of the cardiac
silhouette on the chest roentgenogram. Patients may exhibit asymptomatic ischemia on
an exercise stress test or an ambulatory ECG [1].
Diseases of the heart and circulation are so common and the laity is so well
acquainted with the major symptoms resulting from disorders those patients, and
occasionally physicians, erroneously attribute many noncardiac complaints to
cardiovascular disease.
Dyspnea, one of the cardinal manifestations of diminished cardiac reserve, is not
limited to heart disease but is also characteristic of conditions as diverse as pulmonary
disease, marked obesity, and anxiety. Сhest discomfort may result from causes other
than myocardial ischemia. Whether heart disease is responsible for these symptoms can
frequently be determined by carrying out a careful clinical examination. Noninvasive
testing using ECG at rest and during exercise, echocardiography, roentgenography, and
myocardial imaging usually provides important additional information to permit the
correct interpretation of symptoms; more specialized invasive examinations
(catheterization and angiography) are occasionally necessary.
Diagnosis. The elements of a complete cardiac diagnosis include consideration
of:
1. The underlying etiology: congenital, infectious, hypertensive, or ischemic in
origin disease.
2. The anatomic abnormalities. Which chambers are involved? Which valves are
affected? Is there pericardial involvement? Has there been a myocardial infarction?
3. The physiologic disturbances. Is an arrhythmia present? Is there evidence of
congestive heart failure or of myocardial ischemia?
4. The extent of functional disability. How strenuous is the physical activity
required to elicit symptoms? The latter should be evaluated in the light of the intensity
of therapy.
The identification of myocardial ischemia as the etiology of a patient's exertional
chest discomfort is of great clinical importance. The recognition of ischemia is
insufficient to formulate a therapeutic strategy or prognosis until the underlying
anatomic abnormalities responsible for the myocardial ischemia (coronary
atherosclerosis or aortic stenosis) are identified and a judgment made as to whether
other physiologic disturbances that cause an imbalance between myocardial oxygen
supply and demand, such as severe anemia, thyrotoxicosis, or supraventricular
tachycardia, play a contributory role. The extent of functional disability is a determinant
of whether medical or interventional therapy is utilized [1,6].
The establishment of a correct and complete cardiac diagnosis often requires the
use of six different methods of examination: 1) history, 2) physical examination, 3)
ECG, 4) chest roentgenogram, 5) noninvasive graphic examinations (echocardiogram,
89
radionuclide and other noninvasive imaging techniques), and occasionally 6)
specialized invasive examinations, i.e., cardiac catheterization, angiocardiography, and
coronary arteriography.
Family History. Familial clustering is common in many forms of heart disease.
Genetic transmission may occur, as in hypertrophic cardiomyopathy, the Marfan
syndrome, and sudden death associated with a prolonged QT syndrome. In patients with
essential hypertension or coronary atherosclerosis, the genetic component may be less
obvious but is also of considerable importance. Familial clustering of cardiovascular
diseases may occur not only on a genetic basis but also may be related to familial
dietary or behavior patterns, such as excessive ingestion of salt or calories or cigarette
smoking [4].
Assessment of Functional Impairment. When an attempt is made to determine
the severity of functional impairment in a patient with heart disease, it is helpful to
ascertain with as much precision as possible the level of activity. Thus breathlessness
that occurs after running up two long flights of stairs denotes far less functional
impairment than similar symptoms occurring after taking a few steps on the level. Also,
the degree of customary physical activity at work and during recreation should be
considered. The development of two-flight dyspnea in a marathon runner may be far
more significant than the development of one-flight dyspnea in a previously sedentary
person. Similarly, the history must include a detailed consideration of the patient's
therapeutic regimen. For example, the persistence or development of edema,
breathlessness, and other manifestations of heart failure in a patient whose diet is rigidly
restricted in sodium content and who is receiving optimal doses of diuretics is far more
grave than the development of similar manifestations of heart failure in the absence of
these measures
Electrocardiogram. Although the ECG is an invaluable aspect of every
cardiovascular examination, with the exception of the identification of arrhythmias and
of many instances of acute myocardial infarction, it rarely permits establishment of a
specific diagnosis. In the absence of other abnormal findings, electrocardiographic
changes must not be over-interpreted. The range of normal ECG findings is wide, and
the tracing can be affected significantly by many noncardiac factors, such as age, body
habits, and serum electrolyte concentrations [4].
Natural History. Cardiovascular disorders often present acutely, as in a
previously asymptomatic patient with extensive coronary atherosclerosis that develops
an acute myocardial infarction or the previously asymptomatic patient with
hypertrophic cardiomyopathy whose first clinical manifestation is syncope or even
sudden death. In both instances, the alert physician may recognize the patient at risk of
these complications long before they occur and can often take measures to prevent their
occurrence. For example, the patient with acute myocardial infarction may well have
90
had risk factors for atherosclerosis for many years. Their elimination or reduction might
have delayed or even prevented the infarction. Similarly, the patient with hypertrophic
cardiomyopathy may have had the familial form of this disorder, and a careful family
history might have led to an echocardiography examination and the recognition of the
condition long before the acute manifestations [6].
Pitfalls in cardiovascular medicine
1. Failure by the non-cardiologist to recognize cardiac manifestations of systemic
illnesses. Examples of the latter are:
a) the Down syndrome (associated with endocardial cushion defect);
b) bony abnormalities of the upper extremities (associated with atrial septal detect
in the Holt-Oram syndrome);
c) muscular dystrophies (associated with cardiomyopathy);
d) hemochromatosis and glycogen storage disease (associated with myocardial
infiltration and restrictive cardiomyopathy);
e) congenital deafness (associated with prolonged QT interval and serious cardiac
arrhythmias);
f) Raynaud's disease (associated with primary pulmonary hypertension and
coronary vasospasm);
g) connective tissue disorders i.e., the Marfan syndrome, Ehlers-Danlos and
Hurler syndrome and related disorders of mucopolysaccharide metabolism (aortic
dilatation, prolapsed mitral valve, a variety of arterial abnormalities);
h) acromegaly (hypertension, accelerated coronary atherosclerosis, conduction
defects, cardiomyopathy); hyperthyroidism (heart failure, atrial fibrillation);
j) hypothyroidism (pericardial effusion, coronary artery disease);
k) rheumatoid arthritis (pericarditis, aortic valve disease);
i) scleroderma (cor pulmonale, myocardial fibrosis, pericarditis);
m) systemic lupus erythematosus (valvulitis, myocarditis, pericarditis);
n) sarcoidosis (arrhythmias, cardiomyopathy);
o) exfoliative dermatitis (high-output heart failure).
In patients with systemic disorders a detailed clinical and noninvasive
examination of the cardiovascular system should be carried out to identify
cardiovascular involvement [5].
2. Failure by the cardiologist to recognize an underlying systemic illness among
patients with a cardiac disorder. Patients known or suspected of having heart disease
require a detailed general assessment and a search for the frequent non-cardiac
manifestations of systemic disorders with cardiovascular manifestations. For example,
infective endocarditis should be considered in patients with known congenital or
valvular heart disease with fever, anemia, or albuminuria. A cardiovascular abnormality
may provide the clue critical to the recognition of some systemic disorders. For
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instance, in an elderly person, unexplained atrial fibrillation may provide the first clue
to the diagnosis of thyrotoxicosis.
3. Overreliance and overutilization of laboratory tests, particularly invasive
techniques for the examination of the cardiovascular system. Catheterization of the right
and left sides of the heart, selective angiography, and coronary arteriography provide
precise diagnostic information under many circumstances. For example, they aid in
establishing a specific anatomic diagnosis and in determining the physiologic
consequences of the abnormalities in patients with chest pain of uncertain cause in
whom ischemic heart disease is suspected, and in determining the functional
significance of valvular abnormalities in patients with rheumatic heart disease being
considered for surgical treatment. Although a great deal of attention has been lavished
on these specialized examinations, it should be recognized that they serve to
supplement, not supplant, a careful examination carried out by clinical and noninvasive
techniques. Sometimes coronary arteriography is carried out in patients with chest pain
suspected of having ischemic heart disease instead of taking a careful history; although
coronary arteriography may establish whether the coronary arteries are obstructed, the
results often do not provide a definite answer to the question of whether a patient's
complaint of chest pain is clearly attributable to coronary arteriosclerosis.
Catheterization of the left side of the heart is all too frequently employed to determine
whether operative treatment of valvular disease is indicated, even before the patient has
had a trial of medical therapy.
These invasive tests should be carried out only if, after detailed clinical
examination and assessment by noninvasive tests, the results of the invasive
examination can be expected to modify or aid in the patient's management [6].
Treatment
1. In the absence of evidence of heart disease, a clear, definitive statement to that
effect should be made and the patient should not be asked to return at intervals for
repeated examinations.
2. If there is no evidence for disease, such continued attention may lead to the
patient developing inappropriate anxiety and fixation on the heart.
If there is no evidence of cardiovascular disease but the patient has one or more
risk factors for the development of ischemic heart disease, a plan for their reduction
should be developed and the patient should be retested at intervals to assess that he or
she is complying and that these risk factors are in fact being reduced.
3. Asymptomatic or mildly symptomatic patients with valvular heart disease that
is anatomically severe should be evaluated periodically, every 6 to 12 months, by
clinical and noninvasive examinations. Early signs of deterioration of ventricular
function can be detected in this manner and in appropriate patients may signify the need
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for cardiac catheterization and surgical treatment before the development of disabling
symptoms, irreversible myocardial damage, and an excessive risk of surgical treatment.
4. It is critical to establish clear criteria for deciding on the form of treatment
(medical, angioplasty, or surgical revascularization) in patients with ischemic heart
disease. Mechanical revascularization represents a major therapeutic advance in the
treatment of this most common form of heart disease, but operation has probably been
employed too widely in the U.S.; the mere presence of angina pectoris and/or the
demonstration of critical coronary arterial narrowing at angiography should not reflexly
evoke a decision to treat the patient surgically or by angioplasty [1,2].
Physical examination of the cardiovascular system is a low-cost method for
assessing the cardiovascular system. First, the FD appearance should be evaluated. The
patient may appear tired because of a chronic low cardiac output; the respiratory rate
may be rapid in cases of pulmonary venous congestion. Central cyanosis, often
associated with clubbing of the fingers and toes, indicates right-to-left cardiac or
extracardiac shunting or inadequate oxygenation of blood by the lungs. Cyanosis in the
distal extremities, cool skin, and creased sweating result from vasoconstriction in
patients with severe heart failure. Noncardiovascular details can be equally important
(the diagnosis of infective endocarditis is highly likely in patients with petechiae,
Osier's nodes).
The blood pressure should be taken in both arms and with the patient supine and
upright; the heart rate should be timed for 30 s. Orthostatic hypotension and tachycardia
may indicate a reduced blood volume, while resting tachycardia may be due to heart
failure.
Examination of the optic fundi is essential: the retinal vessels may show evidence
of systemic hypertension, arteriosclerosis, or embolism. The latter may result from
atherosclerosis in larger arteries (e.g., the carotid) or may represent a complication of
valvular heart disease (e.g., endocarditis).
Palpation of the peripheral arterial pulses in the upper and lower extremities is
necessary to define the adequacy of systemic blood flow and to detect the presence of
occlusive arterial lesions. It is also important to examine both legs for evidence of
edema, varicose veins, or thrombophlebitis. The cardiovascular examination includes
careful evaluation of both the carotid arterial and the jugular venous pulses, as well as
deliberate precordial palpation and attentive cardiac auscultation [7].
Approach to the patient with disease of the respiratory system
Patients with disease of the respiratory system generally present because of
symptoms, an abnormality on a chest radiograph, or both. A set of diagnostic
possibilities often is suggested by the initial problems at presentation, including the
particular symptoms and the appearance of any radiographic abnormalities. The
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differential diagnosis is then refined on the basis of additional information gleaned from
physical examination, pulmonary function testing, additional imaging studies, and
bronchoscopic examination [7].
Clinical presentation
History. Dyspnea (shortness of breath) and cough are the primary presenting
symptoms for patients with respiratory system disease. Less common symptoms include
hemoptysis (the coughing up of blood) and chest pain, often with a pleuritic quality.
Dyspnea. When evaluating a patient with shortness of breath, one should first
determine the time course over which the symptom has become manifest. Patients who
were well previously and developed acute shortness of breath (over a period of hours to
days) can have acute disease affecting the airways (an acute attack of asthma), the
pulmonary parenchyma (acute pulmonary edema or an acute infectious process such as
a bacterial pneumonia), the pleural space (a pneumothorax), or the pulmonary
vasculature (a pulmonary embolus).
A subacute presentation (over days to weeks) can suggest an exacerbation of
preexisting airways disease (asthma or chronic bronchitis), a parenchymal infection or a
noninfectious inflammatory process that proceeds at a relatively slow pace
(Pneumocystis carinii pneumonia in a patient with AIDS, mycobacterial or fungal
pneumonia, Wegener's granulomatosis, eosinophilic pneumonia, bronchiolitis obliterans
with organizing pneumonia, and many others), neuromuscular disease (Guillain-Barre
syndrome, myasthenia gravis), pleural disease (pleural effusion from a variety of
possible causes), or chronic cardiac disease (congestive heart failure).
A chronic presentation (over months to years) often indicates chronic obstructive
lung disease, chronic interstitial lung disease, or chronic cardiac disease. Chronic
diseases of airways (not only chronic obstructive lung disease but also asthma) are
characterized by exacerbations and remissions. Patients often have periods when they
are severely limited by shortness of breath, but these may be interspersed with periods
in which symptoms are minimal or absent. In contrast, many of the diseases of
pulmonary parenchyma are characterized by a slow but inexorable progression.
Other Respiratory Symptoms Cough indicates the presence of lung disease, but
cough per se is not useful for the differential diagnosis. The presence of sputum
accompanying the cough often suggests airway disease and may be seen in asthma,
chronic bronchitis, or bronchiectasis [1,4].
Hemoptysis can originate from disease of the airways, the pulmonary
parenchyma, or the vasculature. Diseases of the airways can be inflammatory (acute or
chronic bronchitis, bronchiectasis, or cystic fibrosis) or neoplastic (bronchogenic
carcinoma or bronchial carcinoid tumors). Parenchymal diseases causing hemoptysis
may be either localized (pneumonia, lung abscess, tuberculosis, or infection with
Aspergillus) or diffuse (Goodpasture's syndrome, idiopathic pulmonary hemosiderosis).
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Vascular diseases potentially associated with hemoptysis include pulmonary
thromboembolic disease and pulmonary arteriovenous malformations.
Chest pain caused by diseases of the respiratory system usually originates from
involvement of the parietal pleura. As a result, the pain is accentuated by respiratory
motion and is often referred to as pleuritic. Common examples include primary pleural
disorders, such as neoplasm or inflammatory disorders involving the pleura, or
pulmonary parenchymal disorders that extend to the pleural surface, such as pneumonia
or pulmonary infarction [6].
Additional Historical Information about risk factors for lung disease should be
explicitly explored to assure a complete basis of historical data. A history of current and
past smoking, especially of cigarettes, should be sought from all patients. The smoking
history should include the number of years of smoking, the intensity (i.e., number of
packs per day), and, if the patient no longer smokes, the interval since smoking
cessation. The risk of lung cancer falls progressively with the interval following
discontinuation of smoking, and loss of lung function above the expected age-related
decline ceases with the discontinuation of smoking. Even though chronic obstructive
lung disease and neoplasm are the two most important respiratory complications of
smoking, other respiratory disorders (e.g., spontaneous pneumothorax, eosinophilic
granuloma of the lung, and pulmonary hemorrhage with Goodpasture's syndrome) are
also associated with smoking. A history of significant secondhand (passive) exposure to
smoke, whether in the home or at the workplace, should also be sought as it may be a
risk factor for neoplasm or an exacerbating factor for airways disease.
The patient may have been exposed to other inhaled agents associated with lung
disease, which act either via direct toxicity or through immune mechanisms. Such
exposures can be either occupational or vocational, indicating the importance of detailed
occupational and personal histories, the latter stressing exposures related to hobbies or
the home environment. Important agents include the inorganic dusts associated with
pneumoconiosis (especially asbestos and silica dusts) and organic antigens associated
with hypersensitivity pneumonitis (especially antigens from molds and animal proteins).
Asthma often is exacerbated by exposure to environmental allergens (dust mites, pet
dander, or cockroach allergens in the home or allergens in the outdoor environment
such as pollen and ragweed) or may be caused by occupational exposures
(diisocyanates). Exposure to particular infectious agents can be suggested by contacts
with individuals with known respiratory infections (especially tuberculosis) or by
residence in an area with endemic pathogens (histoplasmosis, coccidioidomycosis,
blastomycosis) [6,7].
A history of coexisting non-respiratory disease or of risk factors for or previous
treatment of such diseases should be sought, as they may predispose a patient to both
infectious and noninfectious respiratory system complications. Common examples
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include systemic rheumatic diseases that are associated with pleural or parenchymal
lung disease, metastatic neoplastic disease in the lung, or impaired host defense
mechanisms and secondary infection, which occurs in the case of hematologic and
lymph node malignancies. Risk factors for AIDS should be sought, as the lungs not only
are the most common site of AIDS-defining infection but also can be involved by non-
infectious complications of AIDS. Treatment of non-respiratory disease can be
associated with respiratory complications, either because of effects on host defense
mechanisms (immunosuppressive agents, cancer chemotherapy) with resulting
infection, or because of direct effects on the pulmonary parenchyma (cancer
chemotherapy, radiation therapy, or treatment with other agents, such as amiodarone,
that cause interstitial lung disease), or on the airways (beta-blocking agents causing
airflow obstruction, angiotensin converting enzyme inhibitors causing cough) [4].
Family history is important for evaluating diseases that have a genetic
component. These include disorders such as cystic fibrosis, a-antitrypsin deficiency,
and asthma.
Physical examination should be directed not only toward ascertaining
abnormalities of the lungs and thorax, but also toward recognizing other findings that
may reflect underlying lung disease.
On inspection, the rate and pattern of breathing as well as the depth and
symmetry of lung expansion are observed. Breathing that is unusually rapid, labored, or
associated with the use of accessory muscles of respiration generally indicates either
augmented respiratory demands or an increased work of breathing. Asymmetric
expansion of the chest is usually due to an asymmetric process affecting the lungs, such
as endobronchial obstruction of a large airway, unilateral parenchymal or pleural
disease, or unilateral phrenic nerve paralysis. Visible abnormalities of the thoracic cage
include kyphoscoliosis and ankylosing spondylitis, each of which can alter compliance
of the thorax, increase the work of breathing, and cause dyspnea.
On palpation, the symmetry of lung expansion can be assessed, generally
confirming the findings observed by inspection. Vibration produced by spoken sounds
is transmitted to the chest wall and is assessed by the presence or absence and symmetry
of tactile fremitus. Transmission of vibration is decreased or absent if pleural liquid is
interposed between the lung and the chest wall, or if an endobronchial obstruction alters
sound transmission. In contrast, transmitted vibration may increase over an area of
underlying pulmonary consolidation.
The relative resonance or dullness of the tissue underlying the chest wall is
assessed by percussion. The normal sound of underlying air-containing lung is resonant.
In contrast, consolidated lung or a pleural effusion sounds dull, while air in the pleural
space sounds hyperresonant [7].
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On auscultation of the lungs, the examiner listens for both the quality and
intensity of the breath sounds and for the presence of extra, or adventitious, sounds.
Normal breath sounds heard through the stethoscope at the periphery of the lung are
described as vesicular breath sounds, in which inspiration is louder and longer than
expiration. If sound transmission is impaired by endobronchial obstruction or by air or
liquid in the pleural space, breath sounds are weaker or absent. When sound
transmission is improved through consolidated lung, the resulting bronchial breath
sounds have a more tubular quality and a more pronounced expiratory phase. Sound
transmission can also be assessed by listening to spoken or whispered sounds; when
these are transmitted through consolidated lung, bronchophony and whispered
pectoriloquy, respectively, are present. The sound of a spoken E becomes more like an
A, though with a nasal or bleating quality, a finding that is termed egophony.
The primary adventitious (abnormal) sounds that can be heard include crackles
(rales), wheezes, and rhonchi. Crackles represent the sound created when alveoli and
small airways open or close during respiration, and often they are associated with
interstitial lung disease, microatelectasis, or filling of alveoli by liquid. Wheezes, which
are generally more prominent during expiration than inspiration, reflect the oscillation
of airway walls that occurs when there is airflow limitation, as may be produced by
bronchospasm, airway edema or collapse, or intraluminal obstruction by neoplasm or
secretions. Rhonchi is the term applied to the sounds created when there is free liquid in
the airway lumen; the viscous interaction between the free liquid and the moving air
creates a low-pitched vibratory sound. Other adventitious sounds include pleural
friction rubs and stridor. The gritty sound of a pleural friction rub indicates inflamed
pleural surfaces rubbing against each other, often during both inspiratory and expiratory
phases of the respiratory cycle. Stridor, which occurs primarily during inspiration,
represents flow through a narrowed upper airway, as occurs in an infant with croup.
A meticulous general physical examination is mandatory in patients with
disorders of the respiratory system. Enlarged lymph nodes in the cervical and
supraclavicular regions should be sought. Disturbances of mentation or even coma
occur in patients with acute carbon dioxide retention and hypoxemia. Telltale stains on
the fingers point to heavy cigarette smoking; infected teeth and gums may occur in
patients with aspiration pneumonitis and lung abscess [1].
Clubbing of the digits can be found in lung cancer, interstitial lung disease, and
chronic infections in the thorax, such as bronchiectasis, lung abscess, and empyema.
Clubbing can also be seen with congenital heart disease associated with right-to-left
shunting and with a variety of chronic inflammatory or infectious diseases, such as
inflammatory bowel disease and endocarditis. A number of systemic diseases, such as
systemic lupus erythematosus, scleroderma, and rheumatoid arthritis, may be associated
with pulmonary complications, even though their primary clinical manifestations and
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physical findings are not primarily related to the lungs. Conversely, other diseases that
most affect the respiratory system, such as sarcoidosis, can have findings on physical
examination not related to the respiratory system, including ocular findings (uveitis,
conjunctival granulomas) and skin findings (erythema nodosum, cutaneous
granulomas).
Chest radiography is often the initial diagnostic study performed to evaluate
patients with respiratory symptoms, but it can also provide the initial evidence of
disease in patients who are free of symptoms. Perhaps the most common example of the
latter situation is the finding of one or more nodules or masses when the radiograph is
performed for a reason other than evaluation of respiratory symptoms.
A number of diagnostic possibilities are often suggested by the radiographic
pattern. A localized region of opacification involving the air spaces is usually
characterized as having an alveolar, an interstitial, or a nodular pattern. In contrast,
increased radiolucency can be localized, as seen with a cyst or bulla, or generalized, as
occurs with emphysema. The chest radiograph is also particularly useful for the
detection of pleural disease, especially if manifested by the presence of air or liquid in
the pleural space. An abnormal appearance of the hila and/or the mediastinum can
suggest a mass or enlargement of lymph nodes [2].
Additional Diagnostic Evaluation. Further information for clarification of
radiographic abnormalities is frequently obtained with computed tomographic scanning
of the chest. This technique is more sensitive than plain radiography in detecting subtle
abnormalities, can suggest the presence of certain diseases based on the pattern of
abnormality, and is very useful as a means of gathering quantitative information about
specific radiographic findings.
Pulmonary function tests: quantitation of forced expiratory flow assesses the
presence of obstructive physiology, which is consistent with diseases affecting the
structure or function of the airways, such as asthma and chronic obstructive lung
disease. Measurement of lung volumes assesses the presence of restrictive disorders,
seen with diseases of the pulmonary parenchyma or respiratory pump and with space-
occupying processes of the pleura.
Bronchoscopy is useful in some settings for visualizing abnormalities of the
airways and for obtaining a variety of samples from either the airway or the pulmonary
parenchyma [5].
Integration of the presenting clinical pattern and diagnostic studies. Patients
with respiratory symptoms but a normal chest radiograph most commonly have diseases
affecting the airways, such as asthma or chronic obstructive pulmonary disease.
However, the latter diagnosis is also commonly associated with radiographic
abnormalities, such as diaphragmatic flattening and attenuation of vascular markings.
Other disorders of the respiratory system for which the chest radiograph is normal
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include disorders of the respiratory pump (either the chest wall or the neuromuscular
apparatus controlling the chest wall) and occasionally interstitial lung disease. Chest
examination and pulmonary function tests are generally helpful in sorting out these
diagnostic possibilities. Obstructive diseases associated with a normal or relatively
normal chest radiograph are often characterized by findings on physical examination
and pulmonary function testing that are typical for these conditions. Similarly, diseases
of the respiratory pump or interstitial diseases may also be suggested by findings on
physical examination or by particular patterns of restrictive disease seen on pulmonary
function testing.
When respiratory symptoms are accompanied by radiographic abnormalities,
diseases of the pulmonary parenchyma or the pleura are usually present. Either diffuse
or localized parenchymal lung disease is generally visualized well on the radiograph,
and both air and liquid in the pleural space (pneumothorax and pleural effusion,
respectively) are usually readily detected by radiography [1-4].
Radiographic findings in the absence of respiratory symptoms often indicate
localized disease affecting the airways or the pulmonary parenchyma. One or more
nodules or masses can suggest intrathoracic malignancy, but they also can be the
manifestation of a current or previous infectious process. Patients with diffuse
parenchymal lung disease present on radiographic examination may be free of
symptoms, as is sometimes the case with pulmonary sarcoidosis.
Chronic obstructive pulmonary disease (COPD) is estimated to affect
32 million persons in the U.S. and is the fourth leading cause of death in this country.
Patients typically have symptoms of chronic bronchitis and emphysema, but the classic
triad also includes asthma. Can you identify COPD when you see it and take the
necessary steps to help patients keep breathing?
The primary cause of COPD is exposure to tobacco smoke. Overall, tobacco
smoking accounts for as much as 90% of COPD risk. However, COPD does occur in
individuals who have never smoked. Environmental factors (eg, pollution), alpha1-
antitrypsin deficiency, intravenous drug use, immunodeficiency syndromes (eg, HIV),
and vasculitis syndromes have also been linked to COPD. In addition, connective tissue
disorders such as Marfan syndrome have been associated.
Marfan syndrome is an autosomal dominant inherited disease of type I collagen,
characterized by abnormal length of the extremities, subluxation of the lenses, and
cardiovascular abnormality. Pulmonary abnormalities, including emphysema, have been
described in approximately 10% of patients [1,2].
The exact prevalence of COPD in the U.S. is difficult to estimate because it is
underdiagnosed and undertreated. Most patients do not present for medical care until the
disease is in a late stage.
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COPD predominantly occurs in individuals older than 40 years. Although current
rates of COPD are higher in men than in women, rates in women have been increasing.
Moreover, severe, early-onset disease probably represents a distinct genotype and is
more common in females. Those with a family history of COPD, as well as black
persons, are also at increased risk for this specific type [2,4].
The value of patient history and physical examination was addressed in the 2013
update to the American College of Physicians/American College of Chest
Physicians/American Thoracic Society/European Respiratory Society
(ACP/ACCP/ATS/ERS) guideline for diagnosis and management of stable COPD.
According to the current guideline, a history of more than 40 pack-years of smoking
was the best single predictor of airflow obstruction; however, the most helpful
information was provided by a combination of the following three signs:
 Self-reported smoking history of more than 55 pack-years;
 Wheezingonauscultation; and
 Self-reportedwheezing.
Signs and symptoms
Patients typically present with a combination of signs and symptoms of chronic
bronchitis, emphysema, and reactive airway disease. Symptoms include the following:
 Cough, usually worse in the mornings and productive of a small amount of
colorless sputum.
 Acute chest illness.
 Breathlessness: The most significant symptom, but usually does not occur until
the sixth decade of life
 Wheezing: May occur in some patients, particularly during exertion and
exacerbations
The sensitivity of physical examination in detecting mild to moderate COPD is
relatively poor, but physical signs are quite specific and sensitive for severe disease.
Findings in severe disease include the following:
 Tachypnea and respiratory distress with simple activities
 Use of accessory respiratory muscles and paradoxical indrawing of lower
intercostal spaces (Hoover sign)
 Cyanosis
 Elevated jugular venous pulse (JVP)
 Peripheral edema
Thoracic examination reveals the following:
 Hyperinflation (barrel chest)
 Wheezing – Frequently heard on forced and unforced expiration
 Diffusely decreased breath sounds
 Hyperresonance on percussion
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 Prolonged expiration
 Coarse crackles beginning with inspiration in some cases
Certain characteristics allow differentiation between disease that is predominantly
chronic bronchitis and that which is predominantly emphysema. Chronic bronchitis
characteristics include the following:
 Patients may be obese
 Frequent cough and expectoration are typical
 Use of accessory muscles of respiration is common
 Coarse rhonchi and wheezing may be heard on auscultation
 Patients may have signs of right heart failure (ie, corpulmonale), such as edema
and cyanosis
Emphysema characteristics include the following:
 Patients may be very thin with a barrel chest
 Patients typically have little or no cough or expectoration
 Breathing may be assisted by pursed lips and use of accessory respiratory
muscles; patients may adopt the tripod sitting position
 The chest may be hyperresonant, and wheezing may be heard
 Heart sounds are very distant
 Overall appearance is more like classic COPD exacerbation [7].
Diagnosis. The formal diagnosis of COPD is made with spirometry; when the
ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is
less than 70% of that predicted for a matched control, it is diagnostic for a significant
obstructive defect. Criteria for assessing the severity of airflow obstruction (based on
the percent predicted postbronchodilator FEV1) are as follows:
 Stage I (mild): FEV1 80% or greater of predicted
 Stage II (moderate): FEV1 50-79% of predicted
 Stage III (severe): FEV1 30-49% of predicted
 Stage IV (very severe): FEV1 less than 30% of predicted or FEV1 less than
50% and chronic respiratory failure
Arterial blood gas (ABG) findings are as follows:

 ABGs provide the best clues as to acuteness and severity of disease
exacerbation
 Patients with mild COPD have mild to moderate hypoxemia without
hypercapnia
 As the disease progresses, hypoxemia worsens and hypercapnia may develop,
with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the
predicted value
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pH usually is near normal; a pH below 7.3 generally indicates acute respiratory
compromise
 Chronic respiratory acidosis leads to compensatory metabolic alkalosis
In patients with emphysema, frontal and lateral chest radiographs reveal the
following:
 Flattening of the diaphragm
 Increased retrosternal air space
 A long, narrow heart shadow
 Rapidly tapering vascular shadows accompanied by hyperlucency of the lungs
 Radiographs in patients with chronic bronchitis show increased
bronchovascular markings and cardiomegaly
Advantages of high-resolution CT include the following:

 Greater sensitivity than standard chest radiography
 High specificity for diagnosing emphysema (outlined bullae are not always
visible on a radiograph)
 May provide an adjunctive means of diagnosing various forms of COPD (eg,
lower lobe disease may suggest alpha1-antitrypsin (AAT) deficiency
 May help the clinician determine whether surgical intervention would benefit
the patient
Other tests are as follows:

 Hematocrit – Patients with polycythemia (hematocrit greater than 52% in men
or 47% in women) should be evaluated for hypoxemia at rest, with exertion, or during
sleep
 Serum potassium – Diuretics, beta-adrenergic agonists, and theophylline act to
lower potassium levels
 Measure AAT in all patients younger than 40 years or in those with a family
history of emphysema at an early age
 Sputum evaluation will show a transformation from mucoid in stable chronic
bronchitis to purulent in acute exacerbations
 Pulse oximetry, combined with clinical observation, provides instant feedback
on a patient's status
 Electrocardiography can help establish that hypoxia is not resulting in cardiac
ischemia and that the underlying cause of respiratory difficulty is not cardiac in nature
 The distance walked in 6 minutes (6MWD) is a good predictor of all-cause and
respiratory mortality in patients with moderate COPD[2, 3] ; patients with COPD who
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desaturate during the 6MWD have a higher mortality rate than do those who do not
desaturate
 Two-dimensional echocardiography can screen for pulmonary hypertension
 Right-sided heart catheterization can confirm pulmonary artery hypertension
and gauge the response to vasodilators
If all three signs are absent, airflow obstruction can be nearly ruled out. COPD is
now known to be a disease with systemic manifestations, and the quantification of these
manifestations has proved to be a better predictor of mortality than lung function alone.
Many patients with COPD may have decreased fat-free mass, impaired systemic muscle
function, osteoporosis, anemia, pulmonary hypertension, corpulmonale, and even left-
sided heart failure. Depression is not uncommon in persons with COPD [1,7].
Management. Smoking cessation continues to be the most important therapeutic
intervention for COPD. Risk factor reduction (eg, influenza vaccine) is appropriate for
all stages of COPD. Approaches to management by stage include the following:
 Stage I (mild obstruction): Short-acting bronchodilator as needed
 Stage II (moderate obstruction): Short-acting bronchodilator as needed; long-
acting bronchodilator(s); cardiopulmonary rehabilitation
 Stage III (severe obstruction): Short-acting bronchodilator as needed; long-
acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if
repeated exacerbations
 Stage IV (very severe obstruction or moderate obstruction with evidence of
chronic respiratory failure): Short-acting bronchodilator as needed; long-acting
bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated
exacerbation; long-term oxygen therapy (if criteria met); consider surgical options such
as lung volume reduction surgery (LVRS) and lung transplantation [1,5].
Agents used include the following:

 Short-acting beta2 -agonist bronchodilators (eg, albuterol, metaproterenol,
levalbuterol, pirbuterol)
 Long-acting beta2 -agonist bronchodilators (eg, salmeterol, formoterol,
arformoterol, indacaterol, vilanterol)
 Respiratory anticholinergics (eg, ipratropium, tiotropium, aclidinium)
 Xanthine derivatives (ie, theophylline)
 Phosphodiesterase-4 Inhibitors (ie, roflumilast)
 Inhaled corticosteroids (eg, fluticasone, budesonide)
 Oral corticosteroids (eg, prednisone)
 Beta2 -agonist and anticholinergic combinations (eg, ipratropium and albuterol,
umeclidinium bromide/vilanterol inhaled)
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 Beta2 -agonist and corticosteroid combinations (eg, budesonide/formoterol,
fluticasone and salmeterol, vilanterol/fluticasone inhaled)
Pulmonary rehabilitation programs are typically multidisciplinary approaches that

emphasize the following:
 Patient and family education
 Smoking cessation
 Medical management (including oxygen and immunization)
 Respiratory and chest physiotherapy
 Physical therapy with bronchopulmonary hygiene, exercise, and vocational
rehabilitation
 Psychosocial support
Indications for admission for acute exacerbations include the following:

 Failure of outpatient treatment
 Marked increase in dyspnea
 Altered mental status
 Increase in hypoxemia or hypercapnia
 Inability to tolerate oral medications such as antibiotics or steroids
Oral and inhaled medications are used for patients with stable disease to reduce
dyspnea and improve exercise tolerance. Most of the medications used are directed at
the following four potentially reversible causes of airflow limitation in a disease state
that has largely fixed obstruction:
 Bronchialsmoothmusclecontraction;
 Bronchial mucosal congestion and edema;
 Airwayinflammation; and
 Increasedairwaysecretions.
 COPD is commonly associated with progressive hypoxemia. Oxygen
administration reduces mortality rates in patients with advanced COPD because of the
favorable effects on pulmonary hemodynamics. Long-term oxygen therapy improves
survival twofold or more in hypoxemic patients with COPD. Hypoxemia is defined as
PaO2 (partial pressure of oxygen in arterial blood) of < 55 mm Hg or oxygen saturation
of < 90%. Oxygen was used for 15-19 hours per day. Therefore, specialists recommend
long-term oxygen therapy for patients with a PaO2 of < 55 mm Hg, a PaO2 of < 59 mm
Hg with evidence of polycythemia, or corpulmonale. Reevaluate these patients one to
three months after initiating therapy, because some patients may not require long-term
oxygen [1,5].
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The use of systemic steroids in the treatment of acute exacerbations is widely
accepted and recommended, given their high efficacy. A meta-analysis concluded that
oral and parenteral corticosteroids significantly reduced treatment failure and the need
for additional medical treatment, and that they increased the rate of improvement in
lung function and dyspnea over the first 72 hours. Note that systemic steroids are not as
effective in treating COPD exacerbations as they are in treating bronchial asthma
exacerbations.
On the other hand, the use of oral steroids in persons with chronic stable COPD is
widely discouraged, given their adverse effects, which include hypertension, glucose
intolerance, osteoporosis, fractures, and cataracts. A Cochrane review showed no
benefit at low-dose therapy and short-lived benefit with higher doses (> 30 mg of
prednisolone). [3,5].
Inhaled corticosteroids provide a more direct route of administration to the
airways, and similar to other inhaled agents, they are only minimally absorbed.
Consequently, aside from the development of thrush, the systemic adverse effects of
these medications at standard doses are negligible. Despite the theoretical benefit, the
current consensus is that inhaled corticosteroids do not decrease the decline in FEV1,
although they have been shown to decrease the frequency of exacerbations and improve
quality of life for symptomatic patients with an FEV1 of < 50%. The current ICSI
guidelines conclude that inhaled steroids are appropriate in patients with recurrent
exacerbations of COPD.
Disorders of the kidney and urinary tract

Approach to the patient with diseases of the kidneys and urinary tract
Diseases of the kidneys and urinary tract frequently give rise to consistent arrays
or clusters of clinical signs, symptoms, and laboratory findings called syndromes.
Syndromes are useful diagnostically because each has fewer causes than the individual
clinical signs and symptoms it contains. For example, any injured capillary bed from
glomerulus to urethral meatus can cause hematuria, but only glomerular injury also can
cause heavy albuminuria and erythrocyte casts, and only a few of the diseases that
injure the glomerular capillaries enough to cause hematuria and proteinuria also cause a
rapid fall in glomerular filtration rate. Routine clinical evaluation is often sufficient to
suggest that a particular syndrome may be present (Table 1), but additional laboratory
measurements beyond the routine, as well as radiologic and/or urologic evaluation and
sequential clinical observations, are usually required to establish the diagnosis. [4,5].
Acute and rapidly progressive renal failure. Whether the glomerular filtration
rate (GFR) falls over days (acute renal failure - ARF) or weeks (rapidly progressive
renal failure - RPRF) is a useful distinction, because the causes of these two syndromes
are somewhat different (Table 1). For example, acute tubular necrosis, from sepsis,
105
nephrotoxic materials, shock, or other cause, is the usual cause of ARF, whereas
extracapillary proliferative (crescentic) glomerulonephritis, due to immunologic injury
or to vasculitis, is an important cause of RPRF but not ARF.
Proof for the existence of either syndrome requires serial determination of the
GFR, blood urea nitrogen, or serum creatinine level. Anuria or oliguria strongly
suggests ARF, since life cannot be sustained for long with such inadequate renal
function. Symptoms and signs of uremia of recent onset suggest RPRF or ARF but also
could result from chronic renal failure (CRF) that has only recently become life-
threatening. Although edema, hypertension, and abnormalities of electrolytes and the
urine sediment (Table 1) are frequent in both ARF and RPRF, they occur in other
syndromes as well and are not specific [7].
Urinary obstruction, acute tubular necrosis, some forms of vasculitis, major renal
vascular accidents, and endogenous and exogenous nephrotoxins are common causes of
ARF. Vasculitis and crescentic glomerulonephritis are common causes of RPRF.
Hemolytic-uremic syndrome, malignant nephrosclerosis, and essential mixed
cryoimmunoglobulinemia occasionally present as RPRF. Idiopathic rapidly progressive
glomerulonephritis - the prototype of a disease that produces RPRF - sometimes causes
ARF. CRF may occur in some patients with diseases that typically cause ARF.
Nevertheless, despite some variability of disease presentations, the finding of ARF or
RPRF narrows the range of causes [4].
Acute nephritis. A number of diseases involve the glomeruli and, to a generally
lesser extent, the tubules in an acute but transient inflammatory process, manifested
clinically by acute reduction in GFR and salt and water retention. This process is called
glomerulonephritis. Expansion of the extracellular volume, if marked, causes
hypertension, pulmonary vascular congestion, and facial and peripheral edema. Since
the causes of this syndrome all can damage the glomerular wall enough to permit red
blood cells and plasma proteins to enter the urinary space and appear in the urine, gross
or microscopic hematuria, red blood cell casts, and proteinuria are necessary for the
diagnosis of acute glomerulonephritis, and their absence suggests other diagnoses.
Acute glomerulonephritis is a transient inflammatory process, so it’s clinical and
laboratory manifestations wax and wane over days to weeks. Many of the diseases that
cause acute glomerulonephritis also cause ARF or RPRF. When acute
glomerulonephritis is associated with RPRF, the term rapidly progressive
glomerulonephritis is often applied as a clinical diagnosis, pending biopsy delineation
of the precise disease process. Other diseases cause an acute but transitory inflammation
of the tubules and interstitium (acute tubulointerstitial nephritis) but not of the
glomerular capillaries. Hematuria, red blood cell casts, and reduction of GFR occur, as
in acute glomerulonephritis, but proteinuria is less marked and, when present, consists
mainly of low-molecular-weight proteins rather than albumin. Apart from the lesser
106
proteinuria, tubulointerstitial nephritis may be manifested by increased urine leukocytes
and especially urine eosinophils, as well as by peripheral blood eosinophilia [1].
Acute glomerulonephritis following infection with group A streptococci is the
prototype of a disease that causes acute nephritis alone. Immune complexes deposit in
the subepithelial region of the glomerular capillary wall, between the basement
membrane and the visceral epithelial cells that separate the membrane from the urinary
space, and provoke an intense but transient inflammatory process. GFR falls but returns
to normal within weeks to months in most patients. Deposition of immune complexes is
also believed to be the cause of acute nephritis following other bacterial and viral
infections and of lupus nephritis, membranoproliferative glomerulonephritis, Henoch-
Schonlein purpura, and Berger's disease, i.e., IgA nephropathy. That the typical
presentations of the last four diseases are chronic renal failure, nephrotic syndrome, and
asymptomatic urinary abnormalities illustrates the weakness of relationships between
pathogenesis and final clinical manifestations.
Renal biopsy is usually required for the evaluation of patients with acute
nephritis, whether or not ARF or RPRF is also present. In patients with RPRF and
glomerulonephritis (rapidly progressive glomerulonephritis), the usual histologic picture
is that of proliferative glomerulonephritis, often with extracapillary crescent formation.
However, this picture may also occur in patients without RPRF, and many other forms
of histologic abnormality may be found in patients with acute glomerulonephritis. Thus,
prediction of histopathology from clinical course is very uncertain. Prognosis and
treatment are influenced strongly by the precise histologic and ultrastructural pattern, as
well as the types of immune complexes and immunoglobulins deposited in the renal
tissues. In patients with acute tubulointerstitial nephritis, inflammatory changes are
prominent in the renal interstitium and evidence of tubule cell injury may be present,
but glomerular abnormalities are often absent altogether [7].
Chronic renal failure. CRF results from progressive and irreversible destruction
of nephrons, regardless of cause. This diagnosis implies that the GFR is known to have
been reduced for at least 3 to 6 months. Often a gradual decline in GFR occurs over a
period of years. Proof of chronicity is also provided by the demonstration of bilateral
reduction of kidney size by scout film, ultrasonography, intravenous pyelography, or
tomography. Other findings of long-standing renal failure, such as renal osteodystrophy
or symptoms of uremia, also help to establish this syndrome. Several laboratory
abnormalities are often regarded as reliable indicators of chronicity of renal disease,
such as anemia, hyperphosphatemia, or hypocalcemia, but these are not specific.
In contrast, the finding of broad casts in the urinary sediment is specific for CRF,
the wide diameters of these casts reflecting the compensatory dilatation and hypertrophy
of surviving nephrons. Proteinuria is a frequent but nonspecific finding, as is hematuria.
Chronic obstructive uropathy, polycystic and medullary cystic diseases, analgesic
107
nephropathy, and the inactive end stage of any chronic tubulointerstitial nephropathy
are conditions in which the urine often contains little or no protein, cells, or casts even
though nephron destruction has progressed to chronic renal failure.
When ARF occurs in the presence of CRF, the acute component must be
evaluated as if CRF were not present, because the acute component is potentially
reversible. The depletion of extracellular fluid volume is the cause of acute deterioration
of renal function, but urinary tract obstruction, drug-induced nephrotoxicity, or
exacerbation of underlying renal disease also may be responsible [7].
Nephrotic syndrome. This diagnosis previously implied that a patient excretes
more than 3.5 g protein per 1.73 m2 surface area per 24 h; the proteinuria consists
mainly of albumin; and that the patient has reduced serum albumin, edema, and
hyperlipidemia. Massive proteinuria alone has now come to define the syndrome, since
this finding connotes serious renal disease whether or not the protein losses lead to
hypoalbuminemia, lipid disturbances, or edema. Provided the proteins in the urine are
not paraproteins readily excreted by the normal kidney (e.g., immunoglobulin light
chains in multiple myeloma), massive proteinuria is invariably a sign of injury to the
glomeruli.
Table 1
Initial Clinical and Laboratory Data Base for Defining Major Syndromes
in Nephrology
Findings that are
Syndromes Important Clues to Diagnosis
Common
Acute or rapidly Anuria Hypertension,
progressive renal Oliguria hematuria
failure Documented recent decline in GFR Proteinuria, pyuria
Acute nephritis Hematuria, RBC casts Casts, edema
Azotemia, oliguria Proteinuria Pyuria
Edema, hypertension Circulatory
congestion
Chronic renal Azotemia for >3 months Hematuria,
failure Prolonged symptoms or signs of uremia proteinuria
Symptoms or signs of renal Casts, oliguria
osteodystrophy Polyuria, nocturia
Kidneys reduced in size bilaterally Edema, hypertension
Broad casts in urinary sediment Electrolyte disorders
2
Nephrotic syndrome Proteinuria >3.5 g per 1.73 m per 24 h Casts
Hypoalbuminemia Edema
Hyperlipidemia
Lipiduria
Asymptomatic Hematuria
urinary abnormal Proteinuria (below nephrotic range)
ities Sterile pyuria, casts
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Findings that are
Syndromes Important Clues to Diagnosis
Common
Urinary tract Bacteriuria >105 colonies per milliliter Hematuria
infection Other infectious agent documented in Mild azotemia
urine Pyuria, leukocyte casts Frequency, Mild proteinuria
urgency Bladder tenderness, flank Fever
tenderness
Renal tubule defects Electrolyte disorders Polyuria, nocturia Hematuria
Symptoms or signs of renal "Tubular" proteinuria
osteodystrophy Enuresis
Large kidneys
Renal transport defects
Hypertension Systolic/diastolic hypertension Proteinuria
Casts
Azotemia
Nephrolithiasis Previous history of stone passage or Hematuria Pyuria
removal Previous history of stone seen Frequency, urgency
by x-ray Renal colic
Urinary tract Azotemia, oliguria, anuria Hematuria
obstruction Polyuria, nocturia, urinary retention Pyuria
Slowing of urinary stream Enuresis, dysuria
Large prostate, large kidneys
Flank tenderness, full bladder after
voiding
Common causes of the nephrotic syndrome include minimal change disease,

idiopathic membranous glomerulopathy, focal and segmental glomerulosclerosis, and
diabetic glomerulosclerosis. Because these diseases typically cause less inflammation
than those that cause acute nephritis, the urine usually contains fewer cellular elements,
and acute changes in GFR and urine volume are uncommon. Hematuria may occur in
some forms of nephrotic syndrome, however, especially chronic membranoproliferative
glomerulonephritis. The presence of cellular or granular casts should suggest lupus
nephritis or acute nephritis associated with massive proteinuria, such as essential mixed
cryoimmunoglobulinemia, acute bacterial endocarditis, visceral sepsis, and Henoch-
Schonlein purpura [7].
Asymptomatic urinary abnormalities. Mild microscopic hematuria, pyuria, and
casts or less than 3.5 g protein per 1.73 m2 surface area per 24 h may be present in the
urine of a patient with no evidence of other nephrologic syndromes. By exclusion, these
patients belong to the syndrome of asymptomatic urinary abnormalities. Isolated
hematuria or proteinuria, or unexplained pyuria, are the most frequent abnormalities in
this syndrome.
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Isolated hematuria, without proteinuria or casts, may be the sole clue to the
presence of neoplasm, stone, or infection (e.g., tuberculosis) in any part of the urinary
tract. Isolated hematuria also may arise from renal papillae in analgesic and sickle cell
nephropathies. Persistent isolated hematuria often requires intravenous pyelography,
cystoscopy, and, occasionally, renal arteriography to identify the source of bleeding.
NephromaI hematuria, in which casts contain red blood cells or hemoglobin pigment,
indicates damage to the nephron. It occurs without proteinuria, mainly in benign
recurrent hematuria and Berger's disease. Nephronal hematuria and proteinuria occur
together in many renal diseases that may lead to chronic renal failure. In general, the
combination of nephronal hematuria and proteinuria suggests a worse prognosis than
either alone.
Isolated proteinuria, without red blood cells or other formed elements in the
urinary sediment, is characteristic of many renal diseases that manifest little or no
inflammatory reaction within the glomeruli (e.g., diabetes mellitus, amyloidosis). Less
than nephrotic-range proteinuria is common in mild forms of all the diseases that can
cause overt nephrotic syndrome. "Tubular" proteinuria is the rule in cystinosis; in
intoxication from cadmium, lead, or mercury; and in the peculiar Balkan nephropathy
localized to a small region along the Danube River [1-4].
Pyuria (leukocyturia) also may be a sole urinary abnormality and may reflect
infection or inflammation of the lower urinary tract rather than parenchymal renal
disease. Prominent pyuria can occur in any inflammatory disease of the kidneys,
especially tubulointerstitial nephritis, lupus nephritis, pyelonephritis, and renal
transplant rejection, but usually in association with mild proteinuria or hematuria. The
finding of leukocyte casts establishes the kidney as the site of the inflammatory
reaction.
Pyuria associated with urine that is sterile on routine bacteriologic culture
presents a special problem. Causes of "sterile pyuria" include: 1) recent bacterial
urinary infection being treated with antibiotics, 2) glucocorticoid therapy, 3) acute
febrile episodes, 4) cyclophosphamide administration, 5) pregnancy, 6) renal transplant
rejection, 7) genitourinary trauma, 8) prostatitis and cystourethritis, and 9) all forms of
tubulointerstitial nephritis. Leukocytes from vaginal secretions may contaminate the
urine, so a midstream, clean-catch urine sample should be collected to substantiate a
urinary origin. Pyuria associated with proteinuria, nephronal hematuria, or casts usually
signifies inflammatory disease of the renal glomeruli, tubules, interstitium, or
microcirculation, and evaluation should focus not on the pyuria but on the nature of the
renal disease [2].
Persistent sterile pyuria that cannot be ascribed to any of the foregoing causes has
a narrow differential diagnosis. Unusual infections, such as tuberculosis, fungi, atypical
mycobacteria, Haemophilus influenzae, anaerobic bacteria, fastidious bacteria that grow
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only on enriched media, and L-forms, all must be sought. Intravenous pyelography may
be needed to detect causes such as urinary tract calculi, papillary necrosis, and renal
infiltration by lymphoma or myeloma cells. The latter is usually suspected because of
other evidence of myeloma or lymphoma, for both rarely involve only the kidneys. If all
tests are negative, cystoscopy may reveal cystitis or trigone inflammation [18].
Urinary tract infection. This syndrome is defined by the demonstration in urine
of pathogenic organisms, bacteria, tubercle bacilli, or fungi. When urine is obtained for
culture, the condition under which the urine is collected must minimize contamination
from external surfaces. Women should void into a wide-mouthed sterile container after
preliminary cleansing of the vulva with a moist, sterile gauze pledged. In men,
midstream collection is usually adequate. Bacterial colony counts of 105 organisms per
milliliter or greater in urine generally indicate urinary tract colonization and infection.
Levels above 102 colonies per milliliter are sufficient to indicate infection in
symptomatic patients and in urine samples obtained by suprapubic aspiration or bladder
catheter. When the urinary tract is anatomically normal, Escherichia coli is the usual
pathogen. After prolonged antibiotic treatment of persistent infections, particularly
when urinary drainage is impaired or stones are present, Klebsiella, Enterobacter, and
Proteus species predominate [1].
А positive urine culture need not imply that an organism is producing tissue
inflammation or injury. In some patients, tissue effects may be trivial; in others, injury
may occur even though symptoms or urinary abnormalities are not present at the time of
evaluation. When bacteriuria is associated with tissue inflammation or injury, clinical
manifestations usually depend on the site(s) involved. Dysuria, frequency, urgency, and
suprapubic tenderness are common symptoms of bladder and urethral inflammation.
Prostatitis also leads to frequency, dysuria, and urgency, and the prostate may be boggy
and tender on rectal examination. Flank pain, chills, fever, nausea and vomiting,
hypotension from sepsis, and leukocyte casts all suggest true renal parenchymal
infection, i.e., pyelonephritis; their absence, however, does riot exclude pyelonephritis.
Renal tubule defects. This syndrome encompasses a large number of acquired
and hereditary disorders, all of which tend to affect tubules more than glomeruli.
Hereditary anatomic defects, including polycystic renal disease, medullary cystic
disease, and medullary sponge kidney, are readily detected by ultrasonography or
intravenous pyelography, which are usually performed because of hematuria,
bacteriuria, flank pain, or unexplained azotemia.
Defects in tubule transport functions, on the other hand, tend not to be associated
with prominent renal anatomic defects and arise either as inherited traits or during the
course of acquired renal disease. In general, these functional defects impair secretion
and/or reabsorption of electrolytes and organic solute» or limit urinary concentrating
and diluting ability. Typical manifestations of such functional disturbances include
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polyuria and nocturia, metabolic acidosis, and various disorders of fluid and electrolyte
balance. Such defects are defined by direct physiologic measurements; their elucidation
requires a sound understanding of normal renal physiology.
Hypertension implies that the average of a series of reliable blood pressure
measurements exceeds 140 mmHg systolic or 90 mmHg diastoli. The pathogenetic
mechanisms, clinical and laboratory manifestations, and therapeutic approaches are
discussed in detail elsewhere.
Nephrolithiasis. This syndrome is recognized with certainty when a stone is
passed, visualized by x-ray, or removed at surgery or cystoscopy. Less certain, but
suggestive, evidences of nephrolithiasis include renal colic; painful hematuria; or
unexplained pyuria, dysuria, and urinary frequency. Colic varies in its symptomatology
but usually begins suddenly in one flank, radiates downward toward the groin, and is
excruciatingly painful.
Most renal stones are composed of calcium, uric acid, cystine, or struvite
(magnesium ammonium phosphate). All are radiopaque except for uric acid stones and
are therefore visible by routine abdominal radiography. Uric acid stones appear as
radiolucent filling defects and can be mistaken for tumor or blood clot.
Urinary tract obstruction. Documentation of the various structural or functional
causes of urinary tract obstruction usually requires radiologic or surgical visualization.
The most common initial evaluation at present is renal ultrasonography, although false-
negative evaluations are not rare, especially when urine flow rate is low. The
manifestations of obstruction, which initiate the search for its causes, are numerous.
Anuria in an adult is almost always due to obstruction of bladder outflow. Less
commonly, blockage of upper urinary drainage from both kidneys or from a solitary
functioning kidney accounts for total or near-total cessation of urine flow. A large
bladder after voiding is a sign of outflow obstruction, usually due to urethral stricture,
tumor, stone, neurogenic causes, or prostatic hypertrophy. Nocturia, frequency and
overflow incontinence, and slowing or hesitancy of micturition also suggest outflow
obstruction. Upper tract obstruction often produces few manifestations. When it is
incomplete or unilateral, urine volume may be normal or even increased because of a
loss of renal concentrating ability. Urinary stasis secondary to obstruction predisposes
to recurrent urinary tract infection; chronic obstruction predisposes to progressive loss
of renal function [7,19].
Disorders of the gastrointestinal system

Approach to the patient with gastrointestinal disease
Biologic considerations. The mucosal surface of the gastrointestinal (GI) tract is
composed of a remarkably dynamic population of epithelial cells that are highly
developed in their capacity for transmembrane absorption and secretion. These
112
secretory and absorptive abilities facilitate the essential function of the digestive tract in
digestion and nutrient uptake, which must be accomplished while maintaining the
barrier between the host and potentially harmful pathogens and mutagens in the lumen.
The latter is accomplished through both the physical integrity of the intact mucosal
surface and the extensive population of resident immune cells [20].
The intestinal surface itself also contains the distinctive M-cells that serve to
sample the antigenic milieu of the lumen. They overlie lymphoid aggregates (Peyer's
patches). The predominance of suppressor lymphocytes in the surface epithelial layer
(intraepithelial lymphocytes) suggests that damping of the body's response to the
enormous number of potentially antigenic substances in the lumen is necessary to
prevent the constant and unrestrained activation of immune and inflammatory
processes. Conversely, the presence of large numbers of helper lymphocytes as well as
other cellular effectors of immune response in the lamina propria and submucosa attests
to a large armamentarium ready to respond when surface defenses have been breached.
No doubt the concentration of so many immune cells capable of attracting and
activating inflammatory cells predisposes to the numerous inflammatory conditions to
which the GI tract is subject.
The mucosal surface of the GI tract is also remarkable for the very rapid turnover
of the epithelial cell population. It is likely that the epithelium turns over in its entirety
every 24 to 72 h. This capacity may permit rapid restitution of a functional cell
population following an acute insult and may reduce the risk of malignancy through the
shedding of cells affected by the many mutagens in the luminal contents. Nevertheless,
this proliferative potential creates the setting for neoplastic disorders, which are so
common in the GI tract. Another fundamental feature of the GI mucosa is the spatial
segregation of the proliferative compartment from the terminally differentiated cells.
This is true throughout the GI tract but is most apparent in the small intestine, where a
gradient of differentiation exists from the depths of the crypts of Lieberkiihn to the
villus tip. This organization has a strong effect on the histology and pathophysiology of
many mucosal disorders, such as celiac sprue [7,.20].
In view of the important secretory and absorptive activities of mucosal surface,
diseases of the GI tract may result in clinical consequences owing to physical disruption
of the mucosal layer (e.g., blood loss, fluid loss, pathogenic invasion) or to nutritional
derangements caused by impaired digestion and nutrient absorption. In focal or
localized disease processes the former effects predominate, whereas the latter may be
especially prominent in disorders that affect extensive areas of the GI tract in a diffuse
manner.
While the essential roles of the GI tract - the absorption of nutrients and the
excretion of the products - are accomplished in large part at the luminal surface, these
processes also depend on the deeper muscular layers for the coordinated propulsion of
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food through the lumen. The complexity of the local and distant neural and endocrine
factors that contribute to the regulation of intestinal motility is only now becoming fully
appreciated. Disruption of normal motility is quite common, with functional bowel
complaints affecting as many as 15% of adults. Alterations in frequency of bowel
movements, abdominal distention, abdominal pain, and nausea, individually or in
varying combinations, may result from dysmotility. In addition, structural lesions may
also indirectly lead to symptoms through their impact on motility involving some or all
regions of the GI tract. These range from the direct effects of an obstructing lesion to
the indirect actions of substances released by a primary mucosal disorder (e.g.,
inflammatory mediators such as arachidonic acid metabolites that also affect smooth-
muscle activity) [20].
Although valid unifying generalizations can be made about the GI tract in its
entirety, the spectrum of diseases affecting this system and their clinical manifestations
are significantly related to the constituent organ(s) involved (Table 2). Thus, esophageal
disorders manifest themselves mainly through their relationship to swallowing; gastric
disorders are dominated by features relating to acid secretion; and disease of the small
and large intestine is evidenced mainly by disruption of nutrition and alterations of
bowel movements. Similarly, diseases of the related ancillary organs, the exocrine
pancreas and the hepatobiliary system, present characteristic clinical challenges.
Finally, the GI tract may be affected by systemic disorders. These include vascular,
inflammatory, infectious, and neoplastic conditions leading to focal or diffuse structural
lesions. Metabolic and endocrine abnormalities as well as some drugs can disrupt
normal bowel motility Table 2 summarizes criteria that may be used to distinguish
functional from organic or structural diseases of the GI tract.
Clinical considerations. Clinical history is essential in directing the clinician's
attention to appropriate diagnostic considerations in the patient with GI symptoms. The
most common complaints resulting from disorders involving the GI tract include pain
and alterations in bowel habit, especially diarrhea or constipation. Of these complaints,
abdominal pain is the most frequent and variable and may reflect a broad spectrum of
problems, from the least threatening to the most urgent. In conjunction with an
estimation of its intensity, an initial distinction should be made between pain of acute
onset and more chronic discomfort. Pain of abrupt onset is often encountered in serious
illness requiring urgent intervention, while a history of chronic discomfort is most often
related to an indolent disorder. Dyspepsia, an ill-defined upper abdominal discomfort, is
especially common. It is often accompanied in varying degrees by feelings of nausea,
bloating, and distention. While it may be associated with peptic ulceration, non-ulcer
dyspepsia (NUD) is common. A change in the pattern or character of pain may be
equally important, possibly signifying the progression to a more critical stage of a
problem (either recent or chronic) that was mild in onset. Ascertaining the location of
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the pain (upper or lower, localized or diffuse), its character (sharp, burning, cramping),
and its relationship to meals will often provide significant insight into the most
important diagnostic considerations. If eating produces the symptom, the clinician
should determine whether the discomfort occurs while the patient is eating (as in
esophageal disorders), shortly after the meal (as often occurs in biliary tract disease and
abdominal angina), or 30 to 90 min later (as is typical of peptic disease). Pain that is not
affected by eating suggests a process outside of the bowel lumen, such as abscess,
peritonitis, pancreatitis, and some malignancies. Conversely, identification of factors
that relieve the symptom is also helpful. For example, eating or antacid use typically
gives relief in peptic ulcer disease or gastritis. A relationship of the discomfort to bowel
movement, especially in association with an altered bowel habit, should focus attention
on a disorder of the small or large bowel, such as inflammatory bowel disease [7].
Alterations in bowel habit can result from either disruption of normal intestinal
motility or significant structural pathology. A thorough determination of the temporal
evolution of the change and the nature of the alteration, in conjunction with other
constitutional symptoms such as weight loss, fever, or anorexia, is important. A
temporary variation in bowel habit in association with some life stress and in the
absence of signs of systemic illness suggests the common "irritable bowel syndrome,"
especially when the alteration varies between diarrhea and constipation. Small, pellet-
like stools are often described by the patient. Associated symptoms of dyspepsia
(bloating, nausea, and "gas") are also common. This diagnosis can essentially be made
on the basis of a thorough history and physical examination and very limited laboratory
testing, to exclude structural disease. In contrast, the onset of worsening constipation in
an adult with previously regular habits, especially when accompanied by systemic
symptoms such as weight loss, suggests the possible presence of an underlying
obstructing process, particularly malignancy. If diarrhea is present, one should
determine the average number of stools, their consistency, their pattern, and the
presence or absence of blood. Although diarrhea refers to an increased frequency of
movements, patients will often use the term to describe loose or watery stools. The
occurrence of nocturnal or true bloody diarrhea almost always reflects structural rather
than functional bowel disease. A pungent stool odor or the presence of undigested meat
in the movement is suggestive of pancreatic insufficiency. An alteration in color can be
seen in cholestasis or steatorrhea (light-colored) or hemorrhage (melenic to maroon or
bright red). Mucus in the movement is usually a sign of a functional bowel syndrome,
while pus is more strongly suggestive of infectious or inflammatory disease. Less
common but more dramatic are the symptoms of acute GI bleeding, including
hematemesis, melena, and hematochezia, which usually lead to prompt efforts to find
medical attention but should always be enquired after by the clinician [20].
115
In the evaluation of male patients, especially those with diarrhea, a tactful inquiry
into sexual activity is essential. Homosexual males are at increased risk for a large
variety of GI disorders, as well as AIDS, which may first manifest itself with GI
symptoms. Such symptoms, especially diarrhea, are common in patients with AIDS.
These patients are susceptible to a wide range of infections and neoplastic disorders of
the GI tract, liver and biliary tract. Careful attention must be given to a general medical
history with an emphasis on present or past use of medications or nonprescription
drugs. Thyroid and other metabolic disorders, especially that affecting calcium
metabolism, can cause a variety of GI symptoms. Unless asked, patients may forget to
mention that they take aspirin almost daily for headache, and this may account for
occult blood found in the stool. The use of daily laxatives may explain chronic diarrhea.
Physical Examination, Endoscopy, and Radiology. All of the cardinal methods
of examination are helpful in evaluating the patient with GI symptoms. Inspection may
disclose signs of cholestasis or nutritional deficiencies. Examination of the abdomen for
an abnormal contour or inspection of the perianal region may reveal signs of a mass or a
draining fistula. Auscultation is also important. A succussion splash may be elicited in
the patients with symptoms of gastric outlet obstruction. The absence of bowel sounds
or an alteration in pitch can lead to recognition of an evolving ileus or an obstructing
process. A bruit may also be appreciated where there are symptoms of ischemic bowel
disease. Careful palpation of the abdomen is especially important in detecting
tenderness and masses, which in the appropriate clinical setting will lead to the
recognition of cholecystitis, Crohn's disease, periappendiceal abscess, and many other
disorders. Findings on abdominal palpation will often be complemented by percussion,
which is essential to assessing liver and spleen size [5,20].
Elicitation of rebound tenderness, either direct or referred, after removal of the
examining hand provides an important clue to localized or more generalized peritonitis,
which is characteristic of many abdominal emergencies, including a perforated viscus,
intraabdominal abscess, or tissue infarction. The clinician should be particularly alert to
these signs in patients with severe pain of abrupt onset. Typically, the patient will
remain immobile to avoid the accentuation of pain that may follow even slight
movement and jarring of the abdomen. This contrasts with the sometimes frantic efforts
to find a position of comfort in patients with severe pain deriving from visceral disease,
e.g., pancreatitis or intestinal ischemia. In these disorders, the absence of findings on
palpation of the abdomen may be in striking contrast to the evident distress of the
patient. Only when the process progresses to tissue destruction (e.g., necrotizing
pancreatitis or intestinal infarction) and secondary peritonitis will the abdominal
examination prove remarkable, often in concert with striking signs of systemic illness,
including hemodynamic instability. In addition to the examination of the abdomen, a
carefully performed digital rectal examination is also essential. In the patient with
116
complaints of incontinence, the integrity of the sphincter can be assessed. Most
important, masses intrinsic to the rectum as well as abnormalities in the pelvis or the
pouch of Douglas may only be detected by this examination, and the presence or
absence of frank or occult blood in the stool is always important diagnostic information.
Sigmoidoscopy should be viewed as a routine part of the physical examination in the
patient with diarrhea or another alteration in bowel habit as well as when there is known
or suspected blood loss from the lower bowel. Sigmoidoscopy, which can be performed
with either a rigid or a flexible fiberoptic instrument, allows for direct inspection of the
rectosigmoid mucosa, permitting the detection of cancers and polyps in this lower
bowel segment that might well be missed by barium x-rays. Inflammatory changes of
the mucosa can help identify patients with infectious dysentery or other forms of colitis,
most notably ulcerative colitis. The findings of edema, granularity, and diffuse friability
(easily induced mucosal bleeding) as well as superficial ulcerations are characteristic of
the latter disorder. Fresh stool samples for microbiologic studies and superficial
mucosal biopsies obtained at the time of sigmoidoscopy can also yield crucial
diagnostic information [7,20].
Table 2
Distinguishing between Functional and Organic/Structural Disease
of Gastrointestinal Tract
Organic
Symptoms Functional
Neoplastic Inflammatory
Weight loss None Common Sometimes
Diarrhea Daytime only Nocturnal Day and night
Blood loss None Frequent Frequent
Fever None Rare Frequent
Pain Cramping, relieved Minor to severe May be localized;
by defecation may be severe
Bowel habit Alternating Constipation Diarrhea or normal
(diarrhea or diarrhea/ (rarely diarrhea)
constipation) constipation Pellet- Change in caliber
like stools
Laboratory tests
Hematocrit Normal Often decreased May be decreased
White blood cell Normal Usually normal Often elevated
count
Erythrocyte Normal Usually increased Usually increased
sedimentation rate
Definitive demonstration or exclusion of structural lesions of the GI tract,

particularly the great majority of disorders that affect primarily the mucosal surface,
often cannot be accomplished by physical examination alone. Many upper and lower GI
117
tract disorders are accessible to inspection via fiberoptic instruments. As a result,
endoscopy has supplanted conventional contrast x-ray studies for many clinical
problems, both because of its heightened precision for diagnosis and the opportunity in
many instances to accomplish meaningful therapeutic intervention. However, it should
be emphasized that no procedure should be considered routine and used
indiscriminately; there must be a rational basis for its use in the individual patient.
Upper GI endoscopy permits evaluation of the esophagus, stomach, duodenum, and,
with specially designed instruments, proximal jejunum. When the clinical history
warrants a diagnostic examination of the upper GI tract for a structural lesion,
endoscopic examination is preferable to radiologic study in most patients when the
choice is available. Side-viewing scopes permit inspection and cannulation of the
ampulla of Vater, facilitating retrograde cholangiopancreatography. Evaluation of some
patients will be further benefited by endoscopic ultrasound, which can delineate
submucosal mass lesions and abnormalities in the pancreas. The colonoscope can be
used to visualize the entire colon and often the terminal ileum, resulting in more
accurate diagnosis of inflammatory bowel disease and mass lesions. Frequently, colonic
polyps can be removed at the time of their initial identification [1,6].
Endoscopic techniques are relatively precise in defining many problems, but the
limitations of these tools, as well as the continued advantages of x-ray studies in some
situations, should be recognized. Endoscopic tools are not useful in assessing GI
motility, which may be assessed more accurately by barium studies. In addition, some
areas, notably the small intestine, remain relatively inaccessible to fiberoptic
instruments. In hospitals where endoscopy is not feasible, the upper GI series and
barium enema remain good diagnostic modalities to evaluate the upper and lower GI
tract, especially when air-contrast techniques are employed. However, they should
generally be avoided in patients with GI bleeding or suspected bowel obstruction. In
addition the physician must exercise judgment in preparing the patient for these studies,
recognizing that cathartics may markedly worsen the condition of a patient with
obstructing lesions or colitis.
Although endoscopy has obviated the need for many conventional GI x- rays,
other radiologic imaging modalities have assumed a crucial role in the approach to the
patient with GI symptoms. These techniques include ultrasound (US), computed
tomography (CT), and magnetic resonance imaging (MRI). Both US and CT are useful
in the delineation of abdominal masses. CT, though more expensive, is often more
effective in the evaluation of the lower abdomen, where inflammatory masses in
patients with Crohn's disease or complications of diverticular disease may be accurately
118
imaged. However, US is an effective and less expensive tool for the evaluation of the
right upper quadrant, including the gall bladder and biliary tract. Imaging techniques are
often complementary in the evaluation of pancreatic disease. In combination with
Doppler analysis, US can be used to assess the patency and direction of blood flow in
the portal vein in the patient with advanced liver disease. MRI may give exquisitely
accurate information on the anatomic extent of invasive rectal cancers and blood flow in
patients with vascular disorders, but the full range of its uses in GI disorders remains to
be delineated. More sophisticated CT and MRI equipment can actually permit the
performance of digital angiography without the invasive catheterization necessary in
conventional visceral angiography [7].
Diagnostic approaches. Abdominal Pain. Determination of the cause of
abdominal pain remains an imposing clinical challenge. Disorders ranging from the
acute and catastrophic to the chronic and indolent can cause abdominal pain.
Furthermore, differential diagnostic considerations may encompass diseases extrinsic to
the G1 tract, such as disorders of the genitourinary tract (e.g., pelvic inflammatory
disease) and the peritoneum. The history and physical examination are essential guides
to a sensible diagnostic approach. The initial goal is to distinguish between an urgent
problem requiring expeditious delineation and a non-acute disorder. In the former
situation, initial clinical impressions based on the history and physical examination can
be further refined through routine laboratory tests such as a complete blood count and
differential as well as plain films of the abdomen. Particular features will dictate the
appropriateness of urgent US or CT examination or the need to proceed promptly with
surgery. In the patient with a long-standing and relatively stable problem, diagnostic
evaluation can be more deliberate. The clinician may be able to reasonably establish a
functional basis for the complaint on the strength of the history and physical
examination alone. Radiologic contrast studies, other imaging modalities (e.g., US,
CT), or endoscopic examination may be appropriate to exclude or identify certain of the
gamut of disorders discussed above. If all these approaches do not determine the cause
of the patient's symptoms, more unusual causes of abdominal pain may have to be
excluded through specific urine or blood tests (e.g., porphyrins) [4,7].
119
Table 3
Overview of Approach to Patients with Common Gastrointestinal Disorders
Site of Possible Potential Procedures or
Common Symptoms
Disorder Physical Signs Laboratory Studies
Esophagus Dysphagia Esophagoscopy
Odynophagia Barium swallow
Heartburn, chest pain Manometry
Hematemesis/melena Bernstein test
Stomach Nausea and vomiting Distention Gastroscopy
Epigastric pain Tenderness Upper GI x-ray series
Hematemesis/melena Succusion splash Nasogastric aspiration
Early satiety Mass Gastric emptying
Pancreas Pain Mass Kidney-ureter-bladder
Weight loss Jaundice x-ray series
Diarrhea Qualitative stool fat and
Steatorrhea muscle fiber
US, CT, MRI,
endoscopic retrograde
cholangiopancreatography
Pancreatic function tests
Small Intestine Pain Tenderness Duodenoscopy
Duodenum Nausea/vomiting Altered bowel Small bowel follow-
Hematemesis sounds through, enteroclysis
Distention Kidney-ureter-bladder
Mass x-ray series
D-Xylose absorption tests
Jejunum Pain Altered bowel CT
Diarrhea sounds Stool cultures, stool
Distention examination for ova
Mass and parasites
Small bowel biopsy
Ileum Pain Altered bowel
Diarrhea sounds
Distention
Mass
Colon Diarrhea Tenderness Sigmoidoscopy
Pain Mass Colonoscopy
Blood Distention Barium enema
Stool culture, stool
examination for ova
and parasites
Clostridium difficile
toxin assay
Rectum Pain Tenderness Sigmoidoscopy
Urgency Anoscopy
Hematochezia
Pruritus
120
Site of Possible Potential Procedures or
Common Symptoms
Disorder Physical Signs Laboratory Studies
Nonspecific Weight loss Complete blood count
Fever Erythrocyte
Anorexia sedimentation rate
Nausea and vomiting Fecal occult blood test
Problems of Swallowing. The approach should be as follows:

1. Thorough determination of the nature of dysphagia. Is the difficulty primarily
in swallowing liquids, solids, or both? The location of the difficulty from the patient's
perspective and presence or absence of accompanying odynophagia are important to
ascertain. These historical clues are complemented by careful visual and neurologic
examination of the oropharynx when appropriate.
2. Routine esophageal x-rays in the upright and lateral or Trendelenburg position.
The horizontal views are essential for demonstration of the swallowing mechanism,
unaided by gravity, and of the esophagogastric junction. For details of the
pharyngoesophageal area, cineradiography is necessary because of the rapidity with
which the contrast medium passes through. Hiatus hernia is extremely common (in 15
to 35% of persons over 50%) and often is asymptomatic unless spontaneous reflux of
gastric contents can be demonstrated to occur repeatedly. Careful attention is usually
needed to detect lower esophageal rings or webs, which may be visible as indentations
in the barium column only from a limited angle.
3. Esophagoscopy. This procedure is desirable for lesions suggested by x-ray or,
if the lesion is unsuspected, to biopsy masses or abnormal mucosa and to obtain
washings for exfoliative cytologic study. The diagnoses of peptic esophagitis and
Barrett's esophagus are made endoscopically. Endoscopy is the most sensitive technique
for identifying esophageal or gastric varices, although they are seldom important in the
absence of hemorrhage. Fiberoptic instruments with a US probe at the tip (endoscopic
ultrasound) are increasingly useful diagnostic tools for particular problems of the
esophagus (and other sites of the GI tract).
4. Manometric studies of the upper esophagus, particularly in conjunction with
cineradiography. At present, this procedure offers the best means of differentiating
among disorders originating in the central nervous system, primary pharyngeal
muscular disease, and cricopharyngeal dystonia. Manometry of the lower esophagus is
useful in the diagnosis of diffuse esophageal spasm, achalasia, and infiltrative diseases
that can alter esophageal motility [20].
Peptic or Digestive Disorders. The approaches to these disorders include the
following.
1. Insertion of a nasograstric tube. This approach is used to establish whether
significant gastric retention (more than 75 mL of gastric contents in the fasting state)
exists and whether acid, bile, blood, or other materials are present. If pyloric obstruction
or gastric atony is present, the tube is used to maintain suction while the patient's
121
electrolyte and fluid balance is restored to normal; the stomach is kept as clean as
possible so that reliable diagnostic investigation may be carried out [1].
2. Upper gastrointestinal endoscopy. This procedure is most helpful in assessing
the mucosa in gastritis or, together with biopsy and brushings for cytology, in
differentiating between peptic and neoplastic ulcerating lesions. It may identify a
specific bleeding site in clinical situations where several potential bleeding sites could
exist, as in the patient with portal hypertension. In addition, it may be possible to
cauterize or otherwise intervene to control hemorrhage via the endoscope (e.g., by
injections of vasoconstricting agents such as epinephrine). The frequent association of
gastritis with Helicobacter pylori in patients with actual peptic ulceration, as well as in
those with nonulcer dyspepsia, has been well documented. Although, at this time, H.
pylori infection can be most reliably confirmed in the individual patient by endoscopy
and biopsy, this approach may be superseded by other, less invasive modalities
including breath and serologic tests. Endoscopy can detect a number of potential
sources of upper GI bleeding that are often missed by x-ray studies (e.g., erosive
gastritis, Mallory-Weiss tear). Gastroscopy is particularly helpful in inspecting the
postoperative stomach, especially in detecting stomal ulceration or so-called alkaline
reflux gastritis. The first and second portions of the duodenum can also be routinely
examined, and important information about ulcers and other lesions can be obtained.
Radiologic studies may be useful when endoscopy is not readily available or in the
assessment of suspected motility disorders (e.g., gastroparesis). In addition, radiologic
examination may be preferred when there are contraindications to safe endoscopy.
3. Gastric acid secretory studies. Although not routinely necessary, these studies
are useful in the diagnosis of the Zollinger-Ellison syndrome or atrophic gastritis and
for determination of completeness of vagotomy. They should not be performed for the
routine diagnosis of uncomplicated duodenal ulcer; also, there is no convincing
evidence that they are useful in determining the choice of surgery for peptic ulcer [20].
Obstructive and Vascular Disorders of the Small Intestine
When intestinal problems present as obstructive syndromes, the plain x-ray film
of the abdomen is the most important diagnostic adjunct to careful physical
examination. Patterns of dilation of individual loops of intestine may be characteristic,
as in volvulus or acute pancreatitis; erect and decubitus views will often show fluid
levels in the affected segments. Motility disorders of the small intestine (temporary ileus
or chronic intestinal pseudoobstruction) may also present with obstructive symptoms
and similar x-ray findings but must be managed medically without surgical intervention.
Air under the diaphragm is diagnostic of a perforated viscus; air in the portal vein
usually results from intestinal necrosis secondary to mesenteric vascular occlusion. The
diagnostic accuracy of the plain x-ray film in all types of intestinal obstruction is about
75%. In patients with symptoms of incomplete obstruction, the radiographic small-
bowel series will often be diagnostic in defining the site and degree of obstruction.
122
Infrequently, in this setting, all conventional x-ray studies are unremarkable. In such
cases, the radiologist may perform a small bowel enteroclysis study by passing a special
tube into the proximal jejunum; the rapid instillation of barium through the tube will
distend the intestine and often reveal subtle lesions missed by other tests.
Vascular diseases of the small intestine are among the most difficult diseases to
diagnose. In chronic mesenteric ischemia, radiographic, endoscopic, and laboratory tests
are usually normal. Early in the course of acute mesenteric ischemia, the plain film of
the abdomen may be unremarkable despite complaints of severe abdominal pain. In
these settings, prompt mesenteric angiography is essential to confirm the diagnosis of
vascular disease [5,20].
Inflammatory and Neoplastic Diseases of Small and Large Intestine. These
patients are usually identified by history, physical examination, and careful examination
of the stools for exudate and blood. Examination of fresh stool samples for common
bacterial pathogens and parasites by laboratories skilled in these techniques is important in
identifying or excluding infectious causes of diarrhea, particularly in the patient with
colitis. Sigmoidoscopy is valuable in identifying mucosal and neoplastic lesions of the
rectum and distal colon. The mucosal surface of the entire colon and terminal ileum can
be examined directly and biopsied through the fiberoptic sigmoidoscope or
colonoscope. The radiologic examination of the small intestine is highly reliable in
identifying the prestenotic and stenotic lesions of Crohn's disease. In the colon, a single
barium enema examination in a well-prepared patient has a diagnostic accuracy of 80-
85%; the addition of air-contrast technique brings the accuracy up over 90%. None of
these figures is meaningful if the patient is poorly prepared for the examination,
however. Colonoscopy may be preferable because of its greater accuracy and the fact
that it enables the operator to remove the vast majority of polyps that are encountered as
well as to obtain preoperative tissue confirmation in the patient who probably has
cancer.
Peroral biopsy of the small intestine and forceps biopsy of the rectosigmoid are of
considerable importance in revealing mucosal disease. Rectal biopsy is an excellent
means of demonstrating amyloidosis, schistosomiasis, and amebiasis. Submucosal
disease is not seen in these superficial biopsies. Hirschsprung's disease is diagnosed
histologically by a deep surgical biopsy of the lower part of the rectum [7].
Malabsorption Syndromes may be suspected on the basis of history and
physical examination and confirmed by examination of the stool. Radiologic
examination is helpful to rule out local lesions and to suggest motor and secretory
dysfunction, but it is rarely diagnostic unless an abnormal small bowel mucosa or
fistulas between the intestine and stomach are demonstrated [20].
A simple screening test for excessive fat in the stools can be accomplished by the
microscopic examination of a stool specimen stained with Sudan. Chemical analysis of
3-day stool collection for fat, with the patient on a standard diet, is used to establish the
diagnosis of steatorrhea. The D-xylose absorption test is about 90% accurate in
123
distinguishing mucosal disease from pancreatic insufficiency. Peroral biopsy of the
small intestine via the endoscope or a specialized biopsy device is of value in the
diagnosis of celiac disease, and it may show the less common infiltrations of the
mucosa by amyloid or bacterial mucoproteins (Whipple's disease). Leakage of protein
into the intestinal lumen may cause hypoproteinemia and can be demonstrated by the
recovery in stools of the serum protein ar-antitrypsin or intravenously administrated
markers such as albumin labeled with iodine or chromium isotopes [6,20].
Pancreas is difficult to study because of its anatomic location and relative
inaccessibility. Calcification of the pancreas on a plain abdominal film is highly
suggestive of chronic pancreatitis and may be associated with fat malabsorption.
Pancreatic exocrine insufficiency can be demonstrated by intubation of the duodenum
and collection of pancreatic juice after stimulation with secretin or a test meal, but a
stool collection for qualitative determination of fat and muscle fiber content is usually
sufficient as an initial diagnostic approach. Abdominal US and CT are the best
radiographic means of searching for pancreatic enlargement. Both techniques may also
be used to guide needle biopsies of the pancreas and may provide sufficient diagnostic
information to obviate the need for exploratory surgery. The pancreatic duct can be
cannulated via the fiberoptic duodenoscope and visualized by the injection of
radiographic dye. Visualization of the duct may be helpful in the diagnosis of pancreatic
pseudocysts, carcinoma, or chronic pancreatitis [2,7].
The grants of medical care, population, and administrative management
Medicare Population Management
High-specialized help 1-1,5 million district
specialized help 200-500 thousand Region
Primary help 1-20 thousand Local districts
Self-help 1-10 person Family
124
Clinical diagnostic
laboratory District department
functional diagnostics
department Surgical department
physiotherapeutic
Emergency
department Consultative department
Social services
Economic service of
medical establishment
Radiology department
Cardiological department
Neurological department
125
Family doctor
Dae hospital
Medical home care

Departments of hospital
alternative medicine
Аntenatal clinic
Administration of medical establishment
Self-supporting service Medical advisory commission

medical establishment and other institutions
municipal oncologic Medico-social

dispensary commission of expert
Red Cross
employment
Other specialized
permanent place of
municipal medical Sanitary-and-epidemic

social security authority
Intercommunication of district hospital with structural subdivisions of
establishments station
Transformation of the stages of realization of medical rehabilitation
Stationary Sanatorium Policlinic
Improvement and
In the case of impaired Medical supervision,
recovery of psycho-
psycho-physiological rehabilitation measures
physiological
functions
functions
Stationary
Out-patient Sanatorium Primary medical
clinic help
Improvement and
In the case of recovery of Improvement
impaired psycho- psycho- and recovery Medical
physiological physiological of psycho- supervision,
functions functions physiological rehabilitation
functions measures
Medical rehabilitation structure
Environmental factors: 1. social

2. biological
ENTRANCE
Persons - rehabilitations subject PROCESS OUTPUT
Dynamics: change of demographic 1. Brought through patients
processes, availability of medical 2. Patients with recovery
care, indication for rehabilitation 3. Patients which functional recovery
4. Reducing of out-patient treatment
5. Reducing of hospital treatment
Managing
METHODS AND subsystem
FACILITIES
REVERSE CONNECTION Guided

subsystem
Other medical services which interact with medical rehabilitation system:

1. primary medical help
2. specialized services
3. medical diagnostic services
126
Functional organizational model of medical rehabilitation at the level of primary medical help
General practitioner / family doctor
Principles Task Methods Stages Organizational

forms
Early start of Indication for Diagnostic rooms
rehabilitation Diseases Non-medicinal get into shape rehabilitation of out-patient's
prevention
clinic
the individual
Continuity psychophysiolo healthy life style Massage program of Physiotherapeutic
gical functions rehabilitation room
recovery
Following Physiotherapy Medical
physical Rehabilitation Day hospital of
capacity
education out-patient's clinic
recovery
Complex character Balneotherapy
Final
Medical care at
Acupuncture and home
Individual reflex therapy
approach
Examination of
Psychotherapy
Mass application capacity
clinical nutrition
positive results for Health centre system
health, social and
professional status Medicinal
127
X. Tasks for final control
Task 1. The 37-years-old patient complains for steady pain in the right epigastric
area, with back spreading, nausea, and vomit. He had gastric ulcer during 15 years, he
was self-treated irregularly. Physical examination: pale, moisture skin; furred tongue,
wooden belly, painful abdominal palpation of pyloroduodenic area, «+» Mendel’s,
Obrazcov’s symptoms. Complete blood count: neutrophilic leukocytosis, erythrocyte
sedimentation rate 28 mm/hour. Negative Gregersen’s reaction. X-ray: the stratified
niche 0,8 х 1,2 cm with inflammatory wall to 7 mm was in duodenal cap.
1.1. Gregersen’s reaction is:
A. determination of H. pylory
B. blood pancreatic enzymes test
C. the urine occult blood test
D. fecal occult blood test
E. urine pancreatic enzymes test
1.2. You diagnosed:
A. duodenal ulcer, exacerbation, severe clinical course, gastrorrhagia
B. cancer of stomach with tumour transformation
C. duodenal ulcer, exacerbation; chronic superficial gastritis
D. duodenal ulcer, associated with H. pylory, exacerbation
E. duodenal ulcer, exacerbation, severe clinical course with penetration ulcer
1.3. Your management program of patient:
A. day hospital treatment
B. planned hospitalization in therapeutic department
C. urgent hospitalization in surgical department
D. planned hospitalization in surgical department
E. out-patient treatment
Task 2. During a prophylactic medical examination of man without complaints,

there were determined: moderate pale skin; cardiac border: rights - on the right edge of
breastbone, overhead - overhead edge of III rib, left - 1 cm to the left from
medioclavicularis line; muffled I heart sounds above an apex, accent of II heart sounds
in II intercostal left of breastbone; systolic murmur above an apex which was spred in
the axillary area.
2.1. At roentgenologic research in resulted case it is possible to educe all signs,
except:
A. to smooth out waist of heart
B. shadow of heart as "sabo" (wooden boot)
C. of ncrease of the left ventricle
D. rejection of contrasting gullet on the arc of large radius in a lateral projection
E. to smooth out waist of heart and increase of the left ventricle
2.2. For the brought case over most characteristic will be:
A. increase of top limit of heart
B. murmur is accompanied by the systolic fremitus
C. pansystolic murmur above an apex
D. strengthening of systolic murmur on inhalation
E. murmur is accompanied by the diastolic fremitus
2.3. This clinical symptomatology most answers such defect of heart as:
A. inborn defect of heart
B. mitral stenosis
C. the combined mitral defect
D. aortic stenosis
E. insufficiency mitral valve
2.4. What complex of research must be executed first of all?
A. biochemical blood tests are for determination of activity of rheumatism
B. biochemical blood tests for determination of activity of rheumatism + of Еcho-CG
C. of ЕCG + of Еcho-CG
D. roentgenologic research of heart + of ЕCG + of Еcho-CG
E. sounding of cavities of heart
2.5. What medical tactic you to enter to this patient?
A. to conduct a secondary prophylaxis
B. to appoint seasonal treatment
C. to recommend the surgical correction of defect of heart
D. only dynamic supervision
E. to appoint bycilin-5 one time in a month during one year
Task 3. The patient of 25 years old appealed to the family doctor with complaints
about pain and swelling up in right knee joint and interphalangeal joints of right foot,
rise body temperature to 37,80С, sickliness. It is ill 2 weeks. To it privately treated
oneself concerning appearance of mucous-festering excretions from an urethra,
periodically feeling of "sand appeared in eyes". Objectively: general case satisfactory.
Temperature of body 37,30С. On a skin single psoriatic eruption a to 5 mm in a
diameter. Conjunctiva of hyperemic, injection scleras. The limits of heart are not
changed. Tones of heart are stored, on an apex heard systolic "cliques". Deformation of
right knee-joint, interphalangeal joints of right foot.
3.1. Your previous diagnosis will be:
А. rheumatic fever, insufficiency mitral valve, rheumatic arthritis
B. rheumatoid arthritis
C. disease of Reiter
129
D. gonococcus arthritis
E. psoriatic arthritis
3.2. Define the etiologic factor of this disease
А. enterovirus
B. streptococcus agalactiae
C. gonococcus
D. chlamydiales
E. not one of resulted
3.3. Define the further tactic of conduct patient:
А. to refer at treatment to dermatovenereologist
B. to refer to rheumatology/therapeutic hospital
C. ambulatory treatment without to the medical certificate
D. treatment on daily hospital
E. ambulatory treatment with to the medical certificate
3.4. Appoint the plan of treatment:
А. meloksicam 15 mg on twenty-four hours
B. azitromicini a 1 g peroral non-permanent + meloksicam 15 mg on twenty-four
hours
C. prednizaloni of 30 mg on twenty-four hours
D. penicillin 3 millions/twenty-four hours intramuscular + celecocsib 400 mg on
twenty-four hours
E. treatment of psoriasis according to recommendations of dermatovenereologist
+ celecocsib 400 mg on twenty-four hours
Task 4. Most characteristic clinical symptom of stable angina pectoris:

A. pain squeezing character
B. pain retrosternal
C. efficiency to nitroglycerine
D. broadened to irradiation pain
E. normal ECG during an attack and after the physical loading
F. vertigo
Task 5. For a patient 55 years, which carried myocardial infarction a few years
ago, began to rise ABP to 160/100 mm hg. p. Heredity after high blood pressure is
burdened. What hypotension drugs will you appoint, taking into account information of
anamnesis?
A. β-adrenoblocker
B. diuretics
C. ACE inhibitors
130
D. direct action vasodilators
E. ACE inhibitors or β-adrenoblocker
Task 6. Basic difference ІІ A stages of heart failure on a left-sided type from one
stages:
A. rice ABP
B. emergence peripheral edemata (transit)
С. tachicardia in a state of rest
D. symptom to engorgement in the greater circulation
Е. symptom to engorgement in the lesser circulation
Task 7. What forms of chronic glomerulonephritis not is appointed at a heparin

A. with an urinary syndrome, progressive course
B. with a hematuria syndrome
C. with a nephrotic syndrome in any stage
D. with a nephrotic syndrome in the stage of chronic renal failure
E. with an urinary syndrome in the stage of chronic renal failure
Task 8. In principles treatment of the second chronic pyelonephritis enters all,

except for:
A. renewal and normalization of passage of urine
B. diuretics
C. immunomodulators
D. glucocortikoids
Task 9. What from the noted indexes to use for monitoring and assessment of
degree of weight of bronchial asthma:
A. OFV1 is a volume of air, which fizzles out at the forced exhalation for the first
second after complete inhalation
B. MPV - index of maximal stream which is formed in times of the forced
exhalation
C. VCL is a vital capacity of lights
D. FVCL - the vital capacity of lights is forced
Task 10. Office worker as a result of high fever and indisposition did not go out
on work. Called to the family doctor home and asked to open the medical certificate. At
implementation of what condition can a doctor give out the medical certificate?
А. on the basis of conclusion of medical-consultative commission;
B. at presence of record in "Magazine of account of calls of doctors home";
131
C. after the personal review of patient by a treating doctor;
D. at presence of results of blood, urine and fluorography test;
E. after passing of complex medical review.
Answers:
1.1 1.2 1.3 2.1 2.2 2.3 2.4 2.5 3.1 3.2
D E C B C E B A C D
3.3 3.4 4 5 6 7 8 9 10
E B C E E E D А C
XI. Final level

Task 1.
The patient of 53 years grumbles about feeling of weight in epigastric area,
periodic nausea, annoying smack in to the mouth, unsteady chair, emaciation, bad
appetite. It is ill 7 years, treated oneself independently after folk recipes. Worsening
marks during two weeks. Objectively: sufficient feed, a skin is moist; peripheral
lymphonodus not palpation. At palpation - the insignificant is painfulness in epigastric
area.
1.1. Taking into account resulted information, you diagnose:
A. unexplored gastric dyspepsia
B. chronic unatrophy gastritis, normoacidis state
C. cancer of stomach
D. chronic atrophic gastritis, hypoacidis state
E. chronic atrophic gastritis, unacidis state
1.2. In accordance with a select diagnosis specify on reliable changes which can
be at roentgenologic investigational stomach for this patient:
A. to smooth of plica, shortening and narrowing of antral divisio, a peristalsis
absents in this area.
B. of plica of ordinary form, evacuation is a speed-up
C. to smooth of plica, evacuation low-spirited, pylorus to hiatus.
D. at the antral divisio to smooth of plica, uneven tumour
E. thickening of plica, a peristalsis is safe.
1.3. What obligatory laboratory research must be done foremost:
A. determination of activity of enzymes of pancreas
B. determination of reaction of Gregersen
C. determination of content in blood of gastrin
D. determination of titer of antibodies to the lamblias
E. determination presence of H. pylori infection
1.4. Define a further medical tactic:
A. foremost to conduct the computer tomography of organs of abdominal cavity
132
B. realization of finish examining patient with further medicinal treatment
C. realization of finish examining patient with further direction to the specialist
D. ambulatory symptomatic treatment and continuation of finish examining
E. planning surgical operation
Task 2.
An indications is to the conducting of day's monitor ABP:
A. detection arterial hypertension
B. differential diagnosis of arterial hypertension and hypertension “white a
dressing-gown”
C. valuing to character of arterial hypertension and influence of different factors
D. detection hypotension
E. valuing to efficiency of therapy
F. enumeration in A, B, E.
G. enumeration in A, B, C, D, E.
Task 3.
Character of beginning of pain is at the angina of effort:
A. without precursors, sudden, on height of the physical loading, gradually grows
to the peak of intensity in the form of crescendo
B. after auras
C. maximum intensity will attack at the beginning
D. pain grows undulating
E. in 4-6 hours after loading, maximum on 2-3 days
Task 4.
A patient which long time suffers on a gout and essential hypertension entered
induction centre of hospital with the signs of polyarthritis and increase of ABP to
170/100 mm hg. p. What hypotension drugs are contra-indicated in this case?
A. diuretics
B. antagonist to the calcium
C. ACE inhibitors
D. β-adrenoblocker
E. direct action vasodilators
Task 5.
The most characteristic pathology of kidneys is at diabetes mellitus:
A. Chronic pyelonephritis
B. renal amyloidosis
133
C. glomerulosclerosis
D. glomerulonefritis
Task 6.
A patient is 55 years with an acute pyelonephritis on a background the
urolithiasis. What complex of researches do you count after a necessity to conduct?
A. urinalysis, complete blood count, bacterial research of urine
B. urinalysis, complete blood count, bacterial research of urine, isotopic
rheography
C. Bacterial research of urine, ultrasonic examination of kidneys, urinary ways,
survey urography
D. Bacterial research of urine, three glass test
E. urinalysis, complete blood count, three glass test, creatinine of blood
Task 7.
The main clinical symptom of chronic obstructive pulmonary disease is all,
except for:
A. dyspnea
B. constant or periodic cough
C. expectoration availability
D. choke seizure
E. rise temperatures
Task 8.
To primary atypical pneumonias take:
A. mycoplasmal
B. legionellal
C. chlamydial
D. staphylococcal
E. pneumococcal
F. right A, B, C
Task 9.
For what anemia a blood test is characteristic: erythrocytes - 3,0x1012/l,
hemoglobin - 75 of gm/l, color index - 0,75, reticulocytes - 2%, leucocytes - 5,5x109/l,
platelets of 220x109/l, eosinophil - 1%, neutrophilic - 64%, lymphocyte - 31%,
monocyte - 4%, speed of precipitation of erythrocytes - a 30 mm/hour., anisocytosis
+++, hypochromic microcytosis?
A. hypoplastic
134
B. iron deficiency
C. megaloblastic
D. hemolytic
Task 10.
Worker 37 years, appealed to the family doctor of 04.10.2009. Became ill 2 days
to the volume, a doctor diagnosed: acute bronchitis. During the second meeting with a
doctor the state of patient became worse, a patient had been sent to stationary treatment
with a diagnosis: pneumonia. In hospital a patient was 16 days, was whereupon written
to work. How to design a disability to this patient?
А. From 02.10.2009 to 04.10.2009 a paper is designed. From 04.10.2009 to
26.10.2009 is a medical certificate;
B. From 02.10.2009 to 04.10.2009 a paper is designed. From 04.10.2009 to
09.10.2009 the first medical certificate is designed in a family out-patient's
clinic, from 10.10.2009 is the second medical certificate in hospital;
C. Designed 2 medical certificates: first - in a family out-patient's clinic from
04.10.2009 to 06.10.2009, second - in hospital from 07.10.2009 to 22.10.2009;
D. Designed 2 medical certificates: first - in a family out-patient's clinic from
04.10.2009 to 09.10.2009, second - in a family out-patient's clinic from
10.10.2009 to 25.10.2009;
E. Designed one medical certificate from 04.10.2009 to 25.10.2009.
Answers:
1.1 1.2 1.3 1.4 2 3 4
D C C B G А А
5 6 7 8 9 10
C C E F B C
135
RECOMMENDED LITERATURE
A. Main
1. Family medicine / R. McWhinney, Thomas Freeman. Oxford, third edition, 2009. –
460 p.
2. Practical General Practice: guidelines for effective clinical management / Alex
Khot, Andrew Polmear. Fourth edition, 2003. – 507 p.
3. Family medicine: ambulatory care and prevention / Mark B. Mengel, L. Peter
Schwiebert. Fifth edition, 2009. – 879 p.
4. Current diagnosis and treatment in family medicine / Jeanette E. South-Paul, Samuel
C. Matheny, Evelyn L. Lewis. 2007. – 1107 p.
5. General Practice / John Muntagn. Oxford, fifth edition, 2011. – 1535p.
6. Davidson's Principles and Practice of Medicine / Nikki R. Colledge, Brian R.
Walker, Stuart H. Ralston. 21st edition, 2010. – 1376 p.
7. Harrison's Principles of Internal Medicine / Dennis Kasper, Anthony Fauci, Stephen
Hauser, Dan Longo, Joseph Loscalzo, J. Jameson. 18th edition, 2011. – 4012 p.
8. American College of Physicians: Preventing firearm violence: A public health
imperative. Ann Intern Med 122:311, 1995
9. Fedson DS: Adult immunization: Summary of the National Vassine Advisory
Committee Report. JAMA 272:1133, 1994
10. Healthy People 2000: National Health Promotion and Disease Prevention
Objectives. Department of Health and Human Services Publication (PHS) 91-50213,
1991
11. Helzlsouer KJ et al: Summary of the round table discussion on strategies for
cancer prevention: Diet, food, additives, supplements, and drugs. Cancer Res 54:2044s,
1994
12. McCormick WS, Inui TS: Geriatric preventive care: Counseling techniques in
practice settings. Clin Geriat Med 8:215, 1992
13. Pope AM, Rall DP (eds): Environmental Medicine: Integrating a Missing
Element into Medical Education. Washington, DC, National Academy Press, 1995
14. Schwarts JS et al: Internists' practices in health promotion and disease prevention.
Ann Intern Med 114:46, 1991
15. Sox HC: Preventive health services in adults. N Engl J Med 330:1589, 1994
16. U.S. Preventive Services Task Force: Guide to Clinical Preventive Services, 2d
ed. Baltimore, Williams & Wilkins, 1995
17. Williams GC et al: “The facts concerning the recent carnival of smoking in
Connecticut” and elsewhere. Ann Intern Med 115:59, 1991
136
B. Additional
18. First Exposure to Internal Medicine: Hospital Medicine / Charles H. Griffith,
Andrew R. Hoellein. Lange, 2007. – 384 p.
19. Differential Diagnosis in Internal Medicine: From Symptom to Diagnosis /
Walter Siegenthaler. Thieme Medical Publishers; 1 edition, 2007. – 1140 p.
20. Textbook of Gastroenterology, 2 Vol. / Tadataka Yamada), David H. Alpers,
Loren Laine, Neil Kaplowitz, Chung Owyang, Don W. Powell. Lippincott Williams &
Wilkins; Fourth edition, 2003. – 3478 p.
21. Murray and Nadel's Textbook of Respiratory Medicine: 2-Volume / Robert J.
Mason, V. Courtney Broaddus, Thomas Martin, Talmadge King Jr., Dean Schraufnagel,
John F. Murray, Jay A. Nadel. Saunders, 5th edition, 2010. – 2400 p.
22. Williams Textbook of Endocrinology / Shlomo Melmed, Kenneth S. Polonsky, P.
Reed, Henry M. Kronenberg. Saunders, 12th edition, 2011. – 1920 p.
23. Williams Hematology / Kenneth Kaushansky, Marshall Lichtman, E. Beutler,
Thomas Kipps, Josef Prchal, Uri Seligsohn. 8th edition, 2010. – 2460 p.
137

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MINISTRY OF PUBLIC HEALTH OF UKRAINE

ZAPOROZHE STATE MEDICAL UNIVERSITY

THE TEXTBOOK FOR THE PRACTICAL CLASSES AND INDIVIDUAL WORK

Content module 1,2

Methodical recommendations compiled in accordance with the program of

The thematic plan of practical classes……………………............................... 5

5 The emergency in the practice of family doctor. The emergency in the 6

7 The emergency in the practice of family doctor in the case of seizure, 6

THE THEMATIC PLAN OF INDEPENDENT WORK OF STUDENT

III. Concrete purposes of the module:

V. Task for initial independent training

2. A medical help is a complex of measures which directed on:

3. Establishments of Public health are:

4. The body of Public health is:

5. What normative document in Ukraine is predefining the professional duties of

6. Which normative document in Ukraine includes these definitions of concepts

7. Principles of Public health are all, except:

8. How many forms of compounding function today in practical activity of family

VI. Basic questions after a theme

VII. Practical skills

VIII. The plan and organizational structure of practical training

Test control of initial level of knowledge: the basis of health legislation of

Analysis of thematic questions

Reception of patients together with family doctors, the analysis of

A decision of practical tasks on the basis of the got knowledge

Current control of knowledge after a theme

Resuming by reading with forming of complex

Kind and volume of medical care, which is given by a general practitioner/

TYPES OF MEDICAL HELP

Paramedical help Emergency Qualifying medical help

 Measures of  Treatment of  Some infectious and

Specialists which give

Management functions: Center of

Appoint to district level for

medical Make an appointment

Organization of urban primary medical help (PMSH)

Out-patient's A doctor with

Counted on 2-4 doctors (the loading is 1500 -

Individual card of pregnant F. 111/o

Communication registration forms

List of registration forms which are get to the patient

List of statistical accounting forms

XI. Tasks for final control

2. What normative document in Ukraine determines a right of citizen for health

3. What normative document is marked in Ukraine as «alteration of primary

4. Which drugs are prescribed by prescription form №2?

5. What drugs are prescribed by prescription form №3?

8. What is included in section "Development of primary medical help" of national

9. Tasks of national project in Public health are:

XII. Practical tasks

III. Concrete purposes of the module:

V. Task for initial independent training

2. The concept "individual health" is:

3. Leading groups of factors, which negatively impact on population health, are:

4. A population health depends on the life style (in %) :

5. A volume, quality of medical care and inefficiency of prophylactic measures,

6. What is a risk factor of morbidity or death?

8. According WHO classification, the individuals of 60-74 years old are:

10. The indexes for estimation of primary prophylaxis are: